'KJJTj,;: itt&i'K. »:•■:*.'<> mmmimi^m:%:i NLM005596654 ^ A TREATISE THE DISEASES NERYOTJS SYSTEM. BY WILLIAM A. HAJIMOND, M. D., professor op diseases of the mind and nervous system in the medical department of the university op the city of new york; president op the new york neurological society; member of the American philosophical society (Philadelphia), of the academy of the natural sciences (philadelphia) ; fellow of the college of physicians op philadelphia; fellow op the american academy op arts and sciences (boston); corresponding mem- ber of the anthropological institute of great britain and ireland, etc., etc. WITH ONE HUNDRED AND NINE ILLUSTRATIONS. SIXTH EDITION, REWRITTEN, ENLARGED AND IMPROVED.' 'Est quoddam prodire tenus, si non datur uljra^l—JSosAEE^.__ i "«■ -a- ■<. ■■ ' ; U I '•• -' 'SUR3U0M GE NEW YORK •■■■ , ;\ T>\r H^±X.XX ^RALS OFFICE Hrll/I— D. APPLETON AND COMPANY; 549 & 551 BROADWAY. 1876. VU2/H Entered, according to Act of Congress, in the year 1576, By D. APPLETON & CO., In the Office of the Librarian of Congress, at Washington. I dedicate this volume to my dear friend S. Weir Mitchell, M.D., of Philadelphia, not only because he is my friend and fellow-laborer of twenty years' standing, but because his acquirements as a physician, and especially a neurologist, are such as to place him among the first of those who work in the most important department of medical science. PEEFAOE. In the preface to the first edition of this work, published five years ago, I wrote as follows : " In the following work I have endeavored to present a Treatise on Diseases of the Nervous System, which, without being superficial, would be concise and explicit, and which, while making no claim to being exhaustive, would nevertheless be sufficiently complete for the instruction and guidance of those who might be disposed to seek infor- mation from its pages. How far I have been successful will soon be determined by the judgment of those more competent than myself to form an unbiased opinion. " One feature I may, however, with justice claim for this work, and that is, that it rests to a great extent on my own observation and ex- perience, and is therefore no mere compilation. The reader will readily perceive that I have views of my own on every disease considered, and that I have not hesitated to express them." In the present edition I am induced to believe that whatever good features the first and subsequent editions possessed are rendered still better, and that the faults of the former, if not altogether eradi- cated, are at least lessened. Certainly I have not failed to take into consideration the suggestions of my critics, and, when they appeared 6 PREFACE. to me to be judicious, I have not declined to act in accordance there- with. For the very favorable appreciation with which the work has been honored in this country, in Great Britain, in France, and Germany, I desire to express my thanks. No better evidence could be offered of the demand for a treatise on the diseases of the nervous system than the fact that five large editions have been published in four years, and that the book has for over a year been out of print. To a great extent the work has been rewritten. There is not a chapter which has escaped extensive alterations and additions, and the amount of new matter is so great that the volume contains twice as much as any one of the previous issues. Besides the changes made in the chapters of the former editions, a number of diseases are now considered which were not embraced in the previous publications, and some of these are, for the first time, treated of in the English language. An edition in the French language, translated by Dr. Labadie- Lagrave, himself an eminent neurologist, will probably be issued in Paris during the present year. Many illustrations, which can scarcely fail to elucidate the text, have been added, so that the number now exceeds a hundred. Most of them are original; others are taken from the monographs of Duchenne, Charcot, Friedreich, Lockhart Clarke, and other French, German, and British authors. In accordance with the many requests I have received from physi- cians in all parts of the country, I had determined to include epidemic cerebro-spinal meningitis within the scope of the work, but renewed consideration has tended still further to convince me that my reasons for omitting it from the first and subsequent editions were correct and that it cannot in any sense be regarded as a disease of the nervous system. But I am inclined to think that exophthalmic goitre is entitled to PREFACE. f be so considered, and I have therefore added a chapter on that affec- tion. As in the former editions, I have not made a place for diseases of the sympathetic nerve. It is possible that some of those which I have placed in other categories may really be affections of the sympathetic, but after a careful consideration of the subject I have thought it best, in the absence of satisfactory evidence, either clinical or patho-anatomi- cal, of the identification of a single malady of this part of the nervous system, to leave the work in this respect for the present unchanged. A new section on Toxic Diseases of the Nervous System appeared to me to be required, and several abnormal conditions embraced in this class are fully considered so far as their relations to the brain, the spinal cord, and the nerves, are concerned. But, with all the alterations and additions, there is much that might with propriety have been embraced in the present volume, had I not been fearful of extending it beyond judicious limits. If, however, future editions should be called for by the profession, I shall not be backward in still further enlarging it, and endeavoring to ren- der it still more worthy of their favor. 43 West Fifty-fourth Street, New York, March 10, 18*76. CONTENTS. PAGE Inteoduotion, . . . . . . . .17 The Instruments and Apparatus employed in the Diagnosis and Treatment of Diseases of the Nervous System. SECTION I. DISEASES OF THE BRAIN. CHAP. ^ I.—Oeeebeal Congestion, ...... 33 Active Cerebral Congestion.—Passive Cerebral Congestion. y II.—Cebebeal Anemia, . . . . . . .56 ^ III.—Oeeebeal H^emoeehage, ...... 66 IV.—Oeeebeal Meningeal ILemoeehage, .... 108 Pachymeningitis and Hsematoma of the Dura Mater. / V.—Paetial Oeeebeal Anaemia feom Obliteeation op Oeeebeal Blood-Vessels, . . . . . .116 (^u^^^T0 Thrombosis of Cerebral Arteries.—Embolism of Cerebral Arteries. —Thrombosis of Cerebral Veins and Sinuses.—Embolism and j Thrombosis of the Cerebral Capillaries. \ VI.—Oeeebeal Softening, . . . . . .145 VviL—Aphasia,.....' 166 VIII.—Acute Oeeebeal Meningitis, ..... 205 IX.—Ohbonio Oeeebeal Meningitis, .... 215 Chronic Verticalar Meningitis.—Chronic Basilar Meningitis. X.—T.UBEECULAR OEEEBEAL MENINGITIS, ..... 245 XI.—Suppurative Encephalitis oe Ceeebeitis, . . . 253 Cerebria. 10 CONTENTS. CHAP. XII.—Diffused Oeeebeal Scleeosis, . XIII.—Multiple Oeeebeal Sclerosis, . • XIV.—Tumoes of TnE Beain, . XV.—Insanity, .....•• General Principles.—Perceptional Insanity.—Intellectual Insan ity.—Emotional Insanity.—Volitional Insanity.—Mania.—Gen eral Paralysis.—Idiocy and Dementia. SECTION II. DISEASES OF THE SPINAL CORD. I.—Spinal Congestion, ....... 377 II.—Spinal Anemia, ....... 385 Anaemia of the Posterior Columns.—Anaemia of the Antero-Lateral Columns. III.—Spinal H^emoeehage—Spinal Meningeal Hemorrhage, . .418 IV.—Spinal Meningitis, ...... 425 Acute Spinal Meningitis.—Chronic Spinal Meningitis. V.—TnE Inflammations of the Spinal Coed, .... 441 Acute Myelitis.—Infanflflle Spinal Paralysis.—Spinal Paralysis of Adults.—Pseudo-Hypertrophic Spinal Paralysis.—Glosso-Labio- Laryngeal Paralysis.—Progressive Muscular Atrophy.—Pro- gressive Facial Atrophy.—Tetanus.—Sclerosis of the Columns of Tiirck.—Primary Symmetrical Lateral Sclerosis.—Amyotro- phic Lateral Spinal Sclerosis.—Progressive Locomotor Ataxia.— Sclerosis of the Columns of Goll.—Disseminated Inflammation of the Spinal Cord.—Secondary Inflammation and Degeneration of the Spinal Cord.—Non-Inflammatory Softening of the Spinal Cord.—Tumors of the Spinal Cord. SECTION III. CEREBRO-SPINAL DISEASES. I.—HTDEOPnOBIA, II.—Epilepsy, III.—Convulsive Teemor, IV.—Chorea, V.—Athetosis, . VI.—Hysteria, 265 276 292 309 642 . 663 696 . 708 722 . 730 CONTENTS. 11 VII.—Hysteeoid Affections, ...... 745 Catalepsy.—Ecstasy.—Hystero-Epilepsy. VIII.—Multiple Ceeebro-Spinal Sclebosis, .... 772 IX.—Paralysis Agitans, ...... 783 X.—Anapeiratio Pabalysis, . . . . . . . 786 XI.—Exophthalmic Goitre, . . . . . .791 SECTION IV. DISEASES OF THE PERIPHERAL NERVOUS SYSIEM. I.—Neural Congestion, ...... 802 II.—Acute Neuritis, ....... 804 III.—Chronic Neueitis—Neueal Soleeosis—Neubal Ateophy, . 807 IV.—Tumoes of Nebves, ...... 810 V.—Neubal Pabalysis, . ...... 811 Facial Paralysis.—Paralysis of Third Nerve. VI.—Neueal Spasm, ....... 820 Facial Spasm.—Torticollis. VII.—Neueal Anesthesia, ...... 823 Anaesthesia of Cutaneous Nerves.—Anaesthesia of the Fifth Pair. VIII.—Neubal Hypebesthesia (Neubalgia). .... 827 Neuralgia of the Fifth Pair of Nerves.—Cervico-Occipital Neural- gia.—Cervico-Brachial Neuralgia.—Dorso-Intercostal Neural- gia.—Lumbo-Abdominal Neuralgia.—Crural Neuralgia.—Sci- atica. SECTION V. TOXIC DISEASES OF THE NERVOUS SYSIEM. I.—Plumbism, ........ 838 II.—Alcoholism, ....... 848 III.—Bbomism,........867 IV.—Hydeabgysm, .....•• 873 V.—Aesenicism, .....••• 875 LIST OF ILLUSTEATIONS. FIG. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. ' 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. Cephalohemometer, . Hammond, jssthesiometer, . . . . " Lombard's Differential Calorimeter, . " . Lombard's Thermo-Electric Pile, . " Dynamometer, .... Mathieu, Dynamograph, . . . . « Duchenne's Trocar, . . Hammond, Stohrer's Battery, . . . . " Three Cells in situ, .... " Miliary Aneurism of Brain, ii u u Atheromatous Artery of Brain, Diagram explanatory of Paralysis in Cases of Cerebral Hemorrhage, . Diagram explanatory of Crossed Paralysis, . Cerebral Arterial Thrombosis, Cerebral Capillary Embolism, . Bouchard, Hammond, Heubner, . Virchow, Cerebral Convolutions, Agraphia, ..... Dynamographic Tracing of Patient affected with Multiple Cerebral Sclerosis, Dynamographic Tracing of Patient affected with Multiple Cerebral Sclerosis, Malignant Tumor of Brain, Aneurismal Tumor of Brain, Intellectual Insanity, .... Emotional Insanity, Acute Mania, with Mental Exaltation, " " " " Depression, a a « « " Dynamographic Tracing of Patient affected with General Paralysis, Broca, Hammond, PAGE 20 21 24 25 26 27 28 29 30 92 92 94 124 142 142 185 198 280 u 281 Otis, 296 Prof. W. R. Smith, . 303 Hammond, 334 341 352 . 354 355 358 14 LIST OF ILLUSTRATIONS. FIG. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. Facsimile of Writing of General Paralytic, Hammond, General Paralysis, .... Idiocy, ...... Dementia, ....•• Morbid Anatomy in Cervical Pachymeningitis, Joffroy, Deformity caused by Cervical Pachymeningitis, Charcot, Deformity caused by Chronic Spinal Meningitis, Hammond, Spinal Cord in Infantile Spinal Paralysis, Charcot, . Altered Nerve-Cells of Cord in Infantile Spi- nal Paralysis, . Muscle in Infantile Spinal Paralysis, Hammond, Atrophy of Muscles in Spinal Paralysis of Adults, ..... Atrophy of Muscles in Spinal Paralysis of Adults, ..... " . Patient with Pseudo - Hypertrophic Spinal Pa- ralysis, ..... " Patient with Pseudo-Hypertrophic Spinal Pa- ralysis, ..... " . Glosso-Labio-Laryngeal Paralysis, . " Writing of Patient affected with Glosso-La- bio-Laryngeal Paralysis, . . . " . Glosso-Labio-Laryngeal Paralysis, . " (( (( it u (i Progressive Muscular Atrophy, " " " "... Duchenne, " . Friedreich, " " "... Duchenne, Spinal Cord in Glosso-Labio-Laryngeal Paraly- sis, ..... Charcot, Progressive Facial Atrophy, . Lande, Muscular Fibre in Progressive Facial Atrophy (Longitudinal Section—normal), . . Hammond, Muscular Fibre in Progressive Facial Atrophy (Longitudinal Section—abnormal), . . " . PAGE 359 361 362 363 430 431 438 459 459 460 462 463 463 463 464 464 469 469 479 489 493 493 505 507, 508 509 520 522 523 525 537 547 547 547 551 551 LIST OF ILLUSTRATIONS. 15 FIG. 66. 67. 68. 69. 70. 71. 72. •73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. Muscular Tissue in Progressive Facial Atrophy (Transverse Section—normal), Muscular Tissue in Progressive Facial Atrophy (Transverse Section—abnormal), Diagram explanatory of Anesthesia in Lesions of Cord, ..... Section of Spinal Cord in Sclerosis of Lateral Columns, ..... Section of Spinal Cord in Lateral Sclerosis, >< " '1 (1 It U u Section of Medulla Oblongata, Deformity in Amyotrophic Lateral Spinal Scle- rosis, ...... Section through Medulla Oblongata in Amyotro- phic Lateral Spinal Sclerosis, . Writing of Patient with Locomotor Ataxia, Dynamographic Tracing of Patient with Loco- motor Ataxia, .... Dynamographic Tracing of Patient with Loco- motor Ataxia, .... Superior Extremity of Healthy Humerus, " " " Diseased Humerus of Pa- tient with Locomotor Ataxia, . Transverse Section of Spinal Cord, . Longitudinal Section of Spinal Cord, Section of Spinal Cord in Locomotor Ataxia, Sclerosis of Columns of Goll, Hammond. Charcot, Hammond, 87. Tumor of the Spinal Cord, 90. Cortical Substance of Brain in Hydrophobia, 91. Nuclei of Pneumogastric and Hypoglossal Nerves in Hydrophobia, . 92. Root of Pneumogastric Nerve in Hydrophobia, 93. Neuroglia-Cells of Cord in Hydrophobia, . 94. Athetosis, . 95. " (after Photograph from Dr. Hubbard), 96. " with Imbecility, 97. Contractions in Hysteria, 98. " " " • 99. Catalepsy (after Photograph from Dr. Early), 551 551 554 573 573 573 573 576 581 590 591 11 591 Charcot, 601 a . 601 Lockhart Clarke, 605 u . 606 Pierret, 612 (C . 617 " 617 [( . 617 " 617 Charcot, . 636 u 636 Leyden, . . 639 Hammond, 656 n . 657 " 658 u . 658 a 724 " 727 Dr. Clay Shaw, 729 Charcot, . 737 u 745 Hammond, . 750 16 LIST OF ILLUSTRATIONS. 100. Catalepsy (after Photograph from Dr. Early), 101. Ecstasy, ..... 102. Hystero-Epilepsy, .... 103. " "..... 104. " " 105. " "..... 106. " »•.... 107. Writing of Patient with Multiple Cerebro- spinal Sclerosis, . . • • 108. Writing of Patient with Anapeiratic Paralysis, 109. Exophthalmic Goitre (after Photograph from Dr. J. B. Crawford), .... PAGE Hammond, 750 Bourneville, . 760 Hammond, 766 " . 767 Charcot, 769 u 770 Bourneville, 771 Hammond, . 781 • 788 794 DISEASES OF THE NERVOUS SYSTEM. INTEODUCTIOI. THE INSTRUMENTS AND APPARATUS EMPLOYED IN THE DIAGNOSIS AND TREATMENT OF DISEASES OF THE NERVOUS SYSTEM. Diseases of the nervous system, like those of the heart, lungs, and larynx, require special means of investigation and treatment. In no department of medical science has progress been more decided during- the last decade than in that class of affections considered in this trea- tise, and undoubtedly a great deal of the advancement is due to the instruments and apparatus by which scientific research in this direction has become practicable. In the present chapter I propose to describe the instruments and apparatus employed in the diagnosis and treatment of diseases of the nervous system, and to explain the methods by which they are used. THE OPHTHALMOSCOPE. The ophthalmoscope consists essentially of a concave mirror perfo- rated in the centre, and of a double-convex lens. Several modifications of this arrangement are in use, but the simplest instrument is, in my opinion, the best for ordinary use, and this is Liebreich's, though, when very great exactness is required, as, for instance, in determining the depth of an atrophic excavation of the optic disk, Dr. Loring's ophthal- moscope is far preferable to any other. Liebreich's ophthalmoscope consists of a polished steel mirror about one and three-quarters inch in diameter, concave, and perforated in the centre by a hole about the one-twelfth of an inch in diameter. The edges of this aperture are beveled, so as to afford as little obstacle as possible to the passage of the rays of light to the eye of the observer. The mirror is set into a bronze ring with a handle, and there is attached also to this ring a clip for holding a concave ocular lens, 2 18 DISEASES OF THE NERVOUS SYSTEM which in some conditions of refraction, either in the eye of the patient or that of the observer, is necessary in order to produce the requisite divergence of the parallel rays emanating from the patient's eye, and thus render the image of the fundus distinct. A direct image is thus obtained. The lamp, which should furnish a steady flame, is placed on the side of the patient's head corresponding to the eye to be examined, and the eye of the observer very close to that of the patient. This process gives a very satisfactory view of the fundus with the optic disk and retinal vessels, but requires care, and is more difficult than that by which the inverted image is obtained. In this case the observer illuminates the fundus with the ophthal- moscopic mirror, and then interposes between the mirror and the eye a double-convex lens which he holds lightly between the thumb and finger, resting the ring-finger on the forehead of the patient, so as to make the hand steady, the little finger being disengaged so as to be employed in raising the eyelid if necessary. The object-lens should have a focal distance of about two inches, and it should be held so as to bring the focus on the pupil. The lamp is placed behind and a little to one side of the eye to be examined. In order to see the optic disk, the patient is told to look at the ear of the observer on the side opposite to the eye being examined. In this way the axis of vision is directed inward, and the optic disk readily brought into view. These examinations are made in a room lighted only by the lamp used in the processes. It is sometimes necessary to dilate the pupil with atropia, in order to obtain a view of the disk, but experience and tact will generally enable the observer to dispense with this rather dis- agreeable procedure. Ophthalmoscopic examinations require the observer to possess a very thorough acquaintance with the anatomy of the eye, and also with the science of optics. Unless these qualifications are enjoyed, it will be much better to send the patient to a competent ophthalmic surgeon for an examination than to rush to hasty conclusions based on the most thorough ignorance. The real value of ophthalmoscopy in diseases of the nervous system is in danger of being disregarded through the scio- lism of pert pretenders, who read papers and write memoirs without ever having seen the optic disk to recognize it. Bouchutl gives the following list of abnormal conditions which are of importance in the diagnosis of diseases of the nervous system : Papillary congestion ; peri-papillary congestion ; papillary anaemia, partial or general ; phlebo-retinal flexuosities ; venous pulsation in the retinal veins ; dilatations of the retinal veins ; retinal varices ; phlebo- retinal heemostases ; phlebo-retinal thromboses ; phlebo-retinal aneu- 1 " Du diagnostic des maladies- du systeme nerveux, par 1'ophthalmoscopic " Paris, 1866, p. 15. INTRODUCTION. 19 rism ; haemorrhages into the retina and choroid. The diseases in which he thinks ophthalmoscopy is valuable as a diagnostic means are—the several varieties of cerebral meningitis ; cerebral haemorrhage ; chronic encephalitis ; cerebral softening ; meningeal haemorrhage ; chronic hy- drocephalus ; tumors of the brain ; contusion, commotion, and compres- sion of the brain ; general paralysis ; atrophy of the brain ; chronic myelitis ; locomotor ataxia ; tetanus ; epilepsy ; essential convulsions ; insanity, and several others of less importance. To these may be added cerebral congestion, general and partial ; cerebral anaemia ; and the various forms of sclerosis affecting the brain and spinal cord. CEPHALOH^EMOMETER. Although this instrument is intended for experiments on the lower animals, it enables us to arrive at very definite conclusions relative to the condition of the cerebral circulation. I first described it in a paper read before the New York Medical Journal Association in 1868, and shortly afterward published in the New York Medical Gazette.1 It was devised in somewhat different form^ independently of each other, by Dr. S. Weir Mitchell and myself, his being made first in point of time. The instrument consists of a brass, or iron, tube nickel-plated, which is received into a round hole made • in the skull with a trephine. Both ends of this tube are open, but into the upper end is secured another brass or iron tube, the lower opening of which is closed by a piece of very thin sheet India-rubber, and the upper opening by a brass cap, into which is fastened a glass tube. This inner arrangement con- tains colored water. To this glass tube a scale is affixed. This second tube is screwed into the first till the thin India-rubber presses upon the dura mater, and the level of the colored water stands at 0, which is in the middle of the scale. Now, when the quantity of blood in the brain is increased, the liquid rises in the tube, being pressed upward by the elevation of the thin rubber closing the lower opening ; when the quantity of blood is lessened, the liquid falls by its own gravity. The various parts of this instrument, as made by Mr. Ford, of this city, are shown in Fig. 1 (a, the first tube, which is to be screwed into the opening in the skull; b, the second tube, closed at the lower end with thin sheet-rubber and containing the colored water ; c, the cap to which is cemented the glass tube ; d, the wrench for securing the first tube into the opening in the skull; e, the instrument with all its parts in their places). It was by this instrument that I was enabled to demonstrate, in the most conclusive manner, that during sleep the amount of blood circu- lating in the cerebral vessels is much less than during wakefulness, to 1 Also Journal of Psychological Medicine, January, 1869, p. 47. 20 DISEASES OF THE NERVOUS SYSTEM. show the effect of bromide of potassium in lessening the amount of blood in the brain, of the sulphate of quinine in increasing it, etc. Fig. i. ^ESTHESIOMETER. The aesthesiometer is an instrument for the purpose of determining the degree of tactile sensibility possessed by the patient. It was de- 1 " Sleep and its Derangements," Philadelphia, 1869, p. 317. INTRODUCTION. 21 vised in 1858 by Dr. Sieveking,1 of London. Its value in cases of aberrations of sensibility depends upon the fact, ascertained by Dr. E. H. Weber, that the capability of distinguishing two impressions, made upon the skin simultaneously, varies in different regions of the body according to the distance they are apart. In sensitive regions, as the end of the finger, the two points of a pair of dividers can be distin- guished at about the twelfth of an inch apart, while in the middle of the back only one point is felt, though they are two inches apart. In accordance with this principle, the aesthesiometer is used to determine the sensibility of the skin in various diseases, it being well known that this is subject to variation. Thus, when the sensibility is intact, two points, touching the back of the hand at the same time, can be distinguished as two points when separated an inch. If, in examining a patient, we should find that, when the two points were two inches apart, the patient felt but a single impression, we should know that he had lost sensibility in the cutaneous nerves of that part of the body. Dr. Sieveking's aesthesiometer is nothing more than a beam-com- pass. It consists of a rod of bell-metal four inches in length, graduated Fig. 2. into inches and tenths of an inch. At one end is a fixed steel point; another steel point is made to slide upon the beam, and can be fixed at 1 British and Foreign Medico-Chirurgkal Review, January, 1858, p. 281. 22 DISEASES OF THE NERVOUS SYSTEM. any distance from the first by a screw which works at the top of the slide. In 1861l I described an aesthesiometer which I believe was the first used in this country. It consisted of a pair of dividers, to one arm of which the arc of a circle, in brass, was affixed. This arc was divided so as to measure tenths of an inch. A short time since, I suggested to Mr. Stohlman, the instrument-maker, a modification of this instrument, which for convenience is, I think, superior to all others. This, as closed, for the pocket-case, and open, as in use, is seen in the accom- nying woodcut (Fig. 2),2 and need not be further described. The minimum normal distances at which the two points of the aesthesiometer can be distinguished in different regions of the body are stated in the following table :a Point of the tongue..................................... i a line- Palmar surface of the third finger......................... 1 Red surface of the lips................................... 2 lines. Palmar surface of second finger...................."....... 2 Dorsal surface of third finger............................. 3 Tip of the nose......................................... 3 The palm over the heads of the metacarpal bones............ 3 " Dorsum of tongue, one inch from the tip................... 4 " Part of the lips covered by the skin....................... 4 " Border of the tongue, an inch from the tip.................. 4 " Metacarpal bone of the thumb............................ 4 " Extremity of the great-toe................................ 5 " Dorsal surface of the second finger........................ 5 " Palm of the hand....................................... 5 " Skin of the cheek....................................... 5 " External surface of the eyelids............................ 5 " Mucous membrane of the hard palate...................... 6 " Skin over the anterior surface of the zygoma................ 7 " Plantar surface of the metatarsal surface of great-toe........ 7 " Dorsal surface of the first finger........................... 7 " On the dorsum of the hand over the heads of the metacarpal bones.............................................. 8 " Mucous membrane of the gums........................... 9 «« Skin over the posterior part of the zygoma.................. 10 " Lower part of the forehead............................... 10 " Lower part of the occiput................................ 12 " Back of the hand....................................... 14 " Neck under the lower jaw................................ 15 «« Vertex................................................ 15 " » " A Clinical Lecture on Chronic Myelitis," delivered in the Baltimore Infirmary, March 16, 1861, American Medical Times, June 15, 1861, p. 379. * First described by me in the Journal of Psychological Medicine, October, 1868, p. 830. » This table is quoted from Miiller's "Physiology," translated by Baly, London, 1840 p. 752. INTRODUCTION Skin over the patella.................... " " sacrum.,................ " " acromion.................. The leg, near the knee and foot.........., Dorsum of the foot, near the toes.......... The skin over the sternum............... " five upper vertebrae .... " " spine near the occiput... " in the lumbar region............ " " middle of the neck....... " over the middle of the back..... The middle of the arm.................. " " thigh................. THERMOMETER. The thermometer is of use for the purpose of determining variations of temperature in different parts of the body. It should be graduated in tenths of a degree, and be held upon the part subjected to examina- tion, so long as the mercury continues to rise or fall. Comparative de- terminations must be made under precisely similar conditions. BECQUEREL'S DISKS. By means of these little instruments very slight variations of tem- perature can be ascertained. They consist of an extremely thin plate of copper about the size of a half-dime, soldered to a thin rod of bis- muth. This latter is contained in a small tube of hard rubber furnished with a handle. The disks are two in number, and by means of delicate silk-covered wires are in communication with the poles of a galvanom- eter. If a lower extremity, for instance, is subjected to examination, one of the disks is placed upon it and the other upon the correspond- ing part of the other limb. If the temperature of both limbs be the same, the needle of the galvanometer remains quiet; if either be warmer than the other, the needle is deflected to the north or south according as one or the other limb has the higher temperature. By this apparatus very much less than the hundredth of a degree of tem- perature can be determined with absolute accuracy.1 dr. Lombard's thermo-electric differential calorimeter. For determining differences of temperature nothing equals this in- strument, both for exactness of results and facility of application. It consists, as shown in the accompanying cuts (Figs. 3 and 4), of 1 See my " Memoir on the Pathology and Treatment of Organic Infantile Paralysis," in Journal of Psychological Medicine, No. 1, July, 1867, p. 53. 16 lines. 18 " 18 " 18 " 18 " 20 " 24 " 24 " 24 " 30 " 30 " 30 " 30 " 24 . DISEASES OF THE NERVOUS SYSTEM. a galvanometer (Fig. 3) and two thermo-electric piles (Fig. 4). The needle of the galvanometer is astatic, and is suspended by a delicate silk fibre so as just to swing clear of the scale it is to traverse. Above the needle and outside of the glass shade is a magnet by means of which the needle is readily made to point to the zero of the scale. Upon the ebonite plate to the left of the galvanometer needle INTRODUCTION. 25 are the bobbins and four little cups of mercury by means of which the connections are made, and the resistance of the thermo-electric cur- rent increased or diminished, according as it is necessary to make the needle more or less delicate in its indications. There are two thermo-electric piles ; one of which is represented in Fig. 4, and which, for convenience of manipulation are furnished with handles. These piles are connected by their positive and negative poles, and the other positive and negative poles are connected with the stanchions seen on the ebonite plate of the galvanometer. Having lowered the little metallic fork at the farther extremity of the bar over the ebonite plate, into the cup of mercury immediately under it, the apparatus is ready for use. The delicacy is increased by lowering one or two, or all three of the others, each one being in con- nection with the bobbin immediately opposite to it, and which, when the fork is out of the mercury, is included in the circuit, and hence has the effect of increasing the resistance. In the figure all the forks are repre- sented as down. To make an observation the thermo-electric piles are placed one on the part the relative temperature of which it is desired to know, and the other on the corresponding sound part. If the pile in connection with the stanchion nearer the corner of the ebonite plate is in contact with the hotter part, the needle will be deflected to the north. If the other be the hotter, the needle will be deflected to the south. The extent of the deflection indicates the relative difference in hundredths of a degree centigrade. It is to be remembered that the instrument must be placed on a firm table or stand, and must be so arranged that the end of the scale to the right of the cut points to the north ; the ebonite plate will therefore be at the south end, and the galvanometer needle points to the east.1 With this apparatus of Dr. Lombard's it is easy to make relative determinations of temperature in a minute or two, and with great ex- actness and delicacy. THE DYNAMOMETER. Several forms of an instrument for measuring the strength of pa- tients have been devised. The best and most generally applicable is that of M. Mathieu, an instrument-maker of Paris. It is very simple, 1 For a fuller description of this instrument and directions for its use, the reader is referred to the British Medical Journal for 1875. 26 DISEASES OF THE NERVOUS SYSTEM. and for ascertaining the strength of the hands leaves nothing to be desired. It consists, as is shown in the cut (Fig. 5), of an elliptical steel spring, to which is attached a semicircle of gilt brass, upon which a scale is marked. An indicator, terminating at one end in a cog-wheel, is capable of being moved freely around the arc of the circle by a steel arm, upon one side of which, cogs, fitting into those of the indicator, are cut. One end of this arm (the lower) touches the elliptical spring, when the indicator points to the zero of the scale ; a brass sheath upon the under side of the scale keeps this arm in place, at the same time allowing it to move freely. Fig. 5. When the dynamometer is taken into the hand and pressed, the two sides of the spring are approximated, and the steel arm with the cogs, being pushed by the lower side of the spring, turns the indicator. One great advantage of this instrument is that, when the pressure is taken off, the indicator does not return to zero, but remains at the point to which it has been carried by the muscular power of the individual. We are thus enabled to see the extent of his strength, after he has made his effort, and do not have to watch him while he is using the instrument. It will also be seen that this dynamometer can be used to measure tractile force; for, if two hooks with cords attached be fastened to the spring at the points a and b, traction on the cords will approxi- mate the two sides of the ellipse, and thus push the steel arm so as to move the indicator as before. THE DYNAMOGRAPH. This instrument, which is of great value in the diagnosis of diseases of the nervous system, is shown in Fig. 6. It consists of the dynamometer B B, to which a toggle-joint, mov- ing a steel rod, is attached. This steel rod plays through a hole in the end of the elliptical spring and moves the lever which raises the pencil D. At A is a screw which varies the point at which the rod touches the lever, and thus increases or lessens the delicacy of the indications. C is a silvered plate upon which the paper is fastened by clips. To the INTRODUCTION. 27 2ower part of this plate, a strip of gilt brass, with cogs cut in it, is at- tached. E is a gilt-brass box containing a watch-movement like that of the sphygmograph. A cog-wheel which projects above the upper side of this box fits into the cogs on the plate which carries the paper. Fig. 6. The wheel for winding up the clock-work, and the lever for stopping it or setting it in motion, are not seen in the figure, they being on the opposite side of the box. To set the instrument in action, the sphygmograph movement is at- tached to the dynamometer at A. The clock-work is then wound up, and the plate holding the paper placed in the groove on top of the box E. The dynamometer is then grasped by the hand and squeezed firm- ly ; the lever is thus moved, and the plate with the paper is carried along by the cog-wheel. As it moves, the pencil traces a line on the paper, the height and regularity of which depend upon the firmness and steadiness with which the dynamometer is pressed. As seen in the cut, the plate with the paper is in motion, and has about half completed its course. The patient should not look at the paper while using the in- strument. The dynamograph, therefore, writes down the muscular power and tone of the individual, and likewise indicates the perfection of what is sometimes called the muscular sense. A person in good health will make a straight line with the pencil. If there is paralysis of the mus- 28 DISEASES OF THE NERVOUS SYSTEM. cles of the arm, or incoordination to the slightest possible extent, the line will be irregular. The papers used may be marked with the date and the name of the patient, and thus a record of his condition is pre- served. The pencil should be of the very softest lead, and the paper should be rough and unsized.1 duchenne's trocar. This very useful little instrument is shown in Fig. 7. It is intro- Fig. 7 duced open as at a. When it has perforated the muscle under exami- nation, the small button at the under part of the handle is pushed for- ward; this propels a half-cylinder of steel against the shoulder at the end of the trocar, and thus a small piece of muscle is detached and caught in the cavity. The lower figure, b, represents the instrument ready to be withdrawn. By drawing the button back, the bit of fibre can be taken out, and is then ready for microscopical examination. electrical apparatus. The electrical apparatus required in the diagnosis and treatment of diseases of the nervous system must be of two kinds: one for furnish- ing the primary or galvanic current, the other for yielding the induced or faradaic current. Among the machines of the first category are those of Stohrer, which are now made very satisfactorily by the Gal- vano-Faradic Manufacturing Company of New York. An idea of this battery (thirty-two cells) will be obtained from the accompanying woodcut (Fig. 8). The case is represented as broken away in front, so as to exhibit the internal arrangement. A combination of Smee's cells is manufactured by Dr. Jerome Kidder, and constitutes a good battery and Daniell's cells can be obtained of any electrical-instrument maker and arranged so as to form a battery for medical purposes. Some time since, my attention was drawn, in another connection altogether, to the simplicity and efficiency of Hill's cell as a generator of a constant and most equable galvanic current. After an examina- 1 The first account of the use of the dynamograph was given by myself in the Journal of Psychological Medicine, January, 1868, p. 139. INTRODUCTION. 29 tion of its construction and action, I was satisfied that, for medical pur- poses, it was vastly superior to every other form of element which had come under my observation. At my suggestion, the Galvano-Faradic Fig. 8. Manufacturing Company, of this city, has constructed, under the super- intendence of Mr. Bartlett, a permanent battery, which, for office or hospital use, is of inestimable value. When erected it becomes, as its 73307395 30 DISEASES OF THE NERVOUS SYSTEM. name implies, a permanent fixture. Several of these have been made; one for myself, of one hundred elements, leaves nothing to be desired when used with Brenner's operating-table. The cells used for this battery have been hitherto applied to te- legraphy. They possess, however, in an eminent degree, the peculiar qualities that are essential for a galvanic battery for therapeutic pur- poses. The battery itself is simple in construction, easily managed, exceedingly economical, utilizing almost all the materials consumed. Each cell contains about half a gallon of fluid. A disk of sheet- copper is laid flat on the bottom of the cell. To the under side of this is affixed a copper wire, covered with gutta-percha. The copper sheet forms the negative plate j the insulated wire which rises to the top of the cell, the positive pole. Two or three inches below the upper mar- gin of the cell is suspended, by a brass hanger, a thick, disk-shaped plate of zinc, concave on the lower side, with a round aperture in the centre. This is the positive plate. To the hanger is attached a binding screw, and this forms the negative pole. Three cells in situ are repre- sented in Fig. 9. Fig. 9. The body of the battery fluid is formed of a solution of sulphate of zinc. Occasionally, as required, crystals of sulphate of copper are dropped through the central aperture in the zinc to the bottom of the fluid. These dissolve, and produce a layer of blue liquid, which covers the copper. Thus, we have copper in the bottom of the cell immersed in a solution of copper, zinc suspended above, immersed in a white liquid, the solution of zinc. {See engraving of these cells.) The mode adopted in other batteries to separate the fluids consists in using a porous diaphragm, or cup, within, and surrounding which are placed dissimilar metals and fluids. The porous septum, it was thought would allow the current to pass, and yet prevent the admixture of the diverse elements. It has, however, been demonstrated that, when two such liquids, and even two gases, are thus separated, they will invariajbly be- INTRODUCTION. 31 come mixed. In this battery, without the intervention of any dia- phragm, the denser liquid, the blue, remains in the bottom of the cell, the lighter one overflows and rests upon it; thus arranged, there is less liability to diffusion or mixing than if the two liquids were placed side by side, in vertical columns, with a porous partition between them. The central aperture in the zinc plate also admits the introduction of a hydrometer to measure the density and strength of the liquid. Pro- vision is also made for preventing too rapid evaporation of the fluid. The occasional addition of a little water, and every three or four weeks dropping in a few crystals of sulphate of copper, is nearly all that is required in the management of this battery. Further directions for its preparation, modus operandi, and care, may be obtained from the manufacturers. Of faradaic batteries, those made by Kidder, the Galvano-Faradic Manufacturing Company, and Meyer, leave nothing to be desired. Although the applications of electricity in the treatment of diseases of the nervous system are not so extensively useful as asserted by some authors, it is nevertheless impossible for the physician to treat severe affections of the kind mentioned without using the agent in some form or other. This is especially true of those diseases which are character- ized by paralysis, in nearly all of which electricity is useful. In atrophic disorders it is also indispensable, and in many hysterical conditions it is extremely valuable. If only one battery can be procured, the induced or faradaic instru- ment will be found more generally useful than the primary or galvanic ; but, if possible, the physician who intends to treat to the utmost ad- vantage diseases of the nervous system should possess both kinds. CAUTERIZING APPARATUS. It is often necessary, in the treatment of diseases of the nervous system, to make use of the actual cautery to the spine and other parts of the body. The instruments formerly employed were very clumsy things made of iron, and, when required for use, heated in a furnace of some kind. The chief objection to iron is, that every time the instru- ment is heated to redness the surface becomes oxidized, and the scale may become loose, stick to the patient's body, or fall between his cloth- ing. Lately, instruments with platina tips of such shapes as may be required have come into general use, and are far preferable to those of iron. Being smaller, they are readily heated to redness or whiteness in a Bunsen's burner where there is gas, or in an alcohol blast-lamp. Before using the cauterizing instrument, the skin should be ren- dered ansesthetic by the ether or rhigolene spray. It is not necessary to carry the spraying to the point of congealing the skin, although there is no objection to so doing. 32 DISEASES OF THE NERVOUS SYSTEM. OTHER INSTRUMENTS AND APPARATUS. Among the other instruments and apparatus required in the diag- nosis and treatment of diseases of the nervous system are the micro- scope, the stethoscope, ear-specula, tuning-forks, urinary test appa- ratus and chemicals, hypodermic syringes, and Richardson's spray apparatus. The latter is of use not only, as above mentioned, for rendering anaesthetic the part to be cauterized, but for refrigerating the skin in cases of chorea and other affections. SECTION I. DISEASES OF THE BKAH5T. CHAPTER I. CEREBRAL CONGESTION. Cerebral congestion is of two kinds, which differ as regards their mode of origin and symptoms. In the active form, there is an increase in the amount of arterial blood circulating in the vessels of the brain ; in the passive, the quantity of venous blood is augmented. Occasion- ally the two conditions coexist. ACTIVE CEREBRAL CONGESTION. This is much the more common form. Of the cases recorded in my note-book, as occurring in my private and hospital practice, over five- sixths were of this description. Andral, who, however, failed to distinguish the first or hypersemic stage, recognized eight varieties, all of which may, with advantage, be comprehended in six, which are appropriately designated from the chief feature characterizing the attack, namely, the apoplectic, the paralytic, the convulsive, the soporific, the maniacal, and the aphasic, the latter being a sixth form, which is now, for the first time, systematically ar- ranged in the present category. Either of these may occur with scarcely a moment's warning. Generally, however, there is a premonitory or first stage, the symptoms of which, though well marked, are not peculiar, exclusively, to any one of the fully-established conditions mentioned. It is therefore impossible to predict with accuracy, from the symptoms of this prodromatic stage, whether the apoplectic, the paralytic, the convulsive, the soporific, the maniacal, or the aphasic form, will be developed. An attentive study of this stage should always be made, 3 34 DISEASES OF THE BRAIN. and active measures taken for the relief of the patient at a time when success can generally be obtained. Symptoms. First Stage, Cerebral Hyperemia.—Among the earliest symptoms of active cerebral congestion, wakefulness is espe- cially noticeable, and may be for a time the only evidence of disorder which attracts the attention of the patient. He goes to bed feeling weary, and as if sleep would very quickly overtake him, but he is dis- appointed, for he obtains but an hour or two of disturbed slumber, which is generally broken by unpleasant dreams. During the remain- der of the night he tosses restlessly from side to side of the bed, his mind either occupied by the thoughts which have occurred to him through the day, or else filled with the most preposterous ideas. He consequently rises unrefreshed, feverish, and ill-prepared for either men- tal or physical exertion.1 So far as the mind is concerned, there is an inability to give the attention to any subject requiring much thought, and at times an absolute want of power to get correct ideas of even simple matters. This is especially seen in those who have arithmetical questions to solve, or long columns of figures to add up. Indeed, men- tal labor of all descriptions is not only difficult, but is irksome in the extreme. Before long the evidences of intellectual derangement become more evident. The ideas are confused and without logical arrangement; the memory begins to fail, especially in regard to recent occurrences ; and there seems to be a special proclivity to forget words, and to substitute others having a similar sound when pronounced, or appearance when written. The names of persons and places are particularly difficult to recollect. The judgment is weak and vacillating ; the most strongly- expressed determination is changed apparently without reason, and again there may be an impossibility of arriving at a decision in cases where ordinarily but little reflection would be necessary. Any effort toward continuous or severe thought increases the difficulties of the mind, and augments the pain or uneasiness which generally exists in the head. Illusions, hallucinations, or delusions, may be present, but are not usually fixed ; and the patient will often laugh at the absurd images he has seen, or ideas he has entertained not five minutes before. Per- sons thus affected will frequently reason clearly in regard to apparitions or voices, of the unreality of which they are fully sensible. The emotional system participates in the general mental disturbance, and the passions are thus easily roused into activity by slight exciting causes. Trifling circumstances produce great annoyance, and the little every-day troubles of life appear of vast importance. The disposition accordingly becomes suspicious, peevish, and fretful. In conjunction with these mental phenomena, there are certain phys- 1 For a more complete account of wakefulness in all its relations, see the author's treatise on " Sleep and its Derangements." J. B. Lippincott & Co., Philadelphia, 1870. CEREBRAL CONGESTION. 35 ical symptoms of disordered cerebral action. Thus there are pain, heat, a feeling of fullness or distention in the head, or the sensation as if a tight band encircled it. Vertigo is very generally complained of, and may be so severe as to prevent the patient moving about. In some cases headache constitutes the chief feature of the disorder, and is al- most constantly present. There are noises, such as roaring, rumbling, and ringing, in the ears, and occasionally loud reports, such as those produced by the discharge of fire-arms. Sometimes there are bright flashes of light from over-excitation of the retina?, and at others dark spots—muscoa volitantes—render the vision indistinct. Ophthalmosco- pic examination, which should never be omitted, shows the arteries of the retina to bo increased in number, diameter, and tortuosity, and oc- casionally the optic disk is found more or less congested. The conjunc- tivas are suffused, the pupils are contracted, there is intolerance of light, and motion of the eyeballs is painful. Loud noises are likewise dis- agreeable. The face is flushed, the carotids and temporals throb with more than ordinary force, and there may be involuntary twitching of one or more of the facial or other muscles. Bleeding from the nose is not infrequent. Sensation and the power of motion are usually affected, and gener- ally, though not always, on one side of the body only. Thus the arm or the leg feels heavy, and a sensation as of ants crawling over it, pins and needles sticking in it, or as if the limb is " asleep," is experienced. These abnormal sensations may be restricted to the face or the trunk. Examination with the aesthesiometer shows that the ability to distin- guish the two points of the instrument at the normal distance apart is less on the affected side than on the other, and that, thus to get the sen- sation of two points, they must be more widely separated when applied to the diseased side than is necessary for the corresponding parts of the sound side. Slight convulsive actions or twitchings of individual muscles or groups of muscles are generally present. Sometimes a few fibres only are affected. The face, and especially the eyelids and angles' of the mouth, are particularly liable to be thus involved. The muscular strength is also lessened generally, but sometimes the difficulty is especially noticed in particular muscles, such as the tibialis anticus or the deltoid, which, losing a portion of their contractile power, cause the patient to experience an awkwardness in raising the foot, or elevating the arm from the side. The face, however, is rarely affected, even when the muscular power is diminished on all the rest of one side of the body, and the tongue, when protruded, comes out straight. Careful observation will generally detect some difficulty, perhaps slight, about the speech. AVords are not pronounced with as much distinct- ness as before, especially when the patient is fatigued, or has been speaking for some time. The Unguals and labials among letters are 36 DISEASES OF THE BRAIN. particularly troublesome, as well as all words which require the nice management of the' end of the tongue for their enunciation. The ar- ticulation is thick, and sometimes whole syllables are slurred over in a slovenly way. The other organs of the body are more or less deranged. The pulse is unusually slow and full, the appetite capricious, the digestion imper- fect, the bowels costive, and the urine, scanty and high colored, often contains oxalate of lime. The foregoing constitute the ordinary assemblage of symptoms which are first met with in congestion of the brain. Some of them may be absent, others so slightly manifested as to escape ordinary observa- tion, and others, again, so strongly exhibited as to excite the grave ap- prehensions of the patient and his friends, and to require him to keep his bed. Generally, however, they are not so severe as to prevent him attending in a measure to his ordinary avocations, and they may alto- gether disappear, either spontaneously or in consequence of appropriate medical treatment. A spontaneous cure is, however, rare, and, without proper manage- ment on the part of the patient or his medical attendant, the symptoms pass sooner or later into one of the fully-developed forms mentioned. Thus, of the cases that have been under my observation, the disease was arrested at the first stage in about ninety-five per cent, by appropriate treatment, while there was not a single instance of spontaneous cure. Second Stage, a. The Apoplectic Form.—Occasionally this va- riety of cerebral congestion is initial, but ordinarily it is preceded by the group of symptoms just detailed. In either event the onset is gen- erally sudden. The patient is perhaps walking in the street, when he staggers, loses consciousness, and falls. The loss of intelligence and sensibility is, however, rarely complete, and may last but a few minutes or even seconds, though sometimes continuing for several hours. Paralysis, to a greater or less extent, is always present for a time. One limb only may be affected, or those of one side, or all four mem- bers. It is never complete, the patient being able to perform some movements, though not to exert his full strength. The face is rarely involved, and the patient, though answering briefly when addressed in a loud voice, speaks indistinctly and with difficulty. The respiration is loud, slow, but rarely stertorous, and it is not often that there is puffing of the lips and cheeks. The pulse is slow, hard, and full. Sometimes the face is flushed and sometimes it is unusually pale. The sphincters generally retain their power. The senses, though weakened, are often capable of being exercised by tolerably strong excitations. A bright light causes uneasiness and closure of the eyelids. A loud noise is productive of discomfort and a limb, when pinched, is withdrawn. CEREBRAL CONGESTION. 37 The power of the mind is greatly lessened, and some faculties are altogether abolished. Answers more or less direct are given to simple questions put in a loud tone, but even moderate intellectual action seems to be impossible. Gradually the attack passes off, leaving the patient in a state of mental and physical depression, which may last for several days. The paralysis usually disappears, but occasionally it does not, one or more limbs or muscles remaining permanently, or for a long time, disabled. It sometimes happens, however, that the termination is not so favor- able. The vessels may remain congested, serum may be effused, and death may result without there being any vascular lesion. Two cases have come under my notice, in which death ensued from this cause in first attacks. A person who has once had a paroxysm, such as has been described, is thereby rendered more liable to subsequent seizures, each one of which still further permanently impairs his mental and physical powers. In one case, occurring in my practice, there have been eleven attacks in five years ; and in another, fourteen in four years. In both of these, and in several similar instances I have witnessed, there was paralysis, which had become more profound with each accession. It is therefore inexact to say, as do some writers, that the paralysis of cerebral con- gestion always disappears in a short time. The apoplectic form of cerebral congestion is more common than any other of the fully-developed varieties, about one-half of all the cases being of this type. b. The Paralytic Form.—Like the apoplectic variety, this may be unpreceded by the premonitory symptoms constituting the first stage, but usually they have been present. The loss of power or of sensi- bility, or of both, may be very circumscribed, limited to a single group of muscles in the one case, or a small portion of the cutaneous surface in the other, or one entire side, or both sides of the body, may be in- volved. It differs from the apoplectic form in no essential respect, except that there is no loss of consciousness. Its onset is sudden. c. The Convulsive Form.—This, like the variety just described, may come on suddenly, or may be preceded by premonitory symptoms. The phenomena of the attack do not generally differ from those attend- ant on an ordinary epileptic paroxysm, except that there is never an aura, and no peculiar cry, such as is so often met with in pure epilepsy. There is the same tonic spasm, followed by clonic convulsions, which may or may not be confined to one side of the body, and which may or may not be followed by temporary or long-continued paralysis. Stupor likewise supervenes, but is neither of so long a duration nor so profound as in true epilepsy. In other cases, and especially in infants or young children, there is no loss of consciousness. The pain in the head is intense, the pupils 38 DISEASES OF THE BRAIN. are contracted and insensible to light, there are vomiting and accelera- tion of the pulse. The convulsive movements, which may be either tonic or clonic, or both alternately, are either quite general or confined to a single limb or even a group of muscles. This form of cerebral congestion is never developed during sleep, for then the brain contains less blood than when the individual is awake. It may occur during stupor induced by certain drugs, constriction of the neck, or a dependent position of the head ; but stupor is not sleep, although the two conditions are frequently confounded. Convulsions occurring during ordinary sleep are never the result of congestion. This point will be more fully considered under the head of epilepsy. After the stupor the patient may feel comparatively well, or there may be delirium continuing for several hours. As in the apoplectic form, there may be a succession of attacks, and the mind and physical power of the patient are thereby greatly weakened. The variety under consideration is, perhaps, more liable to occur in individuals past the age of forty, though I have witnessed several cases in quite young persons. It is not often met with in old age, and, when it is, is generally fatal, probably from secondary lesion. A majority of the cases of epileptiform convulsions, occurring for the first time in persons over the age of forty, are instances of the convulsive form of cerebral congestion. d. The Soporific Form.—This form will be more fully described under the head of passive cerebral congestion, to which condition it is almost entirely restricted. It differs from the apoplectic form in the circumstance that the invasion is gradual; and from this and the para- lytic in the fact that there is no paralysis, although the limbs may be in a state of general resolution. The chief phenomena are, pain in the head, dilatation of the pupils, and stupor. e. The Maniacal Form.—This variety, though not so common as either of the others, is yet not infrequent. It is characterized by an accession of mental derangement not materially different from that in- dicative of acute mania. The delirium is of a very active character the eyes are suffused, the face is red, the head hot, the motility active, and the whole manner, character, disposition, and mental processes are changed. During the paroxysm, the patient may commit some act of violence, and it almost always happens that his combative proclivities are aroused. He may likewise attempt to injure himself. The attack may come on with great suddenness. In the case of a gentleman recently under my charge, it was the result of eating a hearty meal in a great hurry at a railway-station. A few minutes after his return to the train, he was attacked with furious delirium, during which he attempted to injure himself and all within his reach. He was seized and held, but continued, as far as he was able, to bite scratch and kick, at those who were near him. The paroxysm lasted about two CEREBRAL CONGESTION. 39 hours. He then fell into a heavy stupor, from which he did not arouse for two hours longer. For several days his mind was weak, and there was numbness in various parts of his body. Gradually, however, he regained his former powers, but he suffered from occasional confusion of thought and difficulty of speech, with headache and wakefulness for several weeks. In another case—that of a boy thirteen years of age—it was charac- terized by paroxysms of maniacal excitement, during which the subject attempted to bite and otherwise to injure those around him, indulging at the same time in the most profane and obscene language. These seizures took place about once a week. There was generally a distinct recollection of all the events which had happened. In several other cases the seizures were the result of malarial poisoning, and were ex- actly periodical in their occurrence. Paralysis, as in the other forms, may be one of the phenomena of this variety of cerebral congestion. Death may take place during the attack, or from secondary lesions afterward.1 What is called temporary insanity, mania ephemera, or impulsive insanity, generally depends upon cerebral congestion. The subject, therefore, is of vast importance in its medico-legal relations.2 f. The Aphasic Form.—The inception of this type is usually very sudden. There may or may not be the accompaniments of pain in the head, vertigo, and confusion of mind. The chief symptom is the im- pairment or abolition of the faculty of speech, and this may be the only phenomenon. A very interesting case is that of Prof. Lordat, which is graphically described by Trousseau.3 The loss of speech was at first complete, but was entirely regained in twelve hours. Several similar instances have come under my observation. In a case at this time under my charge, the patient, a lawyer, was suddenly deprived of all power of speech, after passing several hours in very in- tense study. There was a little confusion of ideas, but neither pain nor vertigo. There was loss both of the memory of words and of the power of so coordinating the muscles of speech as to articulate. There was no paralysis anywhere. Recovery was complete in less than six hours. In two cases occurring in my own practice, the patients were sud- denly rendered aphasic by inhalation of the nitrite of amyl. The effect 1 The whole subject of cerebral congestion has been well considered by Calmeil, in his " Trait6 des Maladies Inflammatoires du Cerveau." Paris, 1859. 8 See a memoir by the author, entitled " A Medico-Legal Study of the Case of Daniel McFarland," in the Journal of Psychological Medicine for July, 18*70. Also published separately by D. Appleton & Co. New York, 1870. Also a paper on "Morbid Impulse," Psychological and Medico-Legal Journal, August, 1874, 3 "Lectures pn Clinical Medicine," etc. Translated by P. Victor Bazire, M. D Lon- don, 1866, p. 219. ±0 DISEASES OF THE BRAIN. continued for half an hour in one case, and for nearly an hour in the other, after all the other phenomena from the amyl had entirely disap- peared. The subject of aphasia will be more fully considered in the subse- quent part of this work. Third Stage.—This period may be considered as beginning after the immediate effects of the paroxysm, whether it has been of the apo- plectic,^paralytic, convulsive, maniacal, or aphasic.form, have passed off. It is characterized by feebleness of body and mind, by gastric or intes- tinal derangement, by pain in the head, with transient attacks of ver- tigo, and occasionally by numbness and slight paralysis of one or more of the limbs. Many of the symptoms met with in the first stage are again found in this. But the principal phenomena are those connected with secondary lesions, such as inflammation, abscess, softening, and adventitious growths of various kinds. These will be considered under their proper heads. It must not be forgotten that one circumstance always exists, and that is, the proclivity to other paroxysms of some one of the fully-de- veloped forms. PASSIVE CEREBRAL CONGESTION. This condition is the result of causes which increase the amount of venous blood in the brain. It is more commonly met with in old per- sons, and in those of feeble constitution. Women are more frequently affected than men. Symptoms. First Stage.—As in active cerebral congestion, there is a premonitory stage, the symptoms of which are similar to those pre- viously described. There is, however, a tendency to stupor, and the other phenomena are, in the main, less strongly marked. Vertigo, pain, illusions, hallucinations, and delusions, are nevertheless generally pres- ent at one time or another. But the stupor, or tendency to somno- lence, is the most prominent feature, and the sleep, even when compara- tively natural, is attended with dreams unpleasant or even frio-htful in character. The degree of congestion may be suddenly increased, or, what is a more probable sequence, there may be* effusion of serum, and then in either case the second stage, exhibiting itself as in the apoplectic the paralytic, the convulsive, the soporific, the maniacal, or the aphasic form, results. The proportion of cases of passive cerebral congestion which pass to the second stage is greater than in the active form of the affection and it is accordingly a more serious disease. Second Stage, a. The Apoplectic Form.—In this variety the onset of the affection is sudden, like that of active cerebral congestion. CEREBRAL CONGESTION. 41 The loss of consciousness is generally complete, the face is red, the pupils are dilated and insensible to light, the respiration is stertorous, and the fasces and urine may be passed involuntarily. The action of the heart is slow and feeble, and the pulse corresponds to these facts. Pa- ralysis may be general, or confined to a lateral half of the body. If sensibility returns, there are pain in the head, vertigo, tinnitus aurium, generally some embarrassment in the speech from lingual paraly- sis, and more or less loss of the power of motion in other parts of the body. There will also be general or partial anaesthesia. As the condi- tion of the patient improves, these symptoms generally disappear. Death, however, is not an infrequent sequence. This form of cerebral congestion is most common with elderly per- sons, and appears to be particularly apt to attack old women. b. The Paralytic Form.—This does not differ essentially from the apoplectic form, except that there is no loss of consciousness, the pa- ralysis constituting the main symptom. It may be either sudden or gradual in its inception. c. The Convulsive Form.—This may not differ materially from the convulsive form of active congestion, except as regards increased length of the fit and prolonged stupor. Generally, however, there is a repeti- tion of the seizures, and I am led to believe, from my experience, that there is a greater tendency to biting the tongue. Paralysis is a more common sequence, and is of longer duration, and the mind appears to suffer more seriously and at an earlier period. d. The Soporific Form.—The first symptom observed is commonly a general numbness and indisposition to muscular exertion. The drow- siness, which has probably been present to some extent, increases and soon becomes the most notable feature. At first, it is easy to rouse the patient from this stupor, but it gradually becomes more profound and overpowering, until at last a persistent comatose condition is reached. The' faculties of the mind may, in the earlier stages, be ex- cited into a moderate degree of activity ; but with the advancing coma they are no longer capable of being manifested. The cutaneous sensi- bility becomes less and less, the urine dribbles from paralysis of the bladder and its sphincter, and the bowels, if not obstinately constipated, allow their contents to pass involuntarily. With these symptoms, the pupils are dilated, and, as long as sensibility exists, pain in the head is complained of. The faculty of speech is impaired at an early period, but, although the tongue is restrained in its movements, there is no actual paralysis of this or any other muscle. This condition may last for several weeks, and, though recovery occasionally takes place, this is never complete. Death is the more usual termination. e. The Maniacal Form is not often met with in passive cerebral congestion, and, when it is, the delirium, so far from being of a furious type, is low. The patient mutters to himself incoherently, and exhibits 42 DISEASES OF THE BRAIN. great muscular restlessness, but never attempts to do violence to him- self or others. Coma often occurs as a sequence. /. The Aphasic Form.—Aphasia without other complication is not often met with as a consequence of passive cerebral congestion. Two instances only have come under my notice, and in both the development was much slower than is usually the case in the active form of the affec- tion. In both of these there was disease of the right side of the heart, manifested by mitral and tricuspid regurgitation, jugular pulsation, great fullness of the veins of the neck and face, and ascites and general anasarca. The loss of the idea of language was complete in both cases, and persisted for about forty-eight hours. There was no paralysis, stupor, or convulsion, and but slight pain. The ophthalmoscope re- vealed the existence of great turgescence of the retinal veins, with ve- nous pulsation. Causes.—The causes of cerebral congestion are: of the active form, those influences which are capable of increasing the quantity of arterial blood in the brain : of the passive, those which produce a similar effect upon the amount of venous blood circulating in the vessels within the cranium. The causes of the first category induce activity of circulation, those of the second torpidity. The causes of active cerebral congestion may either, by their grad- ual operation, initiate the premonitory stage, or they may suddenly induce the development of this stage into one or other of the varieties already described as constituting the second stage. Among them is temperature either very high or very low. Thus, the disease is more frequent in hot climates than in those of more temperate character, and in the summer months than in the spring or autumn. It is, however, more common in very cold than in warm weather. Thus Andral, of one hundred and fourteen cases, found that twenty-six occurred in sum- mer and fifty in winter. My own experience is to the same effect, as will be seen from the following table, which embraces the cases in my private practice in the city of New York during a period of five years, beginning January, 1865, and ending December, 1870 : January...................... 66 July.......................... 68 February..................... 64 August....................... 74 March........................ 50 September.................... 27 April........................ 39 October....................... 31 May.........................42 November..... ...............52 June......................... 37 December..................... 72 Total......................................................622 An examination of this table shows that one hundred and ten cases occurred in the autumn months, one hundred and thirty-one in the spring, one hundred and seventy-nine in summer, and two hundred and two in winter. All my subsequent experience is to the same effect. CEREBRAL CONGESTION. 43 Passive cerebral congestion is very much more frequent in cold than in warm weather. The direct rays of the sun are capable of producing sudden attacks (insolatio), of which congestion is a prominent feature, but which re- quire separate consideration : and it is not uncommon for artisans, whose heads are exposed to heat from furnaces, to suffer in a similar manner. Some authors contend that certain winds increase the liability to cerebral congestion. Leuret, quoted by Mosmant,1 could attribute an epidemic of cerebral congestion, which appeared at Charenton, to noth- ing but a long-continued wind from the northwest. The supposition that atmospheric electricity is a causative influence rests upon nothing but hypothesis. Unhealthy situations, such as those subject to the influence of ma- laria and to noxious emanations of any kind, and which are not well ventilated, also predispose to attacks of cerebral congestion. The ingestion of a large quantity of food into the stomach may oc- casion passive congestion, by the pressure which the distended organ makes upon the large veins of the abdomen. Rapid eating, even though the quantity of food be moderate, may cause the active form of the affection by some influence exerted through the sympathetic system. Sudden and violent physical exertion, especially if made in the stooping posture, is very liable to induce cerebral congestion. Child- birth is an instance in point, and I have known several cases to be caused by severe straining in the water-closet. The constipation of the bowels rendering such efforts at defecation necessary, is itself produc- tive of the disease. A dependent position of the head and constriction of the neck from the dress are also, by impeding the return of blood from the head, liable to induce congestion of the passive form. Certain articles of food and medicine, such as spices, alcoholic liquors, opium, belladonna, quinine, etc., act either by augmenting the power of the heart, or by their effect on the sympathetic, paralyzing the vaso- motor nerves, and thus increasing the calibre of the cerebral blood-ves- sels. In this connection, the influence of the nitrite of amyl, when in- haled to increase the quantity of blood in the brain, may be cited as an instance of this latter power. Tumors in the neck, or in other parts of the body where the return of blood from the head may be impeded by their pressure, likewise cause congestion. Other causes are to be found in certain diseases, as fevers of various kinds, erysipelas, disorders of menstruation, the suppression of hasmorrhagic or other discharges ; local affections of the brain, as embolus, thrombosis, tubercle or apoplectic clots, and sympathetically by worms in the intestinal canal, or irritation existing in other portions 1 "Essai sur la Congestion CerSbrale." Paris, 1858. 44 DISEASES OF THE BRAIN. of the system. Hypertrophy of the left side of the heart is a common cause of active cerebral congestion ; and any affection of the right side of this organ, tending to impede the return of the venous blood, is an important factor in giving rise to the passive form of the affection under notice. But the most influential and common causes of cerebral hyperemia, and eventually of congestion, are to be found in long-continued intel- lectual exertion, mental anxiety, or sudden, violent, or prolonged emo- tional disturbance. It is from the action of such factors that the pre- monitory symptoms are generally induced, though they may, especially those embraced in the last-named category, immediately develop a fully- formed attack. The fact that cerebral exercise increases the amount of blood in the head is made evident to all of us at times, by the disten- tion of the superficial vessels, the suffusion of the eyes, the heat and pain which we feel when we have overtasked our brains. Cerebral ac- tion is always attended with hyperemia, just as is the activity of the liver, the kidneys, or other organs. Active cerebral congestion is thus induced, and is, within certain limits, perfectly normal. But these limits are liable to be exceeded—and, in this active period of the world's his- tory, often are—and then the condition described as the first stage of congestion is established. The vessels, from continued overdistention, lose their contractility, just as does the India-rubber band, used to keep a bundle of letters together, when the package is too large, or it has been kept stretched for a long time. An additional disturbing force, heat, cold, an overloaded stomach, increased mental labor, emotional excitement, or any of the causes mentioned, may suddenly evolve a fully-developed paroxysm. Emotion acts in a similar manner, though, as has been said, often with more suddenness. The emotions of shame, of anger, and others, cause the face to become red from dilatation of the blood-vessels, and a like effect is produced in the vessels within the cranium. If the emo- tion is very strong or lasting, a correspondingly-increased hyperemia results. There are certain circumstances which render the action of the causes specified more effectual or powerful. These are inherent in the indi- vidual, and may be classed as predisposing causes. Among them are sex, the disease being more common in males ; age, it being more fre- quently met with in middle-aged or old persons ; hereditary influence ; hypertrophy of the left ventricle of the heart, by which the flow of blood to the head is directly increased ; dilatation of the right ventricle by which its power is diminished, and the return of blood from the head impeded; insufficiency of the auriculo-ventricular valves, or constriction at the auricular or ventricular orifices on the same side by which a similar result is produced, and perhaps1, though this point is by no means established, shortness of the neck. CEREBRAL CONGESTION. 45 Diagnosis.—Cerebral congestion may be confounded with cerebral haemorrhage, meningeal haemorrhage, embolism, thrombosis, softening, epilepsy, urinaemia, stomachal vertigo, auditory vertigo, and with the very opposite condition, cerebral anaemia. From each of these affec- tions it is, however, distinguished by well-marked characteristics. The premonitory symptoms are not liable to be mistaken for cere- bral haemorrhage, but this error may be made as regards the second stage. The apoplectic form is, however, distinguished from apoplexy due to extravasation, by the fact that in it the loss of intelligence is rarely complete, and that, when it is so, the mind is dormant but for a few moments ; that sensibility and the power of motion are never alto- gether abolished; that coma, when present, is rarely profound; that the paralysis, when it exists, is seldom limited to one side of the body ; by the general absence of stertor, and puffing of the lips and cheeks in breathing; and by the short duration of the symptoms. From meningeal haemorrhage it is discriminated by the comparative lightness of the symptoms, and by the fact that they do not progres- sively augment in severity or intermit in violence. Cerebral congestion and embolism present some features in com- mon, and it is therefore occasionally difficult to distinguish them. In the former, however, the pulse is slow and the respiration regular and deep ; in the latter, the pulse is more rapid, is often irregular, as is also the respiration; in the former, there is increased heat of the head ; in the latter, the temperature of this part of the body is unchanged : in cerebral congestion the symptoms are transient, in embolism they are more lasting ; in the former there is often a distinct premonitory stage; in the latter, the attack always takes place without a moment's warn- ing. In the former, though there may be cardiac difficulties, they are different from those predisposing to embolism, which are consecutive to endo-carditis—generally rheumatic—and which implicate the semi- lunar or mitral valves, and in the fact that recovery from an attack of cerebral congestion is generally complete, which is rarely the case in embolism. From thrombosis cerebral congestion is diagnosticated by the cir- cumstances that in the former the progress of the disease is slow, that there is usually well-marked paralysis from the beginning; that the phe- nomena indicating mental disturbance are more strongly pronounced *, that the articulation and memory for words are more permanently af- fected ; and, notwithstanding occasional remissions, by the persistency and gradual advance of the symptoms. In softening there are often a sudden loss of consciousness, persistent hemiplegia, and death in a few days. Again, there is delirium without paralysis or convulsions, and in other cases there is a gradual accession of the symptoms. This latter is the only form liable to be mistaken for cerebral congestion. It is attended with headache, feebleness of intel 46 DISEASES OF THE BRAIN. lect, and a gradually-advancing paralysis generally, beginning in one of the lower extremities, and extending to the whole of one side of the body. The speech is always seriously impaired, and the mental dis- order is of a far graver character than that due to cerebral congestion. The gradual advance of the affection to a fatal termination is also a characteristic circumstance. With urinsemia cerebral congestion may be confounded, if only the more obvious head-symptoms be taken into consideration. The history of the case and full inquiry will always, however, enable the proper dis- crimination to be made. Thus, in urinaemia the existence of kidney- disease, as evidenced by a chemical and microscopical examination of the urine, the anasarca of the face or limbs, and the repeated attacks of convulsions and coma, will be sufficient diagnostic marks. From epilepsy cerebral congestion is distinguished by the fact that the former is not preceded by the group of symptoms constituting the first stage of congestion ; that the congestion of the vessels of the face and neck is preceded by a death-like paleness; that an aura is often present; that there may be a peculiar cry; that the patient does not stagger and fall slowly to the ground, but drops as if knocked down by a severe blow; and that the tongue is frequently bitten. The reverse is the case as regards all these phenomena in cerebral congestion. Nev- ertheless, so accurate and experienced an observer as Trousseau, in his clinical lecture on Apoplectiform Cerebral Congestion in its Relations to Fpilepsy and Eclampsia1 confounds the two conditions. Trous- seau's views on this subject do not, however, appear to be accepted by any large number of medical authorities. Epileptic vertigo is, as will be shown at a proper place, a very different affection from any form of cerebral congestion, and is not likely to be confounded with it. Epi- leptic mania has, likewise, very few points in common with the disease under consideration. In stomachal vertigo the attacks of dizziness are often severe, but they are clearly associated with gastric derangement, and only occur while the stomach is digesting its contents. Other symptoms of dys- pepsia will also be noticed, while the mental and physical disturbances, which constitute so prominent a feature of cerebral congestion are ab- sent. The distinction, however, is not always made. • In auditory vertigo, or Meniere's disease, the dizziness is accompa- nied with aural troubles, such as deafness and tinnitus, the face is pale and there is almost invariably vomiting, or at least intense nausea. Moreover, when there is loss of consciousness, the premonitory symp- toms are not such as precede the second stage of cerebral cono-estion but are connected with the function of audition. From cerebral anaemia, the first stage of congestion is frequently not clearly distinguished, and I have seen several cases in which patients 1 "Clinique MSdicale," tome ii., p. 56. Also Bazire's Translation, London, 1866 p. 19. CEREBRAL CONGESTION. 47 had been treated for the one condition when the other was indubitably present. In both there are headache, sense of constriction, vertigo, noises in the ears, numbness, mental confusion, loss of memory, inapti- tude for labor of any kind, and at times loss of consciousness. But in anaemia the face is not flushed, the carotid and temporal arteries do not throb with violence; the pulse is quick, feeble, and irregular, the respi- ration is hurried, the pupils are dilated, there are bellows-murmurs at the base of the heart and in the veins of the neck, and the general as- pect of the patient is not of that rugged appearance so generally asso- ciated with cerebral congestion. In the syncope of cerebral anajmia the paleness of the face, coldness of the skin, and feebleness of the heart's action, will serve to draw the line between it and the apoplectic form of congestion. The ophthalmoscope will at all stages prove of great value in the diagnosis. Prognosis.—The prognosis is materially modified, according to the stage of the disease present when the patient is seen, and the form of attack from which he may be suffering. Active cerebral congestion is a more favorable type than the passive. If the affection has not gone beyond the first stage, a fortunate issue may safely be predicted under the use of suitable medical treatment; but, if, through neglect or im- proper treatment, or indiscretion on the part of the patient, the disease becomes fully developed, the prognosis is much more grave. I have never known a death to take place in any patient from this disease dur- ing the premonitory stage. The apoplectic and soporific forms are the most grave, and the prognosis is rendered more unfavorable with each attack. The epileptic form is ordinarily not dangerous to life, nor is the paralytic, maniacal, or the aphasic, except in old persons. Occasion- ally, however, even in young and robust patients, death ensues during tho paroxysms of these forms. The liability to secondary lesions, such as softening, cerebritis, haem- orrhage, aneurisms, general paralysis, etc., must be taken into account when forming a prognosis. The more frequent the paroxysms of any form, the greater the risk of some such finality. The habits of the patient are also important elements in forming an opinion in regard to the ultimate result. If these are bad, and are per- sisted in, the probability is that no treatment will be of much avail in preventing a recurrence. Moreover, by such a condition of the brain as the excessive use of alcohol, inordinate mental exertion, or continual emotional excitement induces, the chance of escaping some secondary morbid process is very much lessened. Of the one hundred and seven fully-developed cases which have been under my observation during the past eight years, there were eighteen deaths; seven from the apoplectic form, all after repeated attacks; three from the maniacal, one of which was that of a young man about thirty years of age; and seven from secondary lesions. Of these latter, four 48 DISEASES OF THE BRAIN. were from softening, one from cerebritis, one from haemorrhage, and one from general paralysis. Morbid Anatomy.—There are certain appearances seen in the brains of those who have died of cerebral congestion which are characteristic, although it must be confessed that some or all of them are occasionally absent. These are: An increased size of the capillaries and large blood-vessels, both of the brain and the pia mater. It thus happens that, when a section of the brain is made, the red points ordinarily seen are larger and more numerous than usual, and that the pia mater presents in spots, or throughout its extent, a red or rose-colored appearance. The white matter of the brain is increased in consistence and density, and the gray matter is red, or even violet in hue. There is sometimes a large quantity of subarachnoidean effusion, the ventricles may contain an excessive amount of fluid, and the choroid plexuses are often enlarged. If there have been repeated attacks of cerebral congestion, it is not unusual to find, by microscopical examination, little granules of haematin in contact with the blood-vessels. The same means of exploration shows the minuter capillaries to be more than naturally tortuous, and to have little aneurismal swellings. These may or may not involve the whole circumference of the vessel. Their presence and import were first pointed out by Laborde.1 On making a transverse section of the hemisphere, a cribriform ap- pearance is seen, if the patient has repeatedly suffered from attacks of cerebral congestion, and especially if he be advanced in years. This is due to the presence of numerous little holes with sharply-defined mar- gins. The brain-tissue bounding these is generally without material change, either in color or consistence. This condition, called by Du- rand-Fardel,2 to whom the credit of first describing it is usually given, " l'6tat criblS," is supposed to be due to the fact that the vessels have been so distended during life as to press with increased force upon the perivascular tissue, and that, shrinking after death, they no longer fill their former space, which remains empty. Calmeil8 was the first to notice this condition. He has very often found, in maniacs, the white substance rendered cribriform by vessels distended with blood some- times empty, but always greatly dilated. This state, although fre- quently met with in congestion, is not uncommon in other pathological conditions, such as the several forms of softening, of which however congestion is often the first stage. 1 "La ramollissement et congestion du cerveau principalement considered chez de rieillard." Paris, 1866. 8 " Trait6 pratique des maladies des vieillards." Paris, 1854, and deuxieme Edition. 1873. 8 "De la paralysie considered chez les ali4n6s," etc. Paris, 1826. CEREBRAL CONGESTION. Durand-Fardelx calls attention to the fact that, on making sections of the medullary substance of the cerebrum, it is not uncommon to find in cases of congestion rose-colored patches scattered throughout its substance. On examining these with a lens, they are seen to consist of a large number of delicate vessels partially injected. I have never wit- nessed this appearance, except in one instance, nor is it noticed by au- thors on the subject generally. If the congestion has been severe or long continued, the convolutions may be to a considerable extent obliterated by the compression of the brain against the internal wall of the cranium. At the same time, the membranes of the brain are rendered dry and viscous from the pressure to which they have been subjected. In passive congestion the sinuses of the dura mater are the chief seats of vascular turgescence; the veins generally are distended, and there is ordinarily a greater amount of serous effusion in the subarach- noid space than in the active variety of the disease. Pathology.—It is almost useless at this day to discuss the question of the possibility of the quantity of blood in the brain being subject to variation. Still, it may be interesting to recall briefly the facts which establish the affirmative in the matter. In the cases of infants, in whom the anterior fontanelle is still open, the scalp is seen to be elevated above the level of the skull when the head is dependent, and depressed when the head is elevated. The same fact is observed in persons who have suffered injury of the skull, involving the loss of a portion of its substance. During strong emotional excitement, or the action of any cause capable of increasing the force of the circulation, the scalp is elevated. From the action of opposite causes it is depressed. Both in infants and in persons who have received injuries such as those cited, the scalp is seen to be de- pressed during sleep, and to rise as soon as the individual awakes. A dependent position of the head causes a sensation of fullness, or even pain, and blood may flow from the nostrils. The eyes are observed to be " bloodshot," and the countenance indicates congestion. A tu- mor, a ligature, or any other cause capable of exerting pressure on the jugular veins, will produce like effects. Ophthalmoscopic examination under such circumstances shows the veins of the retina to be enlarged, indicating that an obstruction exists to the return of blood through the sinuses and veins within the cranium. Post-mortem examination of persons dying, who, during life, have suffered interruption to the per- fect return of blood from the head, reveals the existence of intracranial congestion. Animals, subjected to experiments calculated to act in the manner stated, are after death found to have congested brains. In animals bled to death the brain is found anaemic to an extreme degree. 1 Op. cit., Paris, 1873, p. 21. 4 50 DISEASES OF THE BRAIN. Direct experiment still more positively establishes the fact under consideration. If a portion of the skull of an animal be removed, and the aperture be then securely closed with a watch-glass, the vessels will be seen to enlarge and contract according to the cause brought into action, and the brain will be correspondingly elevated or depressed. By means of an instrument, devised, independently of each other, by Dr. S. Weir Mitchell and myself, the degree of pressure within the cra- nium can be accurately measured. It is thus seen that the quantity of blood circulating in the brain undergoes material variation.1 The anatomical arrangement of the blood-vessels of the cerebral tis- sue is such as to admit of an enlargement of their calibre without neces- sarily subjecting the perivascular substance to pressure. Robin2 dis- covered the existence of sheaths around these vessels, and his observa- tions were subsequently confirmed by His,3 who ascertained that the same arrangement exists in the spinal cord. According to His, " Fine transverse sections of a hardened brain, having its vessels injected or otherwise, show that all the blood-vessels, arteries, veins, and even capillaries, are surrounded by a clear space, broadest in the case of the larger vessels, but in all cases quite sharply defined externally. In transverse sections, the vessels are seen to be surrounded by a ring-like space, and in parallel sections the space is seen on each side of the trunk of the vessel, and follows it in all its ramifications." These perivascular canals are lined by a hyaline membrane, and are capable of being injected, and, in cases of chronic congestion, may be- come permanently enlarged, so as to cause the appearance referred to under the heading of morbid anatomy. The pathology of the subject receives further elucidation from a con- sideration of the causes capable of giving rise to cerebral congestion, and which have been already mentioned in detail. Treatment.—Recollecting the two grand forms of cerebral conges- tion, the principles which should guide us in treatment will be clearly apparent. In the active type of the disease, the force of the cerebral circulation and the quantity of blood in the blood-vessels of the brain are to be lessened; in the passive variety, the force of the circulation is to be increased, and at the same time the accumulation of blood in the veins to be diminished. In the active form of this affection, the abstraction of blood from the arm was formerly very generally practised but is now rarely performed. I have never seen a case in which it was 1 For a more complete argument on the subject, and for a statement in detail of the experiments of Mr. Durham and myself on this point, the reader is referred to the author's monograph, " Sleep and its Derangements." Philadelphia: J. B. Lippincott & Co. 1870. The cephalo-haemometer referred to in the text is described in that work (Appendix) and also in the introduction to this treatise. a Journal de la physiologie de Vhomme el des animaux, 1859, p. 527. 3 "Zcitschrift fur Wissenschaftliche Zoologie," 1865, B. xv., quoted in the Journal of Anatomy and Physiology. Translation by Dr. Bastian. CEREBRAL CONGESTION. 51 required. Local bleeding is more generally applicable, and a few cups to the nape of the neck will often afford marked relief. Leeches to the temples are also useful, though they are preferably applied just inside the nostrils. I have many times witnessed the most satisfactory results from a couple of leeches thus used, and from accidental nasal haemor- rhage. Cold is another very useful agent in the treatment. It may be ap- plied to the nape of the neck, or directly to the cranium, either as very cold water or in the form of ice. The advantages of position should also be brought to bear. The head should be kept elevated, especially during sleep, and no severe muscular exertion should be taken while stooping. The clothing should be kept loose about the neck. As derivatives, a mustard-plaster applied to the epigastrium is often of service; and the same may be said of warm or even hot water to the feet. Blisters I rarely employ, though I have occasionally done so with advantage. The constant galvanic current possesses the power of contracting the cerebral blood-vessels, wThen so used as to stimulate the sympathetic nerve. For this purpose, one pole should be placed over this nerve in the neck; and the other on the back of the neck, as low down as the seventh cervical vertebra. The current from about fifteen Smee's cells is sufficient, and it should not be allowed to act for more than two minutes. If extreme vertigo be produced, the number of cells should be lessened. This property of the primary current was first pointed out by Bernard, Waller, and Budge, but its demonstration by the ophthal- moscope was first made by myself.1 Observation with this instrument, while the current is acting, shows that the vessels of the retina con- tract, and hence there can be no doubt that the result is produced upon those of the brain. A similar effect is caused by passing the current directly through the brain, the poles being applied to the mastoid processes. A slight feeling of vertigo follows both when the circuit is closed and opened. The good effects of this practice are well marked, a few applications being often sufficient to abolish the vertigo and unpleasant feelings in the head, and to restore mental and physical activity. Of internal remedies the number is not large, and those which it is advisable to employ are generally effectual, with or without the external measures mentioned, in entirely relieving the patient. First among these must be placed the bromide of potassium. Sev- 1 See a memoir entitled " Spinal Irritation," read before the Medical Society of the County of New York, January 17, 1870, and published in the Journal of Psychological Medicine for April of the same year. Also another, " On some of the Effects of Excessive Intellectual Exertion," in the Bellevue and Charity Hospital Reports for 1870. In both these papers, and in my lectures to the class of the Bellevue Hospital Medical College, I have made distinct mention of this fact. 52 DISEASES OF THE BRAIN. eral years ago I pointed out the value of this medicine, and explained the rationale of its action. As others have since claimed the discovery as their own, I hope I may be excused for quoting the following pas- sage from a memoir upon an analogous subject,1 in which the action of the bromide is clearly indicated: " Bromide of potassium can almost always be used with advantage to diminish the amount of blood in the brain, and to allay any excite- ment of the nervous system that may be present in the sthenic form of insomnia. That the first-named of these effects follows its use, I have recently ascertained by experiments upon living animals, the details of which will be given hereafter. Suffice it now to say that I have administered it to dogs whose brains have been exposed to view by trephining the skull, and that I have invariably found it to lessen the quantity of blood circulating within the cranium, and to produce a shrinking of the brain from this cause. Moreover, we have only to observe its effects upon the human subject, to be convinced that this is one of the most important results of its employment. The flushed face, the throbbing of the carotids and temporals, the suffusion of the eyes, the feeling of fullness in the head, all disappear as if by magic under its use. It may be given in doses of from ten to thirty grains, the latter quantity being seldom required, but may be taken with perfect safety in severe cases." Since then, experiments with the cephalo-haemometer and ophthal- moscope have abundantly confirmed these views, and more extensive experience in the treatment of cerebral congestion has placed, the matter beyond the possibility of a doubt. Other observers have also confirmed the opinions here expressed. The prescription which I usually employ consists of bromide of - potassium, 1 j ; water, § iv ; of this a teaspoonful is taken three times a day in a.little water. Occasionally the bromide is increased to § iss, and sometimes a saturated solution—which contains grs. xxx to 3 j__ is used. I continue the medicine till drowsiness, a slight feeling of weakness in the legs, and contraction of the blood-vessels of the retina —detected by the ophthalmoscope—are produced. The more promi- nent head-symptoms generally disappear in four or five days, and the results above-mentioned'ensue in about ten days. Latterly I have used the bromide of sodium in corresponding doses instead of the bromide of potassium. It is more pleasant to the taste and does not cause so much constitutional disturbance as sometimes follows the administration of the bromide of potassium in large doses. The bromide of calcium is also well adapted to the treatment of cases of active cerebral congestion, and has the advantage over the other bromides of acting more promptly. As is well known, ergot possesses the property of constricting the 1 " On Sleep and Insomnia." New York Medical Journal, June, 1865 p. 208 CEREBRAL CONGESTION. 53 organic muscular fibre. This property has for several years past led to its successful application to the treatment of those diseases of the spinal cord in which it is desirable to lessen the amount of blood in its ves- sels. It is only lately, however, that this agent has been employed in similar affections of the brain. From my own experience, as well as from a consideration of the investigations of others, I am entirely satis- fied that ergot does contract the cerebral vessels, and hence that it di- minishes the quantity of intracranial blood. Among the first, if not the very first, to call attention to this property was Dr. Charles Ald- ridge,1 who noticed that after the administration of a full dose he found it to cause " contraction of the arteries of the retina and loss of the capillary tint of the disk." My own observations are entirely in accord with these results. I have repeatedly found a single dose of two drachms of the fluid extract produce a decided diminution in the calibre of the retinal arteries, and a marked pallor of the disk. In addition, some recent experiments which I have performed upon dogs, in which the ergot was administered hypodermically in doses of from one to three drachms of the fluid extract, after the animals had been trephined and the cephalo-haemometer inserted into the opening in the skull, showed from the falling in the tube that the intra-cranial pressure was notably lessened. Applying these facts clinically, it is found that ergot is of very great value in the treatment of active cerebral congestion in all its forms, but especially in the first or hyperaemic stage. I am in the habit of giving drachm-doses of the fluid extract three times a day, in com- bination with some one of the bromides. An excellent formula is sodii bromidi, § j; ergotae ext. fluidi, 3 iv. M. ft. sol. Dose, a teaspoonful three times a day. Or the ergot may be given alone either in the form of the fluid extract, or of the ergotin of Beaujon, which is simply a solid extract. This latter is made into pills of from three to five, or even ten grains each, one of which should be administered three times a day. In the first or hyperaemic stage, and especially where the pain in the head has been a prominent feature, I have frequently seen prompt relief of the cerebral distress, from the administration of ten or fifteen grains of paullinia. The fluid extract, a more eligible preparation than the powder, may be given in doses of a half to a full teaspoonful. In conjunction with these remedies I very generally employ the oxide of zinc, which experience has taught me is a powerful agent in relieving cerebral congestion, and giving tone to the nervous system. It should be given in doses of grs. ij, three times a day, either in the form of a pill or powder, and to avoid any nausea should be taken after meals. At the end of about ten days it will generally be found that under 1 " West Riding Lunatic Asylum Reports," vol. i., p. 71, London, 1871; also vol. iii., p. 230. 54 DISEASES OF THE BRAIN. this treatment all symptoms of congestion—subjective and objective have disappeared, leaving a little debility and mental depression. It then becomes expedient to give tonics and restoratives, and those which have a special action on the nervous system are to be preferred. Among them, strychnia, phosphorus, and cod-liver oil, stand first. Strychnia may be advantageously administered in conjunction with iron and quinine dissolved in dilute phosphoric acid, as in the following formula: Strychnias sul, gr. j ; ferri pyrophosphatis, quinias sul., aa 3 j ; acid, phosp. dil., zingiberis syrupi, aa, | ij. M. ft. mist. Dose, a tea- spoonful three times a day in a little water. I prefer this extempo- raneous prescription to any of the syrups or elixirs with like ingredi- ents. If for any reason the iron and quinine are not indicated, the strychnia can be given alone with the dilute phosphoric acid. Phosphorus almost always acts well in such cases as those under consideration. It may be given in the form of the phosphorated oil, as in the following formula: ]J. Olei phosphorat., § ss; mucil. acacias, | j ; olei bergamii, gtt. xl. M. ft. emulsion. Dose, gtt. xv. three times a day. A very elegant preparation of phosphorus is the phosphide of zinc. The chemical formula of this substance is Zns P, and consequently a grain represents a little more than one-seventh of a grain of phosphorus. The proper dose, therefore, is about the tenth of a grain. I usually prescribe it in cerebral congestion, according to the following pre- scription : I>. Zinci phosphidi, grs. iij ; rosar. conserv., q. s. M. ft. in pil. no. xxx. Dose, one three times a day. Instead of the conserve of roses, grs. x of the extract of nux-vomica may be substituted if strych- nia is not being administered in some other form. Another very useful form for administering phosphorus is the phosphorated resin, which contains four per cent, of phosphorus, thor- oughly rubbed up with ninety-six per cent, of resin. This is made into pills with conserve of roses, or some other excipient. The dose is about half a grain, containing the one-fiftieth of a grain of phosphorus. Latterly I have made much use of arsenious acid in cerebral con- gestion, especially in cases which have been the result of mental exertion or anxiety. Its action is certainly preferable to that of Fowler's solution. It should be given in doses of about the fiftieth of a grain, and after eating, and should be continued for several weeks. Lisle1 administers it in the quantity of from a fourth to the third of a grain daily, and there is no doubt that it may be given to this extent without danger. I have never, however, unless there was manifest insanity, used it in these doses. Such is the treatment I have found to be most advantageous in active cerebral congestion, and I rarely have occasion to supplement it 1 " Du traitement de la congestion ce>ebrale et de la folie avec congestion et hal- lucinations par l'acide aresenieux." Paris, 1871. CEREBRAL CONGESTION. 55 with other measures, unless some special indication is to be fulfilled. Thus, if the bowels are constipated, a mild purgative may be given, or preferably an enema of warm water or olive oil; or, if the urine is scanty and high-colored, saline diuretics are useful. In the passive form of the disease it is sometimes advisable to give stimulants, which may be done from the first in conjunction with the bromide of potassium, sodium, or calcium, with ergot. Alcohol in some form is to be preferred when it is well borne, though carbonate of ammonia is sometimes a useful substitute. In several cases of passive cerebral congestion in old people, and in one notable instance occurring in the person of a very prominent elderly gentleman of this city, I derived the most satisfactory results from sulphuric ether inhaled from a handkerchief to the extent of a teaspoonful, several times a day. The pain, constriction, vertigo, numbness, wakefulness, and inability to exert the mind, were lessened with every dose, and finally entirely disap- peared. Ether may likewise be given by the stomach—gtt. xv several times daily—in case the inhalation is contraindicated from any cause. Of course, any influence capable of interfering with the due return of blood from the head should be counteracted at once. In the two cases of aphasic cerebral congestion of the passive form, to which reference has been made, I derived the most signal benefit from the use of infusion of digitalis in tablespoonful-doses administered every four hours. Hygienic treatment should in both types of the disease be persist^ ently carried out. The food should be nutritious, digestible, and ample, though not excessive, in quantity. Alcohol and tobacco, if used habit- ually by the patient, should be restricted to moderate limits; I have never seen the latter do harm unless used to excess. Tea and coffee may safely be left to the patient's own inclinations and experience. I believe more harm is done by suddenly breaking off a habit, even though it be somewhat injurious, than by tolerating it within due bounds. Ex- ercise in the open air—walking, horseback-riding, or driving—is always beneficial. The same cannot be said of gymnastic contortions, which, to make them worse, are usually performed in hot rooms. Bathing daily and subsequent friction with a tape towel are exceedingly useful in determining blood to the surface of the body. The Turkish bath cannot be too highly commended. But, above all, those persons who have brought on the disorder by inordinate mental exertion or anxiety, must consent to use their brains in a rational manner if they wish to recover or to avoid future attacks. They have received a warning, and, if they do not heed it, sooner or later other diseases, more difficult if not impossible of cure, will make their appearance. But it is not always the case that the most positive advice on this point is followed. Men who would readily see the impropriety of walk- 56 DISEASES OF THE BRAIN. ing three or four miles while suffering with an inflamed knee-joint, do not hesitate to exert a disordered brain to the extreme limit of its power. It is impossible that the action of a brain thus affected can be such as to evoke sound and healthy thoughts. It is not to be won- dered at, therefore, that the subjects of cerebral congestion who insist upon attending to their avocations and on concocting schemes for ob- taining wealth or fame, should perpetrate acts which result in the loss of fortune, and the acquisition of a reputation far different from that sought. The cause of cerebral congestion, whatever it be, must, if practicable, be removed, and it must continue removed. CHAPTER II. CEREBRAL ANjEMIA. Ix cerebral anasmia the quantity of blood in the brain is either re- duced below the normal standard, or the quality of the circulating fluid is impoverished. The first-named condition is due either to direct loss of blood, to deficient action of the heart, to impaired nutrition, or to some cause preventing the due access of blood to the brain; the second to disease of some organ concerned in haematosis or to a general ca- chexia. The two states very often coexist, and they may properly be consid- ered together. Symptoms.—In cerebral anaemia, suddenly induced from profuse haemorrhage, the most prominent symptom is syncope. Vertigo is gen- erally an attendant, and there are paleness of the features and coldness of the extremities. The pulse is frequent, thread-like, and weak. The respiration is feeble and accelerated. But, when the accession is more gradual, headache is very generally present. It may be, and usually is, confined to a limited portion of the head, sometimes to a spot not larger than the point of the finger. A feeling of constriction, especially across the brows, is complained of, and the vertigo, notably increased on rising from the recumbent post- ure, is as troublesome a feature as in the worst attacks of cerebral con- gestion. There is ringing in the ears, and loud noises are not only painful but are exceedingly irritating to the nervous system. The pupils are largely dilated, and are sluggish, contracting slowly and but little on exposure to a strong light. These phenomena may be re- stricted to one eye, a circumstance which generally occasions needless alarm on the part of the patient. The retinae are extremely sensitive, and hence ophthalmoscopic examination is painful. When employed, CEREBRAL ANEMIA. 57 the vessels at the fundus of the eye are seen to be small and straight, and the choroid is paler than is normal. Owing to paresis of the ocular muscles—a very common condition in cases of cerebral anaemia—the attempt to use the eyes, as, for in- stance, in reading, produces pain in them and in the head. In many cases the effort of three or four minutes causes very great uneasiness. The complexion is pale, the lips almost colorless, or else redder than in health. The skin is cold and clammy. Nausea and vomiting are present in extreme cases, and convulsions of an epileptic character may occur. In the rapidly-developed form of the disease; caused by sudden and great loss of blood, they are always present, and in the milder and more gradual variety they are occasion- ally seen. Feebleness of muscular power is always met with, and there may be general or partial paralysis, with the usual derangements of sen- sibility indicative of anaesthesia, such as coldness, formication, and "pins and needles." The mind, of course, participates in the general disorder. In ex- treme cases, due to active hasmorrhage, the patient is completely insen- sible. In less severe forms there may be all the gradations from low delirium to great mental irritability, or a condition of intellectual lassi- tude approaching dementia. Hallucinations and illusions are common in the slowly-developed forms of cerebral- anasmia, and may affect any one or all of the senses. Those of sight and hearing are, however, more prominent. In the case of a young lady under my care, and whose only marked disorder was that under consideration, the hallucination that she saw a black man was almost constantly present. At times she conversed with this im- aginary being, told him not to trouble her, that she no longer feared him, etc. She believed firmly in his presence, and hence had a delusion. In all cases of cerebral anasmia there is more or less drowsiness, from the profound syncope of the rapid form to the rather agreeable languor present in slight cases. In instances of medium severity, the patient readily falls asleep in the sitting posture, but recumbency induces wake- fulness, from the fact that the quantity of blood in the brain is thereby suddenly increased above the habitual standard, and a state of compara- tive hyperasmia is thus induced. I have, in another place,1 called atten- tion to this form of insomnia, and adduced several cases in illustration. Examination of the heart by auscultation reveals the existence of bellows-murmurs both systolic and diastolic. They are heard more loudly at the base of the heart. There are also very generally venous murmurs, which are heard most distinctly in the jugular veins, espe- cially when the head is turned toward the opposite side. Arterial mur- murs may also occasionally be perceived. These sounds are sometimes heard by the patient, and are then ex- 1 " Sleep and its Derangements." 58 DISEASES OF THE BRAIN. ceedingly annoying. I have had under my charge patients suffering from cerebral anasmia, who constantly heard a sound originating ap- parently in the head, and which, as they described it, resembled that caused by a large shell placed to the ear. That these murmurs are anasmic, is shown by the fact that they disappear under appropriate treatment. Cerebral anasmia may be of such intensity and be so suddenly devel- oped as to cause almost instant death. Many cases are on record, of patients having died with symptoms of apoplexy, and in whom post- mortem examination has shown the blood-vessels of the brain to be empty, and the brain itself pale and exsanguined. Paralysis of various forms may likewise result from this condition. Sometimes there is hemiplegia, at others paraplegia, again a single muscle or a group of muscles may be affected, and it may even happen that a general state of paralysis may exist. I have frequently seen a single muscle of the eyeball alone involved, and upon one occasion witnessed the loss of muscular power confined to one side of the face in the person of a lady whose brain was evidently very anaemic. Gintrac* cites the following interesting cases communicated to him by Dr. Hirigoyen: "A young girl twenty years old, affected with amenorrhcea, con- sulted a midwife, who bled her, attributing her trouble to cerebral pleth- ora. She had hardly lost two hundred grammes of blood when hemi- plegia supervened. Iron and tonics entirely dissipated this condition. A young woman, twenty-five years old, was subject to a severe epigastric pain, that had been several times relieved by bloodletting. She was thin, pale, and nervous. Nevertheless, a vein was again opened, but only about one hundred and fifty grammes of blood were taken. Notwithstanding this prudence a syncope ensued, while the arm was being tied up, and there were some convulsive movements. After two or three minutes the patient recovered her senses, but was found to be entirely hemiplegic on the left side, and to have some difficulty of speech. Recourse was had to Hoffman's anodyne, valerian, and appro- priate food, and at the end of thirty-six hours she was relieved." A form of cerebral anaemia met with in young children is of great importance, from the fact of its liability to be confounded with another far more dangerous affection, almost its opposite. This was first clearly described by Dr. Gooch,8 although previously noticed by other ob- servers. In children suffering from this affection, the symptoms so far as they are noticeable, are similar to those present in the anasmia of adults. The drowsiness is well marked, the head is cool, the pulse is 1 " Trait6 theorique et pratique des maladies de l'appareil nerveaux." Tome pre- mier, Paris, 1869, p. 548. 9 " On Some of the most Important Diseases peculiar to Women; with Other Papers." New Sydenham Society Publication. London, 1859, p. 179. CEREBRAL ANEMIA. 59 smail and weak, the features are pinched, the pupils large and insensible to light, and the fontanelle, if still open, has the scalp covering it de- pressed. After death, the vessels of the brain are found to be almost empty, and the ventricles distended with fluid. From its resemblance in some respects to hydrocephalus or tubercular meningitis, this affec- tion was called by Dr. Marshall Hall hydrocephaloid. The distinction, however, is so well defined, that none but the most ignorant or super- ficial observers would fail to recognize it. Causes.—Haemorrhage or other exhausting discharge ranks first among the causes of cerebral anaemia. I have known several severe cases induced by epistaxis, and one by the continued loss of blood from leech-bites. Hasmorrhoidal bleeding has also caused it in my experi- ence. No influence of the kind is, however, more common than uterine bleeding, such as occurs before, during, or after labor, from miscarriages and abortions, especially if they are frequently repeated, and from ex- cessive menstrual discharge. Chronic dysentery and diarrhoea, malarial and other fevers, the rheu- matic, strumous, and cancerous diatheses, diseases of the bones and joints, and long-continued purulent discharges, are likewise causes of cerebral anasmia. I have several times seen the affection apparently caused by conges- tion of internal organs. Niemeyer, referring to this possibility, cites the fact that it may follow the use of Jounod's boot. At the present time, when this appliance is variously modified and extended beyond its legitimate use by itinerant quacks, it is well to call special attention to this liability. Several cases in point have come under my observation, and in one, a young lady suffering from epilepsy with cerebral anaemia, whom I saw in consultation with my friend Dr. J. Marion Sims, severe paroxysms were induced by each application of the " exhauster." In this case the operator placed the whole body, with the exception of the head, in a vacuum. In another instance, exhaustion from the leg alone caused syncope every time the operation was performed. Pressure upon or obliteration of the arteries supplying the brain is another cause. A lady was formerly under my notice, in whom both carotid arteries had been tied, for cirsoid aneurism of the scalp, by the late Dr. Kearney Rodgers and my friend Prof. W. H. Van Buren. When I saw her, several years after the operation, there was well- marked cerebral anasmia, the most striking symptoms of which were vertigo and drowsiness. Tumors of various kinds may act in a similar manner. Feebleness of the heart's action, such as results from fatty degeneration, may also occasion cerebral anaemia. As we have seen, excessive mental exertion is a common cause of cerebral congestion. Strange as it may appear, I have had several cases of cerebral anaemia under my care, in which the disease was clearly the result of a like cause, and these were instances in which the brain had 60 DISEASES OF THE BRAIN. been overtasked to an extreme degree. A little reflection will, I think, show that such cases are strictly in accordance with what takes place in other parts of the body. Thus, we see the moderate use of a muscle or set of muscles increase their size and strength. Inordinate exercise in- duces hypertrophy, but, if the power of the muscles be still more se- verely tried, atrophy results. One of the worst cases of progressive muscular atrophy I ever saw occurred in the person of a ballet-dancer, whose gastrocnemii muscles were the apparent starting-points of the disease. Excessive cerebral action produces exhaustion, and exhaustion causes anaemia, as surely as anaemia causes exhaustion. The action of mental emotions is more obvious. We know that some emotions increase the amount of blood in the brain. Others di- minish it, and sometimes with such suddenness as to cause syncope. Fear is one of these, and we have all seen the face become paler under its influence. Certain medicines are causes of cerebral anasmia, both by their ac- tion on the vaso-motor nerves and in diminishing the power of the heart. Tobacco, tartarized antimony, calomel, oxide of zinc, and the bro- mides of potassium, sodium, calcium, and lithium, are among the chief of these. I was the first to point out this influence of the bromides, and, t in a recently-published memoir,1 have given several cases in illustration of its action. The drowsiness, vertigo, nausea, fainting, weakness of the muscular system, numbness, failure of memory, mental aberration, pallor of the countenance, and anasmia of the retina, all go to show that i the quantity of blood in the brain is diminished. Recent investigations I not yet published have convinced me that the oxide of zinc acts in a j similar manner. Insufficient nutrition, either from deficient or improper food or dis- ease of the digestive or assimilative organs, is a very common cause. Through its influence not only is the absolute amount of blood lessened, but its quality is deteriorated. The quantity sent to the brain is hence diminished, and that which is supplied is lacking in its proper propor- tion of red corpuscles. Many of the cases of cerebral anasmia occurring in large cities originate from such influences, and likewise from the vitiated air of narrow and crowded streets, from cold, and from depri- vation of light. Sudden cerebral anasmia may be produced by the shock caused by physical injuries, or even slight surgical operations unattended by effusion of blood. Thus I have several times seen it follow immediately on the passage of a urethral catheter or bougie for the first time. 1 " On Some of the Effects of the Bromide of Potassium when administered in Lar»e Doses." Qicarterly Journal of Psychological Medicine, January, 1869, p. 46. In this paper I stated that one of the most constant phenomena was contraction of the pupils. Very greatly increased experience has convinced me that this is an occasional circum- stance, which occurs during the early period of administration only. CEREBRAL ANAEMIA. 61 The passage of a galvanic current of too great a degree of intensity through the brain, may be productive of alarming symptoms due to sud- denly-induced cerebral anaemia. Upon one occasion I passed a current from ten cells transversely through the brain of a gentleman—the poles being on the mastoid processes—with the effect of causing syncope, extreme nausea, a cold perspiration on the head and face, and such feeble action of the heart as to cause me to apprehend the most serious results. Placing the head in the dependent position, and causing him to inhale the nitrite of amyl, soon restored him to consciousness, and dissipated the other symptoms. In another, somewhat similiar though not so violent symptoms were induced by the passage of a current from only six cells. Cologne to the nostrils, and a draught of strong whiskey, afforded prompt relief. These cases, as well as others within my knowledge or experience, show how sensitive some persons are to the primary current, and indi- cate the care necessary in the use of this powerful agent. An instance of extreme cerebral anemia, produced by excitation of the pneumogastric nerve by a.galvanic current of too great a degree of intensity, will presently be cited. Diagnosis.—The principal affection with which cerebral anaemia is liable to be confounded, is cerebral congestion. Indeed, there is no ♦ other which can be mistaken for it, if even ordinary perception and judgment be exercised. From this it may be diagnosticated by the history of the case, and a careful inquiry into the etiology, by the fact that drowsiness, not wakefulness, is a prominent symptom; that the pupils are dilated in- stead of being contracted; that the pain is more apt to be fixed in a limited part of the head instead of being general; that it and the ver- tigo are increased by the assumption of the erect position, and dimin- ished by lying down; that the ophthalmoscope shows retinal anasmia; that the face is pale and the skin cold; that the pulse is weak and fre- quent; and that bellows-murmurs are heard at the base of the heart and in the veins of the neck. The effect of stimulants and tonics in mitigating these symptoms, and the fact that they are increased by ex- ertion, and debilitating influences, are also important points to be con- sidered in forming a diagnosis. Attentive consideration of these dif- ferential phenomena will prevent a mistake which may be fatal to the patient. Prognosis.—The prospect of recovery in cases of cerebral anasmia depends mainly upon the removal of the cause, and the adoption of suitable treatment. In those cases which are the result of sudden and profuse loss of blood, the prognosis is grave, and this is especially so if the patient is pulseless and convulsions have occurred. In such in- stances, even though the haemorrhage has been arrested, it may be impossible to save the patient. 62 DISEASES OF THE BRAIN. In the gradually-developed form the prognosis is generally favor- able. Morbid Anatomy.—The vessels of the brain and its membranes are observed upon post-mortem examination to contain less than the normal amount of blood. The tissue of the brain is pale, and section shows a diminished number of the red points in the white substance. Some- times there is an increased amount of serous effusion in the sub- arachnoid space, but the ventricles are generally empty. Pathology.—The questions to be discussed under this head are similar to those connected with the same point in cerebral congestion. That the quantity of blood within the cranium can be diminished as well as increased admits of no doubt, and the fact that the symptoms grouped together as indicating the existence of cerebral anaemia are really the result of deficient blood-supply to the brain is equally certain. The experiments of Kussmaul and Tenner,1 as well as those of other physiologists, are perfectly convincing. To observe in man the effects of even temporarily cutting off the supply of blood to the brain, it is only necessary to compress the carotid arteries for a few moments. I have repeatedly done this in rab- bits to the extent of producing insensibility and convulsions. Jacobi2 relates the following symptoms as generally observed in the human subject: Dimness of sight, dizziness, stupor, weakness in the legs, stag- gering, swooning, loss of consciousness, and sudden apoplectic falling down. ^_ t^-S6 «^- £**o«J <.*--. Dr. Alexander Fleming3 tried the effect of compressing the carotid arteries. " There is felt a soft humming in the ears, a sense of tingling steals over the body, and in a few seconds complete unconsciousness and insensibility supervene and continue as long as the pressure is maintained. I have recently performed this experiment several times, with the effect of producing similar phenomena, together with pallor of the countenance, dilatation of the pupils, and temporary headache. In many cases of cerebral anasmia, the cause, as we have seen, resides in the blood-producing functions, and is such as to cause the formation of blood which does not contain its due supply of red cor- puscles. Here, although there may be no diminution in the actual volume of this fluid circulating in the cerebral vessels, the effect is the same so far as the nutrition of the organ is concerned, and hence the symptoms of anaemia are slowly evolved. Again, it cannot be doubted that spasm of the blood-vessels pro- 1 " Untersuchungen uber Ursprung und Wesen der fallsuchtartigen Zuckungen," Frankfurt, 1857. Also, " On the Nature and Origin of Epileptiform Convulsions, caused by Profuse Bleeding," etc. New Sydenham Soeiety Translation, 1859. 8 Quoted by Kussmaul and Tenner. 8 British and Foreign Medico-Chirurgical Review, April, 1855, p. 529, in a paper en- titled " Note on the Induction of sleep and Anaesthesia by Compression of the Carotids." CEREBRAL ANJEMIA. 63 duced through the sympathetic and vaso-motor nerves explains the origin and continuance of many cases of cerebral anaemia. It is in this way that mental emotions act, and sometimes with such rapidity as to cause instant death. This spasm may be kept up for a very consid- erable period, with the effect of developing the ordinary symptoms of cerebral anasmia, even after the emotion which orignated it has long since disappeared. Treatment.—The first indication to be fulfilled in the treatment of cerebral anasmia is to get rid of the cause. It often happens that this is still in active operation when patients come under our care, and there is no hope of permanent success till it is removed. Thus, if there is hasmorrhage from a divided vessel, from the uterus, the bowels, the lungs, or other part of the body, it must be arrested; if there is ex- hausting discharge from the air-passages, the intestines or the genital organs, it must be stopped; if the digestive or assimilative organs do not perfectly perform their offices, they must be put in good condition, if a tumor or other obstruction to the due course of the blood to the brain exist, it must be removed ; and if the hygienic conditions sur- rounding the patient be bad, or the food inadequate in quantity or quality, they must be improved. No medicine exercises so powerful an effect in cerebral anasmia as alcohol in some form or other. Perhaps, all things considered, the spir- ituous liquors, such as whiskey, brandy, and rum, are more generally applicable. For the influence is more rapidly felt, and there is not the same risk of exciting or aggravating gastric disorder as when vinous or malt liquors are used. The quantity must be regulated according to the circumstances of each case, and should always be large enough to materially increase the force of the heart. But if this were the only effect of alcohol, its benefits in cerebral anasmia would be but temporary, and would certainly be followed by a period of depression. Aside, however, from its stimulating action on the heart, its tendency is to improve the appetite and digestive power, and to relax any spasm of the blood-vessels that may be present. Occasionally it happens that alcohol is badly borne by anasmic patients. The brain has for so long a time been deprived of a due amount of its natural stimulus—blood—that time is required to enable it to tolerate, and be improved in tone by, the increased supply. Thus the physician will find that in some cases the patients will be apparently rendered worse by the remedy which of all others is calculated to do them most good. The headache and vertigo are increased, the general feeling of debility and malaise greatly augmented, and the complaint is made that the liquor has " gone to the head." Now, it must be recollected that the brains of anasmic persons are in very much the same condition as the eyes of those who have for a long time been shut out from their natural stimulus—light. When the 64 DISEASES OF THE BRAIN. full blaze of day is allowed to fall upon their retinas, pain is produced, the pupils are contracted, and the lids close involuntarily. The light must be admitted in a diffused form, and gradually, till the eye becomes accustomed to the excitation. So it is with the use of alcohol in some cases of cerebral anasmia. The quantity must be small at first, and it must be administered in a highly diluted form, though it may be fre- quently repeated. Cases in which this intolerance of stimulants is exhibited are almost invariably of long duration, and are as those in which from a like cause wakefulness is produced by the recumbent posture. The carbonate of ammonia, or the aromatic spirits of ammonia, may be given if there are any special reasons why alcohol should not be used, but they are not to be compared to it in efficacy. In very extreme cases ether is preferable for the time being to any of the foregoing remedies, on account of its diffusive nature ; and trans- fusion may be necessary to save life. My recent experience disposes me to put a very high value upon the nitrite of amyl in the treatment of cerebral anasmia. Aldridge1 has shown that it causes, when inhaled, dilatation of the retinal arteries ; and the other phenomena of its action, the feeling of fullness in the head and the redness of the face and scalp, unite to prove that it exercises a like effect over the vessels of the brain. In the cerebral anaemia of weak and chlorotic girls it is especially valuable, although there is no form of the affection, whether transitory or permanent, in which it will not prove beneficial. Even a single dose of four drops inhaled from a handkerchief has repeatedly in my hands relieved anasmic headaches, and effectually dissipated syncope, the re- sult of a feeble action of the heart. Upon one occasion I had, rather imprudently, perhaps, acted in a case of goitrous exophthalmia upon the pneumogastric nerve with a galvanic current of too great a degree of intensity. The heart was rendered exceedingly weak and irregular in its pulsations. The patient, a lady, became insensible from syncope, and was unable to swallow the brandy I held to her lips. I poured a few drops of the nitrite of amyl on a handkerchief and held it to her mouth. Immediately the action of the heart became stronger, the color began to return to the face, and consciousness was at once regained. In chronic cerebral anaemia, the nitrite of amyl should be admin- istered in doses, by inhalation, of from four to eight drops three times a day. This course may be continued as long as may be necessary, with- out the slightest deleterious result. I have repeatedly persevered with it for a year, in cases of epilepsy, with the happiest effect. It has never in my experience been requisite to use it longer than a few weeks in cases of cerebral anaemia. It may seem strange, with the cases I have given, and with the 1 "West Riding Lunatic Asylum Reports," vol. i., 1871, p. 77. CEREBRAL ANiEMIA. 65 knowledge, from experiment and ophthalmoscopic examination, relative to the power of the primary galvanic current applied to the brain or sympathetic nerve to contract the cerebral blood-vessels, that I should recommend the use of galvanism in cases of cerebral anaemia. Clinical experience, however, shows that it is decidedly beneficial, provided the tension be very low. I am satisfied that not more than two or three cells should be brought into action in such cases, and that the current should only be passed for a few seconds at a time. It appears to give increased tone to the vessel, and to promote the nutrition of the brain in a remarkable degree. As adjuncts to these means, the bitter tonics, such as quinine, gentian, columbo, and quassia, are useful. Iron is almost always re- quired, though there are patients who do not tolerate it. In such cases manganese may be substituted with advantage. I have frequently used the sulphate, in doses of five grains, with excellent results. When iron is borne, I know of no better combination than that given on page 54. Cod-liver oil is also a valuable agent in the disease under consideration. It must not be forgotten that food is the most important factor in relieving chronic cerebral anaemia. The main permanent influence of stimulants and tonics is exerted upon the appetite and digestion, and the blood and tissue forming functions mainly as an excitant. The real strength must come from the food. This should, therefore, be of good quality ; animal food such as milk, eggs, and meats of various kinds, forming its chief portion. The influence of position should always be taken advantage of to facilitate the flow of blood to the head, and the erect posture avoided as far as possible, especially during the early stages of the treatment. Thus the patient should be encouraged to pass a good portion of the day in a recumbent position, and should be instructed to assume it at once on the occurrence of any aggravation of the symptoms. The opposite course is fraught with danger. Physicians are often anxious that their patients should take physical exercise, but it must be remembered that those who suffer from cerebral anaemia have very little vital energy, and a diminished amount of blood is circulating through the organ from which the greater part of their nervous power comes. Muscular exercise lessens the energy, and still further reduces the quantity of blood in the brain, for the muscles require an increased supply while in a state of activity. To be sure, after the strength of the system is in a measure improved, the blood increased in quantity and quality, and the brain supplied with something like its proper pro- portion, moderate physical exercise is of the greatest service. I have several times witnessed severe consequences from- the as- sumption of the sitting or erect position too soon after a profuse hasmorrhage, and in one case death resulted. As regards mental labor, there is not much need of caution, for the 5 66 DISEASES OF THE BRAIN. reason that it is impossible for the patient to undertake it to any dan- gerous extent. But, as he improves in strength, the desire to make use of his increased power may be manifested. It is, therefore, well at this time to prohibit any such exertion as will probably be followed by marked depression. Moderate mental exercise is, however, far from be- ing prejudicial, for it tends to increase the amount of blood in the brain. Emotional disturbance should also, as a rule, be avoided, although at times it may be productive of great benefit, especially if it be pos- sible to bring into action an emotion contrary to that which may have produced the disease. Thus a lady became subject to cerebral anaemia, directly the result of painful emotions due to domestic trouble. The difficulty was very suddenly removed, or rather the knowledge of its re- moval was suddenly communicated to her. The reaction was very great; she was thrown into a state of joyous excitement, attended with consid- erable febrile disturbance, and I was apprehensive for a time that her mind might become permanently deranged, for there were hallucinations and delusions of various kinds, and many symptoms of cerebral conges- tion. But in the course of a few days, during which she was kept in entire seclusion, and as far as possible from all mental and physical agitation, she entirely recovered both from the secondary and primary disorders. One word in regard to what not to do. From what has already been said in this and the previous chapter, the reader will have per- ceived that it would be exceedingly injudicious to administer any of the bromides in the treatment of cerebral anaemia. I should not, therefore, deem it necessary to say any thing further in regard to this point, but for the fact that I am very sure, from my experience, that wrong ideas prevail among some physicians relative to the subject. I see many patients affected with the disease under consideration, who have been treated with the bromide of potassium, and invariably with the effect of aggravating the difficulty. Care in making a diagnosis and a knowl- edge of the fact that the bromides lessen the amount of blood in the brain are points which it is necessary to insist upon, even at the risk of being tiresome by repeating what has already been said. CHAPTER III. CEREBRAL HAEMORRHAGE. Under the designation of cerebral haemorrhage I propose to con- sider that disease which is often known as apoplexy, hemiplegia, or a paralytic stroke, and which is due to the rupture of a blood-vessel and the consequent extravasation of blood either into the substance of the brain or into its ventricles. CEREBRAL HEMORRHAGE. 67 Two forms of the affection, differing essentially only in the extent or seat of the lesion, but presenting different symptoms, are to be dis- tinguished ; these are the apoplectic and paralytic. In the first there is loss of consciousness ; in the second the mind, though perhaps im- paired, is not suspended in its action. Symptoms.—Before the full development of the attack there often is, for several days, a group of symptoms present which indicate cere- bral disorder. These are very much of the same character as those denoting the first stage of cerebral congestion, but, though generally not so numerous, are far more striking. Among the more obvious is a sudden difficulty of speech, arising from slight paralysis of the tongue and other muscles concerned in articulation. Words are not pronounced with the usual distinctness ; the tongue seems to occupy more space in the mouth than it should, and is not moved with the requisite degree of promptness and rapidity. The other muscles on one side of the face may be affected, and hence there is a little distortion, lasting, perhaps, but for a few hours. Defects of sight may occur, usually characterized by the presence of dark spots in the axis of vision. Such conditions are due to minute extravasations in the retinas, and are always of most serious importance. I have known retinal clots to precede by more than a year the occurrence of a more severe lesion. Bleeding from the nose is a common precursor, and, when occurring without being induced by severe muscular exertion, blows, a dependent position of the head, or other obvious cause in a person over the age of forty, is always to be regarded as a symptom of moment. Numbness limited to one side of the body is of itself sufficient to excite apprehension. I have known several cases in which this symptom was the only premonitory sign. • It may be present several days before, or may precede the attack by only a few minutes. In addition, there may be headache, vertigo, slight confusion of mind, a tendency to stupor, and vomiting. None of the premonitory symptoms may be present, and then the attack, if of the apoplectic form, occurs with great suddenness. Even if they have been noticed, there is more or less of abruptness in the onset. Thus the individual is perhaps standing, engaged in conversation, when he is instantaneously struck with unconsciousness, and falls to the ground as if shot; sensibility and the power of motion are abolished, and no signs of vitality are apparent to the ordinary observer, with the exception of the slow and labored action of the heart and respiratory muscles. The breathing is stertorous, the lips and cheeks are puffed out with each expiration, and the pupils are generally largely dilated and insensible to light. Reflex movements are abolished at first, but after a few moments they reappear, and are even more readily excited than in health, owing to the fact that the controlling1 influence of the brain is removed. 68 DISEASES OF THE BRAIN. The voluntary power of swallowing is lost, but it is usually not dif- ficult to cause contraction of the muscles of deglutition by excitation of the pharynx. When these cannot be produced, the prognosis is, if possible, increased in gravity, for the reason that the extravasation is probably in the medulla oblongata, or so situated as to compress it. » The urine and faeces are often evacuated involuntarily. *"*"~~~An apoplectic attack of this character usually terminates in death > ■> • without the patient recovering his intellect in the slightest degree. If 'ftjVrilLs ^e should be prolonged for thirty-six hours, the probability of a fatal termination is materially lessened. I have never seen a case of cerebral haemorrhage that was instantaneously fatal, and, although from ana- tomical and physiological considerations I admit the possibility of such instances, I am persuaded that they must be rare. Jaccoud-1 expresses the opinion that death is immediate in those cases in which the haem- orrhage is in the medulla oblongata, or in those which occur in both hemispheres. Dr. Hughlings Jackson,8 on the contrary, though conced- ing from theoretical grounds that haemorrhage into or near the me- dulla oblongata might cause instant death, has never witnessed such a termination; and Dr. Wilks3 says that apoplexy is very rarely, if ever, a suddenly fatal disease, no matter what part of the brain may be the seat of the effusion. Among the reports of several thousand post- mortem examinations at Guy's Hospital, there was but one in which death was asserted to have been instantaneous, and that was a case of meningeal haemorrhage. Even this was doubtful, for the patient had fallen some distance from the hospital, and was brought in dead. I have several times had cases under my observation in which, it was said, death had been as sudden as though the individual had been struck by lightning ; but careful inquiry and post-mortem examination have either shown that the observers were deceived, or that there had been no extravasation at all, death being the result of heart-disease. Nevertheless there are instances on record in which haemorrhage into the medulla oblongata has produced death with as much sudden- ness as any other possible cause. Ollivier4 cites a case which came under his observation at the Salpetriere: "Batandier (Jeanne Elisabeth), aged sixty-four, of medium height, and inclined to stoutness, was admitted to the Salpetriere, for attacks of hysteria, with which she had been affected since her seventeenth year, when her menses appeared. These attacks were very violent, and occurred at each menstrual period. They stopped during a single pregnancy at the age of thirty years, and disappeared altogether at 1 " Trait6 de pathologie interne." Paris, 1870. Tome premier, p. 166. 2 " On Apoplexy and Cerebral Haemorrhage." " Reynolds's System of Medicine." Lon- don, 1868. Vol. ii., p. 520. 3 " Guy's Hospital Reports," 1866, p. 178. 4 " Traite des maladies de la moelle epiniere." Troisieme Edition, Paris, 1837, tome ii., p. 140. CEREBRAL HEMORRHAGE. QQ forty, when her menses ceased. Her intelligence had not become seriously impaired; she had full power of speech, but complete deafness, existing since infancy, rendered this faculty almost useless to her, and she accordingly communicated with others by means of signs. She was very irascible, her gait was irregular, but nevertheless there was no paralysis. In all other, respects her health was good. On the 28th of October, at mid-day, while in the midst of a group of women, she be- came very angry, uttered a cry, leaned against the wall, and then fell to the ground. She was raised up, but was dead. " Autopsy forty hours after death. . . . The sinuses of the dura mater were gorged with blood, the pia mater was strongly injected, and easily detached from the cerebral substance ; the middle lobe of the brain presented a well-marked depression ; the brain was firm, and of good consistence; the hemispheres, carefully examined, presented a de- cided injection of both the white and gray substance, but no haemor- rhagic foyer, old or recent; the ventricles were empty, the choroid plex- uses thin and granular ; the optic thalami and corpora striata healthy. " After having divided the spinal cord below the medulla oblongata, and having removed the medulla oblongata with the cerebellum, and the pons Varolii, a sanguineous clot, irregularly round, and the size of a walnut, was discovered adherent to the posterior part of the medulla oblongata, and extending above as far as the opening into the fourth ventricle, which it entirely closed. The pyramids were not injured, but the olivary bodies were partly destroyed, the right more than the left. The restiform bodies were entirely detached, and were found in frag- ments in the middle of the clot. The clot was removed and the source of the haemorrhage was discovered to be in the central gray substance, four or five lines below the inferior border of the pons Varolii, which was a little softer than normal, but which in other respects appeared to be healthy, as did also the cerebellum. An enormous quantity of san- guinolent serous fluid filled the spinal canal, and flowed out in part from the foramen magnum, and in part from the opening made in the spine for the examination of the cord, which was healthy and non-injected. " Both lungs were gorged with black blood, but presented no traces of emphysema; the right cavities of the heart were filled with black blood, but the organ was healthy. " All the abdominal organs were in a normal condition." Ollivier remarks, in reference to this case, that death was as instan- taneous as though produced by a sudden luxation of the first or second vertebra. Dr. A. Charrier x has reported the case of a woman who, on the twelfth day after delivery, died instantaneously. At the evening visit, while talking, " she suddenly uttered a cry, turned over on her pillow, and was dead. Death was as instantaneous as though she had been 1 "Hemorrhagic du bulbe rachidien." Archives de physiologic, 1869, p. 660. 70 DISEASES OF THE BRAIN. struck by lightning." At the autopsy a small clot was found in the centre of the medulla oblongata. The rest of the brain and the heart were perfectly healthy. In the majority of cases attended with complete loss of conscious- ness, the course of the disease is not so rapid or hopeless as in the form just described. The patient falls, is comatose, breathes stertorously, and presents a similar general appearance; but after a time conscious- ness begins to return, and it is possible to partially rouse him from the condition of insensibility. He turns over in the bed, though with diffi- culty, and may attempt to speak. Articulation is, however, indistinct, for the muscles of one side of the face are paralyzed, and the tongue, from a like cause, is restricted in its movements. The paralysis is found to exist in the limbs of the same side, and involves the loss of sensi- bility, as well as of motion, though rarely to the same extent. In some exceedingly rare cases, perhaps not clearly understood, the paralysis of the limbs is on the opposite side to that of the face. A man thus af- fected was present at my clinic, in October, 1870, at the Bellevue Hos- pital Medical College. He was a patient under my charge at the New York State Hospital for Diseases of the Nervous System, and had been attacked several years previously. His history, as elicited with great care by my clinical assistant and resident physician of the hospital, Dr. Cross, was perfectly clear on this point. The facial paralysis presents several points of great interest in a diagnostic point of view. The affected side is incapable of expression, but, so long as the patient does not attempt any facial movements, scarcely any distortion is perceived. Should he endeavor to open his mouth to spit, or to puff out his cheeks, the paralysis is at once noticed. Owing to the fact that the antagonism of the muscles is destroyed, the face is drawn toward the sound side, the angle of the mouth being slightly depressed. It is remarkable, however—and the fact is of im- portance as a diagnostic mark between the facial paralysis of cerebral haemorrhage with hemiplegia and the simple facial paralysis from injury or disease of the seventh pair—that the patient does not lose the ability to close the eye of the affected side. If the fifth pair of nerves is involved in the lesion, sensibility is im- paired, which is never the case in simple facial paralysis, and the mas- seter and pterygoid muscles, which receive their motor influence from this nerve, will consequently be paralyzed. The ability to masticate on the affected side is therefore lost, and the cheek hangs lower than on the sound side. The tongue is also only paralyzed upon one side. When, therefore, it is protruded from the mouth, the point deviates toward the paralyzed side, owing to the uncompensated action of the sound genio-hyoglossus. All these paralyses occur on that side of the body opposite to the seat of the lesion. In a very few instances the paralysis has existed on CEREBRAL HEMORRHAGE. 71 the same side with the lesion. This is explained by the fact that it oc- casionally happens, as Longet1 states, that the decussation of the an- terior columns of the cord is imperfect. At times, again, owing to a double extravasation, or to the fact that the lesion is in the mesial Hne of the pons, or that it forces its way so as to involve both hemispheres, both sides of the body are deprived of motion. Very inexact ideas have prevailed relative to the temperature in cases of cerebral haemorrhage. The researches of Bourneville2 have given us more certain data than we previously possessed, and, aside from their value as contributions to symptomatology and pathology, are of great importance in the matter of prognosis. This observer, as the result of numerous determinations, arrived at the following conclusions: -^ That the animal temperature, in the very inception of the apoplectic £' attack, undergoes a very considerable reduction, the thermometer in the rectum indicating 36° (=96.8° Fahr.), and even sometimes falling as low as 35.4° (=95.72° F.). This reduction seems to be influenced par- ticularly by the continuance of the haemorrhage and the supervention of additional centres of extravasation. To this period of temperature- depression succeeds another, during which the animal heat remains, sta- tionary at its normal point. If the patient is destined to recover, this period is prolonged indefinitely; but, if death is to ensue, a third period, characterized by a remarkable elevation of temperature, supervenes. During this stage the thermometer indicates 40° (= 104° Fahr.), or may rise to 41.5° (= 106.7° Fahr.). Charcot * has called attention to the fact that, in a few cases of cere- bral haemorrhage, an acute bed-sore forms on the buttock of the para- lyzed side. From the second to the fourth day after the occurrence of the attack, an erysipelatous redness of irregular outline occupies the buttock, and frequently extends over the greater part of its surface. Within forty-eight hours a dark-colored spot appears on the central portion, and the epidermis of this is raised by the sanguinolent fluid be- neath it. This vesicle breaks, and a sore is thus formed, which gradu- ally extends. Occasionally but very rarely the sore occurs on the sound buttock. I have only witnessed two cases in which these sores were formed, and both were in persons over seventy years of age. Of course, these eschars are not to be confounded with the bed-sores due to long- continued pressure. It is rarely the case that the third nerve is affected. When it is, there is external strabismus from paralysis of the internal rectus muscle, and ptosis from paralysis of the elevator of the upper eyelid. The pupil is dilated, and is insensible to light. 1 " Anatomie et physiologie du syst&me nerveux," tome i., p. 383. 2 " Etudes cliniques et thermom^triques sur les maladies du systeme nerveux." Paris, 1872, p. 116. 8 " Sur la formation rapide d'une eschare a la fesse du cote" paralyse" dans I'h6mipl6gie r6cente de cause cer6brale." Archives de physiologie, 1868, p. 308. 72 DISEASES OF THE BRAIN. Another phenomenon is sometimes observed, and that is the rotation of both eyes toward the sound side. This is accompanied by a like movement in the head, so that, if the patient is paralyzed on the left side, the eyes and head are turned to the right, and consequently, as the patient lies in bed, the right side of the face rests on the pillow. I have observed these symptoms in about one-third of the cases of cere- bral haemorrhage which have come under my observation. They were present from the very beginning, and disappeared in a few days. Slight convulsive or involuntary movements are occasionally noticed. The most frequent of these is yawning, a symptom which Dr. Todd' regards as troublesome, and even unfavorable, but which, in my experi- ence, is not very annoying or dangerous. The other convulsive actions may be on the whole of either side of the body, or on both sides, or may be restricted to a single limb or even a group of muscles. Reflex movements are at first sometimes abolished, but subsequently can generally be excited, especially in the lower extremity, by tickling the sole of the foot. Deglutition, though imperfect, can generally be made to take place by reflex action, unless, as previously stated, the haemorrhage is in, or in the vicinity of, the medulla oblongata. Strong tonic contractions of the muscles of the paralyzed limbs are occasionally a prominent phenomenon. The upper extremity is more apt to be their seat than the lower, and the biceps and triceps muscles are especially liable to be thus affected. This condition may exist at the very beginning of the seizure, or may subsequently supervene. Few systematic authors have noticed the symptom in question—a symptom which is not to be confounded with the secondary contractions coming on several weeks after the attack, and the origin of which is altogether different—attention seems to have been first called to it by Boudet,2 but Durand-Fardel3 studied it more thoroughly, and was the first to determine its connection with a definite lesion. According to this later author, primary contraction is only present in cases of cere- bral haemorrhage, when the extravasation reaches the ventricles or the subarachnoidal space. So long as the blood remains circumscribed in the cerebral tissue, there are no contractions either in the paralyzed or the non-paralyzed limbs. Of twenty-six cases of cerebral haemorrhage, in which death ensued within one month, and in which the ventricles or the meninges had been invaded, there had been, in nineteen, contractions of the paralyzed members; in three, contractions of the sound limbs- and in four, resolution without contraction. Charcot,* in fourteen cases 1 " Clinical Lectures." Second edition. London, 1861, p. 708. 8 " Memoire sur l'h6morrhagie des meninges," Journal des connaissances medico- chirurgicales, 1839. 8 " De la contraction dans l'hemorrhagie c6rebrale." Archives generates de medecine 1843, tome ii., p. 340. Also "Maladies des vieillards." Paris, 1873, p. 225. 4 " Nouvelles rdcherches sur la pathogenie de l'hemorrhagie cerSbrale." Archives de ohysiologie, 1868, p. 110. CEREBRAL HAEMORRHAGE. 73 of ventricular or meningeal invasion, noticed contractions in eleven, and in two epileptiform convulsions. The contractions take place whether the membranes be distended by the clot, or whether rupture ensues. In the less severe apoplectic form of cerebral hasmorrhage now under consideration, the urine and faeces are sometimes passed involuntarily from paralysis of the sphincters, and are at times obstinately retained from paralysis of the bladder and abdominal muscles. The mental symptoms are at first scarcely distinguishable from those which are present in the severest form of the disease. The coma and insensibility are complete, but after a time, which varies in duration with the extent of the lesion, consciousness begins to return. The pa- tient opens his eyes, and gives a little attention when loudly spoken to; and is perhaps able to express, to some extent, his wishes by signs and gestures. Gradually the mental power increases; he attempts to speak, but his words are misplaced or forgotten, and his articulation, owing, as already stated, to the paralysis of the face and tongue, is thick and indistinct. Those words which are enunciated by the movements of the lips and tongue are especially troublesome, while those formed in the throat are not difficult to pronounce. The mental characteristics of the patient will be found to have un- dergone a radical change. He is irritable, unreasonable, and fretful. His sense of the proprieties of life, which may in health have been very delicate, becomes obtuse; his memory is notably impaired, and his rea- soning power greatly diminished. The greatest change, however, is perceived in the emotional faculties. He laughs at the veriest trifles, and sheds tears profusely at the least circumstances calculated to annoy him. Even for years afterward this peculiarity is noticed. Such is the first stage of an attack of cerebral hasmorrhage marked by apoplexy and paralysis, as ordinarily observed when amendment takes place. It is often the case, however, that this stage is not fully developed, owing to the continuance of the hasmorrhage. In such an event the coma becomes more profound, the breathing more irregular and less frequent, the pulse intermits and loses in force, the face be- comes purple from imperfect aeration of the blood, and death ensues. In other cases a certain degree of improvement may be attained, and then the hasmorrhage may recur, and the patient dies comatose. In a few cases which I have had under my charge, the first symptom observed has been intense pain in some part of the head. This has been quickly followed by nausea and the ejection of the contents of the stom- ach. There have also been slight wandering of the mind, and a disposi- tion to stagger in walking. These phenomena have persisted for from four to six hours, and then the patients have gradually passed into a comatose condition, with general resolution of the limbs. Death has ensued within twelve hours after the beginning of the symptoms. In one of these cases, that of a gentleman of this city, he had remarked to 74 DISEASES OF THE BRAIN. me, at six o'clock in the evening, that he was feeling remarkably well all day. For several years he had suffered from cerebral hyperasmia, the result of continued and severe mental application. At about eight o'clock he was seized with the most agonizing pain in the head, at- tended with intense nausea. Repeated vomiting took place, and there had been slight delirium and momentary periods of forgetfulness. My friend Dr. Lente, of Cold Spring, who was in my house at the time, went with me to see him, in response to his message that I would call. We found him as above described; and, as he was firmly convinced that his stomach was at fault, an emetic of salt-water was given him. It acted promptly, but without affording him the least relief. A hypoder- mic injection of a third of a grain of sulphate of morphia was next ad- ministered, but without benefit; and this was followed by a similar quantity after half an hour. He then thought he might sleep a little, but the pain continued. An hour afterward I left him, being of the opinion, in which Dr. Lente shared, that he was either suffering from a cerebral tumor or an extravasation of blood. Two hours afterward I was again sent for. He was then comatose, the limbs in a state of resolution, the breathing of that loud, rauchous character, and the heart beating with the irregularity so indicative of effusion into, or in the neighbor- hood of, the medulla oblongata. Deglutition could not be excited by sub- stances placed in the mouth. The right pupil was strongly dilated, while the left was a mere point. Death ensued within two hours afterward. The post-mortem examination was made the next day by Dr. S. D. Powell, in presence of Drs. Lente, Ripley, Elsberg, and myself. A clot the size of a small orange occupied the posterior part of the middle and central portion of the right lobes. It was entirely confined to the white substance. Another, about as large as a hickory-nut, was situ- ated in the right half of the pons Varolii. In all probability the clot in the right hemisphere began to form first, and that the second, into the pons Varolii, which was the immedi- ate cause of death, did not originate till a considerably later period, in- dicated by the disturbances in the respiration and circulation, and the impossibility of exciting deglutition. In those cases in which the improvement has been progressive up to the point of partial resumption of the mental faculties, we find that a second stage characterized by different symptoms often supervenes. This is the period of inflammation. It may begin at a variable time after the occurrence of the extrava- sation, usually not later than the eighth day. It is marked by febrile excitement and pain in the head, the latter being often very severe. There is gastric derangement, as evidenced by nausea and vomiting ; and convulsive movements of the limbs, with contractions of the flexors of the paralyzed side, are generally present. Delirium is also a promi- nent feature. Sometimes there is obstinate wakefulness, and at others CEREBRAL HEMORRHAGE. 75 a strong tendency to coma. This stage may last three or four days, or at most five or six, when it either causes death by extension of the in- flammation from the immediate vicinity of the lesion to other parts of the brain, terminates in the formation of an abscess, or gradually ends in resolution, with abatement of the symptoms. Disregarding for the present the first two of these results, we proceed with the consideration of the phenomena of a case in which resolution takes place. With the cessation of the inflammatory action, the improvement of, the patient becomes very marked. His speech is every day more dis- tinct, his mind more active, his paralyzed limbs more capable of motion. Usually the leg recovers power with much greater rapidity than the arm, and thus the patient is able to walk tolerably well before he can raise his arm from his side, bend the elbow, or extend the fingers. The paralysis in the leg is most marked in those muscles whose office it is to elevate the foot, and this necessitates a peculiar gait in order to avoid dragging the toqs along the ground. The abductors are rarely affected to any great extent. The patient in walking, therefore, throws the leg out from the body, and then, swinging it around, clears the ground in this manner. In the upper extremity there is almost invariably a disposition tow- ard contraction of the pectoralis major and minor muscles, by which the arm is drawn across the front of the thorax. At the same time the latis- simus dorsi, the trapezius, the rhomboidei, the teres major and minor, are generally in a state of relaxation, and eventually tend to atrophy. The elbow is slightly flexed, the wrist bent upon the forearm, and the fingers drawn in toward the palm of the hand. These actions may, in a great measure, be prevented by appropriate treatment, and they may vary in extent according to the gravity of the attack. It is a curious fact that the muscles of respiration are never paralyzed in cerebral haem- orrhage unless the medulla oblongata be involved. Trousseau' has insisted, with great force, on the fact that, when the arm regains power before the leg, the termination is always fatal. That this is the general result, I am very sure from my own experience, but it is not invariable, for there are now in the New York State Hospital for Diseases of the Nervous System two patients affected with cerebral hasmorrhage whose arms have improved to a very great extent, while the legs are still as much paralyzed as ever. Now, with all these troubles of motility, sensibility may likewise be involved to a greater or less extent. When this is the case, the limbs of the affected side at first feel heavy as if made of lead, and after a while numbness, as exhibited by a feeling as if ants were crawling over the skin, or water trickling over it, as if pins and needles were sticking in it, or as if that part of the body were " asleep," is noticed. Sometimes the 1 " Lectures on Clinical Medicine." Bazire'sTranslation. Parti. London, 1866, p. 16. 76 DISEASES OF THE BRAIN. sense of touch is greatly lessened, while the ability to feel pain is scarcely impaired, and indeed is often considerably increased. Again, there may be hyperaesthesia of the skin of the affected regions, and pain along the course of the nerves. The circulation is inactive in the paralyzed limbs, and this, together with the deficient nervous power, tends to cause a permanent reduction of temperature. The difference may amount to as much as five or six degrees, and, as the ability to resist cold is diminished, the patient is obliged to use additional covering on the paralyzed members. From continued disuse, atrophy of the paralyzed muscles always takes place unless suitable treatment be begun at an early period. Thus far we have only considered those attacks of cerebral hasm- orrhage which are accompianed with unconsciousness. One of these forms kills, without the patient so far recovering as to show whether he is paralyzed or not, though of course he is so to a profound degree ; the other allows of more delay ; the brain can still act to some extent, and, if death does not ensue from continuance of the haemorrhage, the pa- tient is found to be paralyzed on the side of the body opposite to the seat of the brain-lesion. One other form requires notice, and it is, per- haps, the one most frequently met with. It differs from the attacks just described, in the important fact that it is unattended with unconscious- ness. Like the others, this species of cerebral haemorrhage may take place very suddenly, without premonitory symptoms, or it may, like them, happen while the patient is said to be asleep. Generally, however, though there may be no long prodromatic stage, there are symptoms occurring immediately before the attack which indicate both mental and physical disturbance. These are headache, vertigo, numbness, vomiting, irrita- bility of temper, and, perhaps, slight difficulties of speech. When the attack comes, the individual, if standing, falls, from the immediate paralysis of one leg. He is fully sensible of his condition, although there is generally more or less mental change. The arm and face are affected, and the speech is rendered impossible or indistinct. If the patient be sitting or lying, he is aware that something has happened, but does not discover its exact character till he attempts to rise. A distinguished general officer of the army, after a fatiguing day of ceremony, entered his carriage with his wife, to be driven to his hotel. As he passed along Fifth Avenue, he felt an indescribable sen- sation, and immediately afterward noticed that he could only see the half of objects. He made no effort to speak, though he is confident he did not for a moment lose his consciousness. When he attempted to get out of the carriage, he found, to his surprise, that he was paralyzed on the right side, and that his speech was so much impaired that he could not be understood. Another gentleman was reading an amusing book, at which he CEREBRAL HEMORRHAGE. 77 laughed heartily. He felt suddenly a feeling of vertigo, and the book dropped from his hand. He attempted to pick it up, but found he had lost power in the arm, and, on trying to call to his wife, who was in the same room, discovered that he could not speak. At this time he could walk, but in a moment or two afterward he fell, from paralysis of his leg. So far as the paralysis is concerned, I have rarely seen a more severe case than this. x\nother went to bed, perfectly well, to all appearance, having en- joyed uninterrupted good health for several years. In the morning he arose, but felt a little pain in his head. As he stood before his glass, he thought his face was slightly twisted, and he noticed as he was shav- ing himself that he did not feel the razor on one side. While he was testing his facial mobility and sensibility, he experienced a trace of numbness in his left hand. This gradually increased, and in addition the limb lost power. In a few minutes he could not move it at all. By the time I saw him—two hours afterward—the paralysis had ex- tended to the leg. At no period was there insensibility or mental confusion. A gentleman retired at night in good health. On attempting to get out of bed he discovered that he was paralyzed in the leg. Neither the arm nor the face was affected. In the case of a gentleman of this city whom I saw in consultation with Dr. W. M. Polk, and who had for several years suffered from fre- quent severe headaches and other cerebral symptoms, the only phe- nomenon was binocular hemiopia, with occasional slight delirium. Dr. H. Knapp, who saw the patient before I did, discovered no alterations in the functions or structure of the eye, and we all agreed that the case was one of very slight cerebral haemorrhage. Several cases have been under my care in which only the face or the tongue was paralyzed; others in which the arm alone was involved; and others, like the one just mentioned, in which the symptoms were con- fined entirely to the leg. Sometimes there was a momentary feeling of vertigo, sometimes a vacant stare, something like that of the petit mal of epilepsy, sometimes a slight degree of intellectual confusion, some- times headache, and, again, no head-symptoms whatever. The sub- sequent progress of such attacks requires no special consideration beyond that already given to the more severe forms. Now, no matter how light the attack may have been, nor how rapid the improvement, the patient who has had cerebral haemorrhage is never mentally or physically the same as he was before. If the seizure has not been severe, he may advance so far toward a complete cure as to evince very little disorder of his mind or body. But close observation shows that he is not entirely restored, and, though he may do very well for light intellectual and physical exertion, severe labor of either kind is beyond his powers—and no one is more sensible of this fact than himself. Even 78 DISEASES OF THE BRAIN. after years his emotions are abnormally excitable. A patient now in the New York State Hospital for Diseases of the Nervous System in- forms me that he sheds tears every time a funeral passes him, and that even hearing of any one's death, or reading the obituary column in a newspaper, causes his feelings to get the better of him. In the lightest forms of the attack, this easily-aroused emotional disturbance is a marked feature for years subsequently, if it ever entirely disappears. And as regards the muscles which have been paralyzed, it is very certain that, though they may be made strong enough for all practical purposes, they never can be restored to their former sound condition. The character and general mental type of the individual usually undergo some change ; and this may be to the extent of reversing his ordinary traits. Causes.—Advanced age is one of the most influential circumstances which predispose to an attack of cerebral hemorrhage, and this fact has long been known. Thus Hippocrates1 states that apoplexy is most 5^/ common between the ages of forty and sixty, and modern investigation 0 ; establishes the truth of the proposition as regards the actual number of cases. It is probable, however, that the liability increases, as Dr. Flint2 | says, from the age of twenty upward, and that there are not so many cases occurring in persons over sixty as below, for the reason that the number of individuals alive of that age is less. Of three hundred and eighty-three cases of cerebral hasmorrhage which have been under my professional care, at some time or other after the occurrence of the extravasation, in my private and hospital practice, and in which the age of the patient is noted, three hundred and forty- one occurred in persons over forty years of age. Of these, three hun- dred and eleven were between forty and sixty, thirty-three between sixty and seventy, five between seventy and eighty, and three over eighty. Of the thirty-one cases in persons under forty, twenty were between i forty and thirty, ten between thirty and twenty, and one under twenty. This latter was a boy of seventeen, whom I exhibited at my clinic at ^the Bellevue Hospital Medical College in the autumn of 1870. ~ The disease is certainly more common among men than women, y, though some authors have asserted the contrary. Falret ascertained ? that, of twenty-two hundred and ninety-seven cases, sixteen hundred and sixty occurred in males and only six hundred and thirtv-seven in 1 females. In my own experience, of three hundred and eighty-three , cases, two hundred and fifty-nine were in males and one hundred and \ twenty-four in females. Temperament and organization are supposed to have an influence ! in predisposing to cerebral hasmorrhage. It was formerly thought that 1 " Aphorisms," chapter vi., aphorism 67. 9 " A Treatise on the Principles and Practice of Medicine." Third edition Phila- delphia, 1868, p. 582. CEREBRAL HEMORRHAGE. 79 those of sanguine temperament and plethoric habit who had stout bodies, large heads, florid complexions, and short, thick necks, were especially liable ; but more exact and thorough investigation would appear to show that such is not the case, and that thin and pale individuals show fully ; as great a proclivity. Dr. Flint * expresses the opinion that there is no / special apoplectic constitution, and my own experience is decidedly to/ the same effect. That the tendency to cerebral hasmorrhage is often hereditary, ;, appears to be very certainly established. Within my own knowledge, I am aware of several striking instances which support this opinion. A gentleman consulted me for hemiplegia, the result of cerebral hasmor- rhage, whose grandfather, father, two uncles, two brothers, and one sister, had died of this disease, and whose son, thirty-six years of age, had been attacked. In another case a lady had her father, two broth- ers, and one sister, die of the disease ; and, in a third very remarkable j case, the great-grandfather, grandmother, father, four uncles and aunts, and two brothers, all in a direct line, died of cerebral haemorrhage. Piorry2 cites the case of a woman, herself paralytic, whose three ' children had died of convulsions, and whose mother, uncle, and brothers j and sisters, to the number of twelve, had died of cerebral hasmorrhage or convulsions. It has very often happened in my experience that the father or mother of a hemiplegic patient, whose condition resulted from cerebral hasmorrhage, had been affected in a similar manner. As regards the influence of diseases of the heart, Legallois, Briche- teau, Rostan, Andral, and Bouillaud,3 adduce instances in support of the existence of a definite relation. While others, among whom Rochoux, Walshe, and Flint, are to be placed, deny the existence of any such causa- tive influence. As tending to produce active or passive cerebral conges- tion, disease of the left or right side of the heart would reasonably seem to be conducive to the occurrence of cerebral hasmorrhage. The tension of the blood in the vessels of the brain is increased thereby, and the liability to the rupture of a diseased vessel rendered greater. The condition of life has also been supposed to exert an effect in predisposing to cerebral hasmorrhage, it being asserted by some au- thors that the affection is much more common with the rich, and those living in ease, luxury, and refinement, than in the poor and laboring classes. It is difficult to arrive at any very definite conclusion on this point, owing to very obvious reasons, but I am inclined to think the theory to be not well founded. It is only necessary to visit our large hospitals, to see how many of the inmates, drawn as they generally are from the laboring classes, are suffering from cerebral haemorrhage or its effects. Thus far we have only considered the more important, intrinsic, 1 Op. cit., p. 683. 2 " De l'hSredite dans les maladies," p. 107. 3 " Traite de clinique des maladies du coeur," second edition, tome ii., p. 580. 80 DISEASES OF THE BRAIN. predisposing causes ; there are, however, others which may be called extrinsic. Season is one of the chief of these. The disease is much more common in winter than in the other seasons, although some statistics would seem to show more cases during summer. A careful examination of such, however, shows that under the head of apoplexy is included not only cerebral hasmorrhage, but congestion, sunstroke, embolus, and in fact nearly every other affection attended with sudden loss of con- sciousness. My own researches have been very exact on this point, and as their results I find that, of the three hundred and eighty-three cases of which I have notes, one hundred and forty cases occurred in winter, eighty-one in spring, ninety-seven in summer, and fifty-eight in autumn. It has been noticed, too, that sudden variations of temperature, especially from mild to cold weather, increase the number of cases of cerebral hasmorrhage. Of the exciting causes, a long list can readily be made. Among them are the excessive use of alcoholic liquors and other stimulating substances; the use of opium in excess ; the ingestion of large quantities of food, especially such as is stimulating and indigestible ; excessive physical or mental exertion, strong emotional disturbance, such as anx- iety, extreme joy, anger, or terror ; the act of coition, especially in old people ; straining at stool; enlarged prostate, or paralysis of the .bladder, requiring strong muscular efforts for the evacuation of the urine ; childbirth; tight clothing about the neck, chest, or abdomen ; certain occupations which require the head to be depressed ; vomiting, sneezing, coughing, and laughing ; exposure to the direct rays of the sun or other sources of great heat; the sudden arrest of a custom- ary flux, such as hasmorrhoidal bleeding; the stfdden application of cold water to the body ; long-continued bathing in very warm water ; the circumstance that the patient has had a previous attack, and certain diseases, as gout and syphilis. In regard to some of these causes, I may state that several very in- teresting cases have occurred in my own practice. In one, a lady was attacked on hearing that her cook had left her; in another the emotion excited by the fall of a picture from the wall caused a seizure. Four cases produced by straining at stool have come under my observation. In one of them a gentleman well known in public life retained sufficient consciousness and intelligence to take a large key out of his pocket with the non-paralyzed hand, and to rap on the floor for assistance. Two cases occurred during sexual intercourse, one in a man, the other in a woman. In one of these there was, subsequently, a great increase of venereal desire. In one case, the seizure was induced by stooping over to tie the shoe. This was in the boy, seventeen years of age, already mentioned. It must be confessed, however, that very fre- quently, perhaps in the majority of cases, no immediate cause can be CEREBRAL HEMORRHAGE- 81 reasonably alleged. Of the three hundred and eighty-three cases noted by myself, no cause was noted in two hundred and ten.' Relative to the influence of sleep, I am by no means in accord with those authors who regard it as a powerful exciting cause. During sleep the quantity of blood circulating in the cerebral blood-vessels is dimin- ished, and hence there is less tension upon their walls than during wake- fulness. I doubt very much whether cerebral haemorrhage ever occurs during healthy, undisturbed sleep. But there is a condition which supervenes upon sleep, and which, to ordinary observers, presents the usual phenomena of sleep, but which is really a very different state, both as regards the brain and the symp- toms—and that is stupor due to venous congestion. In this affection there is an increase of the pressure upon the brain, produced by the over- distended vessels; and hence coma, to some extent, ensues. This state is characterized by difficulty of awaking the individual, by turgescence of the larger veins of the neck, by a more or less purple hue of the face, by snoring, and by the puffing out of the lips and cheeks in breathing. Both of these latter phenomena are due to paralysis. In this condition it is not unusual for cerebral hasmorrhage to occur, but the existing state is not sleep. So far as my own experience extends, I have not found a majority of the cases, where I have examined into this point, to have taken place either during sleep or the stupor to which I have referred. I have made it a rule, not only in those cases of cerebral hasmorrhage which have been under my own care, but all others, in which I could do so, to inquire particularly with reference to the matter in question, and have found that, in three hundred and eighty-five out of four hundred and sixty- seven cases, the individuals were awake at the time of the attack. Doubtless much of the confusion has arisen, not only from the non- discrimination of sleep from stupor, but also from treating of apoplexy as a disease instead qf regarding it as a symptom due to several very different pathological conditions of which cerebral hasmorrhage is only one, and of which embolism, thrombosis, congestion, meningeal haem- orrhage, and epilepsy, are others. Finally, it may be said of the etiology, that whatever tends to in- crease the flow of blood to the head, or to retard its exit, is capable of acting as an immediate cause of cerebral hasmorrhage. Diagnosis.—The diagnosis of cerebral hasmorrhage is ordinarily not difficult, but it must be confessed that" one or two affections are very liable to be confounded with it, and the attendant circumstances sur- rounding a patient in a condition of insensibility may be such as to materially increase the obstacles to the formation of a correct opinion. Thus, supposing an individual to be found in a state of profound in- sensibility, the condition may be due to compression from injury of the skull, to concussion from a fall or blow, to congestion, to asphyxia, to 6 82 DISEASES OF THE BRAIN. syncope, to a recent epileptic fit, to uraemic intoxication, to hysteria, to narcotism, or to drunkenness. A mistake of. either of these states for cerebral haemorrhage would be, in the end, embarrassing to the physician, and perhaps injurious to the patient. The coma might also be the result of embolism, of thrombosis, of tumor, of abscess, or of meningeal hasmorrhage ; but, as regards these conditions, no opprobrium could be attached to the physician, or harm come to the patient, by any error of diagnosis, although a regard for scientific exactness should always prompt us to be as specific as possible in our inquiries and examinations. From asphyxia, cerebral haemorrhage is distinguished by the fact that in the former the respiration is suspended. The cause is often apparent. A careful examination of the cranium, and a survey of the surrounding circumstances, will enable the physician to ascertain the existence or non-existence of compression from traumatic cause. This cause may either be depression of bone, the rupture of an internal blood-vessel, or the entrance of some foreign body, as a bullet, into the interior of the skull. So far as symptoms are concerned, there might be considerable difficulty in diagnosticating either of these accidents from cerebral haemorrhage, but the history would render a mistake im- possible. Concussion presents more difficulties, because the comatose person may be found in such a situation as to warrant the opinion that he has fallen from a height, or otherwise received a blow on the head, when in fact he is suffering from cerebral haemorrhage. But if he has fallen from a height or been struck, there will probably be more severe bruises about his person than if he is affected with cerebral haemorrhage, and there may be bleeding from the ears or nose—symptoms of cranial injury not met with in the latter condition. If, however, the individual has fallen from a height, he may have done so in consequence of an extravasation of blood in his brain, and he may present all the marks of suffering simply from the concussion, or he may have fractured skull with compression. It is, therefore, im- possible to make a correct diagnosis in all cases, or to lay down any certain rules which will constitute infallible guides. It is perfectly possible to meet with cases such as those referred to, in regard to which no human judgment can be certainly correct. Such instances are of course rare, and accordingly, in the great majority, the circumstances and the presumption will generally lead to a correct opinion. From congestion of the apoplectiform variety cerebral hasmorrhage can generally be distinguished without much difficulty. The absence of stertorous breathing, the short duration of the coma, the transient character of the paralysis, the contraction of the pupils, the fact that the loss of sensibility and the power of motion are not generally confined CEREBRAL HEMORRHAGE. 83 to one side of the body, and the longer continuance of premonitory symptoms, will be sufficient indications of the existence of congestion. Syncope is distinguished by the circumstances that the respiration and circulation are both diminished in power if not suspended, that there is no hemiplegia, that the face is pale, the skin cold, and that these phe- nomena are all transitory in character. The history of the case will also assist us in arriving at a correct judgment. Epilepsy, if seen from the beginning of the paroxysm, cannot be mistaken for cerebral haemorrhage, nor this latter for epilepsy, if the onset of the attack has been witnessed. Even if there are convulsions present in the apoplectic seizure, the error could not readily be com- mitted if attention be paid to the attendant phenomena. For there is no biting of the tongue, the convulsions are persistent, and the animal heat is lowered, whereas in epilepsy the temperature rises at once and remains high—105° Fahr. or thereabouts, during the convulsive stage. But the person found in a comatose condition, with no previous history to guide us, may be supposed to be either in the comatose stage of an epileptic paroxysm, or to be laboring under a seizure due to extravasa- tion of blood. In such a case, if the fit has been epileptic, foam will be found around the mouth, and perhaps blood from injury of the tongue or cheek. Moreover, the stupor of epilepsy is not usually of long duration, and is not generally characterized by stertorous breathing. In uraemia, the coma of which is very similar to that resulting from cerebral haemorrhage, the history of the case is our chief reliance for a correct diagnosis, though the absence of hemiplegia and the general presence of anasarca are of course of great value. Moreover, in very doubtful cases the urine may be drawn off by the catheter, and exam- ined for albumen and tube-casts. If these are present, the probability of the stupor being due to Bright's disease and uraemic intoxication is very much increased. The fact, also, that in uraemia there is a pro- gressive fall of the animal temperature—as low as 91.5° Fahr. being reached — and that there is no subsequent elevation, are important points in this connection. Coma is sometimes a manifestation of hysteria, but a very little acquaintance with the phenomena of this condition will suffice to pre- vent mistakes. In some cases of hysterical coma there is well-marked hemiplegia; but even when this complication is present, the facts that the hysterical diathesis exists, that there have probably been other mani- festations of hysteria, that the pulse is small, weak, and frequent, and that the breathing is free from stertor, will enable a correct diagnosis to be formed. In narcotism the condition often bears a close resemblance to that due to cerebral hasmorrhage. But in the former there is no hemiplegia, the pupils are generally contracted, the respiration is not stertorous, and the coma comes on gradually. 84 DISEASES OF THE BRAIN. Drunkenness and cerebral haemorrhage are often confounded. I have known some sad mistakes of the kind to be made, both by professional and non-professional persons, many of which were unavoidable, for it must be confessed that there are great difficulties connected with the subject. The habit of drinking alcoholic liquors is so general that no reliance can be placed upon the test of smelling the breath. A person may have just taken a glass of wine or of brandy, and be seized with extravasation of blood in his brain immediately afterward, and when not in the least intoxicated. And, even if dead-drunk, he may at the same time have cerebral hasmorrhage. In such a case as the latter, discrimi- nation would be impossible. In ordinary cases of alcoholic intoxication the patient can generally be roused to some extent; the pupils are dilated, but this latter is often the case in haemorrhage; the breathing is usually free from stertor, but some drunkards always snore; the pulse is small and weak, and there is no hemiplegia. When all these symptoms are in accord, there will be little difficulty; when they are not, the physician must be guarded in his expressions of opinion, and diligently inquire into the personal characteristics of the patient and all matters bearing on the history of the case. From the centric diseases previously mentioned, the diagnosis of cerebral hasmorrhage is easy as regards some, and difficult as to others. Thus, from embolism it cannot in many cases be distinguished in the first stage. But when all the phenomena are taken into consideration the chance of error is very much diminished. Embolism is generally accompanied with disease of the left side of the heart, and there is often a history of rheumatism ; there are never any premonitory head-symp- toms ; it occurs in young persons as well as old ; for reasons which will be explained when the subject of partial cerebral anasmia from embolism is considered, the resulting hemiplegia is generally on the right side ; the paralysis generally disappears in a few hours after the attack ; if it does not, there is no gradual improvement, as in cerebral haemorrhage ; there are no contractions or partial convulsions,1 and there is more fre- quently delirium. The gradual development of the symptoms in thrombosis, tumor or abscess, and the frequency with which convulsions ensue in the latter diseases, together with the associated symptoms, will prevent the coma which sometimes exists being mistaken for the stupor of cerebral hasm- orrhage. During the subsequent stages of cerebral haemorrhage, when the mental condition and the hemiplegia are the most prominent features, inquiry into the antecedent history will bring out the foregoing points, and assist us in arriving at a correct idea of the cause. Even, however, 1 Jaccoud (op. cit., p. 141) so asserts, though I have seen one case in which post- mortem examination revealed the presence of an embolus in the middle cerebral artery, and in which there had been convulsions. CEREBRAL HEMORRHAGE. 85 should we be baffled in this respect, no great inconvenience could result either to the patient or physician. Prognosis.—The prognosis depends upon the extent or situation of the haemorrhage, and refers to the probability of saving Hfe during the period of attack and immediately afterward, and of curing or mitigating the subsequent paralysis. In the severe apoplectic form, death is almost inevitable; so far as my experience goes, it is the invariable result. It generally takes place within a few hours. If, however, life be prolonged till the fourth day, there is some hope. Irregularity of pulse, or one very rapid,-impossi- bility of swallowing, involuntary evacuation of the fasces, and cold sweats, render, if possible, the prognosis still more unfavorable. In the apoplectic form attended with paralysis, the gradual increase of the coma and hemiplegia indicate the continuance of the hasmor- rhage, and are consequently of grave importance. About one-third of those attacked with this form die. The prognosis is bad in proportion to the debility and age of the patient, and the circumstances under which the attack has occurred. Thus, if it has supervened in a person who has had no obvious exciting cause, the probability is that there is serious disease of the blood-vessels, whereas, coming on in a young per- son as the result of severe muscular exercise, or mental strain, the prog- nosis is more favorable. A second attack is more apt to prove fatal than a first, and a third than a second, and so on. In the mild form characterized by paralysis, but no loss of conscious- ness, the prognosis is generally favorable. It must be recollected, how- ever, that the risk of inflammation is quite great, both in this and the apoplectic form with paralysis, and that the patient is not safe from it till after the eighth day. And in both forms, if the temperature rise above 100° Fahr.; if the respiration be chiefly abdominal; if the patient is unable to swallow; and rattling of mucus is heard in the throat, the prospect of recovery is bad. The same may be said of pain in the head and contractions of the paralyzed muscles. If, further, as Bourneville has shown, the tempera- ture reaches 104° Fahr., death is inevitable. As regards the probability of recovery from the paralysis, much de- pends upon the opportunities the patient may have for receiving proper medical treatment. The tendency is generally toward amendment even in the worst cases. Gradually the speech improves, the breathing be- comes better, and the arm acquires more strength; but the improve-" ment often stops here, and never goes on unaided to complete recovery. The longer the paralysis has lasted, the less prospect there is of great progress under any treatment; and, if strong contractions producing distortions have taken place, the prognosis is unfavorable. Certain muscles recover better than others. The extensors of the 86 DISEASES OF THE BRAIN. foot and hand are especially intractable, but, as a rule, those of the lower extremity improve more rapidly than those of the upper. The mind ordinarily improves, pari passu with the physical symp- toms, though not always. I have witnessed several exceptions to the Tule. Even in slight cases the intellect may suffer to a great extent, and in no case is it ever in all respects as good as before the attack. Among the unfavorable signs are, persistent irritability of temper, fail- ure of memory, and the existence of delusions. Difficulties of speech, whether as regards the memory of words, or the ability to coordinate the muscles of speech, so as to pronounce them properly, are often very persistent. I have now under my care a gentleman who was attacked with cerebral hasmorrhage two years ago, whose physical powers are quite good, and whose mind is not seriously impaired, but who cannot yet remember sufficient words to carry on an ordinary conversation. When the difficulty is simply due to paralysis of the tongue and facial muscles, the prognosis is more favorable. Morbid Anatomy.—The seat of the extravasation from cerebral hasm- orrhage may be in the substance of the cerebral tissue,, or in the ven- tricles. The former is much the more common. Now, the blood, which is poured out from a ruptured vessel into the substance of the brain must, of course, occupy its place by separating or lacerating the fibres. It thus forms for itself a cavity, which en- larges as the haemorrhage goes on, until at last the resistance to further separation or laceration may be so great as to overcome the tension of the blood, and thus put a stop to the bleeding. The shape of the cavity varies according to the manner by which it has been produced. When it is formed by the separation of the cere- bral fibres, it is generally elongated; whereas, when produced by lacera- tion, it is oval, round, or irregular in form. The situation of the hasm- orrhage modifies the form of the cavity. In the hemisphere it is usually round; in the motor tract, irregular or oval. The variations as regards size are great. I have seen clots no larger than a pea, and again as large as an orange. When hasmorrhage occurs in the motor tract, the clot is almost invariably small; whereas, in the hemispheres, in the cere- bellum, or in the ventricles, it is large. A clot does not always consist of blood alone. Brain-tissue is very often mixed with it, and this is especially the case when the extravasa- tion has been into the white substance of the hemispheres. Gintrac' has collected the data of five hundred and sixty cases of cerebral hasmorrhage, in which there was a single clot, and in these the seat of the extravasation is shown in the following table : 1 "Traite th6orique et pratique des maladies de l'appareilnerveux" Tome deuxieme. Paris, 1869. Art " Hemorrhagica du cerveau." CEREBRAL HEMORRHAGE. 87 Corpora striata...............*................................... 72 Optic thalami. ..'.................................................. 38 Corpora striata and optic thalami simultaneously....................... 48 Middle lobes of the brain........................................... 127 Pons Varolii and crura cerebri...................................... 76 Cerebellum....................................................... 55 Ventricles....................................................... 46 Posterior lobes of the brain......................................... 33 Anterior lobes of the brain......................................... 17 Medulla oblongata................................................. 2 Corpus callosum.................................................. 1 Cortical substance of the brain........... .......................... 45 Total................................................... 560 The ordinary seat of cerebral hasmorrhage is thus seen to be the motor tract, for in nearly one-half of the total number of cases the lesion was situated either in the corpora striata, the optic thalami, the pons Varolii, the crura cerebri, or the medulla oblongata. And of these parts the corpora striata and optic thalami are preeminently liable. Next in order of frequency come the middle lobes. In the great majority of the cases of cerebral hasmorrhage the lesion is situated primarily in the^gray^si^stance. This is probably due to the fact of the greater vascularity which this tissue possesses. It would appear, too, that even when the extravasation is not into the corpus striatum or optic thalamus, it is very apt to be in the immediate vicinity of these organs. M. Duret' has given an anatomical expla- nation of this fact, which appears to be satisfactory. According to this observer, the arteries of the corpus striatum, which are given off gen- erally from the middle cerebral artery, though sometimes from the anterior cerebral, enter the brain through the anterior perforated space. A few delicate branches go to the ventricular ganglion of the corpus striatum, but the larger ramifications are distributed sometimes to the external nucleus of the corpus striatum, but more generally they wind around this organ, and give origin to branches which are widely dis- tributed, reaching even as far as the island of Reil. Thus the largest intra-cerebral arteries are situated in the external portion of the corpus striatum. And this is the exact place where, according to Charcot, cerebral hasmorrhage is most apt to occur. Gendrin 2 had previously remarked that the extravasation in cases of cerebral hasmorrhage almost always come from the branches of the middle cerebral artery. The middle lobe, the island of Reil, the corpus striatum, and the optic thalamus, are nourished through this vessel, and hence the great preponderance of extravasation in these portions of the encephalic mass. 1 " Note sur la distribution des arteres nourricieres du cerveau." Mouvement me- dical, 1873, p. 27. Also, "Recherches anatomiques sur la circulation de l'encephale." Archives de physiologie, 1874, p. 316. 3 " Trait6 philosophique de m6decine pratique." Paris, 1838, tome i., p. 448. 88 DISEASES OF THE BRAIN. It has also been observed—and Durand-Fardel' calls special atten tion to the circumstance—that cerebral hasmorrhage has a manifest ten- dency to be developed and directed, rather toward the central than the peripheral parts of the brain. It is thus, to say, centripetal in its course, in which respect it differs from cerebral softening, which is not less evidently centrifugal—the peripheral regions showing a greater ten- dency than the central to be affected by this morbid process. The right side of the brain appears to be more frequently the seat of cerebral hasmorrhage than the left. Thus, on consulting Gintrac,2 we find that in three hundred and sixty-nine cases in which the side on which the lesion was situated was noted, the parts were affected in the order of frequency shown in the following table: Right. Left. Corpus striatum, optic thalamus, and these bodies simultaneously 73 63 Middle lobes.............................................63 52 Pons Varolii.............................................10 10 Cerebellum......'........................................ 14 12 Cortical substance.....................................'••• 15 8 Posterior lobes........................................... 18 15 Anterior lobes........................................... 6 10 Total......................................... 199 170 The right side had thus a numerical superiority of twenty-nine over the left. It will be observed, also, that in no one part did the left side predominate except in the case of the anterior lobe. On the other hand, Durand-Fardel,3 from an examination of one hundred and seventeen cases of hasmorrhage into the hemispheres, found that the right side was the seat in forty-nine, the left in fifty-seven, and both sides in eleven in- stances. Of eleven cases of cerebellar hasmorrhage, the right lobe was affected six, the left five times, and the middle lobe twice. Generally there is but one recent extravasation, but occasionally two or more occur simultaneously, or at least so near to each other in point of time as to be essentially contemporaneous acts of one morbid pro- cess. Of one hundred and thirty-nine cases cited by Durand-Fardel,* twenty-one were multiple; eighteen of these were double, and three triple. In my own experience two cases of triple lesions have occurred, and two of double lesions. Of the triple cases the right corpus stria- tum, right middle lobe, and left middle lobe, were the seats in one, and the right and left corpora striata, and left anterior lobe, in the other. Of the double cases the seats in one were the right corpus striatum, and right middle lobe, and in the other the right middle and posterior lobe and right half of the pons Varolii. It sometimes happens that the mass of extravasated blood breaks through the cortical substance of the brain, and appears immediately 1 "Traits pratique des maladies des vieillards," Paris, 1873, p. 181 8 Op. et loc. cit. 8 Op cit., p. 185. * Op cit, p. 186. CEREBRAL HEMORRHAGE. §9 under the pia mater and arachnoid; or these membranes may give way, and the blood be effused into the space between them and the dura mater. In a very few of these cases the blood comes primarily from the cortical substance of the brain, but in the greater number the ex- travasation originates more deeply and reaches the surface by lacer- ating the easily-torn white tissue. The blood in these cases undergoes coagulation much more rapidly than when it remains in the cerebral substance, unless the base of the brain be' the seat, in which case it often remains fluid. The extravasation takes place into the ventricles in about one-half of all the cases. The lateral or fourth ventricle may be the seat, or it may exist in both of the former. The blood extravasated into the ventricles remains liquid a longer time than when effused into any other part. This is probably due to the fact that it is subjected to the action of the ventricular fluid, by which its physical properties are altered. In the majority of cases of haemorrhage into the ventricles, the blood comes originally from the corpus striatum, or optic thalamus, but it may also be derived from the choroid plexus, from the septum lucidum, or from the walls of the ventricles. Sometimes it is im- possible to determine its point of origin. It may enter the ventricle through a small opening, in which case the foyer is distinct, or the wall of the ventricle may be largely lacerated and so broken down that the foyer and the ventricle constitute essentially but one cavity. The septum lucidum is not infrequently torn, and the two lateral ventricles are thus converted into one cavity. As regards what may be called the secondary consequences of an extravasation of blood into the cerebral substances, we find that when it is large the convolutions are flattened against the walls of the cranium, the membranes are usually dry, and a distinct feeling of fluctuation can often be detected. In several cases I have known a large extravasation to cause by its own weight a complete rupture of the lobe in which it existed, through the handling required in removing the brain from the skull. At other times the membranes are evidently congested; the brain- tissue, when incised, exhibits an increased number of red points, and the subarachnoidean or ventricular liquid may be largely augmented over the normal quantity. The state of the arteries is a most important and interesting subject for examination, but, as it has an immediate and direct relation with the pathogeny of cerebral hasmorrhage, it will be more properly consid- ered under the head of pathology. Extravasated blood undergoes certain changes. Instead of di- viding into two parts, the clot and the serum, as does blood when exposed to the atmosphere, it remains for a time homogeneous and 90 DISEASES OF THE BRAIN. gelatiniform. About the fifth or sixth day it separates into two parts • the one, the serum, is absorbed by the surrounding tissue; the other consisting mainly of the fibrine and the red corpuscles, contracts and becomes hard. By the fifteenth day it has become fibrinous in texture, and is changed from its former black hue to a yellow color. Micro- scopic examination, made at any period during these changes, reveals the presence of red corpuscles, crystals of hematoidin and sometimes of cholestrin. It never entirely disappears. In the earlier period of the extravasation, the walls of the cavity are rough, and discolored with blood. But, as the changes are going on in the clot, the walls likewise alter in appearance ; the inequalities and irregularities disappear, and a new formation of connective tissue lines the cavity. Blood-vessels appear in it, and aid in the absorption of the fluid portion of the extravasated blood. As the process of separation and absorption goes on, the cavity contracts upon its con- tents, and eventually forms a cicatrix, which incloses the remains of the clot. This cicatrix is generally of a yellow color, and firm in texture. Sometimes, however, absorption does not take place. The con- traction of the walls of the cavity does not therefore ensue, and it remains distended with more or less altered blood. This may be the starting-point of secondary lesions, or a new haemorrhage may occur into the same cavity, or an abscess may result. Pathology.—The theory of cerebral hasmorrhage brings us to the consideration of several important points. One of the first questions to be solved is, Can the rupture of a vessel of the brain take place—not in- cluding traumatic causes—unless the vessel is in a diseased condition ? Both sides of this proposition have their adherents. On the one part, it is urged that cerebral hasmorrhage never takes place spontaneously unless the walls of the bleeding vessel have been so injured by disease as to destroy their strength and elasticity; on the other, that it is per- fectly possible for a blood-vessel to give way, owing to the increased tension of the blood or disease of the perivascular tissue, without the walls of the vessel itself being in the least diseased. While admitting that, in the majority of cases, the structure of the yielding vessel will be found to be impaired, I am satisfied that either of the other two causes may produce a rupture. The reasons for this opinion will be ap- parent in the course of the following remarks. One of the most common diseases to which the cerebral arteries are liable is, chronic endarteritis, a condition which has been well described by Virchow,1 and which is particularly apt to be met with in those who, from age or other debilitating influence, have had their nutrition im- paired. As the consequence of this state, the vessels lose their elas- 1 " Ueber die Erweiterung kleinerer Gefasse." " Archiv fur Path. Anat. und Physiol.," B. m., 1848, and " Cellular-pathologie," Berlin, 1871, S. 458, et seq. CEREBRAL HEMORRHAGE. 91 ticity, become brittle, and are therefore often unable to bear the ordi- nary tension of the blood, much less any severe strain. This disease may terminate in fatty degeneration of the arterial walls, or this last condition may be the primary affection. Fatty degeneration, like chronic endarteritis, is most commonly met with in badly-nourished per- sons, but who are at the same time cachectic. The inner coat is the point of origin, and hence it sometimes happens that this and the mid- dle coat give way, leaving the external coat entire, and thus forming an aneurism. But Bouchard,1 who has examined into this matter with great minuteness, denies that such aneurisms are ever found, and as- serts that the so-called aneurismal sac consists of the lymphatic mem- brane, lining the cavity in the perivascular tissue, through which the vessel passes; and that the blood, in such cases, has already ruptured the vessel. In reality, however, there is no hasmorrhage into the cere- bral tissue till this membrane gives way. In a subsequent memoir, by MM. Charcot and Bouchard,2 this point is still more thoroughly considered, and the opinion expressed that cere- bral hasmorrhage is almost invariably due to what they call miliary aneurisms, which are the result of arteritis, and which are not neces- sarily preceded by atheroma. The existence of these minute aneurisms was first pointed out by Cruveilhier,' and was subsequently recognized by Calmeil.4 Meynert * appears also to have noticed them, and Heschel4 discovered them in the pons Varolii; but no one previous to Charcot and Bouchard called at- tention to the relation which they bear to cerebral haemorrhage. On March 16, 1866, while examining the foyer of a recent extravasation into the brain, they perceived, on the walls of the cavity in the cerebral tissue, two small globular masses attached to a minute vessel. These were miliary aneurisms. One was ruptured, and its contents were in immediate relation with the mass of extravasated blood constituting the apoplectic clot. Previously to this time these observers had noticed these aneurisms, but not before had they associated them with the pathogeny of cerebral haemorrhage; since then, in numerous communi- cations, they have called attention to the importance of their discovery, and its value is generally acknowledged by neuro-pathologists. In the 1 " Etudes sur quelques pointes de la pathog6nie des hemorrhagica cerSbrales." Paris, 1866. 8 " Nouvelles r^cherches sur la pathogenie de l'h6morrhage cer6brale." Archives de physiologie normale et pathologique, 1868, pp. 110-643. 8 " Anatomie pathologique du corps humain," liv. xxxiii., PI. 2, Fig. 3. 4 " Traite" des maladies inflammatoires du cerveau." Paris, 1859, tome ii., p. 522. 6 " Ueber Gefassentartungen in der Varolsbriicke und den Gehirnschenkelm." Allge- meine Wiener Wochenschrift, No. 28, 1864. 6 " Die Capillar-Aneurysmen im Pons Varolii." Wiener Medicinische Wochenschrift, September, 1865. 92 DISEASES OF THE BRAIN. accompanying woodcut (Fig. 10), taken from Bouchard's memoir, is represented one of these aneurisms which has been ruptured into a hasmorrhagic clot: a, the aneurism; b, the clot; c, c, the torn perivascular or lymphatic sheath. Fig. 10. Fig. 11 is from the drawing of a vessel which I recently dissected out of the pons Varolii, into the right lobe of which a large extravasa- tion had taken place. Both lobes were studded with these aneurisms; they were also found in the convolutions in the optic thalami and cor- CEREBRAL HEMORRHAGE. 93 pora striata, and in the white substance of both hemispheres; a large extravasation had also taken place into the right hemisphere. In sixty-nine cases of cerebral haemorrhage in which post-mortem examinations were made, atheroma was found but in fifteen, or twenty- two per cent., while these miliary aneurisms were met with in every case. They appear as little globular masses in the small intracranial vessels, and are in size from one-tenth of a millimetre to one millimetre. If they contain liquid blood, they are red; but, if the blood be coagu- lated, the color is dark, almost black in some cases. In the order of frequency, they are found in the optic thalami, the corpora striata, the convolutions, the tuber annulare, the cerebellum, the centrum ovale, the crura cerebri, and the medulla oblongata. According to Charcot and Bouchard, the arteritis, which results in the formation of these aneurisms, is diffuse in character. It is found not only in the minute artery, which is the subject of the aneurismal dilatation, but extends to the entire system of minute intracranial ves- sels. This arteritis is in some respects analogous with what Rokitansky described under the name of chronic peri-arteritis, and is characterized by disease of the membrane, designated by Robin as the perivascular sheath, and by His as the lymphatic sheath. There are also lesions of the adventitious tunic and of the muscular and internal coats. The dis- eased action proceeds from without inward, and hence the name of peri- arteritis is a very proper one. Charcot and Bouchard claim that, with the following exceptions, all cases of cerebral hasmorrhage are the result of the rupture of. miliary aneurisms, viz., fracture with depression; the haemorrhages which result from thrombosis of the sinuses, and those which occur in the course of certain, depraved states of the system. While admitting that the ma- jority of cases of cerebral hasmorrhage have this origin, I am not pre- pared to go so far as these observers in ascribing all not embraced in the three categories of exceptions above specified, as being due to this cause. I had recently the opportunity of convincing myself that this explanation of the pathogeny of cerebral hasmorrhage is too absolute; for, on examining the brain of a patient who had died from an extrava- sation of blood into the left corpus striatum, optic thalamus, and left lateral ventricle, not a single miliary aneurism could be discovered, al- though they were carefully sought for in all parts of the brain. The patient, a lady forty-three years of age, had suffered from repeated attacks of acute rheumatism, had frequently been affected with head- ache and vertigo, and had been seized with apoplexy while in the water- closet. She had been the subject of heart-disease for over twenty years. I had only the brain submitted to me for examination, but all the ar- teries of this organ were in a state of atheromatous degeneration, and I was able to find what appeared to be the vessel, or one of them, which had given way and produced the extravasation. The accompanying 94 DISEASES OF THE BRAIN. engraving (Fig. 12) represents this artery as seen with an inch-objec- tive. It is perceived that several of the aneurismal dilatations have given way; the internal coat of this, as well as of other arteries, was Fig. 12. found, by microscopical examination, to be in a state of fatty degen- eration; the same state existed in the middle coat, and the external coat was thickened and friable. Lancereaux' reports a very similar case, of which, as it has an im- portant bearing on the subject, I quote the summary which he gives (page 424): " Haemorrhage into the left" [right is evidently meant, and it is so stated on page 252, where the full report of the case is given] " corpus striatum, producing an irruption into the lateral ventricles, and arteritis, albuminuria, cardiac hypertrophy. " A woman, aged fifty-eight, died a few days after an attack charac- terized by left hemiplegia, diminution of sensibility, and vomiting. The autopsy revealed the existence of a hasmorrhagic clot at the exterior and posterior part of the corpus striatum, which, after having separated this ganglion from the optic thalamus, had broken into the ventricular cavity. The nervous tissue, besides being torn, was colored yellow, through the infiltration of hasmatine into its substance. The ventricles contained a small quantity of liquid blood. There existed under the ependyma of the posterior cornu of the right ventricle a hasmorrhagic punctation, and a sanguineous suffusion extended over the whole cir- cumference of the cerebellum. The entire encephalic mass was injected. The walls of the cerebral arteries were thick and opaque. On the branches, even those of the smallest size, were perceived moniliferous dilatations, the result of a primitive alteration of the arterial wall, and the probable points of origin of the hasmorrhage. The aorta was af- fected with endarteritis throughout its whole extent, the aortic orifice was slightly insufficient, and the left ventricle was markedly hyper- trophied ; the renal arteries were indurated, rigid, and calcareous. The 1 " Anatomie pathologique," texte, pp. 252 and 424; atlas, plates 24 and 43. CEREBRAL HEMORRHAGE. 95 kidneys, small, atrophied, and granular, were affected with interstitial nephritis. The arterial system was involved throughout almost its en- tire extent." It would appear, therefore, that we cannot set aside the results ob- tained by Virchow and others, and that, in the present state of our knowledge, it is safe to adopt the opinion expressed by Durand-Fardel,2 that, although " the facts observed as described by MM. Charcot and Bouchard have undoubted value, it would, nevertheless, be premature to attribute to miliary aneurisms an exclusive part in the production of cerebral hasmorrhage." The condition of the perivascular tissue, or the brain-substance, has much to do with the occurrence of hasmorrhage. One reason why ex- travasation more frequently occurs in the brain than in the liver, for instance, is, that its tissue is softer, and therefore not capable of giving as much support to the blood-vessels as is the latter organ. Now, when the cerebral substance is softened by disease in any part, the natural support of the vessels of that part is still further lessened, and the ten- dency to hasmorrhage increased. Again, in the condition sometimes met with in old people, in which the brain becomes atrophied, the ves- sels may undergo dilatation and subsequent rupture. This view is op- posed by Jaccoud,2 but in one case of cerebral hasmorrhage, terminating in death, and in which I had the opportunity of making a post-mortem examination, the right hemisphere, the seat of the extravasation, was very considerably atrophied, and weighed three ounces and a quarter less than the left. The possibility of the existence of this cause may, therefore, be admitted, although it cannot be considered as definitely established. The researches of Cotard3 would appear to show that cere- bral haemorrhage is not infrequently a cause of partial atrophy of the brain. In the next place, the state of the blood, as regards quality and tension, must be considered. There can be no doubt that certain dis- eases affecting the general system may so deteriorate the blood as to render it unfit to properly nourish the blood-vessels, and hence their tissue is more readily broken down. Among these conditions are typhus, scurvy, chlorosis, gout, and syphilis. The tension of the blood in the vessels is subject to constant vari- ation from the operation of many physical and mental causes, and may, through their action, be so increased as to overcome the resistance afforded by the vascular walls. These influences have been sufficiently considered in the section on causes, and need not, therefore, be dwelt upon here at any length. My own opinion of their sufficiency, without preexisting disease of the blood-vessels, to produce rupture and ex- travasation, has been formed after much observation and reflection. 1 Op. cit., p. 262. 2 Op. cit., p. 155. 8 " Etude sur l'atrophie partielle du cerveau," Paris, 1868. 96 DISEASES OF THE BRAIN. Analogous phenomena take place every day, and are not supposed to be due, in any extent, to vascular disease. Thus nasal hasmorrhage occurs from strong muscular exertion of such a character as to retard the flow of blood from the brain, from emotional or other kind of mental excitement, and from hypertrophy of the left side of the heart, by which the amount of blood in the cerebral vessels is increased. All these causes augment the tension, and it would be singular if at times a healthy intracranial vessel did not give way through their influence, as well as one outside of the skull. A point of very great importance remains to be considered as a part ,,h^>^ of the pathology, and that is whether it is possible or not to determine during life in what part of the brain an extravasation has taken place ? While I am afraid we cannot be as explicit in this matter as is desirable, I am very sure we can often, from a careful study of the symptoms, arrive at conclusions more or less accurate, and can sometimes deter- mine the question with absolute certainty. The great difficulty is, that we are not yet sufficiently acquainted with the physiology of the several parts of the brain, and hence are not able to ascribe, with as much sure- ness as is desirable, variations from healthy action, to derangement of the proper anatomical part of the cerebral mass. Besides, when the ex- travasation is large, although it may be strictly confined to the ana- tomical limits of the ganglia or part of the encephalic mass in which it originates, it may act by transmitted pressure upon contiguous ganglia or parts, and hence the symptoms are rendered complex. As we have seen, hasmorrhage is more liable to take place within the ganglia constituting the motor tract than any other part of the brain. This is mainly due to the fact that this is the most vascular part of the cerebral substance. '..>)>''" When the lesion is limited to the corpus striatum of one side, the ; speech is generally affected from paralysis 15F the tongue, and there is loss of the power of voluntary motion on the opposite side, but nO_ • abolition of sensibility, except, perhaps, for a few hours. Cases in illustration of this fact have been given by Andral* and Luys,2 and one instance in my own experience was established by post-mortem examina- tion. The patient, a man of sixty-two years of age, had been hemi- plegic for eleven years, and died suddenly, in April, 1851. Post-mortem examination showed the cause of death to have been fatty degeneration of the heart. On examining the brain, a cicatrix was discovered in the right corpus striatum. The hemiplegia was on the left side, and had never been accompanied with any loss of sensibility. There was no other lesion of the brain, so far as could be ascertained. But there are instances on record in which there has been extravasa- tion into the corpus striatum, and no paralysis of any part of the body. 1 "Clinique m6dicale," tome v., pp. 319-321, 442. 4 " Recherches sur le systeme nerveux c6r6bro-spinal," etc., p. 545. CEREBRAL HEMORRHAGE. 97 Gintrac,1 of forty cases collected by him, found apparent absence of paral- ysis in five. But he admits that this number may perhaps be reduced, for one of the cases was that of an infant one day old, and the other, that of an old man eighty years of age, who had had a cerebral hasm- orrhage ten years before his death, in both of which an exact diagnosis of this point could not have been otherwise than difficult. But in one of the others there was no paralysis, and yet after death a clot as large as a pigeon's egg was discovered in the left corpus striatum. In the second there was no actual paralysis, but a weakness and trembling of the right arm. The post-mortem examination revealed the existence of a clot, as large as an almond, in the left corpus striatum. The third was for a few moments deprived of the power of speech, but he had equal muscular strength on both sides. Then he became weak and died, without having been actually paralyzed. After death a cavity filled with a brown serous fluid was found in the anterior and external part of the right corpus striatum, and the whole of the left posterior lobe was reduced to a yellowish pulp, and was studded with purulent foyers. This was certainly not an uncomplicated case. And thus of the five there was but one in which there was indubitably no paralysis. The optic thalamus is another common seat of extravasation. In such a case the observed symptoms are especially connected with the organs of the special senses. Thus there are double vision, dilatation or convulsive movements of the pupil, blindness, and anaesthesia or hyper- aesthesia^ of the paralyzed parts of the body. As in lesion of the corpus striatum, the paralysis of motion, if present at all, is on the opposite side of the body. The hearing and smell may also be affected. Luys2 has collected a large number of cases in support of the view here enun- ciated. The researches of Virenque 3 also go to show that lesions of the optic thalamus are accompanied with loss of sensibility on the opposite side of the body. His observations, therefore, are entirely confirmatory of those of Tilrck * who in four very carefully recorded cases found hemi- anassthesia coexistent with lesion of the optic thalamus and corpus stri- atum of the opposite side. In those cases of cerebral hasmorrhage limited to the optic thalamus, paralysis of motion when it exists is less intense, than when the corpus striatum is also involved, and is often restricted to the inferior limbs. The speech is rarely involved. The intelligence is not notably lessened, but there is often a marked proclivity to the supervention of hallucinations of the special senses. 1 Op. cit., tome ii., p. 142, et seq. 2 Op. cit., p. 534, et seq. 8 " De la perte de la sensibility generate et speciale d'un cote du corps (h6mianaesthesiae) et de ses relations avec certaines lesions des centres opto-stries." Paris, 1874. * " Ueber die Beziehung gewissen Krankheitsherde des grossen Gehirns zur Anaes- thesie. Sitzungsberichte des Kais. Kon. Academie der Wissenschaften, B. xxxvi., 1869. 7 98 DISEASES OF THE BRAIN. Fig. 18. This is not surprising when we take into consideration the fact that recent physiological observations appear to show that the optic thalami are centres for the special senses. Luys1 has very thoroughly worked up this subject,2 and Ritti has recently in a philosophical essay adduced many facts and arguments to show the relations of lesions of the optic thalamus with hallucinations. In thirty-two cases of hallucinations, mainly of the sight and hearing, but sometimes of all the senses, post - mortem examinations re- vealed the existence of some kind of lesion of the optic thalami. It generally happens that an extravasation, originating in ei- ther the corpus striatum or op- tic thalamus, involves both these ganglia. Hence we have, as the most common symptoms of hasm- orrhage into these organs, loss or impairment of the power of mo- tion, disturbance of sensibility, dilatation or irregular movements of the pupil, aberrations of vision and hearing, etc. As we have seen, a lesion of the corpus striatum and optic thalamus of one side produces loss of the power of motion and of sensibility in the opposite side of the body.' The manner in which this is accomplished will be readily understood from an in- spection of the accompanying diagram (Fig. 13), in which a in- dicates the left opto-striated body, b the left half of the pons Varolii and medulla oblongata, c the left lateral half of the spinal cord, d a sensory nerve-fibre decussating soon after its entrance into the cord, e a motor nerve-fibre decussating at the lower boundary of the medulla oblongata. A lesion existing at f will therefore cause paralysis of motion and of sensibility at g, on the right side of the body. When the extravasation beginning in the left optic thalamus or corpus striatum extends to the fissure of Sylvius so as to involve the posterior part of the third frontal convolution, the island of Reil, or other part supplied by the middle cerebral 'artery, or when it originates in this region, aberrations of speech occur. These are independent of 1 Op. et loc. cit. 2 " Theorie physiologique de l'hallucination." Paris, 1874. CEREBRAL HEMORRHAGE. 99 paralysis of the tongue, and are such as are embraced under the term aphasia. This subject will be hereafter more fully considered. Haemorrhage into the crus cerebri produces hemiplegia of the op- posite side, more or less extensive, according to the size of the clot, with k)ss of sensibility. The third pair arises in part from the crus, and hence may be paralyzed, producing ptosis and external strabismus on the side corresponding to the seat of the lesion, and consequently opposite to the hemiplegia. When the pons Varolii is affected, the crossed paralysis is still more marked. The limbs are paralyzed on the opposite side, and the face in whole or in part on the same side as that in which the haemorrhage takes place. If the extravasation is in the mesial line, both sides of the body are paralyzed. According to Trousseau,1 however, crossed paral- ysis is not always due to a lesion of the pons, as asserted by Gubler,2 and as supported by additional cases collected by Luys.3 Trousseau rests his opinion on one case, in which after death very extensive lesions of the brain were found, but none involving the pons. Nevertheless we find in practice that when an extravasation of blood is confined to one side of the pons, and is not extensive, the face is paralyzed on the corresponding side. The facial nerve makes its exit from the side of the medulla oblongata ; some of its roots of origin can be traced as far as the floor of the fourth ventricle, others come from the lower part of the medulla oblongata, and others de- scend from the upper border of the pons, where they probably decus- sate. Now, a lesion existing in a lateral half of the pons will, therefore, produce a paralysis of the cor- responding facial nerve, and of the opposite spinal nerves; whereas, if it occur above the point of decussation of the encephalic fibres, the paraly- 1 " Lectures on Clinical Medicine," Bazire's translation, Part II., p. 333. 9 " Sur l'h6miplegie alterne," Gaz. hebd., October, 1856, and " Memoire sur les para- lysies alternes," etc., Gaz. hebd., 1859. 3 Op. cit, p. 529, et seq. Fig. 14. a, the left hemisphere; b, right half of pons; c, right half of medulla oblongata; d, right half of spinal cord; e, right facial nerve; /, fibre of origin from nucleus in medulla oblongata; q± descending fibre decussating at upper border of pons; A, ascending fibre; i. sensory root of '.'•*- spinal nerve; k, motor root of sensory nerve; l, lesion in pons; m, lesion in left hemisphere; n, paralyzed part supplied by facial; o, para- lyzed part supplied by spinal nerve. 100 DISEASES OF THE BRAIN. sis will be on the opposite side for all parts of the body. These facts are shown in the accompanying diagram (Fig. 14). It is obvious, from a study of this diagram, that a lesion of one lat- eral half of the pons (at 1) will cause paralysis of motion and of sensi- bility of the opposite side of the body generally, and of the corresponding side of the face; and that a lesion of the hemisphere (at m) will produce paralysis of the opposite side of the face and the body. It is true that it is not definitely settled by histological investigation that the decussation of the ascending roots takes place, but pathology is just as capable of determining the question as histology. Vulpian' asserts that the decussation of the roots of the facial occurs in the mesial line of the medulla oblongata at the junction of the two nuclei of origin ; but, if this were the case, a lesion of one side of the pons would necessarily be followed by double facial paralysis, a sequence which does not in reality ensue. From the contiguity of the pons to the medulla oblongata, an ex- travasation of blood into it is generally accompanied by the symptoms which result from haemorrhage into this latter organ, though they are not as a rule so strongly marked. The principal phenomena indicating the medulla oblongata as the seat of extravasation are, loss of the power of swallowing, from paral- ysis of the glosso-pharyngeal, difficulty of protruding the tongue, from paralysis of the hypoglossal, and huskiness of the voice, tumultuous action of the heart, dyspnoea and gastric derangements, from paralysis of the pneumogastric nerve. There is in addition paralysis of one or both sides of the body. An extravasation into the cortical substance of the cerebrum is char- r L' / acterized by no very definite aggregation of symptoms. There may be i delirium, coma, disorders of speech, convulsions, paralysis, contractions or rigidity of either the paralyzed or sound limbs, vomiting, derange- ment of respiration, and occasionally anaesthesia or hyperaesthesia. Pa- ralysis when present is upon the opposite side of the body from that of \the lesion. When the extravasation is in the white substance of the cerebrum, there may be no marked symptoms of diagnostic value. I have known cases in which large foyers have been formed with no other symptoms than intense pain in the head and persistent vomiting. But when blood is extravasated into the white tissue the quantity is ordinarily great, and as a consequence there are often symptoms present which are due to resultant pressure upon other portions of the encephalic mass. Thus there may be coma, paralysis, loss of sensibility, stertorous res- piration, and other phenomena indicating derangement of the motor and sensory ganglia. The passage of the extravasated blood into the 1 " Essai sur l'origine de plusieurs pairs de nerfs craniens. ThSse de Paris," 1853, p. 32. CEREBRAL HEMORRHAGE. 101 ventricles almost invariably causes contractions or convulsions of the muscles of the opposite side of the body. The researches I have made1 relative to the functions of the cerebel- lum would seem to show that its office is not materially different from that of the cerebrum. Still, I think there are some indications which, although not perhaps giving us the right to form a definite conclusion, are yet sufficiently well marked to enable us to arrive at a probable diagnosis between hasmorrhagic lesion of the cerebrum and that of the cerebellum. Thus, vertigo is almost an invariable accompaniment of the cerebellar extravasation; vomiting is much more generally met with than when the cerebrum is affected; hemiplegia is not so common; the sensibility is never disturbed; and the pain is in the back of the head. Ferrier2 has very clearly shown that irritation of the cerebellum pro- duces nystagmus and defective power of ocular coordination. But I am not aware that these phenomena have been noticed in cases of cerebel- lar haemorrhage. Hillairet,3 in his excellent memoir, does not mention them as features of the affection. He distinguishes two forms of this lesion. In the one, the onset is sudden, and death soon follows; in the other, the course of the affection is slow, and life may be prolonged for a considerable period. In this latter, vomiting is a prominent feature. Hemiplegia, according to him, is always crossed. Sensibility remains unaffected till near the close of the disease by death, and there are no convulsions. The speech is not often affected. The special senses he did not find notably deranged, except in the last stage. In this result he differs with several other writers on the subject. Besides a number of cases, some of which are referred to in the memoirs cited, one has occurred in my experience, in which I had the opportunity of making a post-mortem examination.4 A man had suffered from vertigo, occasional convulsions, attacks of nausea, and vomiting, and a constant and violent pain affecting the back of the head. The symptoms had ensued in consequence of a se- vere blow which he had received on the back of the head, by raising himself too soon while the horse he was riding was passing under a low archway. When this man attempted to walk, he reeled and staggered as if he were drunk. The upper extremities and the organs of speech were not affected; he had the entire control of his legs when lying down, and there was no diminution of sensibility anywhere. At last, he became paraplegic, and shortly afterward died in a convulsion. The post-mor- 1 " The Physiology and Pathology of the Cerebellum." Quarterly Journal of Psycho- logical Medicine, April, 1869. a " Experimental Researches in Cerebral Physiology and Pathology." " West Riding Lunatic Asylum Reports," vol. iii., 1873, p. 69, et seq. 8 "H6morrhagie ce'rebelleuse," Annuaire de medecine et chirurgiepratiques," 1859, p. 39. Also Archives de medecine, 58. 4 Op. cit, p. 209. 102 DISEASES OF THE BRAIN. tern examination showed the existence of an abscess which had oblit- erated nearly the whole of the left lobe of the cerebellum. The other parts of the brain were, so far as could be perceived, perfectly healthy. Besides the occurrence of local secondary lesions, the immediate re- sults of the presence of a foreign body in the cerebral tissue, there are others, which are due to the interruption of the normal brain-functions, which hasmorrhage so generally induces. Thus, atrophy of the cerebral structure may result, as has been pointed out by Cotardl and others, or the degeneration may extend to the spinal cord, as is so well shown by ! Bouchard.2 In this latter event the process does not begin till about ! the end of the fourth or fifth month. It is mainly characterized by the supervention of permanent cVrrtraction of certain of the paralyzed mus- cles, and will be more appropriately considered under another head. Another point in connection with cerebral hasmorrhage requires further elaboration. It is well known that the facial paralysis result- ing from ordinary cerebral hasmorrhage is less extensive and less thor- oughly marked than when it is due to disease or injury of the trunk of the seventh pair or to lesion of the pons Varolii. Thus we have seen that, in the former affection, the orbicularis palpebrarum escapes paral- ysis,3 and the other muscles supplied by the facial nerve are usually not so profoundly paralyzed as when the pons or the nerve is the seat of the disease. Many explanations have been offered of this remarkable circum- stance, but the one given by Landry * is more nearly reconcilable with the anatomy and physiology of the parts involved than any other. The nucleus of the facial is entirely comparable to.the anterior cornua of the cord. It constitutes a little special motor nerve-centre which possesses a certain amount of autonomy. It is through this centre that the muscles of the face are directly made to contract. The encephalic fibres which connect it with the brain are only at the service of the psychical department, and an impulse sent through them is not of itself capable of exciting contraction in the muscles to which the- facial is distributed. But, with the spinal cord, this nucleus pos- sesses reflex excitability, and, as is the case in diseases of the brain in which the anterior columns suppress voluntary movements without 1 "Fjtude sur l'atrophie partielle du cerveau," Pari?, 1868. 2 " Des degenerations secondaires de la moelle 6piniere," Archives gen. de medecine, 1866. Also Hun's translation, American Journal of Insanity, 1869. 8 Bazire, in his translation of Trousseau's " Clinical Lectures," calls attention to the fact that, in ordinary cases of cerebral haemorrhage, the patient, though able to close the eye of the affected side, cannot do so without, at the same time, closing the other, a fact which shows some loss of power. Since my notice was directed to this circumstance, I have observed that the patient is often sensible of the fact that the eye of the affected side cannot be closed as strongly or as rapidly as the other eye. * Quoted by Poincare, " Lecons sur la physiologie normale et pathologique du systeme nerveux," tome deuxieme, Paris, 1874, p. 55. CEREBRAL HAEMORRHAGE. 103 destroying the reflex manifestations of which the gray substance of the cord is susceptible, so the cerebral lesion leaves to the nucleus of the facial the power to determine reflex contractions. It therefore con- tinues to be excited by sensitive excitations which reach it from the periphery. Thus, in facial hemiplegia of cerebral origin, we observe, from time to time, certain movements which appear to be voluntary because the provocative sensitive impression, which may only consist of the contact of air, remains unperceived. Accordingly, the orbicularis palpebrarum appears, above all the other muscles, to preserve its mobil- ity, for its movements are principally excited by the stimulus of the light, which the lesion of the cerebral lobes does not prevent being reflected to the nucleus of the facial. In extensive diseases of the pons, however, the nucleus of the facial, situated as it is, in immediate proximity to this organ, is almost always compromised with it. In such a case, therefore, both reflex excitability and voluntary power are destroyed, and the paralysis is complete. Treatment.—The means of treatment in cerebral hasmorrhage are, first, those which are applicable to the prodromatic stage, with a view of preventing any lesion; second, those proper during the seizure; and, third, those which are to be directed against the consequences of an attack. It often happens that an attack may be prevented, even where the threatenings are very decided. The condition of the brain is such that the indications are to lessen the tension of the blood as much as pos- sible. As I have already remarked, under the head of cerebral conges- tion, the bromides of potassium and sodium are peculiarly efficacious in accomplishing'this end. Lately, in consequence of the investigations of Dr. S. We,ir Mitchell, of Philadelphia, I have made much use of the bromide_of^ lithium in cerebral congestion with or without a tendency to hasmorrhage, and have reason to prefer it to either the potassium or sodium salt. One feature of its action, which renders it especially use- ful in such cases as those now under notice, is the short interval which elapses between its administration and the effect. I am very sure I have given it successfully in several cases in which the bromides men- tioned would not have acted so happily. In one of these, a gentleman from the South, who had already had an attack, and who was in conse- quence hemiplegic, was relieved of his vertigo, headache, numbness, and thickness of speech, by one dose of thirty grains, in less than half an hour. The bromide of calcium, a compound to which I have recently called attention,1 is still more eligible. It acts more rapidly than any of the other bromides, and may be given for a longer period with less derangement of the organism. The dose is from fifteen to thirty grains, or even more, if only a single dose is to be administered. The oxide of zinc may also be given with advantage. 1 Note relative to Bromide of Calcium. New York Medical Journal, December, 1871, p. 594. 104 DISEASES OF THE BRAIN. p> ' The bowels, if costive, should be opened by a brisk purgativej the stomach, if overloaded, should be emptied by an emetic, during the action of which warm water should be freely drunk so as to obviate, as far as possible, all straining; muscular exertion should be avoided, the head should be kept cool and well elevated, and the mind in a state of the utmost tranquillity. During an attack, and throughout the whole period of reparation of damages, the less that is done in the vast majority of cases the better. The question of the propriety of bloodletting will generally even yet arise, but should in nearly every case be decided in the negative. I say nearly, for I know of but one possible form of attack in which it can by any possibility not only not be useful, but fail to do harm; and that is in a strong, plethoric person, with a full, bounding pulse, in whom, from the gradual development of the symptoms, we have reason to sus- pect that the haemorrhage is still going on. In such a case, six or eight ounces of blood may be taken from the arm. But, in the case of cere- bral hasmorrhage, attended by coma and the ordinary symptoms of the apoplectic condition, there is nothing to be done in the way of medica- tion which can afford the slightest prospect of relief. It is true, a pa- tient thus situated may recover if his attack is not of the severest kind, but it is not through any medicines we give him. Correct views rela- tive to this point are far from being prevalent, and can only be estab- lished by regard being paid to the morbid anatomy and pathology of the subject. A clot in the brain is, to all intents and purposes, a foreign body, and both it and the walls of the cavity must undergo certain fixed and definite changes. In order that these changes may go on with the ut- most possible regularity and certainty, all the powers of the system are requisite. The processes are not morbid; on the contrary, they are in the highest degree conservative. To take blood from a body which* is striving by all its agencies to repair an injury, is to deprive it of a por- tion of its strength without in the slightest degree accelerating the actions at the seat of the lesion. As Trousseau' remarks, no physician ever thinks of bleeding for an extravasation of blood under the skin, for he knows how perfectly absurd such a practice would be; and yet, except as regards location, there is no difference between it and the cerebral clot. A prize-fighter, for instance, receives a blow in the face, which ruptures a blood-vessel and gives him a " black eye." He has an extravasation of blood into the cellular tissue. What would be thought of the physician who would recommend bloodletting from the arm, with a view of causing the absorption of the clot ? The prize-fighter has found out by experience that he can open the skin with a knife, and let the blood out. The practice is excellent, and would be admirable for the brain also, were this organ of no more vital importance than the 1 " Lectures on Clinical Medicine," Bazire's translation, Part I., p. 10. CEREBRAL HEMORRHAGE. 105 skin of the face. I have never bled a patient for cerebral hasmorrhage since 1849, and I am very sure that I have had no reason to regret the abandonment of the practice. It is a common practice for purgatives to be given, and even so con- servative a practitioner as Dr. J. Hughlings Jackson l puts " two drops of croton-oil on the tongue," why, he does not state, and certainly the practice is in direct antagonism not only with his assertion that " the chief thing is to keep the patient quiet," but with the general tenor of his theory of treatment. I have seen great annoyance and an aggrava- tion of the symptoms from the indiscriminate administration of croton-oil. It is only, in my opinion, admissible when there is obstinate constipa- tion, and when after three or four days the bowels have not been moved. And then as regards iodide of potassium. There seems to be an idea prevalent that this substance exerts a powerful influence in causing the more rapid absorption of the extravasated blood, and hence it is frequently administered in large and frequently-repeated doses. I have often seen patients, at as early a period as possible, while still in a state of profound coma, dosed with the iodide of potassium to the extent of five grains every hour, with the object of causing the immediate absorp- tion of the extravasated blood. That such a result is impossible no one acquainted with the morbid anatomy and the pathology of the subject will deny. In fact, there is nothing to be done beyond keeping the patient perfectly quiet, with the head well elevated, and in a room, when possible, with a temperature of about 60° and thoroughly ventilated. Indications should be met as they arise. The bowels, if not moved naturally every day, may be emptied by an enema of warm water ; the urine, if not passed by the patient, should be drawn off with the cathe- ter ; the strength, if feeble, as indicated by the pulse, should be kept up by the cautious use of stimulants ; and, if the patient is restless and does not sleep well, some one of the bromides should be administered. Ergot may, on theoretical grounds, be recommended in those cases in which we have reason to believe that the hasmorrhage is still going on; but I have no personal experience of its power in such instances. If administered, it should be given with no sparing hand. The food should be of the most nutritious character, so as to be small in quantity, and should be taken, frequently, day and night. Beef-tea, or the extract of beef, made according to Liebig's formula, supplies every indication. If symptoms of inflammation make their appearance, cold applica- tions may be made to the scalp, or a blister may be applied to the nape of the neck. Blisters or mustard-plasters to the wrist or ankles are absurd. 1 Reynolds's " System of Medicine," vol. ii., article " Apoplexy and Cerebral Haemor- rhage," p. 541. 106 DISEASES OF THE BRAIN. Nothing should be done for the relief of the paralysis till all signs of irritation of the brain have disappeared, and the patient begins to feel the restraint of confinement, and to make efforts to move his par- alyzed limbs. These evidences of improvement generally begin soon after the eighth day. In about two weeks, therefore, it will be proper, in the majority of cases, to take active measures to restore the power of motion, and to prevent those contractions which tend to make a res- toration much more difficult. The agents to be employed are pas- sive motion, strychnia, phosphorus, and electricity. The first is accom- plished by flexing and extending the joints of the affected limbs, by friction, and by kneading the muscles with the fingers. These move- ments should be performed every day for five or ten minutes at a time. The patient should likewise be encouraged to move the limbs by his own volition as often as possible short of causing fatigue. Strychnia should be given in doses of the one-twenty-fourth of a grain three times a day, or, preferably, by subcutaneous injection, in somewhat smaller doses once a day. In old cases of hemiplegia, the effects of strychnia thus administered are often well marked, and are exhibited when ad- ministration by the stomach has failed to produce a beneficial result. This is seen in the following brief abstract of sixteen cases which will serve as types of numerous others which have occurred in my private practice: Case I.—H. A., aged fifty ; male ; right hemiplegia. Came under treatment January, 1865; strychnia ineffectual by the stomach; thir- teen injections, of from one-thirty-second to one-twenty-fourth grain; much improved. Case II.—J. S.; forty-two; male; left hemiplegia. February, 1865; thirteen injections; much improved. Case III.—S. T.; sixty; female; right hemiplegia. February, 1865; strychnia ineffectual by the stomach; nine injections; much improved. Case IV.—I. S.; sixty; female; right hemiplegia. April, 1865; five injections; much improved. Case V.—M. T.; fifty-two; male; right hemiplegia. April, 1865; strychnia ineffectual by the stomach; eleven injections; cured. Case VI.—O. S.; sixty-three; female; left hemiplegia. April 30, 1865; secondary contractions; twenty-two injections; no improvement. Case VII.—B. R; fortyrseven; male; left hemiplegia. June 11, 1865; strychnia ineffectual by the stomach; seven injections; much improved. Case VIII.—R. F.; fifty; male; left hemiplegia. June 17, 1865; strychnia ineffectual by the stomach; eight injections; cured. Case IX.—T. W.; forty-eight; male; left hemiplegia. September 5, 1865; eight injections; much improved. Case X.—T. S.; forty-nine; male; left hemiplegia. September 7, 1865; secondary contractions; five injections; no improvement. CEREBRAL HEMORRHAGE. 107 Case XI.—J. J.; fifty-seven; male; left hemiplegia. September 11, 1865; secondary contractions; no improvement. Case XII.—J. W.; fifty-two; male; right hemiplegia, affecting arm only, at the time treatment was begun. September 27,1865; strychnia ineffectual internally; six injections cured. Case XIII.—W. M.; forty-five; male; left hemiplegia. October 19, 1865; strychnia ineffectual internally; seven injections; cured. Case XIV.—S. M.; forty-one; male; right hemiplegia. June 17, 1867; arm alone affected; strychnia ineffectual by the stomach; twenty injections; cured. Case XV.—M. C; forty-four; male; right hemiplegia, affecting tongue and face only. July 1, 1867; ten injections; so much improved as to be able to talk with fluency. Case XVI.—C. C; fifty; male; right hemiplegia. May 4, 1869; strychnia ineffectual by the stomach; thirty-five injections; much im- proved. Dr. Charles Hunter * has called attention to the advantages to be derived from the • hypodermic use of strychnia in hemiplegia; and my former clinical assistant, Dr. R. A. Vance,2 has adduced several cases to the same effect. Instances in support of the views above set forth oc- cur daily in my private practice, and at the New York State Hospital for Diseases of the Nervous System. I have every reason, therefore, to be convinced of the good results to be derived from the practice. Phosphorus administered in the form of phosphide of zinc, separately or in combination with the extract of nux-vomica, according to the for- mula given on page 54, is also a useful remedy. But no agent is so valuable in hemiplegia as electricity, and amend- ment almost invariably follows its use, even in old cases, in which there are tonic contractions. If the case is seen soon after the seizure, the induced current will generally be sufficient to produce contractions of the paralyzed muscles. The poles, terminated by wet sponges, should be applied to the skin covering the muscles, or in some cases to the nerves. The current should be strong enough to cause slight pain, or, if sensibility is lessened, to produce contraction. In old cases attended with atrophy of the muscles, and diminished or abolished electro-con- tractility, the primary current may be necessary. It should be applied in such a manner as to be interrupted, for contractions are only caused when the circuit is closed and opened. As the muscles improve in size and irritability, the induced current should be used. Care should be taken not to fatigue the patient, or to cause excessive pain by em- ploying a current of too great a degree of intensity. As regards the restoration of sensibility, it will generally be found 1 British and Foreign Medico-Chirurgical Review, April, 1868. 2 Journal of Psychological Medicine, April, 1870. The first thirteen cases cited in this work were published in Dr. Vance's paper. 108 DISEASES OF THE BRAIN. to be less difficult than the removal of the motor paralysis. The anaes- thesia very often disappears or becomes much less spontaneously, and it does so from the centre to the periphery; that is, if there be anaesthesia of the leg, the sensibility returns in the upper part first, and subsequent- ly in the lower part. The treatment consists mainly in the use of the electric wire-brush, which should be passed gently over the skin pre- viously made dry. The other pole consists of a wet sponge. Either the induced or primary current may be used. If the latter, however, be employed, the wire-brush should constitute the positive pole. I have frequently succeeded in curing almost complete anaesthesia from cerebral hasmorrhage by this treatment alone. In recent cases it will almost invariably prove effectual. Hyperaesthesia, if present, may be similarly managed.1 CHAPTER IV. CEREBRAL MENINGEAL HAEMORRHAGE. By the term cerebral meningeal hasmorrhage is to be understood— 1. An extravasation of blood between the cranium and the dura mater; or, 2. An extravasation into the cavity of the arachnoid between the two layers of which this membrane is composed; or, 3. An extravasa- tion into the sub-arachnoideal space between the arachnoid and the pia mater, or into the tissues of this latter membrane, or between it and the brain. There are thus—1. Extra-meningeal haemorrhages; 2. In- tra-arachnoideal haemorrhages; and, 3. Sub-arachnoideal haemorrhages. The first are almost always the result of traumatic cause, involving injuries of the cranium, by which the vessels of the dura mater are wounded. Extra-meningeal haemorrhage may likewise be produced by the operation of trephining, should any of the vessels of the dura ma- ter be divided. It is, however, beyond doubt that this species may originate inde- pendently of wounds and injuries. The distinction between intra- and sub-arachnoideal haemorrhages was first pointed out by Prus,2 to whom we are also indebted for much valuable information on the subject. Of one hundred and seventy-two cases collected by Gintrac,8 five 1 The subject of the employment of electricity in medicine is too extensive to receive more than slight notice in a work like the present. For full details in regard to it, the reader is referred to the author's translation of Meyer's " Electricity in its Relations to Practical Medicine," second edition. New York, D. Appleton & Co., 1872. 2" M6moire sur les deux maladies connues sous le nom d'apoplexie ni6ning6e.—M6" moires de l'acad&me de medecine," tome xi., 1845, p. 18. 8 Op. cit, tome i. p. 732. CEREBRAL MENINGEAL HAEMORRHAGE. 109 were extra-meningeal, one hundred and nine intra-arachnoideal, and thirty-four sub-arachnoideal. Symptoms.—The most prominent symptom of meningeal hasmorrhage is coma, which may appear suddenly, or be preceded by premonitory | symptoms, such as headache, vertigo, and general convulsions. The stupor is usually profound, and does not differ from that observed in the severe forms of cerebral hasmorrhage. The power of motion is generally lost throughout the body, and consequently there is usually no hemiplegia. The reason for this is, that the haemorrhage is so ex- tensive as to press upon both hemispheres. Reflex and automatic movements remain, except when the medulla oblongata is involved, when some of them are abolished. If the extravasation is in this latter situation, death soon takes place from cessation of respiratory actions. Anaesthesia is present in the skin of those parts in which the power of " motion is lost. In ordinary cases the patient may pass out of the comatose condi- tion from the fact of the brain becoming accustomed to the pressure, and he then may be able to speak, and to move his limbs, but his men- tal and physical faculties are greatly enfeebled, and a renewal of the hasmorrhage again plunges him into a state of coma, from which he may again emerge. This sequence may be repeated several times, until death at last takes place. Before this termination there are vomiting, incontinence of urine and fasces, insensibility, and occasionally general convulsions. In a case reported by Dugast,1 a woman entered the H6pital Neckar in a state of marked prostration. Her intelligence was not markedly impaired, but, though she understood almost every thing said to her, she answered only by monosyllables often unintelligible, and pronounced in a low voice. She was affected with paralysis of the left side of the face, and an incomplete paralysis both of motion and sensibility of the right side of the rest of the body. Four days afterward she was in a state of complete prostration, the paralysis was general. Up to this time the intelligence had remained almost intact. She died that day. The post-mortem examination showed the existence of a large sub-arachnoid extravasation at the base of the brain. On the inferior surface of the pons the blood had become consolidated into a clot which pressed upon the left lobe. On the right side of the pons the blood had not coagulated. This case is interesting as bearing upon the subject of cross-paralysis already con- sidered in the previous chapter. It has sometimes happened that meningeal hasmorrhage, resulting from an injury of the cranium, has not caused any very prominent symptoms for a considerable period afterward. A teamster was struck l" Quelques considerations sur les h6morrhagies memng^es c6r6brales. Th6se de Paris," 1869. 110 DISEASES OF THE BRAIN. on the head by a club in the hands of another man, was stunned for a few minutes, then recovered, and went about his business without com- plaining of his head. In about twelve hours afterward coma super- vened, and he died without being aroused. A case is reported by Dr. Gibson,1 in which a still longer period intervened. A man, sixty years of age, was found one morning, about eight o'clock, seated as if asleep at a desk, his arms crossed before him, and his head resting on them. It was discovered that he was profoundly insensible.. He was sent to the hospital, where he lay comatose, breathing stertorously, and paralyzed on the whole of one side. At the end of two days he died. On post-mortem examination there was found fracture of the left side of the cranium, with rupture of the dura mater and middle meningeal artery, from which latter, extensive haemorrhage had taken place. It was ascertained that, five days before, he had fallen down a stone staircase, was stunned for a few minutes, but had soon recovered his senses. Doubtless during the whole of the intervening period the bleeding from the ruptured vessel had been going on. Prus, in the memoir cited, attempts to draw a symptomatological distinction between sub-arachnoideal and intra-arachnoideal hasmor- rhage. Thus for him headache, dryness of the tongue, fever and deliri- um, are indications of intra-arachnoideal hasmorrhage. Somnolence and coma are common to both forms, but, when they are conjoined with the phenomena mentioned, intra-arachnoideal hasmorrhage is to be diag- nosticated. But most authors doubt if the discrimination can in reality be made during life. Valleix2 declares that the difference is of greater anatomical than symptomatological importance, and Durand-Fardel* admits that it is difficult to present a characteristic view of the course and phenomena of sub-arachnoideal hasmorrhage. I must confess that I see no greater anatomical reason for any difference in the symptoms of the two forms of meningeal hasmorrhage than there is for a dif- ference between inflammation of the pia mater and inflammation of the arachnoid. Neither are there any characteristic symptoms which would serve to distinguish hasmorrhage of the dura mater from either of the other forms. Causes.—Among the predisposing causes of meningeal hasmorrhage age occupies the first place. It is more frequently met with in young in- fants, and in old persons, than in those of middle age. Legendre * in two hundred and forty-eight cases occurring in infants, and in which post- mortem examinations were made, found no instance of the child being over three years of age. Between one and two years would appear from his researches to be the period in which children are most liable to the supervention of meningeal haemorrhage. 1 Edinburgh Medical Journal, September, 1870, p. 199. 2 " Guide de m6decine practicien," tome ii., Paris, 1866, p. 4. 3 Op cit, p. 178. 4 " Recherches sur quelques maladies de l'enfance." Paris, 1846, p. 113, et seq. CEREBRAL MENINGEAL HEMORRHAGE. m But Gintrac's l cases are of different import as regards this point, for of one hundred and sixty-five in which the age was noted, only ten were under ten years of age, while thirty-seven were between the ages of thirty and forty, sixty-seven were between fifty-one. and eighty years of age, and two of eighty-seven and eighty-eight years respectively. Meningeal haemorrhage is often produced by injuries of the skull, and results from sudden rupture of a healthy artery or vein. It may follow blows on the head, falls, or injuries with instruments which perforate the cranium, and may or may not be associated with fractures of the bones. Extreme heat acting upon the head, venereal excesses, severe mus- cular efforts, excessive mental exertion, amenrrohoea, overfeeding, and constipation of the bowels, have been cited as exciting causes. The larger vessels, or the capillaries, may give way from being diseased, and consequently unable to resist the ordinary tension of the blood. Such a condition may be the result of the long-continued excessive use of alcoholic liquors, or may be due to hepatic disease. Prognosis.—The ordinary termination of meningeal hasmorrhage is death. Of thirty-one cases in old persons, cited by Durand-Fardel, death occurred in twenty-six before the end of the fifth day, in one it took place on the seventh day, in two on the fifteenth, and in two in from twenty to twenty-five days. Legendre, in infants, ascertained the duration to be from eight to twelve days. Prus found death to ensue in cases of sub-arachnoideal hasmorrhage before the end of the eighteenth day, but in instances of the intra-arachnoideal form life was sometimes prolonged for over a month. But recovery has occasionally taken place through the formation of false membranes in such a manner as to circumscribe the extravasation, and thus to conduce to the absorption of its fluid portion, and Legendre has described a process occurring in children by which the sanguineous cyst is transformed into one containing serum, thus producing a species of hydrocephalus. Such terminations are, however, so very rare as to mitigate but to a very slight degree the gravity of the prognosis. Diagnosis.—The diagnosis of meningeal hasmorrhage is a matter of much difficulty. Still, there are certain characteristics which aid us somewhat in arriving at a correct opinion. Thus, from cerebral hasmor- rhage, it may usually be distinguished by the.fact that the coma, when it exists, comes on gradually, that the headache is a much more prominent symptom, that there is not often hemiplegia—the paralysis amounting to a general resolution—and above all, by the remissions which so fre- quently mark its course. Durand-Fardel2 declares that when the coma and general abolition of the faculties indicate the existence of strong cerebral pressure not accompanied by paralysis, properly so called, or 1 Op. cit, p. 733. * Op. cit, p. 168. 112 DISEASES OF THE BRAIN. only by incomplete paralysis, perhaps more strongly marked on one side than on the other, we may suspect the presence of meningeal hasm- orrhage; that a cerebral haemorrhage, or an acute softening sufficiently extensive to produce such pronounced symptoms of compression is always accompanied by complete paralysis involving a lateral half of the body, and that the full development of the phenomena is ordinarily preceded by violent headache. From cerebral congestion the diagnosis must be occasionally almost if not altogether impossible, and the same is true of cerebral softening. The remissions when present in meningeal hasmorrhage will afford im- portant assistance in establishing the existence of the disease, but when they are absent the difficulties in the way of an exact discrimination may be insurmountable. Morbid Anatomy and Pathology.—An extravasation of blood be- tween the cranium and the dura mater, extra-meningeal haemorrhage, is, as has already been said, almost invariably the result of traumatic cause. Gintrac,1 however, with his usual industry, has collected five cases in which it appeared to be idiopathic. The first of these he quotes from Dr. J. H. Wythes,2 of Port Carbon, Pennsylvania, but he omits to state that the child had been playing on the door-step, and that a pain in its ankle was supposed by the parents to have been due to a sprain. It is probable, therefore, that the child fell and struck its head. The next morning it was found dead in bed. On post-mortem examination, an extravasation of blood, amounting to about half an ounce, was found between the skull and dura mater, on the upper surface. In the other cases the blood appears to have been effused during extreme congestion of the meningeal vessels, one or more of the latter having given way under the excessive tension to which they were sub- jected. In one quoted from Abercrombie, there were numerous clots scattered over the interior surface of the dura mater, and which seemed to have come from the Pacchionian bodies. These elevations were very vascular, being gorged with blood. The anatomical characteristics of intra- and sub-arachnoideal haem- orrhages have been very thoroughly given by Prus.3 In the former the blood is extravasated by exhalation, that is, there is no visible rupture of blood-vessels, and, if life be prolonged to the fourth or fifth day, a false membrane is formed by which the clot is retained in appo- sition with either the parietal or visceral layer of the arachnoid. This membrane eventually becomes organized by the formation of vessels in it, and may, therefore, be the source of another hasmorrhage; for, as Charcot and Vulpian4 have shown, these vessels are numerous, large, 1 Op. cit, tome i., p. 646. 2 " Three Cases of Infantile Apoplexy." North American Medico-Chirurgical Review, January, 1858, p. 70. 3 Op. et loc. cit. 4 Gazette hebdomadaire, 1860, pp. 728, 789, 821. CEREBRAL MENINGEAL HEMORRHAGE. H3 possessed of very thin walls, and are, therefore, in a favorable condition for giving way under the tension of the blood. Brudet1 previous to Prus had described the false membranes which play so important a part in intra-meningeal hasmorrhage, and had pointed out their resemblance to the arachnoid and their liability to be the source of other haemorrhages, and at about the period of Prus's pub- lication Mr. Prescott Hewett2 called attention to extravasations at- tached to the free surface of the arachnoid, and kept in position by a false membrane not distinguishable by the naked eye from a true serous membrane. The clot may be extensive, covering nearly the whole surface of a hemisphere. The vessels which have given way, and have thus produced an intra-arachnoideal haemorrhage, are usually found in an atheromatous condition, and the vessels of the neo-membranes are es- pecially liable to be thus diseased. Dr. Sutherland3 in a very interesting memoir gives the details of ten cases of arachnoid cysts occurring in the insane: " On removing the skull-cap and dura mater, instead of the convolutions of the brain, with its vascular pia mater meeting the eye, there appears a reddish, pulpy, fluctuating swelling on the surface of the brain, having such a uniform appearance that the outline of the convolutions beneath it is invisible. On attempting to strip off the cyst from the surface of the brain it is usually found adhering to the visceral arachnoid along the centre of the longitudinal fissure ; it is easily separated from the convolutions on either side ; but if large enough to embrace the entire hemisphere is found again to be adherent below, but in this situation usually to the parietal layer of the arachnoid membrane." Of the ten cases reported by Dr. Sutherland, four were in all proba- bility due to injury of the head. In five the mental aberration was organic dementia, in three general paralysis, and in two idiocy and im- becility. In sub-arachnoideal hasmorrhages the blood is, as we have seen, ex- travasated into the space between the arachnoid and the pia mater, and is often entangled in the meshes of this latter membrane. As the blood when extravasated is mingled to a greater or less extent with the cerebro-spinal fluid, it often remains liquid. The quantity thrown out is frequently very large, amounting in some cases to apparently as much as sixteen or even twenty ounces. These figures must, however, be taken with some allowance for the amount of cerebro-spinal fluid with which the blood is combined. 1 " Memoire sur l'hemorrhagie des meninges," Journal des connaissances medico-chi- rurgicales, 1839. 2 Medico- Chirurgical Transactions, vol. xxviii., 1845. 3 " Arachnoid Cysts." " West Riding Lunatic Asylum Medical Reports," vol. L, 1871, p. 218. 8 114 DISEASES OF THE BRAIN. The anatomical relations are such as to admit of sub-arachnoideal haemorrhages being very extensively distributed throughout the cranio- vertebral cavity. In one case in which I made a post-mortem examina- tion, it occupied the whole base of the skull, and, in a case cited by Prus, the whole base of the cranium was filled with blood, all the ven- tricles were in the same condition, and even the sub-arachnoid cavity of the spinal cord was invaded. New membranes are never met with in this form of meningeal haem- orrhage. Atheroma of the arteries, especially of those at the base of the cranium, is the disease which is ordinarily the immediate cause of the extravasation, and the torn vessel can generally be discovered with- out difficulty. Aneurisms of the basilar, the internal carotid, or other arteries of the base of the brain, have by their rupture been the cause of sub-arachnoideal haemorrhage. Treatment.—There is nothing to add under this head to the remarks already made relative to the management of cases of cerebral haemor- rhage. PACHYMENINGITIS AND HEMATOMA OF THE DURA MATER. A peculiar form of meningeal haemorrhage, called hasmatoma, is met with under the dura mater. The blood is not diffused, but is collected in sacs which are formed of false membranes, the result of chronic in- flammation of the dura mater; or pachymeningitis as it has been desig- nated by Virchow. These capsules are flattened ovals in shape, are three or four inches in diameter, and half an inch thick. They are usually situated at the vertex, and involve both hemispheres. When this is the case, the paralysis which results is bilateral. Symptoms.—The initial symptoms of hasmatoma of the dura mater are the results of chronic inflammation, and are slow in their progress. In many respects they resemble those indicative of softening, and consist of weakness of intellect, vertigo, a dull, circumscribed, persistent pain, and more or less tendency to stupor. The power of motion is generally diminished on both sides of the body, though occasionally there is hemiparesis. Paralysis is scarcely ever complete. Contractions of the limbs and twitching of the muscles, especially of those of the face, have occasionally been observed. Gradually, through a period extending over several months, the stupor increases, and finally the patient be- comes apoplectic. During the whole course of the disease the pupils are strongly contracted. The patient dies comatose and frequently convulsed. Causes.—Early and old age are both predisposing causes, the disease being met with mainly in children and very old persons. It is frequently seen in the insane, and may probably result from rheumatism, the ex- cessive use of alcoholic liquors, and fevers. The cause is sometimes to be found in wounds or injuries of the skull. CEREBRAL MENINGEAL HEMORRHAGE. H5 Diagnosis.—It is doubtful if hasmatoma of the dura mater can be definitely recognized either in the stage of inflammation or that of hasm- orrhage. Legendre 1 states that, in children, the most important diag- nostic mark is the permanent contraction of the hands and feet, which is so generally present; but this symptom is certainly met with in other cerebral disorders, and may even result from reflex irritations. The diagnosis is rendered still more difficult by the fact that the disease under consideration is often associated with other cerebral disorders which mask or modify its symptoms. The absence of fever, the con- traction of the pupils, the slowness and irregularity of the pulse, the facts that there are no vomitings and no general convulsions, that the nerves distributed to the several parts of the face are not paralyzed, that there are constant and very severe headache and a gradually in- creasing tendency to stupor, are, according to Jaccoud,2 sufficient to indicate the presence of hasmatoma of the dura mater. I am of the opinion that they only enable us to give a guess which has some basis in probability, for I have several times witnessed exactly such a condi- tion as that described, and after death found other morbid conditions than hasmatoma. Prognosis.—This is unfavorable, death resulting sooner or later, ac- cording to the extent of the disease and the natural powers of the patient. Morbid Anatomy and Pathology.—The first stage of hasmatoma of the dura mater is characterized by the formation of the false mem- branes, to which allusion has already been made. These membranes are found on the internal surface of the dura mater, and are reticulated, presenting somewhat the appearance of spiders' webs. They generally have their seat near the sagittal suture, and extend to both hemispheres, being only separated from them by the arachnoid and pia mater. Virchow, who has studied their formation with greater care than any other observer, has found more than twenty layers of them, one on top of the other, and traversed by numerous blood-vessels. Owing to this great vascularity, to the extreme tenuity of the vessels, and to the absence of any perivascular support, hasmorrhage is liable to occur, and the several lamellae thus constitute a sac into which the blood may be poured. This, pressing upon the cerebrum below, and con- stantly being enlarged by subsequent haemorrhages, gives rise to the symptoms observed during life. The vessels may be more liable to rup- ture from the existence of atheromatous degeneration of their coats. Anatomically and pathologically hasmatoma of the dura mater differs from intra-arachnoideal hasmorrhage in the facts that the extravasation is between the dura mater and parietal layer of the arachnoid, and that the formation of the membrane precedes the haemorrhage. Those 1 "Recherches sur quelques maladies de l'enfance," Paris, 1846. 2 "Traite de pathologie interne," tome i., Paris, 1870. 116 DISEASES OF THE BRAIN. authors who regard the arachnoid as consisting of but a single layer, and who consequently do not admit the existence of intra-arachnoideal hasmorrhage, must consequently concede that there are two kinds of extra-arachnoideal haemorrhage, one in which the membrane forms sub- sequently to the appearance of the extravasation, and the other in which the hasmorrhage is the direct consequence of the formation of the mem- brane. Others again, as, for example, Gintrac and Durand-Fardel, evidently regard what they describe as intra-arachnoideal haemorrhage, as iden- tical with hasmatoma of the dura mater; and it is quite certain that many of the cases adduced by Gintrac as examples of intra-arachnoi- deal haemorrhage are in reality instances of pachymeningitis with sub- sequent sanguineous extravasation. The difficulties in the way of a complete understanding of the subject are greatly lessened by remem- bering the distinction pointed out above, that hasmatoma of the dura mater is a secondary affection, the direct result of inflammation and the formation of false membranes; while in intra-arachnoideal hasmorrhage the membrane is derived from the extravasated blood, which is the first step in the morbid process. The size of the cysts is subject to much variation, the quantity of blood ranging from one or two to sixteen or even more ounces. By the pressure which they exert upon the brain, the convolutions are flattened, and even softening of the cerebral tissue may be produced. Treatment.—This requires no amplification at my hands, as I do not believe in the efficacy of any means for curing the affection. All that can be done is to palliate the more violent symptoms, such as the head- ache and feebleness of mind and body, by anodynes and stimulants, and of these, morphia administered hypodermically, and alcohol in some one or other of its numerous forms, are to be preferred. Bloodletting and blistering are worse than useless. CHAPTER V. PARTIAL CEREBRAL ANAEMIA FROM OBLITERATION OF CEREBRAL BLOOD- VESSELS (ISCHA3MIA). Obliteration of cerebral blood-vessels may take place— 1. By thrombosis of the arteries. 2. By embolism of the arteries. 3. By thrombosis of the veins or sinuses. 4. By embolism or thrombosis of the capillaries. I.—THROMBOSIS OF CEREBRAL ARTERIES. By cerebral arterial thrombosis is understood a condition in which PARTIAL CEREBRAL ANEMIA, ETC. H7 an artery of the brain undergoes narrowing of its calibre by the depo- sition of fibrine from the blood on its internal surface. The clot thus formed is called a thrombus. Symptoms.—The phenomena observed in consequence of the forma- tion of a thrombus in a cerebral artery are gradual in their development, and are often interrupted by stages of apparent improvement. Head- ache, as in so many other affections of the brain, is a prominent symp- tom and is almost constantly present. It is not usually diffused over the whole head, but occupies a place having a close relation in situation with the seat of the disease. It is rarely of a very aggravated charac- acter, and is remarkable rather for its persistency than its severity. In several cases which have come under my notice, the pupil of the eye of the affected side was dilated from the first, and there were ptosis and strabismus, showing that the third nerve Was involved. At a very early period in the progress of the disease it is not un- common to meet with marked difficulties in the faculty of speech, and these not only relate to the articulation, but to the memory of words. As regards the first-mentioned form, there may be restraint in the movements of the tongue, the lips, or both, or there may be a loss of coordinating power in the muscles concerned in speech without any actual paralysis. Special inconvenience is, therefore, experienced when attempts are made to pronounce words in which the labial and lingual letters are prominent. The gutturals in such cases are enunciated without difficulty. In the other form in which the memory of words is impaired, the patient is constantly at a loss for language with which to express his ideas; and, though the proper words may be supplied to him, he almost immediately forgets them again. The full considera- tion of this interesting subject will be found under the head of aphasia. Vertigo, though generally present, is not usually severe, at least in the early stages. The incipient symptoms of paralysis soon make their appearance in the majority of cases, and, though there is a gradual advance in the loss of power, there are periods of almost entire remission. Thus the leg, or the arm, or the face, may be the original seat of the paralysis, and eventually the whole of one side be involved. In a case of prob- able thrombosis in a gentleman now under my charge, the paralysis was at first limited to the muscles supplied by the ulnar nerve and those concerned in deglutition. For one period of five days after I first saw him, there was an entire remission of his symptoms, and he could move his hand and swallow as well as ever, but gradually the power was again lost, and other muscles became involved. At the present time he is almost entirely hemiplegic. Sensibility is also generally abolished or impaired on the paralyzed side, and thus the various forms of numbness, such as tingling, formi cation, etc., are present. 118 DISEASES OF THE BRAIN. The mental symptoms are usually apparent from the first, but may be altogether absent or else so slightly shown as not to attract atten- tion. The memory is impaired, not only as regards words, to which reference has already been made, but also events and circumstances, especially those of recent date. The names of persons and things are likewise readily forgotten. In the case of a gentleman whom I saw in consultation, and in whom I diagnosticated thrombosis, there was left hemiplegia involving both arm and leg, but not the foot, which had begun in the fingers and gradually extended. There was no special difficulty of speech except as regarded the recollection of words, but the memory was wonderfully impaired in every other respect. I en- tered his room upon one occasion just as the servant was carrying out a tray with the remains of his breakfast. Not three minutes had elapsed since he had eaten, and yet he assured me he had tasted noth- ing since the day before. The loss of memory was the first symptom observed in this case. Soon afterward he began to improve, and he is now, after fifteen months, free from paralysis, and with his memory almost as good as ever. The loss of memory in such cases seems to be due in the main to the fact that the power of concentrating the atten- tion upon any subject is very much diminished. There is likewise an indisposition to exert the powers of the mind or body, and thus the patient tends to pass into a condition of apathy. Somnolence is a fre- quent symptom. An interesting case' of what was probably cerebral arterial throm- bosis was admitted to the New York State Hospital for Diseases of the Nervous System, August 22, 1870, and came under my observation. The patient, a man forty-one years of age, was temperate, and had never had either syphilis or rheumatism. In March, 1868, he was seized with a dull pain in the right knee, accompanied with numbness. There soon followed formications and pricking sensations, limited to the right foot. These gradually extended upward, and, at the end of two weeks, had reached the shoulder, when he became entirely hemiplegic. Dur- ing this attack his consciousness was not affected, and his organs of special sense, except his touch, were unimpaired. On the 11th of May following, the patient suddenly lost the power of speech, but ex- perienced no disturbance of consciousness. He remained completely aphasic for four months, being only able during this time to utter a few sounds which could not be interpreted into intelligible words. He then began to enunciate a few words, and gradually acquired more facil- ity, though his power of coordination was far from perfect when he came to the hospital. His paralysis remained complete for nearly a year. When admitted there was hemiplegia of the right side of the body 1 See the author's " Clinical Lectures on Diseases of the Nervous System." New York, 1874, p. 1. Case reported by Dr. T. M. B. Cross. PARTIAL CEREBRAL ANAEMIA, ETC. 119 except the face; his eyesight, hearing, and other special senses, were unimpaired, and his intellect was clear. There was no loss of the mem- ory of words, and no impairment of the motor power of the tongue, but simply a defect in the faculty of coordination of the muscles used in articulation. There was more difficulty in pronouncing labials and Un- guals than gutturals. Tactile sensibility, electro-muscular sensibility, and contractility, together with the temperature, were markedly dimin- ished in the right arm, while sensibility to pain and deep pressure was normal. The bladder and rectum were not paralyzed. In talking, he had a peculiar hesitating, stammering manner, highly characteristic of his disease. There were certain words which he was totally unable to pronounce with any degree of accuracy, even after much effort—"Peter Piper"—words which begin with explosive labial letters, and others similarly constructed troubled him greatly. The ophthalmoscope showed the existence of atrophy of both of the disks, and of retinal anaemia. Under the use of strychnine hypodermically administered, phospho- rus, and the primary current to his brain and the faradaic to the para- lyzed parts, very marked improvement in all his symptoms was produced. He regained a considerable amount of power in the arm, became able to walk several miles at a time, and acquired the ability to articulate distinctly any words he wished to say. The sensibility returned, and the nutrition of the affected limbs was manifestly improved. In another case, also the subject of a clinical lecture,1 there was probably thrombosis of the basilar artery. The patient, a woman, aged thirty-five, while at work wringing out clothes and exerting a good deal of force, experienced a sensation of numbness in the right arm and leg, which was attended with slight loss of power, though not enough to cause her to desist from her labor. At the time of the attack there were no head-symptoms of any kind, and she noticed no paralysis of the face. Her speech was not affected. At the time of her admission into the New York State Hospital for Diseases of the Nervous System, there was paralysis of motion and sensibility of the right arm and of motion on the left side of the face. The case was therefore one of cross-paralysis, and it was this fact' which mainly induced me to locate the lesion in the pons Varolii. The speech was indistinct, but this was manifestly due to paraly- sis of the tongue and of the other muscles concerned in articulation. In the case in question there had been acute articular rheumatism, but the heart was free from functional or organic disease. The attack was not manifested with the suddenness which characterizes embolism, and there were no loss of the faculty of language, and no mental dis- turbance, which would probably have resulted had the middle cerebral artery been occluded. Besides, the face and the limbs would have 1 Op. cit, p. 130. 120 DISEASES OF THE BRAIN. been paralyzed on the same side, all of which considerations induced me to believe that the case was one of thrombosis of a limited portion of the .basilar artery. During the first stage of thrombosis, before the artery is entirely closed, amendment, and even complete recovery, may take place. The remissions in the symptoms already referred to are due to the establish- ment of the collateral circulation, and this may become so complete as to eventuate in cure. It must be confessed, however, that the condi- tion of anasmia to which the foregoing symptoms are due, in the great majority of cases ends in softening—a subject which will presently be considered as one of the consequences of thrombosis and other morbid states. Causes.—Thrombosis of an artery may result from atheroma or from endarteritis, by reason of which its elasticity is diminished and the smoothness of its lining membrane destroyed. Both these condi- tions retard the course of the blood, and favor the deposition of fibrine on the internal periphery. The walls of the vessels may be healthy, and a thrombus may then be formed through a weak action of the heart—the result of fatty degeneration or other cause impairing its strength. Certain conditions of the system, such as that which accompanies rheumatism, may induce thrombosis through the excessive amount of fibrine present in the blood and which renders this fluid more readily coagulable. It is probable, also, that other diseases and particular articles of food—as, for instance, alcohol, fat, and starch—when taken in excess, especially when conjoined with insufficient physical exercise, may so alter the composition of the blood—inducing hyperinosis—as to lead to a like result. Inordinate mental exertion, tending as it does to diminish the tone of the arteries by keeping them in a condition of over- distention, may likewise cause the formation of thrombi. It has apparently resulted from exposure to intense heat, from sup- pression of the menstrual flow, from severe emotional disturbance, and from blows on the head. It is much more common in males than in females, and in persons of advanced years than in the young. Pressure may be exerted upon a cerebral artery by a tumor or other extraneous body, and narrowing of its calibre and a consequent throm- bus be produced. Gintracx cites a case of the kind. A young man had suffered for several days with headache and loss of power in the lower extremities. Coma supervened, but he was still able to answer questions. There was then pain in the back of the head, the pupils were dilated, the mouth was drawn to the right, the respiration was laborious but not stertorous, and the left side became completely paralyzed. He died on the fifth day. On post-mortem examination a 1 Op. cit., tome i., p. 444. Quoted from Roupell, Medical Times, 1844, vol. ix., p. 870. PARTIAL CEREBRAL ANAEMIA, ETC. 121 firm clot was found to occlude the right middle cerebral artery, and it extended to the internal carotid artery, but did not pass into the middle cerebral artery beyond th e point of obstruction. At this place in the fissure of Sylvius a small granulated mass, something like a Pacchi- onian gland, pressed upon the artery and closed it. In such a case the symptoms will of course be developed with much greater rapidity than when the cause of the occlusion resides in the artery itself. Diagnosis.—Arterial thrombosis is distinguished from cerebral con- gestion by the facts that the mental and other symptoms are more pro- found in character, and that the patient has generally passed the prime of life. The existence of paralysis among the early symptoms will likewise tend to the formation of a correct opinion. From cerebral hasmorrhage it is diagnosticated by the circumstance of its gradual de- velopment; from encephalitis by the absence of fever and the more chronic nature of the disease; and from embolism by its slow progress and the impossibility of defining the exact period of its beginning. Prognosis.—The prognosis in cerebral arterial thrombosis is unfa- vorable, for the reason that, although the morbid process may advance slowly, and may even be spontaneously arrested in its course before the artery is closed, the tendency to complete obliteration is always great, and the chance of sufficient circulation being carried on by the collateral vessels is very remote. The disposition to softening, there- fore, always exists, and generally cannot be overcome. The inade- quacy of any medical treatment to control the action going on within the artery, or to aid to any great extent in the development of the collateral circulation, is also an element in forming an opinion as to the ultimate result. Morbid Anatomy and Pathology.—Although Virchowl was the first to write distinctly in regard to the nature of thrombosis, the condition was recognized long before his researches were made, and cases of clots plugging up the vessels are to be found detailed by many of the older medical authors, among whom Abercrombie, Carswell, and Cruveilhier, may be mentioned. Since Virchow began his observations in this direc- tion, many instances have been recorded and a large number of memoirs have been issued upon the subject. An interesting case was related by Dr. Packard,2 of Philadelphia, at a meeting of the Pathological Society of that city held in December, 1859. The patient, who had been under the care of Dr. Heller, was a bachelor, fifty-one years of age. At six o'clock in the morning, at the beginning of February, he was seized with paralysis of the left arm and leg. He was a man of very regular habits, and of fanatical love for every thing instructive, and an accomplished scholar in botany, geography, and languages. The paralysis was soon relieved, and he was able, four weeks afterward, to go out again and to 1 Froriep's Neue Notizen, 1846, Heft xxxvii. 2 North American Medico-Chirurgical Review, vol. iv., 1860, p. 306. 122 DISEASES OF THE BRAIN. use his arm tolerably well. About the middle of March, in consequence of a fatiguing walk the previous evening, and an attack of diarrhoea during the night, complete paralysis returned. From this he never re- covered, but yet did not die till the December following. Previous to this termination he had confusion of ideas and delirium. Upon post- mortem examination, among other morbid changes, a cavity in the right corpus striatum was found, and this was surrounded by a spot of soft- ening of the cerebral substance as large as an egg. The basilar artery was completely blocked up with clots, as was also the right carotid. These vessels were atheromatous, and the basilar artery was aneuris- mally dilated. The clots had all the appearance of being old. Dr. Dickinsonx has brought forward five cases of occlusion of arte- ries, several of which I am disposed to think were of embolism, instead of thrombosis, as he considers them to be. Dr. Dickinson nowhere alludes to Virchow's investigations, but gives the whole credit of the discovery of the relation between emboli and the formation of concre- tions in the heart to Dr. Kirkes. The conclusions which he draws from his cases are by no means original, although he evidently so regards them. The questions to be considered in connection with the morbid anatomy of arterial thrombosis relate to the condition of the artery, the nature of the clot, and the changes which take place in those parts of the brain which are deprived of their due supply of blood. The affections of the artery, being similar to those which render it liable to rupture, need not be dwelt upon at any length here, as they have already been noticed under the head of the morbid anatomy of cerebral hasmorrhage. Suffice it, therefore, to say that endarteritis and atheromatous degeneration are the diseased states generally met with. The calibre of the diseased vessel is diminished and the blood is therefore primarily obstructed in its course even before the beginning of the formation of a clot. In addition the internal coat of the artery is roughened, and hence the fibrine of the blood is readily caught and de- posited on the internal periphery. Little by little the layer becomes thicker from fresh accretions, until finally the vessel is entirely occluded. The clot which closes the vessel is, in the beginning, coagulated blood, and hence consists of fibrine and white and red blood-corpuscles. It adheres to the arterial wall and may be of a brown, yellow, gray, or white color. The consistence is greater at the base than at the pe- riphery, and it may contain granules of calcareous matter composed mainly of phosphate of lime.9 The elements, with the exception of the fibrine, are gradually disintegrated and washed away by the current of 1 " On the Formation of Coagulae in the Cerebral Arteries." St. George's Hospital Re- ports, vol. i., 1866, p. 257. 2 Lancereaux, " De la thrombose et de l'embolie cSrebrales. These de Paris," 1862, p. 86. PARTIAL CEREBRAL ANEMIA, ETC. 123 blood which continues to flow through the vessel before it is entirely closed, and therefore the layers nearest the arterial wall consist almost entirely of fibrine, and the one nearest the centre of the vessel, which is the latest formed, of fibrine and corpuscles. An examination of such a clot with the microscope shows that the above-mentioned morphological elements are found in its centre, more or less changed, however, accord- ing to the age of the formation. A thrombus may undergo purulent softening and disintegration to such an extent as to result in its break- ing up into fragments, which may lodge in the vessel or its branches farther on, and thus constitute emboli. The region of the brain to which the artery undergoing occlusion is distributed is, of course, deprived to some extent of its blood, and hence presents at first an appearance of anaemia. And this is not prevented by the increase of the collateral circulation, which is never sufficiently vigorous to compensate entirely for the loss by the primary vessel. Microscopic examination shows the capillaries to be smaller and less numerous than in the normal condition, though there is not any palpa- ble softening. But after the artery is entirely closed a change ensues. The anasmic portion of the brain becomes red or pink, and this color is deepest on the borders, owing to the collateral circulation which is now fully es- tablished. This stage has been called red softening, but I am disposed to think the designation erroneous, and that it is liable to convey false ideas of the pathology. For it is perfectly possible at this time for the anasmic portion of the brain to be restored through the activity of the collateral circulation, with the effect of causing a cessation of the symp- toms. If, however, this should be insufficient to provide for the due nutrition of the affected region, softening takes place, and a cure be- comes almost impossible. Obliteration of a cerebral artery by thrombus does not always pro- duce notable symptoms. For these to follow, the morbid process must be set up in a vessel with but few and small collateral branches. Thus, if the internal carotid be obstructed, the circulation is carried on through the circle of Willis by the supply of blood derived from the vertebrals. The basilar artery might also be occluded at any limited region between a pair of transverse arteries, and the circulation still kept up by the carotids on the one side, and the vertebrals on the other. But any closure so as to involve one or more of the transverse arteries must lead to anasmia, and subsequent softening of the pons Varolii. Thus, in a case reported by Bennett,1 in which there had been vertigo and other head-symptoms for several years, and in which paralysis of the left arm, without loss of consciousness, had suddenly supervened, the basilar artery was found entirely obliterated throughout its entire extent, all 1 " Clinical Lectures on the Principles and Practice of Medicine," third edition, Edin- burgh, 1850, p. 370. 124 DISEASES OF THE BRAIN. the transverse arteries were of course closed, and the supply of blood to the pons was cut off on both sides of the mesial line. A somewhat similar case has recently been reported to me by a physician of this city. The patient had suffered with paresis of all the limbs, with pain in the back of the head, occasional vertigo, irregu- larity of the respiration and circulation, and double facial paralysis for several months. He died suddenly while sitting quietly in his chair. On post-mortem examination the basilar artery was found occluded, Fig. 15. a, artery of the corpus callosum (anterior cerebral, right}; &, middle cerebral artery; c, posterior cerebral artery; d, superior cerebellar artery; 6, anterior inferior cerebellar artery; f, posterior inferior cere- bellar artery; & obliteration of artery of corpus callosum (anterior cerebral, right); h. obliteration of middle cerebral artery; i, obliteration of basilar artery; k, obliteration of vertebral artery (left). and distended by a thrombus which reached from the point of union of the vertebrals to the posterior cerebral arteries, into the left one of which it extended two or three lines. A very interesting memoir by Hayem x alleges occlusion of the basilar artery by thrombus to be a cause of sudden death. In all his cases, four in number, the artery was closed throughout a great part of 1 " Sur la thrombose par art6rite du tronc basilaire, comme cause du mort rapide." Archives de Physiologie Normale et Pathologique, 1868, p. 270. PARTIAL CEREBRAL ANAEMIA, ETC. 125 its extent, as the result of extensive arteritis and the formation of dense clots. In the fourth case there was also thrombosis of the left middle cerebral artery, with difficulty of speech. The cerebral vessels most liable to be closed by thrombosis are the internal carotid, the middle cerebral, the basilar and the vertebral; after these come the anterior cerebral, the posterior communicating, and the posterior cerebral. It is by no means rare to find two or more arteries simultaneously affected, and in one case cited by Gintracx the whole circle of Willis was obstructed, and, in a remarkably interesting case described by Heubner,5 the right anterior cerebral artery, the left middle cerebral, the basilar, and the left vertebral were obliterated by thrombosis of syphilitic origin (Fig. 15). The arrows in the figure represent the course which the blood took by reason of the several ob- structions to its circulation. The vessels the closure of which produces the greatest disturbance of function are the anterior, middle, and posterior cerebral, which supply the hemispheres, the corpus striatum, optic thalamus, and other impor- tant ganglia. Besides the effect due directly to the anasmia, more or less disturbance results from the congestion posterior to the clot, and the consequent effusion of serum. Treatment.—A knowledge of the morbid anatomy and pathology of cerebral arterial thrombosis must satisfy us of the insufficiency of any medical treatment to cause the absorption of the clot obliterating the channel of the artery. Yet I have several times heard it gravely pro- posed to administer the iodide of potassium, with the view of accom- plishing this object. As regards facilitating the establishment of the collateral circulation, Nature will generally take care of this, and may even so far overdo it as to cause hasmorrhage from the rupture of ves- sels not accustomed to the increased tension of the blood. It may therefore be necessary, in this latter condition of excessive action, to give the bromide of potassium in large doses. Should the circulation be feeble, the skin cold, and the patient disposed to somnolence, we have reason to suppose that the collateral circulation is not being formed with sufficient rapidity, and therefore the patient should be kept with the head low, brandy or other spirituous liquors administered, and the body wrapped up in warm blankets. For some time after the successful establishment of the collateral cir- culation there is more or less feebleness of mind and body. For this condition strychnia and phosphorus are especially applicable, and may be administered according to the formulas recommended under the heads of cerebral congestion and cerebral hasmorrhage. Electricity is almost always useful. 1 Op. cit, p. 443. a "Die Luetische Erkrankung der Hirnarterien," Leipzig, 1874, pp. 87, 194. 126 DISEASES OF THE BRAIN. II.--EMBOLISM OF CEREBRAL ARTERIES. Embolism is the term applied by Virchow to the closure of an ar- tery by an embolus, which is a clot formed in some other part of the body and transported by the current of the blood to the vessel which it oc- cludes. It therefore differs from thrombosis in the facts that it is not associated with previous disease of the artery, and that the closure of the vessel is sudden. Symptoms.—In cerebral embolism there are no premonitory symp- toms. As in cerebral haemorrhage, the patient may be sitting per- fectly quiet when he suddenly loses consciousness and falls to the ground, comatose. As the stupor passes off, he finds that he is par- alyzed upon the side of the body opposite to the seat of the lesion. Or there may be no coma, but merely slight confusion of ideas for a moment or two with sudden accession of paralysis on a limited por- tion of one side, involving only the arm or leg. Or, again, the face or the tongue may be the only part paralyzed. Or there may be no paralysis anywhere, and no mental symptoms except as regards the faculty of language, which is entirely or partially lost. Sometimes there are ocular troubles, such as ptosis, strabismus, or blindness. Experience shows that the embolus, for reasons which will be given hereafter, generally lodges in the left middle cerebral artery, and that with the right hemiplegia—if there be paralysis at all—there is often aberration of the faculty of speech. The symptoms of mental derangement, with the exception of the coma of severe attacks, are not ordinarily prominent. I have, however, witnessed several cases in which they formed a very striking feature of the case. In one of these, in which the clinical history of the patient disclosed the preexistence of several attacks of acute articular rheu- matism, with subsequent endocarditis and mitral and aortic valvular lesions, there were hallucinations and delusions in addition to the complete paralysis of the left side. All these phenomena entirely dis- appeared within thirty-six hours. This case is one of the few in my experience in which the embolus had occluded an artery on the right side of the brain. In another, likewise with valvular disease of the left side of the heart, there was delirium from the first, and this disappeared as the collateral circulation was established. Erlenmeyer has written very excellently of cerebral embolism, but is, I think, incorrect in some points of his symptomatology. He states the ordinary phenomena of an attack to be as follows: There are no prodromata; sudden loss of consciousness, with pa- ralysis of several parts of the body. The facial, the hypoglossal, and the nerves of the extremities, are always more or less affected. Sensi- PARTIAL CEREBRAL ANAEMIA, ETC. 127 bility is abolished in the conjunctiva, but is retained in the cornea. The pupils remain sensitive, and are neither contracted nor dilated, neither are there symptoms of concussion or compression. There are no vomitings and no contractions. The pulse is weak and small, and the temperature rather below the normal standard. Occasionally there are epileptiform convulsions. Psychical troubles do not ordinarily ap- pear till the collateral circulation becomes active, and local hyperasmia is thus induced. The principal exception I have to make to the foregoing sequence of symptoms is the too absolute assertion of the paralysis of the facial, hypoglossal, and other nerves. I have seen several cases in which there was no paralysis to be detected in any part of the body by the most careful examination, and several others are on record. In one very in- teresting instance, occurring in a lady who had had repeated attacks of acute rheumatism, and who had at the time marked aortic insufficiency, headache and vertigo suddenly occurred while she was conversing with a friend, and her speech was cut short with as much suddenness as though she had been shot. There was no paralysis of the tongue, but all idea of language was abolished. Within forty-eight hours she re- covered entirely the faculty of speech. In another, that of a gentle- man with a similar clinical history, headache, vertigo, confusion of ideas, and amnesic aphasia, suddenly supervened. That both these were cases of embolism can scarcely, I think, be doubted. And. then, as regards the state of the pupils, my experience does not coincide with that of Erlenmeyer, for I have frequently found either dilatation or contraction of both pupils, or dilatation of one and con- traction of the other. In examining a case of recent embolism, the ophthalmoscope should always be used to view the fundus of the eye, and even in old cases valuable signs will often be obtained. The middle cerebral artery, the ordinary seat of embolus, arises from the internal carotid, after the an- terior cerebral and ophthalmic have been given off. Occlusion of its channel must, of course, throw an increased amount of blood into these last-named arteries, and, as the arteria centralis retinas is derived from the ophthalmic, it and its branches become enlarged. The ophthal- moscope will enable us to discover the congestion thus produced, and will often be the means of helping us to determine, in the absence of pa- ralysis, which side of the brain is the seat of the lesion. In older cases we will frequently find retinal congestion. The following case I quote not only as being the first of which I have any knowledge in which the ophthalmoscope was used in a case of cerebral embolism, but as being interesting from the fact that the embolus was on the right side. It is reported as Cerebral Embolism following Valvular Disease of the Heart.—John Turnbull, aged seventeen, was admitted into the Hull General Infirm- 128 DISEASES OF THE BRAIN. ary, on April 25, 1867. He was tall, much wasted, and had a suffering expression, and converging strabismus of the left eye, the mouth being drawn very slightly toward the left side. Pulse 70, very thrilling in character, and a large coarse systolic murmur near the left nipple. He was perfectly sensible, complained of severe frontal headache, with confusion of vision, and stated that he had been in much the same con- dition for seven weeks, his illness beginning spontaneously with head- ache and vomiting, unaccompanied by loss of consciousness or con- vulsions. He had had an attack of acute rheumatism in the previous summer. He was ordered gr. iij of blue-pill and gr. ij of extract of henbane in a pill, and a draught of acetate of ammonia, three times a day, and spirit-lotion to the head. " No marked alteration in his con- dition, except progressive debility, took place till May 2d, when he complained of increased headache and dimness of vision, and, being un- able to expectorate, from excessive weakness, death from bronchial obstruction threatened. With the aid of some champagne, he rallied in about twenty-four hours, and at the end of a week was much im- proved, having a clean tongue and good appetite, but the headache, stra- bismus, and deviation of the tongue to the left, remained. On May 16th it was noticed that these symptoms had passed off, with the exception of the last mentioned. He was ordered a mineral-acid mixture. " A week later, as he still complained of some dimness of sight, he was examined with the ophthalmoscope. The retinal vessels were found much enlarged, and the veins very tortuous; the optic' nerve- entrance of an intense red color, not being distinguishable from the surrounding parts except by the entrance of the vessels, the redness being chiefly due to a number of very fine vessels radiating from the centre. There was no morbid effusion in any part. He could spell easily from No. 15 of Jaeger's test-types (being unable to read and write). He was again examined at the end of another week, when the optic nerve-entrance was observed to be paler in color, so that its cir- cumference could be distinguished, but still much injected, and the vessels nearly as large and tortuous as before; sight was apparently perfect. He was discharged convalescent. " The peculiar form of paralysis in this case denoted some morbid condition within the cranium, which appeared to have its most easy and natural explanation in cerebral embolism, an opinion further sup- ported by the perfect recovery of the patient. The case received much additional interest from the information afforded by the ophthalmo- scope, for one may fairly believe that the intense congestion of the retinas denoted a similar condition of the brain, perhaps a state of re- action after the circulation had been reestablished through collateral channels." * 1 British Medical Journal, 1867; also Quarterly Journal of Psychological Medicine, January, 1868, p. 178. PARTIAL CEREBRAL AN.EMIA, ETC. 129 Causes.—The most common first step in the causation of cerebral embolism is acute articular rheumatism, which, by inducing acute en- docarditis, leads to the formation of emboli on the valves of the heart and other parts of the endocardium. Aneurisms of the aorta or other large artery, resulting in the coagulation of the blood in the aneurismal sacs, may likewise induce it, by a portion of the clot being washed off by the current. Esmarch' details a case in which, while an examina- tion was being made of an aneurism of the carotid, the patient sud- denly fell back in an apoplectic stupor. The whole right side was at once paralyzed, the facial muscles on the left side were convulsed, and four days afterward death ensued. Post-mortem examination showed that the left internal carotid, the middle cerebral, and the ophthalmic, were completely closed by coagula, which were identical in structure and appearance with the clot in the aneurismal sac. Emboli may also originate in the lungs, and, entering the left auricle through the pulmonary veins, finally lodge in a cerebral artery. Age appears to exercise no influence over the formation of emboli, but men are much more commonly the subjects than women, for the rea- son, undoubtedly, that they are more liable to attacks of rheumatism. Of sixty-two cases under my care, either alone or in consultation, in which I had reason to diagnosticate cerebral embolism, there was organic disease of the heart in all but four. Three of the cases were over sixty years of age; seven between fifty and sixty; eleven between forty and fifty; twenty-nine between thirty and forty; and twelve under thirty. Thirty-nine were males and twenty-three were females. Diagnosis.—From cerebral hasmorrhage, embolism may be distin- guished by the following signs. It occurs without relation to age, while hasmorrhage is much more frequent in persons over forty; there are no prodromata; the resultant paralysis is generally on the right side, while in haemorrhage there is no such predisposition; and it is in the great majority of cases associated with organic disease of the left side of the heart. Care, however, must be taken not to over-estimate the value of this diagnostic mark, valuable as it is. In one case under my charge, in which the symptoms pointed strongly to the existence of a cerebral embolus, and in which, after death, the left middle cerebral - artery was found occluded, the heart was perfectly healthy; and in one other, in which cerebral embolus was diagnosticated, and in which there was mitral regurgitation, extravasation into the corpus striatum was discovered to be the cause of death. A case has recently been re- ported by Dr. J. Hughlings Jackson,3 in which there was cerebral haem- orrhage with hemiplegia, together with extensive valvular disease of the heart. A patient now in the New York State Hospital for Diseases of the 1 Archivfur Pathologie, Anatomie und Physiologie, B. xi., Heft 5, 1857. 2 British Medical Journal, October 29, 1870, p. 459. 9 130 DISEASES OF THE BRAIN. Nervous System has left hemiplegia, involving face, arm, and leg. It has already lasted seven months, although greatly improved. The hand and arm are much contracted. The attack was apparently in- duced by strong muscular exertion being made while in a stooping and constrained position. Most physicians will be disposed to agree with my diagnosis, that the case is one of cerebral haemorrhage, for the obvious cause of the paroxysm, the lesion being on the right side of the brain, the steady improvement and the muscular contractions, all point to extravasation of blood instead of embolus. Yet he is under twenty years of age, and, before the seizure, had an attack of acute rheumatism, with heart-symptoms. He now has aortic and mitral regurgitation. Such cases as the above are very instructive, and they show us how necessary it is to weigh all the facts, and how great is the possibility of making a mistake after all. For, although I am inclined to the view of hasmorrhage, no definite opinion can be given without a post-mor- tem examination. Still in a case of partial or complete hemiplegia, with or without apoplexy, in which the patient was below the age of forty, with the hemiplegia involving the right side, no muscular contractions and or- ganic disease of the left side of the heart, with or without previous attacks of acute articular rheumatism, cerebral embolus may safely be said to be the cause of the symptoms. Moreover, the paralysis from embolism, if it does not disappear within seventy-two hours after the seizure, does not gradually fade away as it so frequently does to a great extent in hasmorrhage. It is a somewhat remarkable fact that in cerebral embolism the pa- ralysis may be very extensive and complete without the occurrence of other notable symptoms. Thus in the case of a young lady whom I saw in consultation with Drs. Polk and M. A. Wilson, there had been in childhood a severe attack of inflammatory rheumatism and several minor attacks subsequently. On the last day of September, 187-1, she sud- denly became hemiplegic on the left side, but did not lose consciousness. There was no aphasia, pain in the head, convulsive movements, nor mental disturbance. The paralysis, however, involved the left arm and leg, and was exceedingly profound. The face was affected for a short time, but the tongue retained its motor power. Three months after- ward she could stand and walk a little, but was not able to raise the foot from the ground; the arm was absolutely immovable. Here the clinical history, accompanied as it was with a record of heart-disturb- ance for several years, was such as to leave no doubt as to the lesion being embolism of an artery—probably the middle cerebral—of the right side of the brain. The suddenness with which embolism takes place, to say nothing of the other points in the clinical history, will suffice for the discrimination from thrombosis. PARTIAL CEREBRAL ANAEMIA, ETC. 131 Prognosis.—The prognosis in cerebral embolism is grave, for the reason that the tendency to softening of the anasmic cerebral tissue always exists. But, if the patient passes over the first four or five days without any aggravation of his symptoms, and especially if they be mitigated in violence, there is considerable hope of a favorable result. Still, a guarded opinion should always be given till all head-symptoms have disappeared. Morbid Anatomy and Pathology.—The first rational explanation of embolism was made by Virchow,1 in 1847, who, in his paper on acute inflammation of the arteries, distinctly explained the manner in which the vessels were occluded by clots transported in the blood from dis- tant parts of the body, and who associated these coagula with valvular disease of the heart. In two of the cases cited by him in which arteries were found closed by such clots, the valves of the heart were discovered to have others still attached to them, and exhibited traces of the sep- aration of those which were found in the vessels. Subsequently (in 1852), Dr. Senhouse Kirkes a called special atten- tion to the plugging up of the middle cerebral artery as a cause of soft- ening of the brain. Three cases, in which death followed, are adduced, in each of which the condition Of non-inflammatory softening was found to exist in the brain. Dr. Kirkes's observations appear to have been made without any knowledge of Virchow's prior researches. He states that the paralysis met with in young persons may be due to the inter- ruption of a due supply of nutriment to the brain by the occlusion of an artery by a plug derived from the left side of the heart. SchUtzenberger,3 among others, has written with great fullness on this subject. Among other conclusions not specially applicable to the particular point now under consideration, he states that fibrinous con- cretions may form in the heart or large vessels, may subsequently be detached and carried by the blood to the cerebral arteries, where they produce symptoms not essentially different from those noticed in cere- bral hasmorrhage or acute softening. The only material points of difference under this head between thrombosis and embolism are, the suddenness of the attack, the part of the brain most liable to be affected, the origin of the clot, and the state of the blood-vessel which is obliterated. Relative to the first, the abrupt closure of a vessel as in embolism will, of course, produce more violent symptoms than if the occlusion 1 " Ueber die akute Entzundung der Arterien." Archiv fur Pathol. Anatomie, B. i., 1847, p. 272. In a paper on " Occlusion of the Pulmonary Artery," published in Froriep's NeueNotizen in 1846, he enunciated a similar theory. 2 " On some of the Principal Effects resulting from the Detachment of Fibrinous Deposits from the Interior of the Heart, and their Mixture with the Circulating Fluid." Medico-Chirurgical Transactions, voL xxxv., 1852. 3 Gazette des Hopitaux, No. 80, 1857. 132 DISEASES OF THE BRAIN. has taken place gradually, and thus time have been afforded for the establishment of the collateral circulation. In the first case, not only is the blood at once shut off from a portion of the brain, but the vessels behind the clot receive a greater quantity than they normally do, and hence the regions they supply are immediately congested. In examina- tion of the brain of a person who has died during the first stage of cerebral embolism, we find those parts of the brain ordinarily supplied by the obliterated vessel paler than natural, with a zone of congested tissue, and perhaps numerous small extravasations of blood on the periphery. The place where emboli are most frequently found is, as has already been stated, the left middle cerebral artery. The left common carotid arises from the arch of the aorta in a line almost exactly coinciding with the course of the blood-current. It therefore happens that an embolus which has formed on the lining membrane of the heart, and which has passed into the aorta after having been detached, enters this vessel instead of the innominata. From the common carotid it passes into the internal carotid and thence with the stronger and more direct current into the middle cerebral artery, which is lodged in the fissure of Sylvius. Of forty-two cases of cerebral embolism collected by Meissner, in thirty-four the left hemisphere was the seat. Of sixty- two cases occurring in my own practice, and to which reference has been made, fifty were accompanied with right hemiplegia, and were consequently on the left side of the brain. Post-mortem examinations were made in eleven of these cases, and in all the embolus occupied the left middle cerebral artery. Of these latter was the case of a prominent elderly gentleman of Providence, Rhode Island, whom I was requested to visit in consul- tation with Drs. Parsons and Collins, of that city. Three days be- fore, while ascending a hill, he had suddenly become semi-unconscious and hemiplegic on the right side. There was also well-marked aphasia. When I saw him he was in a state of partial coma, from which he could be roused so as to be made to comprehend, but was unable to talk, and was entirely paralyzed in the face, arm, and leg, of the right side. The clinical history indicated the existence of disease of the left side of the heart. I diagnosticated an embolus of the left middle cerebral artery, and expressed the opinion that death would ensue within a few hours. In both of these views the other medical gentlemen fully con- curred. The patient died about eight hours afterward. The post- mortem examination was made the following day, and proved the correctness of the opinion that had been expressed, for an embolus completely occluded the left middle cerebral artery, at the point where it divides into the branches which supply the island of Reil and the convolutions of the base of the anterior and middle lobes. The pathology of the genesis of the clot has already been sufficiently PARTIAL CEREBRAL ANEMIA, ETC. 133 dwelt upon in other connections, and the fact that the artery in which it is found is not diseased has been mentioned. The further consequences of embolism belong to cerebral softening, and will be considered under that head. Treatment.—It is not necessary to make any remarks on this point in addition to those made in regard to the treatment of thrombosis. There is very little to be done besides meeting indications as they arise, and attempting to relieve the paralysis and other symptoms, for which ends my views have been sufficiently expressed in the preceding chapters. III.-—THROMBOSIS OF CEREBRAL VEIN'S AND SINUSES. It was, until the researches of Virchow, generally supposed that the coagulation of the blood in the veins was the immediate result of phlebitis; but through his investigations it is now very well understood that, in the great majority of cases, the inflammation of the veins is a consequence of the formation of a thrombus, and not a cause. For reasons which will be given further on, the sinuses of the dura mater are especially liable to be the seat of autocthonous coagulas. Symptoms.—It is very doubtful if venous cerebral thrombosis pos- sesses such a characteristic symptomatology as to admit of its being identified during the life of the patient. There are headache, convul- sions epileptiform in character, paralysis of different parts of the body, particularly of the ocular muscles, giving rise to squinting and double vision, disturbances of sensibility, and, toward the close of the disease, coma. Occasionally there is apoplexy at an early stage. Certain symptoms have been laid down by authors as indicative of the existence of thrombosis of particular sinuses. Jaccoud,1 however, appears to discredit their importance, and I am disposed to agree with him that, though it may be well to know them, it is safer not to attrib- ute to them an absolute value. Thus, Von Dusch2 asserts that epistaxis is symptomatic of obliteration of the superior longitudinal sinus ; Ger- hardts finds a difference in the size of the external jugular veins—that of the affected side being more collapsed than the other—indicative of thrombosis of the lateral sinus ; Griesinger4 states that the presence of a painful circumscribed oedema behind the ear is evidence of jthe existence of thrombosis of the transverse sinus extending into the veins which lead to the sigmoid fossa; and Corazza 5 thinks obliteration of the superior longitudinal sinus is signified by oedema of the frontal 1 "Traits de pathologie interne," tome premier, Paris, 1870, p. 149. 2 Henle und Pfeufer's "Zeitschrift fur ration. Medicin," B. vii., 1859, p. 161. Also the New Sydenham Translation—"On Thrombosis of the Cerebral Sinuses," London, 1861. s Deutsche Klinik, 1857, No. 45. 4 " Beobachtungen ueber Hirnkrankheiten," Archiv der Heilkunde, 1863. 6 "Revista Clinica," 1866. 134 DISEASES OF THE BRAIN. veins, and exophthalmos. An important point in the symptomatology of thrombosis of the encephalic veins and sinuses is the often simulta- neous presence of suppurative inflammation of the ear. This is ex- plained by the fact that the relations of the mastoid cells and the petrous portion of the temporal bone to the lateral, the cavernous, and the petrosal sinuses, are so intimate that the extension of a morbid process to them, from the parts of the cranium in question, is readily accomplished. Owing to the inflammatory action so frequently set up in the vein or sinus in which a thrombus has been produced, pus enters the gen- eral circulation, and hence abscesses are liable to occur in distant parts of the body. In the very interesting case which forms the basis of Von Dusch's important paper, the principal phenomenon observed during the life of the patient—an infant nine months old—was a large abscess occupying the anterior and outer portion of the right thigh, from which half a pint of pus was obtained, by incision, and which continued to discharge for several days. Death occurred in a few days without being preceded by convulsions, coma, or other head-symptoms. On examination after death, the anterior part of the superior longitudinal sinus was found to be completely closed by a firm, pale, triangular clot of blood, adherent to the walls. Posteriorly the clot did not entirely fill the calibre of the sinus, and was softer. Similar clots were also found in the left lateral sinus, and in the veins terminating in the superior longitudinal sinus. In a case reported by Abercrombie * as " Suppuration within the Left Lateral Sinus," the affection undoubtedly resulted from an exten- sion of inflammation from the cranium to the veins. The patient, a young lady aged sixteen, complained of severe headache, which ex- tended over the whole head. She had an oppressed look, and great heaviness of the eyes; pulse 120; tongue clear and moist; face rather pale. She had been liable to suppuration of the ears, and the left ear had been discharging pus for three weeks; had complained of head- ache for a fortnight. A few days afterward, her strength began to fail, there was a tendency to stupor, and slight delirium was present. There was constant complaint of pain in the head. Finally, she became more comatose, but was sensible when roused, and knew those about her a few minutes before her death. On post-mortem examination the membranes of the brain were found congested, but the brain-substance was not diseased. The left lateral sinus was inflamed throughout its whole extent. " Its inner coat was dark-colored, irregular, and fungous. At one place the cavity was nearly obliterated. The disease extended into the torcular Herophili, 1 " Observations on Chronic Inflammation of the Brain and its Membranes." Edin- burgh Medical and Surgical Journal, vol. xiv., 1818, p. 288. PARTIAL CEREBRAL ANEMIA, ETC. 135 and affected a little the termination of the longitudinal sinus. Behind the auditory portion of the temporal bone, near the foramen lacerum, and in the course of the left lateral sinus, a portion of the bone nearly the size of a shilling was dark-colored and carious on the inner table. It was at this place that the sinus appeared to be most diseased." It is stated that the walls of the sinus were so thickened as to pre- vent the passage of the blood, and that evidently no blood had trav- ersed it for some time. Although Abercrombie failed to recognize the real nature of the morbid process, there can be no doubt that the sinus was closed by an old coagulum, which had been adherent to the walls. Prichard1 reports the case of a girl sixteen years of age, in whom epileptic convulsions had existed for two years, and recurred very fre- quently, sometimes several times a day. There appeared to have been no other symptoms indicating cerebral disturbance except that it is mentioned that at one time she was slightly delirious, and then was free from fits. She was treated actively for nine months, and then died in a convulsion, of the usual character. Examination after death showed that "the left lateral sinus, through its whole extent, was filled up by a substance very different in its nature from a recent coagulum, and apparently consisting of a deposi- tion of lymph, which had become organized. It appeared so com- pletely to occupy the calibre of the sinus as to have entirely impeded the passage of the blood through it." Another case, reported by the same author,2 is that of a girl twenty- two years of age, whose mother had been insane, and whose complaint " began by a feverish disorder, under which she labored about nine weeks. It was followed by a melancholy and pensive habit. She was observed to spend most of her time in reading religious books, and attended a meeting of Calvinistic dissenters." When she first came under treatment, her appearance was very wild; she was mischievous, and fond of destroying her clothes. In about three months and a half she was discharged cured, but was readmitted a month afterward, and remained in the hospital till her death, which took place about three years subsequently. During this period her constitutional tendency to scrofula showed itself in a decided manner. The glands of the neck were frequently swollen and inflamed, and she was repeatedly attacked by pneumonic symptoms. When these disorders became a little relieved, her mental alienation was aggravated. She generally sat with her hands folded, and her eyes fixed downward. She died from general debility and exhaustion, but without additional head-symptoms. Post-mortem examination revealed the existence of thickening of the dura mater, serous effusion between this membrane and the pia mater, fluid within the pia mater, and thickening of this membrane. 1 " A Treatise on Diseases of the Nervous System." London, 1822, p. 176. 2 Op. cit, p. 357. 136 DISEASES OF THE BRAIN. The substance of the brain was very firm, the pineal gland was large. " The longitudinal sinus contained a firm coagulum, resembling a poly- pus, which extended into the lateral sinus." In only one instance have I had the opportunity of making a post- mortem examination in a case of thrombosis of a cerebral sinus. The patient, a man forty years of age, had been upon a drunken debauch for several days, when he gradually passed into a condition of stupor, which was at first mistaken for the continued effect of alcoholic intoxi- cation. As it continued for two days after all stimulants had been withheld, this idea was abandoned, and the diagnosis of cerebral hasmorrhage was made. I saw him at this time, and was disposed to agree with this opinion. There were profound stupor, stertorous breathing, and complete resolution of all the limbs. Much to my surprise, however, the state of coma gradually passed off, and as sensi- bility returned the patient complained of intense pain in the forehead and vortex, which was accompanied by twitchings of the muscles of both sides of the face, and of both upper extremities. On the tenth day right hemiplegia suddenly ensued, unattended with loss of con- sciousness, though there was a slight disposition to stupor manifested as soon as the attention failed to be engaged. The pupil of the left eye was dilated. On the twelfth day a severe epileptiform convulsion ensued, which was succeeded by another on the same day, during which the tongue was very severely bitten. Control of the bladder and rectum was now lost, and on the fourteenth day the convulsive state became permanently established, and the patient died that night without regaining consciousness though the convulsions became somewhat less violent. The post-mortem examination was made the following morning. The pia mater and arachnoid were somewhat congested, though the subarachnoideal fluid was not notably increased in quantity. The sub- stance of the brain was healthy, and there was no extravasation of blood anywhere to be found. But, on laying open the longitudinal sinus, a firm coagulum was found completely occluding it, from its beginning anteriorly, to its termination in the torcular Herophili, partly filling this cavity, being attached to its anterior wall,, and extending for the distance of an inch and a quarter into the left lateral sinus. The thrombus was much more dense and compact in its anterior than in its posterior part, and that portion which occupied the lateral sinus was evidently of more recent formation than the rest. A consideration of the symptoms exhibited by these cases will serve to show the truth of the assertion made in the beginning of my remarks on the subject, that there are no such characteristic symptoms of thrombosis of the cerebral sinuses as will suffice for the identification of the disease. The most that can be premised is a not very decided probability. PARTIAL CEREBRAL ANAEMIA, ETC. 137 Causes.—Among the causes of thrombosis of the cerebral veins and sinuses, those affections of the heart in which the force of its systole is lessened, and those in which there is an obstacle to the return of the venous blood, occupy a prominent place. Through the action of either of these categories of diseases the circulation within the cranium is retarded, the blood tends to accumulate in the large veins and sinuses, and, its course being abnormally slow, coagulation is liable to ensue. Tumors in the neck, by compressing the internal jugular veins, also tend to the same result by backing up the blood in the lateral sinus. An intra-cranial tumor may exercise a like effect by direct pressure upon a sinus. Thrombosis may result from the extension of inflammation from the cranium or the cerebral tissue to the sinuses. Such is the case when the suppuration of the ear terminates by the formation of a thrombus in the lateral, cavernous, or petrosal sinus, or when abscess of the brain or an extravasation of blood produces a like effect. The condition in question may also be caused by injuries of the skull; it has been known to follow the operation of trephining and other surgical procedures on the cranium, and may also result from carbuncles, of or near the head, and from erysipelas occurring in like situations. Age appears to be of some influence as a predisposing cause of venous cerebral thrombosis. Thus, of thirty-seven cases cited by Gin- trac,1 fourteen were between the ages of three weeks and ten years, eleven between eleven and twenty years, six between twenty-one and thirty years, four were forty-five, fifty-five, sixty-five, and sixty-eight years old respectively, and two were of advanced age, not exactly known. As Gintrac remarks, the first period of life is that which is most favorable to the occurrence of venous cerebral thrombosis, adoles- cence and adult age are a little less favorable, and old age is the least so of all. Sex seems to be of no predisposing power: of thirty-one cases in which the sex was stated, fifteen were males and sixteen females. Prognosis.—The elements for forming a prognosis being of a very indeterminate character, it is difficult to form an opinion relative to the probable result in the case of a person presenting the symptoms which have been mentioned. It is perhaps, however, warrantable to say that thrombosis of the cerebral veins or sinuses must from the very nature of the lesion be a most grave disorder, if not one necessarily fatal, sooner or later. If the vein or sinus in which the clot exists be small, and if the causes be of such a character as to admit of removal, and thus the extension of the coagulation be preventable, the prognosis would of course be more favorable than if an opposite state of affairs exists. After all, the only data from which a judgment can be formed are the severity of the symptoms and the course and duration of the 1 Op. el he. cit, p. 528. 138 DISEASES OF THE BRAIN. disease. The symptoms themselves can be of very little service in this respect, for, as we have seen, they have no such pathognomonic value as to indicate to us the pathological condition with which we have to deal. Diagnosis.—After the remarks already made incidentally with ref- erence to this point, there is nothing to say which can elucidate the subj ect. Morbid Anatomy and Pathology.—The ordinary seat of the affection under consideration, when not the result of some other contiguous lesion, is the superior longitudinal sinus ; when due to suppuration of the ear, the clot is usually first found in the lateral sinus ; when resulting from injury, it has a near topographical relation to the seat. Through the occlusion of the sinus it becomes distended on the distal side of the clot, and the blood is thus thrown back upon the capillaries and eventu- ally upon the arteries. A state of cerebial ischasmia is therefore in- duced, to which the symptoms of the first stage of the disease are, in the main, to be ascribed. This ischasmia may lead to extravasation of blood, to inflammation, or to softening. An increased effusion of serum into the sub-arachnoid space and into the ventricles is an almost neces- sary consequence. The clot differs in character according to its age. When recent, it is soft in consistence and almost black in color, and is not adherent to the walls of the sinus in which it is situated. When old, it is grayish, dense, and unresisting, and attached to the wall of the vessel. If it be divided, a soft, broken-down mass is often found occupying the centre. This consists of fat and other elements of the regressive metamorphosis which the substance of the thrombus has undergone. It was undoubtedly this matter which Abercrombie and other writers mistook for pus. Other points in the morbid anatomy and pathology of venous cere- bral thrombosis have been sufficiently considered in the remarks which have already been made. Treatment.—There are no means at present known to science by which the affection can be cured, or its consequences prevented. All that can be done is to treat the symptoms as they arise, to search for their cause, and to remove the latter if removal be possible. Life may, in some cases, be prolonged by the judicious use of quinine and stimu- lants. Convulsions may be lessened in force and frequency by the em- ployment of the bromides, and pain assuaged by hypodermic injections of morphia, by a pill containing half a grain of codeia, given at bed- time, and repeated if necessary, or by directly taking off a part of the intra-cranial vascular tension by leeches to the inside of the nostrils, or cups to the nape of the neck. IV.—EMBOLISM AND THROMBOSIS OF THE CEREBRAL CAPILLARIES. The capillaries of the brain may be occluded either by embolism or thrombosis, as are the larger vessels. But the phenomena of these PARTIAL CEREBRAL ANJ3MIA, ETC. 139 lesions are so indefinite and obscure that it is impossible, in the present state of our knowledge, to identify them during the lifetime of the sub- ject. There is, therefore, little to be said relative to partial cerebral anaemia resulting from obstruction of the blood in the capillaries, other than to call attention to the genesis, the morbid anatomy, and the pathology of the processes in question. It will, accordingly, be more convenient to consider the subject without subdivision into symptoms, causes, etc. Embolism of the cerebral capillaries may be the result of deposit of pigment, of fat, of pus, or of the debris of various tissues, normal or abnormal, which have undergone decomposition. Pigment may be deposited in the capillaries whenever the blood— as it does in certain diseases—contains an abnormal amount of pig- mentary corpuscles. Meckel1 appears to have been the first to call attention to the condition in question. In the case of a lunatic, he dis- covered the spleen to be enlarged, and to be covered with dark pig- ment. Virchow2 soon afterward, in the case of a patient who had been subject to ague, found the spleen enlarged, black, from excess of pig- ment, and the blood in the heart to contain cells with pigment. Meckel attributed a great degree of importance to the occurrence of melanae- mia—as the blood-disease is called—for the reason that he considered the pigmentary obstruction of the capillaries a condition liable to result therefrom, and, as a consequence, when those of the brain are thus af- fected, the supervention of head-symptoms. Virchow, however, whilei admitting the possibility of such a sequence of phenomena, is not able to add any facts tending to elucidate the subject. Frerichs 3 has called attention to the pigment liver as associated with pigmentary emboli in the capillaries of the brain. Thus he says: " The next organ in point of frequency to the liver, which undergoes important organic and functional derangements, is the brain. Numer- ous particles of pigment, which have passed unarrested through the vessels of the liver and the lungs, accumulate in the narrow capillaries of this organ, and particularly in those of the cortical substance. Even by simple inspection of the shade of color, we can form an approximate notion of the quantity of coloring-matter which has been deposited, and of the extent of the vascular obstruction. We must not, however, rely entirely upon inspection, for slight accumulations of pigment in the capillaries easily escape notice, particularly when viewed with an un- practised eye, and can only be distinguished with the assistance of the microscope. In addition to the above, it is not at all uncommon for the vessels to become obstructed by a colorless fibrinous-like coagulum which of course does not affect the shade of color. The mechanical 1 Allg. Zeitschrift fur Psychiatrie, 1847, cited by Virchow. " Die Cellular-Pathologic," Berlin, 1871, p. 263, and Jaccoud, op. cit, p. 144. 2 Op. cit. 3 "Klinik der Leberkrankheiten," Sydenham Society Translation, vol. i., p. 314. 140 DISEASES OF THE BRAIN. interruption to the circulation which is produced in this way, not unfrequently gives rise to rupture of the small vessels, and the forma- tion of numerous capillary apoplexies. Meckel long ago made observa- tions of this nature. Planer described eight cases in which small ex- travasations were scattered through the gray and white substance of the brain. These numerous haemorrhages have not come under my own observation ; but in two cases I have observed extravasation into the meninges." Frerichs states that he has seen three cases in which there were functional derangements indicative of material changes in the cortical substance of the brain. One of them was that of a lady in her fortieth year, who, after an attack of quotidian fever, accompanied by somno- lence, suffered from protracted loss of memory. The functions of vege- tative life resumed their normal condition, and there were no derange- ments of motion or sensation present. The headache and giddiness gradually diminished after the removal of the intermittent fever, by means of quinine ; but the weakness of memory, and the inability to find suitable words for objects and ideas, were still on the increase two months after the cessation of the ague. Another case was that of a girl, aged nine years, living in the same district, where, according to the evidence of two medical men, intermit- tent fever, terminating fatally, was at the time very prevalent. This girl, whose mental powers had previously been normal, had undergone several attacks of tertian fever. After a protracted use of preparations of bark, she recovered in her bodily symptoms ; but her mental facul- ties gave way, and a state of complete idiocy, accompanied by a raven- ous appetite, supervened. In regard to these cases, Frerichs further remarks that it is un- certain whether atrophy of the brain had resulted from occlusion of the capillaries, or whether it had been induced by the extensive capillary apoplexies consequent upon this occlusion, or whether the intermittent fever was complicated with other accidental changes in the brain. He gives the details of several other cases of intermittent fever, accompa- nied by head-symptoms, and in which, after death, the cerebral capilla- ries—principally those of the cortical substance—were occluded by de- posits of pigment, originating in the liver and spleen, and transported to the brain by the current of the circulation. A case is reported by Bright,1 of a man, who died of paralysis fol- lowing fever, in whom the cortical substance of the brain was the color of black-lead. Sydenham had not failed to notice the fact that mental derange- ment sometimes remains after intermittent fever, which, if treated by depletion, passed into imbecility. Cases of like character have frequently come under my notice. In 1 "Reports of Medical Cases," London, 1801, chapter ci., plates xvii. and xix. PARTIAL CEREBRAL ANEMIA, ETC. 141 one of these there had been repeated attacks of intermittent fever, and the spleen was greatly enlarged. The patient, a young man twenty- two years of age, had suffered from epilepsy for several months, the first paroxysm ensuing shortly after a severe seizure of fever, and being preceded by headache, vertigo, confusion of ideas, and twitching of the muscles of the face. When I first saw him his mind was considerably impaired, and he was having three and sometimes four or five epileptic fits every week. All his mental symptoms were improved by the use of arsenic; his fits ceased, and his spleen became much reduced in size. Those physicians who have practised in malarious regions can scarcely have failed to notice the fact that the enlarged livers and spleens, which are so frequently produced by repeated febrile attacks, are often coexistent with cerebral symptoms, such as have been de- scribed.1 The vessels of the cortical substance appear to be more liable to oc- clusion from pigmentary emboli than any other part of the brain. Some recent researches of my own would seem to show that the vessels of the retina are also apt to be so obstructed, and that some cases of pigmen- tary deposit in the eye are in reality instances of pigmentary embolism of the intra-ocular vessels. Although the symptoms of the affection in question have nothing characteristic about them, yet its existence may be suspected with some show of probability, when pain in the head, delirium, convulsions, ver- tigo, paralysis, and other disturbances of sensibility and motility, coexist with enlarged spleen or liver, and when there is the previous history of malarial fever. Embolism of the cerebral capillaries from migration of fat is a con- dition which certainly occurs, but which has not as yet been very thoroughly studied. Todd,* in a woman who died comatose and hemi- plegic, found after death an extravasation of blood into the right corpus striatum, and that " the vessels of the softened portion of the corpus striatum, immediately surrounding the clot, were thickly studded with oil-globules, which in some situations were aggregated into dark masses so large as here and there almost to fill up the vessels. The minutest capillaries, as well as the larger arteries, exhibited these deposits, and few could be discovered without them. Bergmann,8 who has devoted much attention to the subject of fat- embolism, has recently * reported a case in which a man, who died in consequence of injuries received from a fall, was found to have many 1 A further consideration will be given to this very interesting subject in the forthcom ing memoir of the author, on " Pigmentary Cerebral Embolism, and other Affections of the Nervous System the Results of Malarial Poisoning." 3 "Clinical Lectures," London, 1861, p. 733. 3 " Zur Lehre von der Fettembolie." Dorpat, 1863. 4 " Ein Fall todlicher Fettembolie." Berliner klinische Wochenschrift, No. 33, 1873. 142 DISEASES OF THE BRAIN. hasmorrhagic extravasations into the lungs, and numerous oil-globules in the pulmonary capillaries. The brain does not appear to have been examined, but probably the cerebral capillaries would have been found in a like condition. In order to throw additional light on this subject, I have performed a number of experiments upon animals, of which the description of one will be sufficient, as the results were analogous in all essential respects. Into the left ventricle of the heart of a medium-sized dog sixty min- ims of olive oil were injected.1 The animal was killed six hours after- ward by section of the medulla oblongata. The brain was removed from the skull and carefully examined. The membranes were decidedly congested. The arteries of the base of the brain contained numerous oil- globules, and this was especially the case with both the middle cerebral Fig. 17. arteries. The minute terminal branches of these vessels were filled with fat, and several of them were entirely occluded. The microscope showed the capillaries throughout the brain, both of the cortical and medullary substance, to be gorged with fat-globules, aggregated in masses, so as to prevent, in many instances, the passage of the blood. In other experiments I allowed a longer time to elapse before kill- ing the animals, and in one death took place spontaneously during a state of profound coma. The post-mortem appearances were more strongly marked, and in the latter several centres of incipient softening had been set up. 1 The heart was penetrated through the thoracic wall by the needle of an hypodermic syringe, and the injection made very slowly. The left ventricle was chosen in order to avoid, as far as possible, the stoppage of the oil in the lungs. PARTIAL CEREBRAL ANAEMIA, ETC. 143 Nothing is known relative to the symptomatology or pathology of fat-embolism of the cerebral capillaries, or of the elements of a correct diagnosis or prognosis of the affection. The cerebral capillaries may be obliterated, as Virchowa has shown, by deposits of pus or of the debris of organic structures undergoing disintegration. Thus a thrombus undergoes such a transformation that a puriform mass originates in its centre through changes taking place in the central layers of the clot, and the whole eventually beeomes con- verted into a finely-granular substance which is capable of being trans- ported to distant parts of the body and occluding the smaller vessels and the capillaries; or, for instance, ulceration following endocarditis takes place in one of the cardiac valves, as a consequence of acute or chronic softening. The minute fragments of the valve are carried away by the current of the blood, and are deposited in the vessels of remote parts, such as the eyes, the brain, the kidney, and spleen. The accom- panying cuts (Figs. 16 and 17) represent these capillary emboli in the penicillii of the splenic artery, following endocarditis. In Fig. 16 the vessels are magnified ten diameters; in Fig. 17 three hundred. Whether such emboli are capable or not of transferring specific dis- ease to other parts where they are deposited, or whether, as some authors, differing from Virchow, assert, they merely act in a mechanical manner, is as yet undetermined. The weight of evidence appears to favor the view of Virchow, that they act not only by occluding the capillaries, but also by their inherent specificity originating new centres of local disease. Thrombosis.—Thrombosis of the cerebral capillaries may, like the same condition of the larger vessels, result from any cause capable of inducing a stoppage or retardation in them of the circulation of the blood. One of the most common of these factors is calcareous deposit, a state which is only to be detected after death, and which, like many other analogous morbid processes, was first clearly pointed out by Vir- chow.2 According to him it depends upon the failure of the kidneys to excrete the mineral matter which is taken up by the blood from the bones, and which in consequence is deposited in other organs. Some authors regard calcareous deposit as being a process more anal- ogous to embolism than to thrombosis, but it must be recollected that the mineral substance is not in a morphological state in the blood, but is held in solution up to the time of its separation at the places where it is found. It would, in my opinion, be equally logical to regard the deposition of fibrine upon the internal coat of a vessel as embolism, for it is held in solution till it becomes attached to the wall, and in this respect does not differ from the condition of the calcareous matter. 1 "Die Cellular-Pathologie," Berlin, 1871, p. 237, et seq. 2 Op. cit, p. 252. 144 DISEASES OF THE BRAIN. In the first place, the serum of the blood holding the mineral sub- stance in solution is probably infiltrated through the vascular walls in- to the peri-vascular tissue and the deposition effected there. Eventual- ly, as the change in the surrounding substance tends to prevent further transudation, and as the vessels degenerate from their normal struct- ure, the metastatic deposit is made around their internal circumference and the channel is finally occluded. At the same time the capillaries lose their elasticity and become hard and brittle. The brain in the vicinity of these centres of morbid action may be so saturated with the calcareous matter as to give a distinct grating sound when cut, and the molecules of phosphate or carbonate of lime may even be seen with the naked eye and distinctly felt when a portion of the brain is rubbed be- tween the fingers. Marcex reports the case of a man, fifty-five years of age, who died in a state of complete dementia. On post-mortem examination the mem- branes were found adherent to the brain; in the centrum ovale of both sides there existed large lacunae of a yellow color and with the appear- ance of elder-pith. In addition, there were numerous calcareous incrus- tations forming sharp protuberances and giving a sensation to the finger like that experienced when the tongue of a cat is gently rubbed. The capillaries were likewise incrusted. The cerebral substance contained .several old hasmorrhagic foyers. The calcareous concretions were found to consist of crystallized carbonate of lime and of the same substance in globular masses. Subjected to the action of dilute hydrochloric acid, they were dissolved with the evolution of carbonic-acid gas; an organic substance analogous in its characteristics to the corpora amylacea re- mained; it was not, however, colored blue by iodine. The capillaries surrounding these masses had undergone various de- grees of calcareous incrustation. On some, the crystals were scattered here and there on the walls ; on others they formed groups or plaques, more or less enveloping the circumference of the vessel. There were some in which the channel was entirely obstructed by the colorless crys- tals, without any other foreign matter, fatty, granular, or pigmentary, being present. Thrombosis of the cerebral capillaries may also be the consequence of atheromatous degeneration and of moniliform dilatation. The white substance of the cerebrum, the cortical layer, and the cor- pora striata are more liable to be the seats of this process than the other parts of the encephalio mass. 1 "Bulletin de la soci6t6 anatomique," 1863, p. 468, cited by Gintrac, op. cit, p. 473 CEREBRAL SOFTENING. 145 CHAPTER VI. CEREBRAL SOFTENING. As a consequence of several of the conditions described in the fore- going pages, and especially as resulting from thrombosis and embolism in their various forms, cerebral softening naturally comes next in order for consideration. Most authors treat of it in direct connection with obliteration of the cerebral arteries; but, although frequently due to this cause, it may be produced by others, and occlusion is not always followed, by softening. For these reasons I have preferred to consider it as it really is, a distinct pathological condition—as much so as sclero- sis or any other morbid anatomical state. Symptoms.—When softening is the result of hasmorrhage, of arterial embolism, or of arterial or venous thrombosis or embolism, the symp- toms peculiar to those affections are first met with. Thus there are troubles of the intelligence, the sensibility, and the power of motion, such as have already been described under the heads mentioned, and, if the morbid process goes on within the cranium to its full development, there are peculiar aggravations and the evolution of new symptoms. If coma has existed from the beginning, it may continue with little or no remission, and the patient may die without regaining consciousness, or may become only partially sensible. The condition of softening is not usually set up after either hasmorrhage, thrombosis, or embolism, till about the tenth day, though some cases are more rapid in their progress, and the symptoms now to be mentioned are those which are coincident with what some pathologists have designated the "second stage;" the "yellow softening" of others. The "first stage," or "red softening " of these writers, is, in my opinion, not in reality softening, but ra'ther the congestion due to overaction in the collateral circulation. In addition to the continued paralysis of motion and the loss of sensibility which exist on one side of the body, the mental symptoms become more strongly marked. There may be delirium with the occur- rence of hallucinations and delusions, though these are generally eva- nescent. Occasionally a fixed idea obtains possession of the patient's mind, and for a while influences him in his conduct, but his mental tenacity is not strong enough to enable him to retain it for any length of time, so it soon yields to another. The intelligence is notably diminished, so that the patient is unable to conceive an exact idea of his situation, or to obtain a moderately complete notion of quite simple matters which may be submitted for his mental action. Thus he refuses to credit the assertion that he is ill, declares that his health, both in mind and body, is excellent, and that 10 146 DISEASES OF THE BRAIN. he is fully capable of transacting his business or of performing any intellectual operation. The memory is invariably impaired, and things of the greatest familiarity are forgotten. Thus a patient laboring under cerebral soft- ening, the result of embolism, could not tell his wife's name, nor by what means he came to my office. Another, sent to me by Dr. Michel, of St. Louis, in whom thrombosis was the probable cause, could not tell me where he came from, nor the names of his children. He insisted with great vehemence that he was perfectly able to attend to his ordi- nary business, and yet was unable to add three numerals together. In another case, likewise having the clinical history of thrombosis, which I saw in consultation with my friend Dr. J. W. Ranney, of this city, the patient, a gentleman of about sixty years old, could not tell his age; declared that Dr. Ranney, whom he had known for many years, was a grocer, "who lived around the corner;" and held to the delusion that his sons had made several forcible attempts to rob him. The power of giving the attention to subjects is very greatly less- ened. The patient may seem to be listening to what is said, or observ- ing what is passing about him, but, if he be questioned he at once shows that he really has not been heeding ; even when things are for- cibly brought to his mind, and he is told to mark them, he is incapable of doing so to any considerable extent. The speech is almost invariably affected either in the form consti- tuting aphasia, or from paralysis of the tongue and other muscles con- cerned in articulation. There is a disposition to misplace words, or to clip them by cutting off the last syllable. Thus a patient reading the title of a book in my library called it the " Unit. Stat. Dispenst." for United States Dispensatory; another was the "Philosoph. as Absol. Scien." for Philosophy as Absolute Science; and he told me he was "a lawy. by professi.," when he meant to say he was a lawyer by profes- sion. The same fault is shown in reading from a printed page, and in writing. Only a few days ago I received a letter from a gentleman, in which the final letter of nearly every word was omitted. The emotions, especially those of a sorrowful character, are very easily excited, and therefore the least untoward event causes the exhibition of feeling. Sometimes the patient sheds tears without being able to assign any cause, or may get into uncontrollable fits of weeping; occasionally of laughing. All these symptoms indicate failure of the mental power, but it is, nevertheless, true that softening of the cerebral tissue may exist with- out the manifestation of the least degree of imbecility. It not unfre- quently happens that, while there is a general loss of intelligence, some one or two faculties of the mind are notably increased in vigor. I have a patient now under my charge whose intellectual force is greatly reduced, who cannot pronounce the simplest sentence correctly, CEREBRAL SOFTENING. 147 who is paralyzed throughout the whole of one side, and who has so lost the sense of propriety that if he feels the desire to urinate he yields to it at once, no matter where he may be or who are present, but whose volitional power is even greater than before the accession of his disease. Thus he will read volume after volume, turning over the pages regu- larly, and scarcely, except by oversight, skipping a word, although it is very certain he does not comprehend a tenth part of what he reads, and that what he does for a moment understand is immediately for- gotten. The strength of his will is also shown in the impossibility of inducing him to do any thing which either caprice or habit prompts him not to do. His appreciation of harmony has become so sensitive that a discord of sounds made on the piano causes him real mental suffering, whereas when he was in health his musical taste and discrimination of the pitch and quality of sounds were below mediocrity. - Drowsiness is very generally present; at first, perhaps, to a slight extent, but sooner or later as a prominent feature. Headache is very common, and is usually dull and circumscribed. The forehead is its most common seat. Other sensation^ in the head, such as vertigo, full- ness, weight, and constriction, are scarcely ever absent. Gradually, the condition of the' patient, mentally and physically, becomes weaker and weaker, and death ensues, immediately preceded by coma, convulsions, delirium, or a combination of these phenomena. Not unfrequently, softening of the brain is not preceded by hasm- orrhage, thrombosis, embolism, or other evident affection, but begins obscurely, and advances very gradually. Such cases are often directly due to disease and obliteration of the cerebral capillaries, as described in the immediately preceding chapter, or they may be the result of a slow inflammatory process. In this form the symptoms make their ap- pearance in succession; but the paralysis, instead of being present from the inception, comes on very slowly, commencing as a slight weakness, conjoined with numbness, in one or more of the extremities, or in the face. Ordinarily, the first evidence of paresis is discovered in the leg, which is not lifted clear of the ground. The toe consequently strikes against the inequalities of the pavement, and the patient is apt to fall. Sometimes the weakness is shown by the leg suddenly giving way at the knee. I have had several patients with cerebral softening, in whom this accident was of common occurrence, and who had thereby received severe injuries. Or, when the arm is the paretic member, the grasp, as shown by the dynamometer, is materially lessened in strength, and things held in the hand are dropped. I have now a patient in charge in whom the affection is in its very earliest stages, and of which the only manifestations are, clipping of the words in speech and paresis of one arm. This inability of the muscles to maintain a continuous contraction for a short time, though met with in several other affections, is to some ex- 146 DISEASES OF THE BRAIN. tent characteristic of cerebral softening, and, in conjunction with the other phenomena, is a valuable indication. Even before it has become so far developed as to attract the attention of the patient or those about him, its existence may be ascertained by means of the dynamograph described in the preliminary chapter of this treatise. It will often be found that a straight line cannot be made, but that the pencil pursues a zigzag course, or else one descending with more or less regularity. The paralysis usually goes on to complete loss of power, though its progress is often very slow, and is marked occasionally by periods of decided improvement. At these times the patient's friends imagine that he is about to recover, and if, as is sometimes the case, the mental symptoms are likewise mitigated, their hopes are still further exalted. It is necessary that the physician should not be deceived. In a case which I saw in consultation with Dr. Chamberlain, of this city, I diag- nosticated chronic softening. At the time, there were feebleness of memory, paresis of one side of the body, and difficulties of speech. I gave an unfavorable prognosis, but soon afterward amendment began, and the patient, who was an insurance agent or appraiser,- resumed his business to some extent. I nevertheless adhered to my opinion, for I had seen too many cases of similar character to be deceived in so clear a one as this. I never saw the patient again, and am therefore unac- quainted with the subsequent phenomena, except that about a year afterward I was invited by Dr. Chamberlain to be present at the post- mortem examination. His brain contained a foyer of softened tissue as large as a walnut, apparently the result of obliteration of the posterior branch of the left middle cerebral artery, and involving a portion of the middle lobe of the left hemisphere. In another case, which I had very thorough opportunity for study- ing, the patient, a gentleman thirty-five years of age, was the subject of chronic softening, without any history of previous lesions. The dis- ease had come on very insidiously, first showing itself by a slight im- pediment of speech and impairment of memory. Gradually he lost power in both arms and both legs, though the right side was more affected than the left. His gait became titubating, and although he never lost the ability to walk, yet he did so with great and increasing difficulty. But his stages of apparent improvement were at first nu- merous and well marked. His memory at such times was stronger, his countenance brighter, his articulation distinct, his emotions more under command, his power of attention increased, his intelligence equal to all ordinary occasions, and his walk free from any sign of debility. Then all these steps would be suddenly lost, and he would again become imbecile and weak. Finally, a severe convulsion, more evident on the right side than the left, supervened one evening after dinner, as he was quietly smoking a cigar. Between seven and twelve o'clock that night he had over a hundred fits. He died at the latter hour. The post- CEREBRAL SOFTENING. 149 mortem examination revealed the existence of a large centre of soft- ening, involving the middle lobe of the left hemisphere. Sometimes the course of the disease is still more irregular. No evidence of cerebral disorder is perceived beyond aphasia, and the patient remains in the full possession of his intellect, and without pa- ralysis, up to a short time before death. Durand-Fardell cites the case of a man, thirty years of age, who entered the Hotel Dieu, presenting all the signs of pulmonary phthisis. In a few days afterward he expe- rienced difficulty of articulation, in thirty hours he became comatose, and, in twenty more, died. The post-mortem examination revealed the existence of softening of the inferior surface of the left middle lobe of the cerebrum. Although it is not so stated—Durand-Fardel hav- ing written previous to Virchow's observations—there is little doubt that the cause of the softening was an old embolus in the left middle cerebral artery. Lallemand,8 in his first letter, cites several cases in which the dis- ease was marked by singular symptoms, such as convulsions, contrac- tions, and delirium. In a case which I saw in consultation with Prof. C. A. Budd and Dr. J. T. Taylor, occurring in a gentleman about thirty-five years of age, there were coma and violent hemi-convulsions, evidently due to softening from embolism, of which there had been two attacks, the last several weeks previously. Death ensued, but no post-mortem ex- amination was, I believe, obtained. A gentleman is now under my charge who has valvular disease on the left side of the heart, the consequence of rheumatic endocarditis, and who, six months since, had an apoplectic attack conjoined with aphasia and right hemiplegia. He soon became able to speak pretty well, and regained power and sensibility to a great extent in the para- lyzed limbs. During the past two weeks, however, he has exhibited symptoms of mental derangement, as shown by the existence of hal- lucinations and delusions, and is gradually losing the power of motion and of sensation on the right side. His speech is as perfect as it ever was, and there is yet no sign of dementia. It has happened that individuals have died who, on post-mortem examination, were found to have softening of the brain, but who, during life, had exhibited no symptoms of this or any other cerebral disorder. Rostan, who was the first to write systematically on the disease, refers to such cases, and Durand-Fardel is still more explicit. The latter says : " We meet with softening of the brain in persons who, up to the time of death, had presented no appreciable derangement of the cere- 1 " Traite" du ramollissement cerebrale," Paris, 1843. 2" Recherches anatomico-pathologiques sur l'enc6phale et ses dependances," Paris, 1824. 150 DISEASES OF THE BRAIN. bral functions, and in whom softening has been developed without having given any evidence whatever of its existence." In such in- stances the white matter of the hemisphere can alone be involved. One such case verified by post-morten examination has occurred within my own experience. The patient, a soldier of the Second United States Infantry, died at Fort Riley, in Kansas, of which post I was medical officer, of chronic dysentery, the result of exposure. There were no mental symptoms, no difficulty of speech, no paralysis; nothing, in fact, indicating the existence of brain-disease. He died in full pos- session of his intellectual faculties. The post-mortem examination re- vealed the existence of ulceration of the small intestines, and, as the cause of death was very evident, the brain was not examined. I re- served it, however, for purposes of study, and, on making a section of the right hemisphere an hour afterward, discovered an encysted centre of softening, including more than two-thirds of the posterior lobe. The right posterior cerebral artery was entirely obliterated by thrombosis. The man had been at the fort several months, and had never made complaint of any illness till he was attacked with dysentery six weeks before. The duration of cerebral softening is very variable. Rostan found it to range from a few days to several years. Andral, from an analysis of one hundred and five cases, found that the period was from twelve days to three years. The most rapid case occurring in my experience terminated in death at the end of eighty hours. Some confusion on this point has arisen from the fact that some authors regard embolism and thrombosis as essentially identical with softening, a doctrine which is clearly erroneous, as, in many cases of these affections, recovery or death may take' place without the stage of softening being reached. In the case above referred to, post-mortem examination showed that the condition known as yellow softening was just making its appear- ance. As I have already stated, I cannot regard the alteration called by some pathologists red softening any thing more than the congestion due to the active collateral circulation. The case of longest duration, of which I have any personal knowl- edge, was that of an eminent scientific gentleman, who had suffered from the symptoms of softening of the brain for nearly four years, when he died. There was no post-mortem examination, but the history of the case was that of thrombosis of the left middle cerebral artery, and the course of the disease left no room for doubt as to its nature. The symptoms of cerebral softening which I have specified are those which are in general the result of the morbid processes existing in the cortical substance of the hemispheres, or" in the optic thalami, or corpora striata. Generally, as Laborde x has shown, whenever the corti- 1" Le ramollissement et la congestion du cerveau principalement considers chez le Fieillard," Paris, 1866, p. 1, el seq. CEREBRAL SOFTENING. 151 cal substance is the seat of softening there is at least one other centre occupying the central part of the brain, or especially the corpus stria- tum or optic thalamus. But the other portions of the encephalic mass are liable to be similarly affected, and then the phenomena are of a dif- ferent character. Thus the pons Varolii may undergo softening from occlusion of the basilar artery, or of one or more of its transverse branches, or from disease of its capillaries, or from chronic inflammation of its substance, and if the disease be limited to this ganglion there is no marked mental deteriora- tion or other evidence of intellectual derangement. The symptoms are in the main connected with sensibility, and the power of motion with ar- ticulation, and with the respiratory, circulatory, and stomachal functions, as evidenced by dyspnoea, irregular action of the heart, and nausea and vomiting. In the case of an elderly gentleman whom I saw in the early part of 1874, and who had been affected for about a year, there was almost complete paralysis of the lower part of the face on both sides, there was great difficulty of swallowing, the tongue could not be pro- truded, speech was very indistinct, the respiration and action of the heart were irregular, and the limbs were partially paralyzed. There was a general loss of sensibility throughout the whole body, and attacks of vertigo and epileptiform convulsions had been frequent. At the same time the intellect was as clear and exact in its operations as it ever had been. I diagnosticated glosso-labio-laryngeal paralysis, and expressed the opinion that the patient would not live over a month. He died in two weeks. The post-mortem examination showed the hemispheres and cerebellum and the membranes to be healthy. The basilar artery was entirely closed by a thrombus. The pons Varolii was as soft as cream, and the membranes peeled off as easily as if they had never been at- tached to it. Examined microscopically after due preparation, the cap- illaries were found to be in a state of atheromatous degeneration. The medulla oblongata was not softened, but extreme atrophy of nerve-cells had taken place in the nuclei of the facial nerve of both sides. This point will be further considered under the head of atrophy of nerve-cells. Softening of the cerebellum can scarcely, in the present state of our knowledge, be diagnosticated from any other affection of that organ. The rapid form, such as results from embolism of the larger vessels, pre- sents so many analogies with hasmorrhage that there are no sure signs by which a discrimination can be made; and the slow form due to disease of the capillaries or to chronic inflammation is not distinguished from abscess or tumor. But it may be inferred that the cerebellum is the seat of structural change when the category of symptoms cited under the head of cerebral haemorrhage is present, and the history of the case will often aid us in forming an opinion of its nature not very wide of the mark. When death results from cerebral softening, it may be directly due 152 DISEASES OF THE BRAIN. either to the disease itself, or to some intercurrent affection. Thus the patient may die from pure exhaustion or from slow asphyxia caused by the imperfect action of the respiratory function, or he may choke to death either by being unable to swallow food which he has taken into his mouth, or by the regurgitation of the contents of the stomach during a convulsion, or a severe convulsive seizure may cause immediate as- phyxia, or a series of convulsions may produce a more gradual asphyxia, or he may die in a state of profound coma. The intercurrent affections may be either meningitis or hypostatic congestion of the lungs from long confinement to the recumbent pos- ture, or diarrhoea, or a fresh attack of thrombosis or embolism. Causes.—The etiology of cerebral softening has already been con- sidered to some extent under the heads of cerebral haemorrhage, and obliteration of cerebral arteries and veins and of the capillaries, from embolism and thrombosis, of which conditions it is so often a sequence; but, as it may occur without having been preceded by either of these or other noticeable affections, a few additional observations are necessary. Age is certainly a strong predisposing, if not an actual exciting cause, although the disease is observed at all periods of life. Rostan, whose cases were collected at the Salpetriere, a hospital containing only old women, found that there were ten cases in persons between the ages of sixty and sixty-nine, twenty between seventy and seventy-nine, and ten between eighty and eighty-seven. Andral, excluding cases occur- ring in infants, found that, of one hundred and fifty-three cases, there were between the ages of 15 and 20.....................................................10 20 " 30.....................................................18 30 " 40.....................................................H 40 " 50..........................................'..........19 50 " 60...................................................'..27 60 " 70.....................................................Si 10 " 80.....................................................30 80 " 89..................................................... 4 Durand-Fardel, from an analysis of fifty-five cases, found between the ages of 30 and 40..................................................... a 40 " 50..........................................'...'.'.'.".'.'.'. 8 50 " 55..................................................... 2 60 " 70................................................... 14 70 " 80........................................'.'.'.".'."'.'.'.'.■".!28 80 " 87.....................................................5 The period of life, therefore, at which softening is most apt to occur, *s from the age of fifty to eighty. During the past ten years, forty-five cases of cerebral softening, not CEREBRAL SOFTENING. 153 the result either of hasmorrhage, arterial embolism, or of arterial or ve- nous thrombosis, have been under my care or been seen by me in consulta- tion. Of these, one was under twenty years of age; four were between twenty and thirty years; nine between thirty and forty; twelve between forty and fifty; eight between fifty and sixty; eight between sixty and seventy; and three between seventy and eighty. The general results, therefore, go to show the greater proclivity which advanced age gives to the occurrence of the disease. In one of those between seventy and eighty, the mind was scarcely impaired till about two months before death, though there had been paresis, headache, and aphasia, for two years. No definite statistics have been collected relative to the influence of sex, although the opinion appears to prevail that the affection is more liable to occur in females than in males. Of the forty-five cases just cited, twenty-nine were males and sixteen females. The season of the year does not appear to exercise much influence. Durand-Fardel, from sixty-three cases, found that seventeen occurred in winter, thirteen in spring, twenty in summer, and thirteen in autumn. I have found it difficult in many cases, from the insidious or latent charac- ter of the early symptoms, to fix the period of beginning with accuracy. Intense and long-continued intellectual exertion is one of the most common causes of cerebral softening. Eleven of the cases occurring in my experience were clearly the result of this cause. Severe and pro- tracted emotional disturbance was apparently the cause in four cases. Rostan, among the causes, cites insolation, the action of intense cold, blows upon the head, and excessive use of alcoholic liquors. The influence of obliteration of the cerebral arteries, sinuses, veins, and capillaries, in producing partial cerebral anaemia, and hence as lead- ing to the supervention of softening, has already been dwelt upon at suf- ficient length. Diagnosis.—The history of hasmorrhage, thrombosis, or embolism, when these conditions have either of them given rise to softening, will aid in the diagnosis. The signs which serve to distinguish these affec- tions from others have already been amply considered. When there is no such previous clinical history, softening of the brain may be confounded with chronic meningitis, meningeal hasmor- rhage, or tumors. From chronic meningitis it is to be distinguished in many cases by the facts that in the former the headache is generally diffused, while in softening it is fixed, that the paralysis is more limited, that there are frequent spasms of the limbs, that there are well-marked febrile exacerbations, and that there is not the progressive enfeeble- ment of the intellect so characteristic of the vast majority of cases of cerebral softening. At the same time it must be admitted that the diag- nosis sometimes cannot be clearly made out. In meningeal hasmorrhage coma occurs as an early symptom, gradu- 154 DISEASES OF THE BRAIN. ally increasing in intensity, whereas in softening it comes on at a late period. Hasmatoma of the dura mater, however, may readily be con- founded with softening. The history of the case will aid in the forma- tion of a correct diagnosis. In tumors the most prominent symptoms are pain and convulsions, while the intellect usually remains unaffected. The pain is exceedingly intense, while in softening it is dull. The speech in tumors is generally unaffected. Prognosis.—Cerebral softening in general ends in death. Neverthe- less, it is not altogether hopeless. If the patient be young, of good constitution, and of temperate habits ; if the centre of softening be small, and not involving the more important parts of the brain, there is some encouragement to expect a favorable termination. Some of the cases cited in this chapter go to show that recovery is possible, and I have certainly seen others with the ordinary initial symptoms of cere- bral softening recover with appropriate medication. Such patients, however, were all under the age of forty, and were of good constitution and habits. In softening due to embolism, and occurring after rheuma- tism and endocarditis, the liability to future attacks must not be over- looked. I have seen as many as six attacks of embolism occurring in the same patient, and yet no morbid condition beyond that of anasmia set up, and again cases in which a single embolus has caused softening and death. Morbid Anatomy.—In the softening of the brain which results from the obliteration of arteries or veins by embolism or thrombosis, the first stage after that of congestion from the excessive action of the collateral circulation is what is called yellow softening. This is not, as some authors have supposed, produced by the infiltration of pus into the cerebral substance, but is caused by regressive metamorphosis of the brain-cells into fat, the granules of which are mixed with the coloring matter of the blood which gives rise to the peculiar yellow color. The white corpuscles of the blood also undergo degeneration into fat. These altered white corpuscles were described by Gluge l as inflam- mation corpuscles, under the idea that softening was always the result of inflammation. Laborde,4 who has studied this subject with great success, shows, however, very conclusively that the transformation is a true degeneration, a part of the fat-corpuscles being derived, as stated above, from the nervous fibres, the cylinders of which disappear, the contents being extravasated, and with the myeline being converted into fat; and another part consisting of altered white blood-corpuscles. At this time the cerebral tissue is pulpy, constituting a centre of softening or a, foyer, the consistence of which is greater at the circumference than at the centre. The blood-vessels passing through the disorganized por- 1 " Atlas of Pathological Histology." Translated by Leidy. Philadelphia, 1853. 2 Op. cit. CEREBRAL SOFTENING. 155 tion are easily separated from the perivascular tissue and are covered with oil-globules. The second stage is designated white softening, and in it the brain- substance loses altogether its morphological characteristics, and appears as a white, cream-like matter so soft that a weak stream of water, al- lowed to impinge upon it, washes it away. In this semi-liquid matter, whitish flakes of denser tissue are suspended. Microscopical examina- tion shows that all traces of nervous structure have disappeared, and that no anatomical elements remain except oil-globules and organic cor- puscles somewhat resembling leucocytes. When the morbid process involves the cortical substance of the cerebrum, the convolutions undergo a peculiar kind of transformation first pointed out by Cruveilhier, and then by Durand-Fardel* as occur- ring in the senile form of softening. This is characterized by the formation of yellow plates, irregular in form, soft to the touch, but yet sufficiently dense to resist the action of a thin stream of water. Microscopically they are seen to consist of nucleated fibres, fat-corpuscles, fat-globules, and degenerated capillaries, with blood-crystals and granular matter. Essentially, therefore, they are formed of connective tissue. The degenerated nerve-tissues, constituting a focus of softening, may undergo absorption. In such a case, a cicatrix, similar in general characteristics to that resulting from the curative process of hasmorrhage, remains. In the softening resulting from inflammation, a somewhat different set of morbid appearances exists. Thrombosis and embolism produce a true death of the parts previously supplied by the occluded vessels, a ne- crobiosis, as it has been called by Virchow. The process is accompanied, as we have seen, by degeneration of the nervous tissue, but in the soft- ening due to inflammation new formations result. Sometimes the two coexist, but the latter is occasionally an entirely independent action. When such is the case, connective tissue is generated, and the ner- vous substance is rapidly broken down. An exudation of an albumi- nous fluid containing fine granules, the disintegrating nervous substance and numerous flakes of coagulated fibrine, takes place, and with blood- corpuscles causes the centre of softening to present the appearance of a reddish pultaceous mass, easily washed away by the action of a weak stream of water. With age the color of this softened tissue becomes brown or yellow. Sometimes, when the inflammation has extended to the deeper parts of the cerebrum, the contents of the cyst are pene- trated by the new connective tissue. The pulpy mass undergoes partial absorption, and is replaced by a'white turbid liquid, called by Cruveil- hier and Dechambre " milk of lime " (lait de chaux). Durand-Fardel designates this form of softening " cellular infiltration." 1 " Maladies des vieillards," Paris, 1854, p. 72. 156 DISEASES OF THE BRAIN. The softening resulting from occlusion of the capillaries, a condition not recognizable during life, does not differ essentially, except in its situation, from that which follows embolism or thrombosis of the larger vessels. The centres of the process are, however, smaller, are generally numerous, and usually met with either in the cortical or white sub- stance, or in the corpora striata. The morbid anatomy of the affected vessels has been sufficiently considered in the previous chapter. When disease of the capillaries has been the cause of the softening, these may be ruptured, and we meet with minute extravasations of blood in the disintegrated perivascular tissue, constituting the "capillary hasmorrhage " of Cruveilhier. Pathology.—The first definite accounts of cerebral softening were given by Lallemand l and Rostan,2 both of whom published their works in the same year, 1820. In the very beginning of his first letter, Lallemand awards to MM. Recamier, Bayle, and Cayot, the credit of describing the condition under consideration, and of giving it the designation by which it is so general- ly known, even out of France, of ramollissement. Lallemand then pro- ceeds to define the term by saying that, by ramollissement of the brain, he understands a kind of liquefaction of a part of its substance, the re- mainder preserving its ordinary consistence. He then quotes cases from Morgagni and Abercrombie, and cites others from his own experi- ence; and then concludes by declaring that he does not hesitate to range cerebral softening among the inflammations, in which opinion he is supported by Abercrombie.8 Rostan 4 regarded the disease as some- times being due to inflammation, and sometimes to degeneration of the blood-vessels. Bouillaud6 viewed it as an anatomical feature of inflam- mation. Cruveilhier * considered what he called red softening as result- ing from the capillary hasmorrhage previously mentioned, and that other forms were certainly due to inflammation. Andral7 recognized the fact that softening might result from inflam- mation or capillary hasmorrhage, but he also insisted that it might be due to special alterations of nutrition, caused by different morbid influ- ences, such as obliteration of the arteries supplying the brain, or im- poverishment of the blood. MM. de la Berge and Monneret8 adopted in part the views of Ros- tan relative to degeneration of the cerebral vessels as a cause of soften- 1 " Recherches anatomico-pathologiques sur Pencephale," Paris, 1820. 2 " Recherches sur le ramollissement du cerveau," Paris, 1820. My references to Rostan's work are to the second edition, of 1823. 8 Op. cit, p. 205. 4 Op. cit, chapter vii. B "Traite" de l'encephalite," Paris, 1825. * Art. " Apoplexie," in " Dictionnaire de m^decine et de chirurgie pratiques." ' " Clinique m6dicale." 6 "Compendium de m6decine pratique." CEREBRAL SOFTENING. 157 ing. CarswellJ regarded softening occurring during life as being af- fected by these circumstances—inflammation, obliteration of arteries, and modification of nutrition. Fuchs2 appears to think that inflammation is not a necessary ante- cedent, but that congestion is. He also admits obstruction of the arteries at the base of the brain to be a cause. The studies of Durand-Fardels have been very thorough, and have contributed greatly to our knowledge of cerebral softening. According to him, the affection is an inflammation which does not differ essentially from other inflammations occurring in the young or old. White soften- ing he regards as the chronic form of the disease. Other pathologists published the results of their observations and generally to the same effect as those which have been quoted, viz., that cerebral softening was an inflammatory process, and sometimes one re- sulting from obliteration or disease of the arteries. A few, however, held to the view of Lallemand and Durand-Fardel, that inflammation was always the starting-point. In 1847 Virchow published his observations relative to embolism, and the partial cerebral anaemia produced by occlusion of an artery thus be- came a recognized fact. In reality, it came to be regarded as the only cause capable of giving rise to softening, and many pathologists of the present day entertain such an opinion. But I think this is carrying the theory further than facts will warrant. I cannot altogether disregard the researches of Durand-Fardel,4 Calmeil,5 Rokitansky,6 Wedl,7 and others, and although I cannot agree that all cerebral softening is a con- sequence of inflammation, I am very sure it has this and other causes besides thrombosis and embolism. Calmeil's work is a monument of careful observations and scientific deductions, and his fifth chapter (tome ii.), entitled " Du ramollissement cbr'ebral local aigu, ou de Venc'epha- lite locale aigue sans caillots sanguinis si'egeant sous la forme d^un foyer ou des plusieurs foyers circonscrits, soit a la surface, soit dans la pro- fondeur de la masse enckphalique" contains cases which are amply sufficient to establish the point for which he contends. He shows, too, in other chapters of his treatise, that softening results about the periph- ery of clots due to cerebral haemorrhage. The weak feature of Calmeil's otherwise very complete work is, that he altogether ignores Virchow, and those after him, who have confirmed his facts and theories. 1 Art. " Softening of Organs," in " Cyclopaedia of Practical Medicine," vol. iv., p. 176, American edition. 8 " Beobachtungen und Bemerkungen fiber Gehirnerweichung," Leipzig, 1838. 8 " Traite du ramollissement du cerveau," Paris, 1843. 4 "Maladies des vieillards," Paris, 1854. 6 " Traite des maladies inflammatoires du cerveau," Paris, 1859. 6 " Pathological Anatomy," Sydenham Society translation, 1850. ' " Rudiments of Pathological Histology," Sydenham Society translation, 1855. 158 DISEASES OF THE BRAIN. Soulier,1 on the other hand, can see in softening nothing of the nature of inflammation. For him it is always a necrobiosis, produced by the cessation of the physiological action of the blood, obliteration by embolus or thrombus, by diminution of the calibre of the vessels, or oc- clusion resulting from atheroma or obstruction of a vein or sinus. He admits that the obliteration of an artery may cause congestion behind the point of obstruction, by which the coagulation and capillary hasmor- rhage of acute softening—the capillary apoplexy of Cruveilhier—are to be explained. This red ramollissement has, however, nothing of the nature of inflammation about it. The only points in which I differ with Soulier are, that I cannot regard softening as being solely due to occlusion of blood-vessels, and that I am very sure the congestion which follows thrombosis or embo- lism is not necessarily the first stage of softening. There is no more reason why partial cerebral anasmia should always result in softening, than that ligation of the femoral artery should always lead to gangrene of the parts below. Obstruction of veins and sinuses in the brain may be followed by softening. The clot is usually the result of injuries or disease of the cranial bones or cerebral membranes, especially the dura mater. It may also be caused by certain cachectic conditions in which the blood is deteriorated in quality, such as typhus and typhoid fevers and cholera. Four cases, in which this latter affection was followed by thrombo- sis of the superior longitudinal sinuses, with consecutive softening, have come under my observation. In two of them there were also thrombi in both femoral veins. The upper surfaces of both hemispheres were the seats of the softening, which involved the gray matter only. Thrombosis of the veins or sinuses may also in general terms be produced by whatever cause is capable of retarding the current of blood. Mr. Toynbee,2 in his chapter on diseases of the mastoid cells, has brought forward several cases in which the lateral sinus was occluded by coagula, and in which there was cerebral softening. Cerebral softening may also result from the formation of adven- titious growths, or from the presence of foreign bodies in the brain. In such cases the process begins with inflammation, and' is similar to the action which sometimes goes on around an extravasation of blood. Acute cerebritis or meningitis may likewise result in softening. This fact is admitted by Drs. Russell Reynolds and Bastian, in their admirable essays on cerebritis and softening of the brain, though with evident reluctance. We see, therefore, that cerebral softening may be caused either by anasmia or inflammation, and that it is of two kinds, inflammatory and 1 Journal de medechie de Lyon, Fevrier, 1867. 2 " The Diseases of the Ear, their Nature, Diagnosis, and Treatment," London, 1860. CEREBRAL SOFTENING. 159 non-inflammatory. The seat of the softening may be in any part of the brain, although some regions are more liable than others. When due to thrombosis, there appears to be no predilection for any particular location, but, as embolism is generally found on the left side in the middle cerebral artery, the parts of the brain supplied by this vessel are more liable than the corresponding parts of the right side. Durand-Fardel, however, did not arrive at this conclusion. Of one hundred and sixty-nine cases of softening, he found the left hemisphere the seat in sixty-nine, the right in seventy-one, both in twenty-six, and the middle line in three. The gray matter is generally supposed to be more frequently the seat of softening than the white. It is true that, of thirty-three cases of acute softening observed by Durand-Fardel,1 the convolutions were involved in thirty-one, but in nine only were they the sole part af- fected. In fifty-three cases which the same author collected from the writ- ings of Rostan, Lallemand, and others, the centres of softening were found to be as stated in the following table. Occasionally more than one region was involved. Convolutions and white substance................................. 22 Convolutions alone.............................................. 6 White substance alone.......................................... 5 Corpus striatum and optic thalamus............................... 6 Corpus striatum alone........................................... 11 Optic thalamus alone........................................... 4 Pons Varolii................................................... 3 Crux cerebri................................................... 1 Corpus callosum............................................... 1 Walls of the ventricles (septum).................................. 1 Fornix........................................................ 1 Cerebellum.................................................... 1 Rostan, on the other hand, found the corpora striata and the optic thalami to be the parts most frequently affected, and after these the central part of the hemispheres. He met with but few cases involving the median line. As regards the frequency with which the convolutions with the white substance were involved, as compared with the motor tract, he found that, of one hundred and seventy-seven cases of acute and chronic softening, the convolutions and white substance were affected in one hundred and nineteen, and the corpora striata and optic thalami in fifty-eight. The middle lobe is more liable than any other, as is seen in the fol- lowing statement of Durand-Fardel, based upon an analysis of ninety- five cases: 1 "Traite du ramollissement du cerveau," Paris, 1843. 160 DISEASES OF THE BRAIN. Posterior lobe.................................................. 18 Middle........................................................51 Anterior...................................................... 13 Posterior and middle............................................ 7 Posterior and anterior.......*................................... 2 Middle and anterior............................................. 2 Whole convexity of hemisphere................................... 1 Middle line.................................................... 1 In more than one-half of the cases, therefore, the middle lobe was the seat of the disease. A question connected with the pathology of cerebral softening, as with haemorrhage, is, " Can we determine, from a consideration of the symptoms, what part of the brain is the seat of the lesion ?" The answer must be the same. We can do so with some approach to ac- curacy, but, till we are better acquainted with the physiology of the different ganglia composing the brain, we cannot expect to do so with absolute certainty. Indeed, owing to the greater extent of tissue in- volved, compared to that affected in haemorrhage, we have a more com- plicated set of phenomena to deal with. I have nothing further to add to the remarks made on a similar point, under the head of cerebral haemorrhage. Treatment.—The treatment proper for cerebral softening should de- pend very much upon the cause from which it has arisen, and must more or less be directed against the symptoms which are manifested. Thus, if there is reason to suspect the existence of thrombosis or embo- lism, and a consequent anasmic condition of a portion of the brain, the judicious use of stimulants and tonics is advisable, while the body should be kept warm by additional clothing, or the application of artificial heat—at the same time the recumbent posture should be assumed, and the head supported on a low pillow. Mental exertion should, of course, be absolutely interdicted. If there be much headache, it is probably due to too great an activity of the collateral circulation, and in such a case some one of the bromides may be given in large doses, repeated as often as may be necessary. I have frequently seen great relief follow their administration. Delirium is often due to a like cause and may be similarly treated. Dr. ReynoldsJ speaks highly of the Indian hemp in doses of a quarter to half a grain of the extract; but I have found the bromide of potas- sium, in doses of thirty grains every three or four hours, more effica- cious. It is also the most beneficial remedy in the convulsions which frequently precede a fatal termination. In that form of softening which is obscure in its origin and gradual in its progress, there is a little more hope of a favorable result, though even here it must be confessed that treatment is not often effectual. 1 Article, " Softening of the Brain," in " System of Medicine," vol. ii. CEREBRAL SOFTENING. 161 Still, as I have said, when speaking of the prognosis, there are un- doubtedly cases in which recovery has taken place, and I am very sure that I have several times succeeded in curing individuals who, so far as I have been able to judge, were affected with cerebral softening. As these cases are interesting in themselves, and as the histories will show the means of treatment employed, I do not hesitate to' transcribe the fol- lowing typical ones from my case-book: I.—Mr. R., a gentleman, twenty-four years of age, awoke one morn- ing about the middle of March, 1870, with a sensation of numbness ex- tending through the whole of the left arm and leg, and with a feeliiig of vertigo which was insupportable when he arose from the bed. He sat down in a chair, and while in this position was conscious of a buzz- ing sound in the right ear. In the course of half an hour the vertigo passed off, but the numbness and sound in the ear remained, and he oc- casionally saw double. In a few days afterward he noticed a slight difficulty of articulation, owing to apparent thickness of the tongue, and about the same time observed that in the morning the pillow was wet with the saliva which had run from his mouth during sleep. His uncle, a wealthy gentleman of this city, sent him off traveling, but he returned in a few weeks with loss of power in the left arm and leg, which had be- gun to be manifested to a slight extent before his departure. He came under my charge May 15, 1870. At this time the paralysis, of both motion and sensation, was well marked on the left side, as shown by the aesthesiometer and dynamom- eter. The line made by the dynamograph with the right hand was perfectly straight, while that made by the left was at an angle of forty- five degrees with the other. In his conversation he clipped his words, and sometimes left out the smaller ones. His memory he stated was materially impaired. There was almost constant headache over the whole frontal region, and attacks of vertigo were frequent. There was no marked paralysis of the face, though the muscles of both sides were paretic, and he often had double vision. The right pupil was largely dilated and was insensible to light. Ophthalmoscopic examination showed the left eye to be perfectly normal, but the retinal vessels of the right were smaller and straight, and the choroid was paler than natural. Upon inquiry I ascertained that he had given extraordinary atten- tion to his business for a period of several months before the attack of numbness, frequently being up making calculations till three o'clock in the morning, and thus depriving himself of the necessary amount of sleep. My opinion was, that he was suffering from incipient softening of the brain due to disease of the capillaries, which, in its turn, resulted from cerebral congestion and exhaustion. I was further of the opinion that the lesion involved the right hemisphere and motor tract. 11 162 DISEASES OF THE BRAIN. I prescribed the phosphide of zinc in the dose of the tenth of a grain, with half a grain of extract of nux-vomica in pill three times a day, with the constant galvanic current three times a week, the latter to be derived from fifteen of Smee's cells, and to be passed from fore- head to occiput for three or four minutes at a time. At the end of ten days he had lost his diplopia, the pupil of the right eye had regained its natural diameter and irritability, and the vertigo and headache had notably diminished. The treatment was continued, and at the end of a month he had recovered the sensibility and power on the paralyzed side to such an extent, and had improved so much in other respects, that I advised him to take a short journey. He was absent two weeks, during which period he continued to take the pills as before, and on his return was, to all appearance, well. He has since remained in ex- cellent health. II.—Mr. R. W., a merchant of this city, consulted me in April, 1868, under the following circumstances: After a long period of great domestic anxiety, during which he had been engaged in some heavy commercial transactions, and had suffered from wakefulness, he experienced one afternoon, while riding in the park in his carriage, a slight quivering motion at the apex of the tongue. It continued until he reached home; and then, upon looking in a mir- ror, he could see the fibrillary movement very distinctly. He was not alarmed, and went to bed at his usual hour. In the morning he noticed a little thickness of speech, but the movement had ceased. That after- noon he had a violent headache, attended with vertigo and nausea. Be- coming alarmed, he sent for his family physician, who ascribed the symptoms to indigestion, and administered a mild cathartic. The fol- lowing day, on attempting to rise from the bed to go to the water- closet, he was attacked with such a severe vertigo that he was obliged to lie down again; and, though he did not for a moment lose conscious- ness, his fasces escaped from him involuntarily. From this time he gradually lost strength in both arms and legs, and his speech became very defective. His memory suffered to such an extent that he forgot the names of his children. There was very little headache, the vertigo had ceased, there was no disturbance of vision, and no loss of power over the sphincters. About six weeks after the occurrence of the first symptom noticed, he came under my care. At this time there was anaesthesia of both sides of the body, both legs and both arms had lost power; he clipped his words, and frequently substituted others of similar sound or meaning for those he ought to have used. His memory was much weakened, and there was a strong tendency to stupor. There were no troubles of the special senses— ophthalmoscopic examination revealed nothing abnormal—there was no facial paralysis. I diagnosticated softening of the brain from general cerebral anaemia consequent upon congestion and cerebral exhaustion, CEREBRAL SOFTENING. 163 and I prescribed a liberal allowance of wine, a full and nutritious diet, carriage exercise, and amusements of various kinds. This was the very reverse of the treatment to which he had been subjected. In addition, I recommended the constant galvanic current, to be applied as in the previous case, and gave the following prescription: !>,. Olei phosphorat. \ ss; mucil. acacias, 3 j; ol. bergamii, gtt. xv. M. ft. emulsio. Dose, gtt. xv. ter die. The treatment was carried out with the result of obtaining a gradual and permanent improvement, so that at the end of about six months the patient was well. He then went to Europe, where he now is, with as good health as he has ever enjoyed. Other cases, similar in their general features, have been under my care with a like result in each, and several others have been very decid- edly improved and relieved of the more prominent symptoms of the disease, without, however, regaining full health. The means of treat- ment thus far consist in the use of tonics, stimulants, and especially phosphorus and strychnine, the avoidance of all severe mental exertion, and all excessive emotion, open-air exercise, and the use of the constant galvanic current. The beneficial effects of maintaining the physical strength were several years since pointed out by Mr. F. Skeyx in a clinical lect- ure delivered at St. Bartholomew's Hospital, but it must be con- fessed that the opposite plan of treatment has been very generally followed. Softening from the effects of thrombosis or embolism _ is, as I have said, not much under the control of the physician. Patients recover from it, however, when they are of good constitution, and when the focus of softening has not been extensive. The mind and body may, and in such cases generally do, remain feeble, and we are therefore consulted for the relief of the condition. In such cases tonics, and among them phosphorus, strychnine, and wine, occupy a prominent place; the constant galvanic current to the head, and the induced to the paralyzed muscles, will rarely fail to be of service. III.—Thus a gentleman, who had been a distinguished officer of the army, suffered from loss of memory, defective articulation, ptosis, double vision, and right hemiplegia, probably the result of embolism. Several years before he came under my charge, he had been treated by Dr. J. T. Metcalfe, for heart-disease, the result of acute rheumatism. I gave the phosphide of zinc and extract of nux-vomica according to the for- mula previously mentioned, advised a liberal use of wine and beef- steaks, applied the primary current to the brain, and the induced cur- rent to his paralyzed arm and leg, and in a few weeks had the satisfac- tion of seeing such a degree of improvement as almost to constitute a 1 " On the Value of Tonic Treatment in some Diseases of the Brain, more especially Cnses of Ramollissement," Dublin Hospital Gazette, November, 1858. 164 DISEASES OF THE BRAIN. cure. The ocular troubles had disappeared, his memory had improved, he talked as well as ever, and the numbness and loss of strength were no longer remarked unless he over-exerted himself, which, owing to his general feeling of Hen aise, he was very apt to do. He remained in this condition for over a year, when he had several other attacks of embolism, each of which left him more weak, mentally and physically, than before, and of which he eventually died. There were some interesting features connected with this case, which will be referred to at greater length under the head of aphasia. IV.—In another case, in which there was reason to think a, foyer of softening had been absorbed, a marked relief from the sequelas was obtained. The patient, a literary gentleman of distinction, had, several years previously to my seeing him, suffered from an attack of acute rheumatism with endocarditis. About a month after his recovery, as he was sitting in his library before the fire, he felt a sensation as if one side of his face had suddenly become much heavier than the other. Al- most immediately afterward he lost consciousness, and fell to the floor. He could not have been in this condition longer than five minutes when he came to himself, to find that he was paralyzed in the right arm and leg. Attempting to call for assistance, he found he could not articulate. His wife soon afterward entered the room, and medical aid was obtained. He was bled to the extent of sixteen ounces, and purged with croton-oil. The following day he was much better; could move his arm and leg, and articulate with some degree of distinctness, but toward even- ing headache ensued, he became delirious, and the paralysis increased. Of the condition immediately following, he could give no very clear account. He only knew that he was confined to his bed for several weeks, was delirious part of the time, and that, after the acute attack passed off, he was left with an enfeebled mind, imperfect articulation, and paralysis of the arm and leg on the right side. He went to Europe, traveled extensively, and returned at the end of a year very much improved, but still with some degree of mental weakness, defective speech, and paralysis, remaining. When he came under my observation, the following were the prin- cipal symptoms observed: The strength of the right arm, as measured with the dynamometer, was not one-third that of the left; the exten- sors of the leg and foot were almost entirely paralyzed, so that in walking he abducted the leg so as to cause the foot to clear the ground ; electro-muscular contractility was much weakened, though the induced current caused feeble contractions. His speech was af- fected mainly as regarded the memory of words. He spoke with a good deal of volubility, but constantly used the wrong expressions. Thus, when he wished to tell me that he had visited Europe for the CEREBRAL SOFTENING. 165 benefit of his health, he said : " I went to Elope for the bequest of my hedge," and then went on—continually making other mistakes—to tell me a long story which I could scarcely understand. His emotions were easily disturbed: he cried because he had to wait a few minutes in my reception-room before seeing me. Ophthalmoscopic examination showed pale choroids and straight and attenuated retinal vessels. Auscultation revealed the existence of both mitral and aortic regurgitation. Taking into consideration the history of the case and the present condition of the patient, I diagnosticated embolism of the left middle cerebral artery, subsequent softening and eventual absorption of the diseased part of the brain. My idea was that the brain, as a whole, was anaemic, and that, with improved nutrition of it and the paralyzed limbs, amelioration of the symptoms was possible. I therefore prescribed the phosphide of zinc and nux-vomica pills as before mentioned, directed the use of wine to the extent of half a bottle of champagne daily, and advised that animal food should form the principal portion of each meal. Since his illness he had, by direc- tion of his physician, left off the use of coffee. I directed it to be resumed, and to be taken strong. The primary galvanic current was passed through the head in the manner previously indicated in this chapter, and the induced current was applied for half an hour three times a week to the arm and leg, each paralyzed muscle receiving a full share of attention. It was not long before signs of amendment were noticed. His strength became greater in the arm, and he was able to extend the leg and to raise the foot after half a dozen electrical applications. His speech next gave evidence of improvement, and his mind became stronger. The treatment was continued for about four months, with only an intermission of a week. At the end of that time his gait was almost natural, though he still swung the foot a very little, his arm was nearly as strong as the other, his mind was not perceptibly weaker than that of other persons of his age (fifty-five), and his speech was excellent except when he was excited and very anxious to express himself correctly and fluently. There is one point in regard to which a few words are perhaps necessary, and that is to enter a protest against the use of counter- irritation of any kind, and to discountenance, as far as I can, the em- ployment of the actual cautery. I have never seen the least advantage follow the application of croton-oil to the shaven scalp, nor can I con- ceive how such a measure can be recommended on rational grounds. I have several times witnessed its action, and have invariably seen it aggravate the symptoms. In the case of a gentleman from St. Louis, affected with cerebral softening, the effect was to make his speech still more imperfect and his mind weaker. A lady, who was affected 166 DISEASES OF THE BRAIN. With all the more prominent symptoms of softening of the brain, had all the phenomena increased in violence after the application of the actual cautery to the nape of the neck. I could easily adduce other examples to the same effect, were it necessary. CHAPTER VII. APHASIA. The subject of aphasia is of such interest, and so much attention has recently been given to it by physiologists and pathologists, that, although it is only a symptom common to several morbid conditions, a treatise on diseases of the nervous system would scarcely be re- garded as complete without its being fully considered. By aphasia is understood a condition produced by an affection of the brain by which the idea of language, or of its expression, is im- paired. The word is derived from the Greek—a, privative, and facie, speech—and, as stated by Trousseau, was proposed by M. Chrysaphis, a distinguished Greek scholar, as a substitute for alalia, used by Lor- dat, and aphemia, employed by Broca, to designate the same condition. In the definition which I have given of aphasia, the term is limited to impairment of the idea of language or of its expression. It does not, therefore, include those cases in which the individuals are able to speak, but will not; such as are met with among the insane. The idea of language is as perfect as ever, and is doubtless entertained, but the person does not speak because he does not will to do so, and this fail- ure may arise either from a lack of the necessary power, or from a stubborn determination not to speak. A lady was a short time since under my charge who had been treated by a homoeopathic physician as a case of aphasia. A very slight examination was sufficient to con- vince me that the case was one of hysteria. She had not spoken for several months, but upon one occasion she came to my office with her maid, whom she required to repeat the alphabet, and when the right letter was reached she signified the fact by raising her hand. She thus spelled out the words she wished to use. Subsequently she procured a card with all the letters on it, such as are used for children learning their alphabet, and she composed her words from this. Of course all these facts showed that her idea of language was intact, but she still might have lost the power of coordinating the muscles concerned in articulation so as to express herself in spoken words. Although I was sure this was not the case, I failed to make her speak, until one morn- ing she became very much interested in something I was saying, and, finding her alphabet too slow a means of expression, dropped it and APHASIA. 167 began to speak with great fluency. After talking with energy for a quarter of an hour, she suddenly recollected herself and took up her card of letters again, but the charm was broken, and by degrees she resumed her speech. At one time this lady was under the care of my friend Prof. Flint, for some chest or throat difficulty, and on one occa- sion spoke very well. Neither does aphasia embrace cases of inability to speak from paral- ysis of the tongue or other muscles of articulation. Defective speech from this cause is frequently met with in hemiplegia, in glosso-labio- laryngeal paralysis, and some other affections. In such instances the idea of language remains, but the patient does not speak because he is unable to put the organs of articulation in motion. A few days ago a gentleman, a prominent merchant of the city, was sent to me as a case of aphasia. As he entered my consulting-room, I saw that he was hemiplegic on the left side, and, on telling him to put out his tongue, found that he could not get it beyond the teeth, or touch the roof of his mouth with it. The history of the case was that of ordinary cere- bral hasmorrhage, and he regained the power of speaking after several applications of the primary and induced galvanic currents had been made to the tongue and muscles of the face. The distinction between aphonia and aphasia must also be made. In the one the idea of speech is undisturbed, and articulation is not inter- fered with except as regards phonation. Aphonic patients can whisper, but are unable to speak in full voice, owing to some laryngeal affection impairing the tone of the vocal chords. The fact that the faculty of speech may be deranged independently either of the will, paralysis, or loss of voice, appears to have been noticed at a very early period in the progress of science. Thus Isaiah J says, " For with stammering lips and another tongue will he speak to this people;" and again,2 "Thou shalt not see a fierce people, a people of a deeper speech than thou canst perceive; of a stammering tongue that thou canst not understand." Thucydides mentions that many, who suffered from the plague which raged at Athens, found on recovering that they had not only forgotten the names of their friends and relations, but also their own names. Pliny,3 in the chapter entitled Memorial Fxempla, says, in speak- ing of this faculty : "For nothing is so weak in man; disease, falls, injuries, even a fright, may impair it partially, or destroy it altogether. A blow from a stone has abolished the memory of the alphabet. A fall from a high roof has caused a man to cease to recognize his mother and neighbors, another even forgot his slaves, and Messala Corvinus, the orator, could not recall his own name." * 1 Chapter xxviii., 11. 2 Chapter xxxiii., 19. 3 Lib. vii., cap. xxiv. 4 Trousseau has translated this passage somewhat differently. I quote from an illu ' ruinated copy printed at Tarvisium (Treviso), in October, 1479. 168 DISEASES OF THE BRAIN. Suetonius 1 relates that Claudius so far lost his memory that he for- got the names of persons to whom he desired to speak, and could not even recollect the words he wished to use. Passing over several authors of later times who have recognized the existence of the difficulty in question, we come to Crichton,2 who re- marks as follows: " There is a very singular defect in memory, of which I have myself seen two remarkable instances. It ought rather to be considered as a defect of that principle by which ideas and their proper expressions are associated, than of memory, for it consists in this, that the person, although he has a distinct notion of what he means to say, cannot produce the words which ought to characterize his thoughts. The first case of this kind which occurred to me in practice was that of an attorney much respected for his integrity and talents, but who had many sad failings to which our physical nature too often subjects us. Although nearly in his seventieth year, and married to an amiable lady much younger than himself, he kept a mistress, whom he was in the habit of visiting every evening. The arms of Venus are not wielded with impunity at the age of seventy. He was suddenly seized with great prostration of strength, giddiness, forgetfulness, insensibility to all concerns of life, and every symptom of approaching fatuity. His for- getfulness was of the kind alluded to. When he wished to ask for any thing, he constantly made use of some inappropriate term. Instead of asking for a piece of bread, he would probably ask for his boots ; but, if these were brought, he knew they did not correspond with the idea he had of the thing he wished to have, and was therefore angry. Yet he would still demand some of his boots and shoes, meaning bread. If he wanted a tumbler to drink out of, it was a thousand to one he did not call for a certain chamber-utensil, and, if it was the said utensil he wanted, he would call it a tumbler or a dish. He evidently was con- scious that he pronounced wrong words, for, when the proper expres- sions were spoken by another person, and he was asked if it were not such a thing he wanted, he always seemed aware of his mistake, and cor- rected himself by adopting the appropriate expression. This gentleman was cured of the complaint by large doses of valerian and other proper l.iedicines." Dr. Crichton subsequently met with another case similar to the fore- going, and he quotes the following from Prof. Gruner, of Jena, in vol. vii. of the Psychological Magazine. The patient, a learned gentleman, after his recovery from an acute fever, suffered a loss of memory for words. Among the first things he desired to have was coffee (koffee), but, instead of pronouncing the letter/, he substituted in its place a z, 1 " C. Suetonii Tranquilli," xii. Caesares. 2 "An Inquiry into the Nature and Origin of Mental Derangement, comprehending a Concise System of the Physiology and Pathology of the Human Mind, and a History of the Passions and their Effects," London, 1798, vol. i., p. 371. APHASIA. 169 and therefore asked for a cat (kazze). In every word which had an fhe committed a similar mistake, substituting a z for it. He also cites, from Van Goens, the case of Madame Hennert, wife of the professor of mathematics at Utrecht, who suffered a similar de- fect of memory. When she wished to ask for a chair she asked for a table, and when she wanted a book she demanded a glass. But, what was singular in her case was, that when the proper expression of her thought was mentioned to her, she could not pronounce it. She was angry if people brought her the thing she had named in- stead of the thing she desired. Sometimes she herself discovered that she had given a wrong name to her thoughts. This complaint continued several months, after which she gradually recovered the right use of her recollection. It was only in this particular point that her memory seemed to be defective, for M. Van Goens assures us that she con- ducted her household affairs with as much regularity as she ever had done, and that she used to show her husband the situation of the heavens on a map with as much accuracy as when she was in perfect health. The following case, in Gesner's EndeeJcungen der Neuesten Zeit in der Arzneigelehrheit, is likewise quoted by Crichton: " A man, aged seventy, was seized, about the beginning of January, with a kind of cramp in the muscles of the mouth, accompanied with a sense of tickling all over the surface of the body, as if ants were creep- ing over it. On the 20th of the same month, after having experienced an attack of giddiness and confusion of ideas, a remarkable alteration of his speech was observed to have taken place. He articulated easily and fluently, but made use of strange words, which nobody understood. The number of these does not at present seem to be great, but they are frequently repeated. Some of them he seems to forget entirely, and then new ones are formed. When he speaks quick he sometimes pro- nounces numbers, and now and then he employs common words in their proper sense. He is conscious that he speaks nonsense. What he writes is equally faulty with what he speaks. He cannot write his name. The words he writes are those he speaks, and they are always written conformably to his manner of pronouncing them. He cannot read, and yet many external objects seem to awaken in him the idea of their presence." Dr. Rush,1 in the work the title of which is cited below, in chapter xii., which treats of Derangement in the Memory, refers so specifically to affections of the speech that I quote his language with some degree of fullness, and I do so with the less hesitation as his observations appear to have escaped notice, both in this country and in Europe. He says: " 1. There is an oblivion of names and vocables of all kinds. " 2. There is an oblivion of names and vocables, and a substitution 1 " Medical Inquiries and Observations upon Diseases of the Mind." Fourth edition. Philadelphia, 1830, p. 274. The first edition was published in 1812. 170 DISEASES OF THE BRAIN. of a word no ways related to them. Thus, I knew a gentleman afflicted with this disease, who, in calling for a knife, asked for a bushel of wheat. " 3. There is an oblivion of the names of substances in a vernacular language, and a facility of calling them by their proper names in a dead or foreign language. Of this, Wepfer relates three instances. They were all Germans, and yet they called the objects around them only by Latin names. Dr. Johnson, when dying, forgot the words of the Lord's prayer in English, but attempted to repeat them in Latin. Delirious persons, from this disease of the memory, often address their physicians in Latin or in a foreign tongue. " 4. There is an oblivion of all foreign and acquired languages, and a recollection only of vernacular language. Dr. Scandella, an ingenious Italian, who visited this country a few years ago, was master of the Italian, French, and English languages. In the beginning of the yellow fever which terminated his life in the city of New York in the autumn of 1798, he spoke English only ; in the middle of his disease he spoke French only; but on the day of his death he spoke only in the language of his native country. " 5. There is an oblivion of the sound of words, but not of the let- ters which compose them. I have heard of a clergyman in Newburyport, who, in conversing with his neighbors, made it a practice to spell every word that he employed to convey his ideas to them. " 6. There is an oblivion of the mode of spelling the most familiar words. I once met with it as a premonitory symptom of palsy. It oc- curs in old people, and extends to an inability, in some instances, to remember any more of their names than their initial letters. I once saw a will subscribed in this way by a man in the eightieth year of his age, who during his life always wrote a neat and legible hand. " 9. There is an oblivion of names and ideas, but not of numbers. We had a citizen of Philadelphia many years ago, who, in consequence of a slight paralytic disease, forgot the names of all his friends, but could designate them correctly by mentioning their ages, with which he had previously made himself acquainted." Dr. Rush remarks of these cases, that " there appears to be some- thing like a palsy of the mind, quoad these specific objects." Thus far there had been no attempt to define with precision the seat of the faculty of language, or even to establish its existence; but, in the early part of the nineteenth century, Dr. Gall, a German physician, an- nounced that such a faculty did exist, and that it was seated in those convolutions of the brain which rest upon the posterior part of the supra-orbital plate, and that a large development of the organ was indi- cated by prominence and depression of the eyes. He was first led to believe in the existence of such an organ by observing that some of the scholars with whom, as a young man, he had to compete, excelled him APHASIA. 171 in the ability to learn by heart, and he noticed that those thus endowed with great memory for words possessed prominent eyes. From these circumstances, he was gradually carried on to the foundation of his phrenological system. In reality, however, Gall considered that there were two organs of language in each hemisphere—the one originating the idea of words, the other the talent for philology, and for acquiring the spirit of lan- guages. The former organ he describes as lying on the posterior half of the supra-orbital plate, as before mentioned. It gives a talent for learning and recollecting words, and persons possessing it large, recite long passages by heart after reading them once or twice. The other is placed on the middle of the supra-orbital plate, and when it is large the eyeball is not only rendered prominent but is depressed, causing the lower eyelid to assume the appearance of a bag or fold. Persons having this organ large have not only an excellent memory for words, but a particular talent for the study of languages, for criticism, and in gen- eral terms for all that has reference to literature. Dr. Spurzheim, however, admits but one organ, lying transversely on the posterior portion of the supra-orbital plate, and this view is ac- cepted by Combe and other distinguished phrenological authorities.1 In support of his theory that there is such an organ, Gall cites the case of a notary reported by Pinel.2 The latter, in speaking of apo- plexy, says this affection may be limited in its action to the words which are used to express ideas. In the case mentioned, the patient forgot, after an attack of apoplexy, his own name, that of his wife, those of his children and friends, although there was not the least paralysis of his tongue. He no longer knew how to read or write, and yet his memory as regarded other things was unimpaired. Dr. Gall3 refers also to the case of a soldier, sent to him by Baron Larrey, who was affected in a manner similar to that of the notary. It was not his tongue which was involved, for he was able to move it about in all directions, and to pronounce words, but he had lost the memory for words, although he recollected other things as well as ever. I shall presently have occasion to refer to a still more interesting case, reported by Larrey, and one which appears to have escaped the notice of all writers on the subject of aphasia. Spurzheim mentions the case of. one Lereard, of Marseilles, who, having received a blow from a foil on the eyebrow (which one is not stated), lost the memory of proper names entirely. He sometimes even forgot the names of his intimate friends, and even of his father. 1 For a full account of the subject, the reader is referred to a " System of Phrenol- ogy)" by George Combe, Boston, 1834, or to " Phrenology," etc., by J. S. Spurzheim, Boston, 1833. 2 " Traite mddico-philosophique, sur Validation mentale." Second edition. Paris, 1809, p. 90. 8 "Physiologie du cerveau," vol. iv., p. 84. 172 DISEASES OF THE BRAIN. Gall, therefore, located the organ of language in a limited part of the anterior lobe of each hemisphere; but he adduced very little evi- dence to support his opinion, and hence his views did not meet with any thing like general acceptance. A number of cases, however, re- ported by Lallemand, Rostan, and others, support it, while several ad- duced by the same authors are opposed to it. In 1825 Bouillaud,1 who had collected a great number of cases of affections of the brain, was surprised to find how frequently the loss of speech coexisted with disease or injury of the anterior lobes. He also confirmed, what others before him had noticed", that the loss of the power of expressing ideas in articulate language was often the only evi- dence of a brain-affection. He made one very important step in advance, and his views on this particular point are adopted—and often without credit—by the majority of the present writers on aphasia; he divided the faculty of speech into two distinct categories of phenomena: 1. The faculty of creating words as representatives of our ideas, and of recollecting them—internal speech. 2. The power of coordinating the movements necessary for the ar- ticulation of these words—external speech. This classification forms the basis of the division of aphasia into the two varieties, the amnesic and the ataxic. The cases which Bouillaud adduced in support of his theory were many of them in patients who exhibited no other symptoms than the loss of the power of articulate language. They preserved their intelli- gence, comprehended perfectly questions put to them, and knew the value of words; but, although there was no paralysis of either the tongue or the lips, they were unable to utter a word. At the post- mortem examination, the lesion was always found in the anterior lobes. Sixty-four cases formed the basis of his conclusions. A part was direct, and went to show that lesion of the anterior lobes was accompanied by derangement in the faculty of speech; the other part was indirect, and established the fact that, when the anterior lobes were not affected, the lesion being in some other region of the brain, the faculty of speech remained intact. Cruveilhier opposed Bouillaud's views, and, in a paper read at the Athenee de Medecine in the same year, brought forward seven cases of persons, some of whom had lost the faculty of speech, but who, on post- mortem examination, were found to have no disease of the anterior lobes; and others who had spoken, but in whom there were more or less profound changes in these parts. Subsequently Andral2 reported the results of the analysis of thirty- 1 "Traite de l'encephalite," Paris, 1825; and also, "Recherches cliniques, propres a demontrer que la perte de la parole correspond a la lesion des lobules ant6rieurs du cer- veau," Archives de med., 1825, 2 " Clinique m6dicale," tome ii., p. 135. APHASIA. 173 seven cases of lesion of one or both anterior lobes. Of these, speech was abolished twenty-one times, and preserved sixteen times. Lalle- mand l also opposed Bouillaud with several cases; but the latter rejoined2 with a fresh array of thirteen cases in support of his doctrine, and with many arguments against the validity of those brought against him. Longet3 declares that Bouillaud appears to have refuted many of the objections of his adversaries, and to have demonstrated that some of their cases were badly interpreted. At the same time, while admitting that it is possible that different parts of the brain preside over different voluntary movements, he affirms that there is nothing positively estab- lished as regards the localization of the active principles of these move- ments. Subsequently, in other memoirs, Bouillaud brought forward addi- tional cases in support of his theory, making a total of one hundred and three, and offered a prize of five hundred francs to any one who would adduce an instance of profound lesion of the anterior lobes without troubles of speech. Many years subsequently Velpeau announced that he should claim this prize, for that, in March, 1843, he had related the case, and presented the brain, of a wig-maker who had come under his care for prostatic disease. This man was in full possession of his reasoning faculties, and, moreover, was noted for his unconquerable loquacity. He died a few days subsequently, and on post-mortem ex- amination a scirrhous tumor was found to have entirely taken the place of the two anterior lobes of the brain. Very little faith seems to have been put by physiologists or pathologists in the history of this case. If it proves any thing, it is that the anterior lobes are useless appendages to the rest of the cerebral system. But Bouillaud was not content with the deductions to be drawn from pathology. In a series of experiments, he endeavored to establish the truth of his idea, and thus bring the science of physiology to his support. These experiments were detailed in a paper4 read before the Academy of Sciences, in September, 1827, which, was subsequently (1830) published in the tenth volume of Magendie's Journal de Physi- ologie, from which I quote. The experiments relative to the anterior lobes were made on dogs. Only one was entirely successful—the animals in the others dying too soon after to admit of satisfactory deductions being made. But the twentieth experiment was more satisfactory. On the 28th of June, 1826, he passed a gimlet through the anterior 1 Op. cit, lettres 6, 7, 8. a " Exposition de nouveaux faits a l'appui de 1'opinion qui localise dans les lobes an- turieurs du cerveau le principe legislateur de la parole." " Bulletin de l'Academie de Modecine," 1839, tome iv., p. 282. 3 " Traite" de la physiologie," tome ii., p. 438. * " Recherches expe'rimentales sur les fonctions du cerveau (lobes cerebraux) en gene- ral et sur celles de sa portion ant^rieure en particulier." 174 DISEASES OF THE BRAIN. part of the brain of an active, docile, and intelligent dog. Immediately afterward the animal was convulsed, and could not rise from the ground. Sight and hearing remained. Symptoms of compression soon came on; the result, probably, of the haemorrhage. Eventually, the animal re- covered, but it was found to have lost much of its intelligence and agility. The faculty of memory seemed to have been entirely abolished, and there was a decided expression of imbecility in its countenance. It could no longer ascend or descend a staircase; the fore-legs were lifted very high in walking, and its movements were all badly coordinated. When struck or made to walk, it uttered sharp cries, but it had lost entirely the ability to bark. As Bouillaud remarks, "it no longer barked, either to show its affection, or to drive away strangers who came to the house." Once only, on the 18th of July, it tried to bark at a passer-by, but failed in the attempt. This is the only experiment I have been able to find which has any bearing upon the question of the localization of the faculty of language. And I do not quote it as proving much on the subject. The difficulties in the way of experimentation are almost insuperable, to say nothing of the fact that it is doubtful if any of the sounds made by animals can be compared with human speech. But unintentional experiments have been performed upon the human subject, which tend to show that, though the faculty of lan- guage may be located in one or both anterior lobes, either may be seriously injured without the faculty of language suffering to any ap- preciable extent. Two of them have happened in this country, and, although referred to in connection with aphasia by Seguin and Harris, I take satisfaction in bringing them forward on account of their great importance to the question under consideration. The first is related by Dr. Harlow,1 of Vermont: The subject was a strong, healthy man, twenty-five years of age, and was engaged in ramming down a charge of powder in a rock to be blasted, when an explosion took place, and the tamping-iron was driven clear through his head. In a few minutes he recovered his consciousness, was put into a cart and carried three-quarters of a mile to his residence, where he got out and walked into the house. Two hours afterward he was seen by Dr. Harlow. He was then quite conscious and collected in his mind, but exhausted by extensive haemorrhage from the hole in the top of his head. Blood, pus, and particles of brain, continued to be discharged for several days, but by January 1, 1849, the wound was quite closed and his recovery complete. There was no pain in the head, but a queer feeling, which he could not describe. As regarded his mind, he was fitful and vacillating, though obstinate, as he had always been. He 1 Boston Medical and Surgical Journal, December, 1849, vol. xxxix., p. 389. Also, "Descriptive Catalogue of the Warren Anatomical Museum," Boston, 1870, p. 145. APHASIA. 175 became very profane, never having been so before the accident. He lived till May 21, 1861, twelve and a half years subsequent to the acci- dent, when he died, after having had several convulsions. His cranium was obtained, and, with the bar, is now preserved in the Warren Ana- tomical Museum at Boston. Dr. J. B. S. Jackson1 thus describes the skull: " The whole of the small wing of the sphenoid bone upon the left side is gone, with a large portion of the large wing, and a large por- tion of the orbital process of the frontal bone, leaving an opening in the base of the skull two inches in length, one inch in width poste- riorly, and tapering gradually and irregularly to a point anteriorly. This opening extends from the sphenoidal fissure to the situation of the frontal sinus, and its centre is an inch from the median line. The optic foramen and the foramen rotundum are intact. Below the base of the skull the whole posterior portion of the upper maxillary bone is gone. The malar bone is uninjured; but it has been very perceptibly forced outward, and the external surface inclines somewhat outward from above downward. The lower jaw is also uninjured. The opening in the base, above described, is continuous with a line of old and united fracture that extends through the supra-orbitary ridge in the situation of the foramen, inclines toward and then from the median line, and terminates in an extensive fracture that was caused by the bar as it came out through the top of the head. This fracture is situated in the left half of the frontal bone, but inferiorly it extends somewhat over the median line. In form it is about quadrilateral; but it measures two and a half by one and three-quarter inches. Two large pieces of bone are seen to have been detached and upraised, the upper one having been separated at the coronal suture from the parietal bone, and being so closely united that the fracture does not show upon the outer surface. The lower piece shows the line of fracture all around. Owing to the loss of bone, two openings are left in the skull; one that separates the two fragments has nearly a triangular form, extends rather across the median line, and is four inches in circumference ; the other, situated between the lower fragment and the left half of the frontal bone, is long and irregularly narrow, and is two and five-eighths inches in circum- ference. The edges of the fractured bones are smooth, and there is nowhere any new deposit." From this account it will be seen that the left anterior lobe of the brain suffered severely by this terrible injury, and yet it is not stated that the subject had ever shown any difficulties of speech. If the faculty of language resides in the whole of the lobe, such an immunity could scarcely have existed. It must be noted, however, and the photo- graph of the cranium establishes the fact, that the third frontal convo- lution and the island of Reil escaped all injury. Another interesting 1 " Descriptive Catalogue of Warren Anatomical Museum," loc. cit. 176 DISEASES OF THE BRAIN. circumstance is the addiction to profanity after the accident. A Uke phenomenon has been noticed in cases of aphasia. The second instance is almost as extraordinary. I quote the history of the case, 952, from Dr. Jackson:l " Cast of the head of a man who was transfixed through the head by an iron gas-pipe, and who, to a very considerable extent, recovered from the accident. "The patient, a healthy and intelligent man, about twenty-seven years of age, was blasting coal when the charge exploded unexpectedly, and the pipe was driven through his head, entering at the junction of the middle and outer thirds of the right supra-orbitary ridge, and emerg- ing near the junction of the left parietal, occipital, and temporal bones. One of his fellow-miners saw him upon his hands and knees, and strug- gling as if to rise ; and, going to his assistance, he placed his knee up- on his chest, supported his head with one hand and with the other with- drew the pipe. This last projected about equally from the front and back of the head, and much force was required for its withdrawal." Brain escaped from the anterior opening, and coma and collapse supervened. " In seven weeks he sat up, and in one more walked about. The right hand he used somewhat, but less well than the left. For about ten months after the accident his memory for some things was nearly lost, but during the next two months there was a considerable improvement." The accident happened on May 14, 1867, and in June, 1868, the patient, with the gas-pipe, was exhibited to the Massachusetts Medical Society. "The man appeared to be in a good state of general health; and, though his mental powers were considerably impaired, there was nothing unusual in his expression, nor would there be noticed, in a few minutes' conversation with him, any marked deficiency of intellect." It is very evident that in this case the right anterior lobe was seriously injured—the left escaping—and yet there does not appear to have been any aberration of speech. It is to be regretted, however, that the history is not more specific as to the things in regard to which the memory was deficient. There are other cases which militate against Bouillaud's doctrine. Thus, M. Petera states that a drunken cavalry-soldier fell from his horse on the back of his head, and fractured his skull. Stupor set in at once, followed by the most violent delirium. The man kept constantly shout- ing the worst possible oaths, and held connected conversation with im- aginary persons. He died at the end of thirty-six hours, without hav- ing recovered his reason. On dissection, a fracture of the roof and base of the skull was discovered in all its length. The posterior lobes of the 1 Op. cit, p. 149. 2 Quoted by Trousseau, "Lectures on Clinical Medicine." Translated by Bazire, vol. i., p. 256. APHASIA. 177 brain were found, on post-mortem examination, to have sustained no injury, but both anterior lobes were in a pulpy condition, through a most violent contusion, caused by their being knocked against the an- terior wall of the cranium. The whole thickness of the lobes was dis- organized. As Trousseau remarks, this case shows that the two frontal lobes may be destroyed in their anterior portion without causing a loss of the faculty of speech. Trousseau also cites the case of two officers, who, after a quarrel, fought a duel. One of them fired first, and the ball entered his adversary's head at one temple, passed through the brain, and then raised the temporal bone on the opposite side. The ball was extracted, and the patient immediately made a sign with his hands, and expressed his thanks in a very low voice. He recovered, for the time being, and, during five months thereafter, could speak perfect- ly well, and was remarkable for the wit and fluency of his conversation and writing. He subsequently died of softening; and it was found, on post-mortem examination, that the ball had passed through the two frontal lobes in their middle portion. A still more striking case is re- ferred to by Dr. Bazire, in a note to Trousseau's lecture on aphasia, in the work cited. It was reported in 1843 by M. Aug. Berard, to the Anatomical Society of Paris. The patient, a miner, was knocked down and severely injured by an explosion in a mine. He did not lose con- sciousness, but managed to creep out of his hole and to call to his help some men who were working a short distance off. He begged them to fetch a cart and to take him to M. Berard's house. He was there ex- amined. The whole frontal region was laid open, the integuments hung in shreds, the bones were splintered and in detached fragments, and the brain was exposed. Both anterior cerebral lobes were completely de- stroyed, and in their stead was a mixture of blood, of bony splinters, and brain-substance. In spite of this frightful injury, the man could relate in all its details how the accident had occurred. He died the next day. Whether or not we accept this case in all the import claimed for it, there can be no doubt that Bouillaud is wrong in claiming that injury of the anterior lobes is necessarily followed by some derangement in the faculty of speech. It is only fair, however, to state that latterly he has admitted that the organ of language may occupy the posterior part of either lobe. Dr. M. Dax, in 1836, read a paper before the medical congress which met that year at Montpellier, in which he came to the conclusion that the faculty of language " was seated, not as Gall and. Bouillaud had contended, in both anterior lobes of the brain, but that it occupied only the left anterior lobe." He based this opinion on one hundred and forty cases of aphasia attended with paralysis, and in which the loss of power was on the right side; showing, therefore, that the lesion which produced the aberration of speech also caused the hemiplegia, and that 12 178 DISEASES OF THE BRAIN. this lesion must have been on the left side. This paper at the time at- tracted very little attention, and was forgotten till the year 1861 wit- nessed the reopening of the discussion.1 It would be very easy to quote a large number of cases confirmatory of Dr. Dax's doctrine, but a few will suffice to show the general bearing of a great many others. The following case seems to have escaped notice. It is not the one referred to by Gall as being sent to him by Larrey. In that case the left anterior lobe was injured and there was aphasia, but the lesion was caused by a sword. Baron Larreys presented to the Academy the cranium of a subject, with the following history: Toward the end of the year 1815 an officer of dragoons came to the hospital with a wound from a ball which he had received at Waterloo. The missile had entered the left side of the cranium at a point about six or eight millimetres from the eyebrow and near the temporal ridge. At first he had suffered loss of consciousness and profuse hasmorrhage, but had recovered, with but slight loss of motor power. So far as his mind was concerned, there was no derangement except as regarded the faculty of speech; he had lost the memory of substantives. For this reason he was unable to drill his company, and, though able to distin- guish his men by their size, their form, their complexion, or their voice, he could not call them by name. He refused to allow the operation of trephining to be performed, and in 1827 died of phthisis. A post-mortem examination was made. The ball was found em- bedded in the thickness of the bone, having elevated and fractured the internal table. The dura mater was strongly adherent to the whole of the left anterior cranial fossa; it was also thicker and denser than in the natural state. A spheroidal excavation, five centimetres in its horizontal and seven or eight in its vertical diameter, was discovered at the summit and on the temporal side of the left anterior lobe of the brain. Mr. Thomas Hood 3 reported the history of a patient, a sober, intel- ligent man, sixty years of age, who, on the evening of September 2, 1822, suddenly began to speak incoherently, and became quite unintelli- gible to those around him. It was discovered that he had forgotten the name of every object in Nature. His recollection of things seemed to be unimpaired, but the names by which men and things were known were entirely obliterated from his mind, or rather he had lost the faculty by which they were called up at the control of the will. He was by no means inattentive, however, to what was going on, and he recognized 1 Dr. Marc Dax's memoir was republished in the Gazette hebdomadaire, No. 17, April, 1865. 2 " Blessure du cerveau avec perte de memoire des noms substantives," Journal de physiologie de Magendie, tome viii., 1828, p. 1. 3 "Phrenological Transactions." Quoted by George Combe in his "System of Phre- nology," Boston, 1834, p. 429. APHASIA. 179 friends and acquaintances perhaps as quickly as on any former occasion; but their names, or even his own or his wife's name, or the names of any of his domestics, appeared to have no place in his recollection. " On the morning of the 4th of September," says Mr. Hood, " much against the wishes of his family, he put on his clothes and went out to the workshop, and when I made my visit he gave me to understand, by a variety of signs, that he was perfectly well in every respect, with the exception of some slight sensations referable to the eyes and eyebrows. I prevailed on him with some difficulty to submit to the reapplication of leeches, and to allow a blister to be placed over the left temple. He was now so well in bodily health that he would not be confined to the house, and his judgment, in so far as I could form an estimate of it, was unimpaired, but his memory of words was so much a blank, that the monosyllables of affirmation and negation seemed to be the only two words in the language the use and significance of which he never en- tirely forgot. He comprehended distinctly every word which was spoken or addressed to him; and, though he had ideas adequate to form a full reply, the words by which these ideas are expressed seemed to have been entirely obliterated from his mind. By way of experiment I would sometimes mention to him the name of a person or thing, his own name for example, or the name of some one of his domestics, when he would repeat it after me distinctly once or twice; but generally before he could do so a third time the word was gone from him as completely as if he had never heard it pronounced. When any person read to him from a book, he had no difficulty in perceiving the meaning of the passage, but he could not himself then read, and the reason seemed to be that he had forgotten the elements of written language, viz., the names of the let- ters of the alphabet. In the course of a short time he became very ex- pert in the use of signs, and his convalescence was marked by his im- perceptibly acquiring some general terms which were with him, at first, of very extensive and varied application. In the progress of his recov- ery, time and space came both under the general application of time. All future events and objects before him were, as he expressed it, ' next time ;' but past events and objects behind him were designated ' last time.'' One day, being asked his age, he made me to understand that he could not tell; but, pointing to his wife, uttered the words, ' many times' repeatedly, as much as to say that he had often told her his age. When she answered sixty, he answered in the affirmative." On the 10th of January he suddenly became paralytic on the left side [this is evidently a typographical error for right side]. On the 17th of August he had an attack of apoplexy, and on the 21st he expired. In the Phrenological Journal, vol. iii., p. 28, Mr. Hood has reported the dissection of his brain: " In the left hemisphere, lesion of the parts was found, which terminated at half an inch from the surface of the brain, where it rests on the middle of the supra-orbital plate." Two 180 DISEASES OF THE BRAIN. small depressions or cysts were found in the substance of the brain, " and the cavity considered as a whole expanded from the anterior part of the brain till it opened into the ventricle in the form of a trumpet. The right hemisphere did not present any remarkable appearance." Dr. Thomas Hun,1 of Albany, in detailing a case of amnesia in which there were no symptoms of paralysis, and in which there was no post-mortem examination, cites the case of a lady who died of cancer of the brain, occupying, at the time of her death, the greater portion of the left anterior lobe. In the early stages of her disease she was often unable to call the most familiar objects by name, and had to ex- press herself by signs or by pointing at the object. When the word she wanted was pronounced before her, she recognized it, and was able to repeat it. Other cases, and especially several which have occurred in my own experience, are reserved for future consideration. Up to this period we have the organ of articulate language limited to the left anterior lobe of the brain, but in 1861 its location was still further restricted. In that year M. Gratiolet, in discussing before the Anthropological Society of Paris a question relative to the comparative development of the brain and mind among different races, brought up the subject of cerebral localization, to which he announced himself as being strongly opposed. M. Auburtin, on the contrary, contended that the localization of the faculty of speech at least was definitely estab- lished, through the researches of Bouillaud, in the anterior lobes. In support of this view, he adduced cases which had already been brought forward, and cited others in addition, which went to show that loss of speech was the consequence of traumatic lesion of these parts of the brain. His adversaries cited other cases in which persons had preserved the faculty of language notwithstanding extensive lesions of the an- terior lobes. M. Auburtin responded that, if such profound and exten- sive injuries had not interfered with speech, it was because that part of the lobes in which the organ is situated was not involved. And he then cited the case of a patient in the Hospital for Incurables, who for many years had been deprived of the power of speech, and he declared that he would renounce the doctrine of Bouillaud if the autopsy of this patient did not reveal disease of the anterior lobes. The patient in question was under the charge of M. Broca, and the latter, a decided opponent, accepted the challenge of M. Auburtin, and declared that, when the man died, the examination should be made. Some time afterward the patient died, the post-mortem examination was made, and the lesion was found to occupy the left anterior lobe." From this time forward, M. Broca, who had been a most determined 1 American Journal of Insanity, vol. vii., 1850-51, p. 359. 2 See "Etude sur la localisation de la faculte du langage articule." These de Paris de M. Carrier, 1867. APHASIA. 181 opponent of Bouillaud's views of localization, became converted, and carried them to a still more extreme point than even M. Marc Dax had done. Taking, as his principal case, the one to which M. Auburtin had pinned his faith, he read, in 1861, before the Anatomical Society of Paris, a memoir,1 in which he discusses the question of the location of the faculty in question with all his perspicuity and directness. As the two cases cited by him are of historical interest, I give the chief details of them: A man named Le Borgne, who had been an inmate of another de- partment of Bicetre for over twenty years, was transferred to one of the wards under M. Broca's care, to be treated for a severe attack of phlegmonous erysipelas. The man was a confirmed epileptic, and had not spoken, since his entrance into the hospital, more than a few words, which he employed for the expression of all his ideas. It is stated that in other respects his intelligence was good. Le Borgne was known in the hospital by the name of " Tan," a word which he habitually used, and which, with the oath, " Sacr'e nom de Dieu" constituted his entire vocabulary. " Tan," owing to the constancy with which he used it, was the name by which he was known in the hospital; and, when he could not make himself understood by his signs, he employed the oath, and gave other manifestations of anger. For several years he had remained in the hospital with no other lesion than that of speech, with an occasional epileptic paroxysm; but, after a few years, his right arm became paralyzed, and four years sub- sequently the leg of the same side was involved; his sight was likewise enfeebled, and for the past seven years he had been entirely confined to his bed. Notwithstanding the fact that he was almost in a dying condition when M. Broca first saw him, some important points in his cerebral difficulty were noted. To any question put to him, he replied, as usual, " Tan" but at the same time endeavored to make himself understood by signs. Thus he raised six fingers to indicate that six days had elapsed since the inception of his erysipelas, and by opening and shut- ting his hand four times and then raising one finger signified that he had been twenty-one years in Bicetre. Sensibility was lessened on the affected side; there was no deviation of the tongue, which could be moved freely in all directions, and no paralysis of the face beyond a slight weakness shown by the swelling of the left side when he breathed; there was a little difficulty of swallow- ing, from the fact that the muscles of the pharynx were gradually be- coming implicated. After a few days the man died. As I have said, the autopsy showed that the lesion was situated in the left anterior lobe. More exactly, however, it should now be stated 1 " Sur le siege de la faculte de langage articule avec deux observations d'aphemie." Bulletin de la societe anatomique, tome iv., 1861. L82 DISEASES OF THE BRAIN. that it involved the inferior marginal convolution of the temporo- sphenoidal lobe, the convolutions of the island of Reil, and in the fron- tal lobe, the frontal transverse convolution, and the posterior half of the second and third frontal convolutions. The left corpus striatum was also affected. According to Broca, the disease had in all probabil- ity begun in the third frontal convolution, and had gradually extended to the other parts; the paralysis marking the implication of the island of Reil and the corpus striatum. The other case was that of a man named Le Long, aged eighty-four years, who had entered the hospital for a fracture of the neck of the femur. Eighteen months before, he had been treated in the medical service for a temporary apoplexy, which had deprived him of the faculty of speech, but had caused no paralysis. Le Long, whose intelligence, facial expression, and ability to gesticulate, were very striking, made himself perfectly well understood, although able to pronounce indistinct- ly a very few words, but which were nevertheless properly applied. These words were "oui" "?ion, toujours, tois" for trois, and Lelo for Le Long. Thus when asked, " Can you write ? " he answered, " Oui." " Have you any children ? " " Oui." " How many ? " " Tois," but at the same time, as if aware that he was not answering correctly, he raised four fingers. " How many boys ? " " Tois," raising two fingers. " How many girls ? " " Tois," holding up two fingers. " What time is it by this watch ?" " Tois," at the same time raising ten fingers to signify that it was ten o'clock. " How old are you ? " To this question he replied by two gestures ; the one consisting of raising eight fingers, the other of four fingers, by which he meant that he was eighty-four years old. Aside from this application of the word tois to all numbers, his answers were perfectly correct. The tongue was neither paralyzed nor thickened; on one side the larynx was mobile, and his limbs possessed their normal power for his age. It was therefore a case of pure aphasia, or, as Broca then designated the affection, aphemia. Twelve days after the accident, the patient died. The post-mortem examination revealed the existence of lesions, almost identical in situa- tion with those of the former case. The posterior part of the third left frontal convolution, and the contiguous part of the second, had been absorbed and replaced by a serous fluid. Two cases can scarcely decide any point in pathology; but, without venturing to assert positively that the organ of language resides exclusively in the posterior part of the third frontal convolution, M. Broca expressed the opinion that the in- tegrity of this convolution, and perhaps of the second, is indispensable to the normal operation of the function of speech. Many cases were adduced by Charcot,1 by Falret,2 by Perroud' of 1 Gazette hebdomadaire, 1863, pp. 473, 525. 2 Archives de medecine, tome iv., Mars et Mai, 1864. 3 Journal de medecine de Lyon, Janvier et Fevrier, 1864. APHASIA. 183 Lyons, by Trousseau,1 and others, in support of the localization of the faculty of articulate language in the left side of the brain. Most of these cases were accompanied by right hemiplegia, and, in several, post- mortem examinations showed the lesion to exist in the parts designated by Broca. In the early part of 1863, M. G. Dax, son of the M. Dax who had placed the organ of language in the left hemisphere, presented, through M. Lelut, a memoir to the Academy, in which he claimed with his father that aphasia was always the result of lesion of the left hemisphere, but he assigned a still more restricted position, by limiting it to the anterior and exterior part of the middle lobe. He cited forty cases of loss of the power of speech, coincident with lesion of the left hemisphere. Now, besides these direct cases, there are others which bear with almost as much effect on the affirmative of the doctrine in question. Thus M. Fernet, in 1863, presented a case to the Society de Biologie, in which there was left hemiplegia, but no aphasia. After death, soften- ing of the right hemisphere, from thrombosis of the right middle cere- bral artery, was found to exist. M. Parrota adduced another case in which there was complete atrophy of the island of Reil, and of the third convolution of the right side, but in which there was no trouble of speech. These cases go to show that the organ of articulate language is not situated in the right hemisphere. M. Lesur3 has reported a case which is of very great interest. A child was kicked on the head by a horse, and a fracture of the frontal bone was thus produced. The operation of trephining was performed at a point about an inch and a quarter above the left eye. After the operation and during the progress of the case, it was observed that, whenever pressure was made upon the brain through the hole in the cranium, the child lost the power of speech, and that when this pressure was removed she regained it. A similar case occurred several years ago in my own practice. Among British writers, Dr. Hughlings Jackson4 has given the histo- ries of thirty-four cases of loss of speech coinciding with right hemiple- gia. He is entitled to the credit of making a beautiful application of anatomy and physiology to the pathology of the subject under considera- tion. The part of the brain designated by Broca as the seat of the organ of articulate language is nourished by the left middle cerebral artery. An obstruction of this artery would of course interfere with the perfect action of that region, and thus aberrations of speech would be produced. But the same artery also supplies blood to the corpus striatum of the same side. Hence the frequency with which aphasia is associated with right hemiplegia. The cause of the obstruction is gener- ally, according to Dr. Jackson, embolism, for in twenty of his cases the 1 Clinique medicale. 2 Gazette hebdomadaire, 1863, p. 506. 8 Gazette des hopitaux. * " London Hospital Reports," vol. i. 184 DISEASES OF THE BRAIN. heart was more or less affected, and in thirteen of them there was valvu- lar disease. Among other British writers, some of whom will be more fully re- ferred to hereafter, must be mentioned, Dr. Sanders,1 Dr. Moxon,2 Dr. Ogle,3 Dr. Bateman,4 and Dr. Bastian.6 The matter does not appear to have attracted much attention from German physiologists and pathologists, since the discussion in the French Academy in 1861. Previous to that period several excellent memoirs upon the physiology of speech were published by Germans, among which that of Dr. Bergman" is preeminent. A memoir by Nasse * is also interesting. In 1865 Von Benedict and Braunwart8 published a very thorough paper on the subject, and other observers have reported cases. In this country there have been several very excellent memoirs upon aphasia, and, as we have already seen, the subject early attracted atten- tion, and the fact that such a condition could exist without other mani- fest symptoms was fully recognized. Thus Prof. A. Flint9 detailed the histories of six cases, in one of which post-mortem examination showed extensive disease of the left anterior lobe, and in four, in which the situation of the hemiplegia was noted, the right was the affected side. Dr. H. B. Wilbur,10 in a memoir on aphasia, treats of the aberrations of the faculty of language as they existed in certain idiots under his observation. His cases, though interesting, are scarcely in point, as the difficulties of speech were clearly the result of mental deficiencies. A very important memoir is that of Dr. E. C. Seguin,11 in which a very excellent history of the subject is given, with the citation of forty- eight cases from the records of the New York Hospital, in which there were difficulties of speech coexisting with hemiplegia, and two in which there was no hemiplegia. In several of these cases, however, as Dr. Seguin states, the loss of the faculty of speech was due to paralysis of the tongue and other muscles concerned in articulation. Another excellent paper is by Dr. T. W. Fisher,12 of Boston. Dr. Fisher has studied the subject very philosophically, and records thirty- 1 Edinburgh Medical Journal, August, 1866. 2 British and Foreign Medico-Chirurgical Review, April, 1866. 3 "St. George's Hospital Reports," vol. ii., 1867. 4 Journal of Mental Science, January, 1868, and subsequent numbers. 6 British and Foreign Medico-Chirurgical Review, January and April, 1869. 6 "Einige Bemurkungen iiber Storungen des Gediichtniss und der Sprache. Allgt- m:ine Zeitschrift fur Psychiatrie, 1849, s. 657. ' Allgemeine Zeitschrift u. s. w., 1853, s. 523. 8 Canstatt's " Jahresbericht," 1865, s. 31. 9 Medical Record (New York), March 1, 1866. 10 American Journal of Insanity, July, 1867. 11 Quarterly Journal of Psychological Medicine, etc., January, 1868. 12 Boston Medical and Surgical Journal, September 1, 1870, and subsequent numbers. APHASIA. 185 eight cases in which post-mortem examinations were made with definite results. Cases have also been published by Bartholow 1 and others. With this outline statement of the history of the subject of aphasia, we are in a position to inquire more fully into the evidence which locates the organ of language in a particular region of the brain. A clear idea of the anatomy of the parts fixed upon latterly as the seat of the faculty will aid in the understanding of the subject. The following account is condensed by Dr. Bateman2 from Broca's description in his essay " Sur le siege de la faculte du langage arti- cule:" " The anterior lobe of the brain comprises all that part of the hemi- sphere situated above the fissure of Sylvius, which separates it from the temporo-sphenoidal lobe and in front of the furrow of Rolando which divides it from the parietal lobe. The furrow of Rolando separates the frontal from the parietal lobe; it traverses from above downward all the external surface of the cerebral hemisphere, starting from the inter- hemispheric median fissure, and ending at the fissure of Sylvius. In front, this furrow is bounded by the transverse frontal convolution, and behind by the transverse parietal convolution. The anterior lobe is composed of two stories or divisions—one inferior or orbital, the other Fig. 18. FROM BKOOA, AS MODIFIED BY DE. HtTOHLINGS JACKSON. 1. First Frontal Convolution; 2. Second Frontal Convolution; 3. Third Frontal Convolution; O. Orbi- tal Convolutions; E F. Transverse Frontal Convolution; P. Parietal Lobe; T S. Temporo-sphe- noidal Lobe; Tl. First Temporo-sphenoidal Convolution; T 2. Second Temporo-sphenoidal Convo- lution; I. Island of Reil; R R. Furrow of Rolando; S. Fissure of Sylvius. superior—situated beneath the frontal and under the most anterior part of the parietal. This superior division of the anterior lobe is composed of four fundamental convolutions; one posterior, the others anterior. The posterior is that which has been described as the transverse frontal, 1 Medical Repertory, Cincinnati, January, 1869. 4 Op. cit, p. 522. 1SG DISEASES OF THE BRAIN. and which forms the anterior border of the furrow of Rolando; the three other convolutions have all an antero-posterior direction and are distin- guished by the names of superior or first frontal, middle or second, and inferior or third frontal convolutions. This last, by its posterior half, forms the superior border of the fissure of Sylvius, the inferior border being formed by the superior convolution of the temporo-sphenoidal lobe. In drawing asunder these two convolutions which bound the fis- sure of Sylvius, the lobe of the insula (the island of Reil) is exposed, which covers the extra-ventricular nucleus of the corpus striatum. The result of these relations is that a lesion, which is propagated from the frontal to the temporo-sphenoidal lobe, or vice versa, will pass almost necessarily by the lobe of the insula, and thence, in all probability, it will extend to the extra-ventricular nucleus of the corpus striatum, see- ing that the proper substance of the insula, which separates the nucleus from the surface of the brain, is composed only of a very thin layer." The lobe of the insula, or the island of Reil, is found in no other mammal than man and the monkey. In the latter, however, it is very slightly developed, and has no trace of convolutions. In aberrations of speech this part is very often involved in the lesion. Now, although there are several cases on record in which post-mor- tem examination would appear to show that lesion of the third left frontal convolution is sufficient to produce derangement of the faculty of articulate language, the weight of evidence is decidedly against limit- ing the seat of the organ to this part. Thus, of five hundred and fifty- six cases of aphasia tabulated by Seguin,1 the third frontal convolution was damaged but in nineteen. While, therefore, we must admit that injury or disease of this limited region will cause aphasia, it is going too far to assert that the lesion must exist in this situation in order that aphasia may be produced. Moreover, Seguin gives another table of cases which must definitely settle the matter, and which I quote in full. It relates to autopsies which were made with special reference to the point in question, and in which the details given were sufficient clearly to indicate the location of the lesion. QUESTION OF THIRD LEFT FRONTAL CONVOLUTION. AUTHORITIES. For. Against. Trousseau, 1865 (in Academie de Medecine)............. Peter, Legrand, Beclard, Delpech, Berard, Farge, Jackson, Bigelow......................................... Jackson, Richardson, Russel.......................... New York Hospital, 1830-'67......................... Bellevue Hospital, October, 1867...................... Total................................... 14 18 18 34 1 Op. cit., p. 97. APHASIA. 187 Other cases might readily be adduced, but the above are amply suf- ficient to decide the question against Broca's doctrine. One case of aphasia occurring without lesion of the third frontal convolution would of course invalidate his claim that this part is the exclusive seat of the organ of language, and no number of cases showing coexistence of aphasia with disease or injury of the third left frontal convolution would be sufficient to establish the point affirmatively with the results of our present experience disproved. Nevertheless, as showing further that disease of this part will cause aphasia, I subjoin the following case from Dr. W. Ogle's1 very interesting memoir: "Joel B., October 18, 1866. Had rheumatic fever and endocarditis twenty-five years ago, but since that has had good health. While at work, October 15th, fell down suddenly without losing consciousness, and found that he was speechless, and hemiplegic on the right side. " On admission he was found to have extensive heart-disease, with the pulse characteristics of aortic regurgitation. There was complete lax palsy of the right arm and leg, with unimpaired sensibility. There was at first some difficulty in deglutition and in protruding the tongue, but this latter symptom passed away in a few days. There was slight pain in the left side of the head. " His speech was limited to the two words ' yes ' and ' no.' These he used correctly. After he had been in the hospital some time, he recovered the power of saying some few words, chiefly monosyllables. " He could write with his left hand, with sufficient distinctness, words which he could not pronounce when asked to do so. In his writ- ing there was often a tendency to reduplication of letters. For instance, he wrote ' Testatament' for ' Testament.' But I cannot say whether this was more than the result of deficient education. " His mind seemed quite clear. He understood all that was said to him; took interest in all that was going on about him; listened to con- versation with an animated, lively look, laughing at any little joke, and expressing himself frequently by suitable pantomime. In December he was attacked by oedema of the lungs, and died on the 20th." Post-mortem.—QEdematous lungs, extensive aortic and mitral disease. " Much semi-gelatinous fluid in subarachnoid space. Surface of brain healthy, excepting at one limited spot. This was the posterior part of the third frontal convolution on the left side. Here was a softened, almost diffluent patch about three-quarters of an inch in breadth, reach- ing from the highest point of the third convolution backward and down- ward to the fissure of Sylvius. The softened patch was not actually the most posterior part of the convolution, for there was a narrow un- softened strip between it and the transverse frontal convolution. In cutting into the brain, a second small patch of softening was seen in the centre of the left hemisphere, external to and rather above the corpus 1 " Aphasia and Agraphia," " St. George's Hospital Reports," vol. ii., 1867, p. 105. 18S DISEASES OF THE BRAIN. striatum, and extending toward the posterior termination of the fissure of Sylvius. All the rest of the brain was apparently healthy. " The left middle cerebral artery was firm in its main trunk, but in one of its secondary branches at a bifurcation was a hard shotty bit of fibrine completely obstructing the passage, so that when water was in- jected into the vessel it could not pass, though considerable force was used. There were also fibrinous blocks in the spleen." The theory of M. Marc Dax locates the faculty of speech in the left hemisphere. He based this opinion upon the fact that aphasia is associated almost, if not invariably, with right hemiplegia, when there is any paralysis at all. That this is really the case is beyond question. Without, however, referring again to the cases cited by M. Dax, I quote the following table from Dr. Seguin's paper: APHASIA WITH HEMIPLEGIA. AUTHORITIES. Trousseau, 1865 (Academie de Medecine)..... Baillarger, later in 1865 (Salpetriere)......... Jackson, loc. cit........................... Robertson, loc. cit......................... Medical Times and Gazette, September 9, 1865. Archives Generaux de Medecine, 1866........ Flint, New York Medical Record, vol. i........ New York Hospital, 1830-'67............... Total.......................... Right Left Hemiplegia. Hemiplegia. 125 10 30 1 34 3 3 2 2 4 43 3 243 17 From this table we learn that, of two hundred and sixty cases of aphasia associated with paralysis, the left hemisphere—as determined by the situation of the hemiplegia—was the seat of the lesion in two hun- dred and forty-three cases, and the right in only seventeen. I also quote the following table from Dr. Seguin: QUESTION OF LEFT ANTERIOR LOBE. AUTOPSIES BY Marc Dax, in 1861, and G. Dax (Academie de Medecine, 1863)........................................... Bouillaud, 1848................................... " 1865..................................... Trousseau (Academie de Medecine).................... Vulpian (Lecons de Physiologie)...................... New York Hospital, 1830-'67........................ Jackson, Richardson, A. Clark, 1866-'67................ Peter, Legrand, Beclard, Delpech, Berard, one each...... Farge, Bigelow, Detmold, and Stokes, one each.......... Total................................... For. 514 Against. 370 85 31 " •• 18 16 5 2 6 3 . t .. 5 •• 4 31 This table is based on autopsies, and may be considered conclusive APHASIA. 189 as to the relative frequency with which aphasia is connected with dis- ease of the left anterior lobe. From various sources I have obtained the following additional cases, in which the seat of the lesion was determined either by post-mortem examination or by the situation of the hemiplegia: AUTHORITIES. Left Hemisphere. Right Hemisphere. 1 2 6 30 15 25 1 Falret....................................... • W.Ogle....................................... 1 W. Wadham....................................... 1 Total.. 80 2 The immense preponderance of disease of the left hemisphere, and especially of its anterior lobe, as a concomitant of aphasia, is therefore placed beyond a doubt. Indeed, so far as I am aware, the fact is not questioned. How, now, is it to be explained ? We cannot claim, even with all the disparity of cases, that the organ of language is located in the left anterior lobe, or even in the left hemi- sphere, to the exclusion of the other. Broca has attempted to account for the assumed restriction, on the ground that the left hemisphere re- ceives a larger supply of blood, and is earlier developed than the right. This is doubtless correct, but still the fact remains that lesion of the right hemisphere is sometimes followed by aberrations of speech ; the left remaining perfectly healthy. One such case—and there are several on record in which the autopsy confirmed the deductions drawn from the symptoms—is sufficient to overturn the theory which restricts the situation to one side of the brain; and one such as that reported by Dr. Simpson,1 in which there was extensive lesion of the third left frontal convolution in its posterior part, and no epilepsy, paralysis, or aberra- tion of speech, is of course utterly destructive of Broca's views. The fact that aphasia is more frequently conjoined with right hemi- plegia is undoubtedly due mainly to the fact previously insisted upon in my remarks on cerebral embolism, that the left middle cerebral artery is much more liable to be plugged by an embolus than the right; and it is by embolism that aphasia is generally caused. Dr. Hughlings Jackson 2 has very satisfactorily worked out the relation, and my own experience, presently to be related, abundantly confirms the fact. At the same time it appears to be clearly shown that the left ante- 1 Medical Times and Gazette, December 21, 1867. 2 " London Hospital Reports," vol. i., loc. cit. 190 DISEASES OF THE BRAIN. rior lobe, or rather, in accordance with Dr. Jackson's views, those parts of the brain nourished by the left middle cerebral artery, are more in- timately connected with the faculty of articulate language than any other region of the encephalic mass. It is probably true, as originally advanced by Dr. Moxon,1 and since urged by Dr. William Ogle,* that the organ of speech is to be found in both hemispheres, and that one side is more generally employed than the other, just as we ordinarily give a preference to one eye or one ear or one hand, and that this side is the left. Gratiolet's facts, adopted by Broca to support his view of exclusiveness, will certainly lend force to the argument in favor of pref- erence. This careful anatomist found that the left hemisphere is de- veloped before the right, and that it is better nourished. Both of these circumstances are owing to the greater supply of blood which it re- ceives. Undoubtedly many of the cases which have been brought forward as militating against the doctrine of localization of the organ of speech are not cases of aphasia at all, but simply instances of inability to speak, from paralysis of the muscles concerned in speech. This is certainly true of the greater number of Seguin's cases, and also, as Bartholow3 has stated, of those adduced by Ladame. Again, in very many instances the post-mortem examination has not been properly made, and lesions involving one or the other anterior lobe have been overlooked. It is now a well-recognized fact that the cere- bral tissue may be materially diseased, and the lesion not be detected without microscopical examination. Giving a very full consideration, therefore, to the facts and argu- ments which have been urged on all sides of the question, I am con- strained, while rejecting the restricted location of MM. Dax, and the still more limited situation contended for by Broca, to believe: 1. That the organ of language is situated in both hemispheres, and in that part which is nourished by the middle cerebral artery. 2. That while the more frequent occurrence of right hemiplegia, in connection with aphasia, is in great part the result of the anatomical arrangement of the arteries which favors embolism on that side, there is strong evidence to show that the left side of the brain is more intimate- ly connected with the faculty of speech than the right. These views are further supported by several interesting cases, the histories of which I now propose to relate: Case I.—In the summer of 1857, while I was on duty, as medical officer of the army, with a body of troops and topographical engineers, making a road from Fort Riley to Bridger's Pass, in the Rocky Mountains, 1 " On the Connection between Loss of Speech and Paralysis of the Right Side," Brit- ish and Foreign Medico-Chirurgical Review, April, 1866, p. 481. 2 " Aphasia and Agraphia," " St. George's Hospital Reports," vol. ii., p. 83. 3 " On Aphasia," Journal of Psychological Medicine, etc., vol. ii., p. 341, et seq. APHASIA. 191 a quarrel occurred between two of the laborers, which resulted in one of them striking the other a violent blow on the head with a club. The injured man fell to the ground stunned, and remained in a state of coma for several hours. Upon examining him a few minutes after the affair took place, I ascertained that there was no stertor and no indica- tion of paralysis. He was unconscious and breathing quietly, with a pulse of about 80. He had received a blow on the left temple, which, though laying open the scalp, had not fractured the skull. Gradually he regained consciousness so as to be able to comprehend what was passing about him, but he had entirely lost the memory of words, though not the faculty of articulation. Thus he was unable to speak unless the words were first repeated to him, and then he could do so without any defect of articulation, provided too many words were not given to him at once. Thus when I said to him in Spanish—he was a Mexican, and could not speak English—" Como sientes ahora ? " " How do you feel now ? " he repeated, " Como sien. sien. sien.," and then, looking at me in ap- parent despair, burst into tears. And this was repeated time and again during the hour I spent with him. The next morning, at about seven o'clock, as he attempted to rise from his bed, he fell, and was found a few minutes afterward by the hospital attendant, lying on the ground in a state of complete coma. I saw him almost immediately; he was breathing stertorously, blowing out his lips and cheeks at each expiration, and exhibiting a general reso- lution of all his limbs. He died at about eleven o'clock A. m. that day. That afternoon I made a post-mortem examination. On removing the calvarium, the first thing that attracted my attention was an ecchy- mosed spot about the size of a half-dollar-piece, involving the left ante- rior lobe at its lateral and posterior margin. There was no extensive hasmorrhage at this point. But, on the opposite side, there had been a rupture of the middle meningeal artery, and an immense extravasation of blood which had infiltrated between the lobes of the right hemisphere and collected in the base of the skull. My theory of the case was that the hasmorrhage from the artery had been suddenly stopped during the condition of primary insensibility before any considerable quantity of blood had been effused, and that during the night his heart had re- covered its power; and this, with the muscular effort he made in at- tempting to get out of bed, had dislodged the coagulum, and allowed the hasmorrhage to take place. At that time I attached no especial im- portance to the injury of the left anterior lobe; but, since the debate in the French Academy in 1861, I have had no doubt that to it the amne- sic aphasia was entirely due. It will be observed that there was no defect of articulation in this case, either from paralysis or incoordination, but that the difficulty was solely as regarded the memory of words. 192 DISEASES OF THE BRAIN. Case II.—J. II., a captain of a coasting-vessel, consulted me in No- vember, 1864, for a difficulty of speech with which he had been affected for several months. Upon inquiry, I ascertained that one morning early he had been called from his bed upon some duty connected with his vessel; that he had risen rather hastily and gone on deck; that while giving an order he suddenly became very dizzy, and fell, unconscious. He soon regained his senses, but found that he was paralyzed on the right side, and had lost the ability to speak. He soon afterward reached port, and remained at home for three months, during which period the paralysis disappeared almost entirely, and he reacquired the ability to speak. The aphasia was of both the amnesic and ataxic forms. He could neither speak nor write. He then went to sea again as a passenger to Cuba, and while in Havana had another attack similar to the first, but without paralysis of motion, though there was loss of sensibility on the right side. The memory for words was entirely destroyed, though he could pronounce distinctly any word he was told to say, if he did not allow too long a period to elapse between the direction and the response. About four months after his last seizure he consulted me. At this time he could say a few words, and he employed them to express all his ideas, assisting himself with very energetic gestures, which, however, were rarely expressive of his thoughts. The words he thus constantly used were " sifi," which signified both yes and no, and " time of day," which he employed when he had any other answer than a simple affirmative or negative to give. Besides these expressions, he had an oath, " Hell to pay !" which he ejaculated whenever he did not succeed in making himself understood, and sometimes without any such exciting cause. These were the only expressions he could originate, but he could pronounce distinctly any word he was told to say, and even as many as three short successive words. When told to write, he took the pen, and, on my telling him to give me his name and address, wrote " Time of day," and then, seeing that that was not the correct answer, immediately followed it with " Hell to pay ! " On my remarking to him that he had given me wrong information, he immediately wrote " sifi." Any word, however, which I told him to write, he did without any difficulty, and thus I obtained several long sentences from him. From his brother, who came with him, I obtained the facts in his history I have mentioned. Examining his heart, I found that he had a strong systolic murmur, and was told by his brother that he had had, fifteen years ago, a first attack of acute articular rheumatism, which had been followed by several other attacks. The main point of interest about this case—and it is one of those I shall again draw attention to—is, the occurrence of ataxic aphasia with hemiplegia as concomitants of the first attack, while the second was characterized by purely amnesic aphasia and no paralysis. APHASIA. 193 Case III.—During the winter of 1868-'69, a man came to my cli- nique, at the Bellevue Hospital Medical College, who was aphasic, and from whose friends, his own gestures, and the few words he could speak, I obtained the following history: Some months previously he had been working in a stone-quarry, and was struck by some piece of machinery on the left side of the head, at about the junction of the frontal with the temporal bone. For a short time he was unconscious, recovering, how- ever, without paralysis, but with loss of the memory of words. When he came under my observation, he was very intelligent, comprehended every word said to him, and made repeated and persistent efforts to talk, but he could not utter a word spontaneously beyond " yes " and " no," which he always used correctly. Thus, when I asked him where he was born, he became much excited, gesticulated violently, and apparently made every effort to tell me. The perspiration stood out in large drops on his forehead, but no sound came from his lips. Then the following conversation took place: " Were you born in Prussia ? " " No." "In Bavaria?" "No." " In Austria ? " " No." "In Switzerland?" "Yes, yes, yes, Switzerland, Switzerland," at the same time laughing, and moving his hands actively in all directions. He could pronounce words well, but could not write. I took occasion to speak at length on the subject of aphasia, and gave it as my opinion that there had been a fracture of the internal table of the skull, and that a fragment of bone was pressing on the pos- terior and lateral part of the anterior lobe. My friend Prof. Sayre was present, and I advised him to trephine the patient, with the view of elevating any depressed piece of bone, and restoring the normal func- tion of that part of the brain. The operation was performed a few days afterward, the patient being placed under the influence of ether. The internal table was found to be fractured, and a splinter was pressing on the posterior frontal convolution. It was removed, and, as soon as the patient emerged from the anassthetic condition, he spoke perfectly well. This, as will be seen, was also a case of amnesic aphasia, unaccom- panied by paralysis. Case IV.—A. E., formerly a bookseller, consulted me in the autumn of 1869 for what was considered by his friends to be, and what probably was, softening of the brain. Before any symptom of disease appeared, he had been noted for his remarkable memory, but was now excedingly forgetful, especially as regarded words. Thus he had forgotten his first name, and could not tell me the names of his children. His conversation was marked by great hesitancy, from his not remembering the words he wished to use, and there was, besides, marked difficulty of articulation, and some words he could not pronounce at all. There was right hemi- 13 194 DISEASES OF THE BRAIN. plegia, which had gradually been getting worse, and which, when I saw him, was extensive enough to interfere materially with the movements of his arm and leg. The left side was not affected, and the tongue and face were apparently not paralyzed. He was subsequently lost at sea in the steamer City of Boston. This case, therefore, exhibited both the amnesic and ataxic forms of aphasia, and was accompanied by right hemiplegia. I regard the con- dition as being due to thrombosis, probably of the left middle cerebral artery. Case V.—W. W., aged forty-one, entered the New York State Hos- pital for Diseases of the Nervous System, August 22, 1870, hemiplegic on the right side, and affected with ataxic aphasia. In the month of March, 1868, as ascertained by Dr. Cross, the resident-physician of the hospital, he was seized with a dull pain in the right knee, accompanied with numbness, formication, and pricking sensations, limited to the right foot, while general numbness of the whole side soon supervened. These, with loss of power, gradually extended and increased till at the end of two weeks the patient was entirely hemiplegic. There was at no time any loss of consciousness nor any mental aberration. On the 11th of May following, the patient suddenly lost the power of speech, but his mind remained perfectly clear, and, though he could not utter a word, he understood well every thing that was said to him. He remained nearly completely aphasic for four months, being only able during that time to utter a few sounds, which could not be interpreted into intelli- gible words. About September, 1868, he began to enunciate a few words, at first very slowly and indistinctly, and gradually acquired more facility. When I presented him before the class at the Bellevue Hospital Medi- cal College, in November, 1870, although he could talk, his power of co- ordination was very imperfect, and many words were articulated with great difficulty. This trouble was chiefly manifested in regard to labials and Unguals, such words as "truly rural," "Peter Piper," "baker," and others of the kind, causing him to make repeated efforts before he could even imperfectly pronounce them. There was no paralysis of the tongue, no deviation when it was protruded, and but very slight if any paresis of the orbicularis oris or other facial muscles. The arm and. leg on the right side were profoundly paralyzed. In this case there was no loss of the memory for words, and no diffi- culty in writing. It was, so far as the aphasia was concerned, entirely ataxic in character, and accompanied by right hemiplegia. My opinion was, that the symptoms were to be attributed to throm- bosis of the left middle cerebral artery. Case VI.—R. M., aged twenty-five, noticed one day that his right foot was unusually cold. A few days afterward he had his first attack of hemiplegia of the right side. Suddenly, and without the least APHASIA. 195 warning, except a severe vertigo, he fell, but immediately arose. There was no loss of consciousness, and with assistance he was able to walk to his residence, a short distance off. His face was drawn to the left side, and speech and memory were slightly impaired. In February, 1869, having recovered motility, he was seized with another attack of right hemiplegia. This time he partially lost con- sciousness, and his speech again became affected. By April, 1869, he was able to resume his work as a weaver, but his arm was still weak. In July he had another attack, which was slight. In May, 1870, he again suddenly became hemiplegic on the right side. There was no loss of consciousness. The face and tongue were affected. With assistance he walked home, and in a week had quite recovered. In July, 1870, he had his fifth and thus far last attack. While chopping wood he was suddenly seized with a violent pain in the head, followed by vertigo. He fell, but did not lose consciousness. There were right hemiplegia again, difficulty of speech, and dilatation of the left pupil. For five days afterward he was delirious, but finally re- covered, with loss of power in the right arm and leg, and increased difficulty of speech. September 1st, he was admitted to the New York State Hospital for Diseases of the Nervous System. At this time the paralysis had entirely disappeared; the tongue could be moved freely in any direction, and his articulation was perfect. But his memory for words was greatly impaired, though facts and circumstances were re- membered perfectly well. His speech was therefore hesitating, and if asked to repeat a sentence of three or four words he could not do it. Thus he could not repeat the words " sugar, coffee, crackers," although he began immediately after I had finished saying them. Examination showed that the patient had hypertrophy of the heart, with aortic insufficiency.1 My diagnosis was, repeated attacks of embo- lism of the left middle cerebral artery, or its branches. This case was one of partial amnesic aphasia, with ataxic aphasia, which had disappeared with the hemiplegia. Case VII.—Mrs. S. H. W., aged thirty-two, married. On the 26th of June, 1860, about three weeks after the birth of her child, she was suddenly seized with a severe pain in the right shoulder, which extend- ed down the arm. Symptoms of albuminuria, accompanied by general dropsy, immediately ensued, and in a few weeks the dyspnoea from hydrothorax was alarming. Coma and a convulsion followed. Soon after the fit, which marked the height of her disease, as she was sitting by the bed, resting her head on her folded arms, her right side became completely paralyzed, and she lost the ability to speak. She was not 1 I have condensed the histories of this and the preceding case from the reports of Dr. Cross, in my clinical lecture on " Partial Cerebral Anaemia," published in the Journal of Psychological Medicine for January, 1871. 196 DISEASES OF THE BRAIN. entirely clear in her mind for a week after the attack, but gradually the dropsy disappeared, her intellect improved, and the paralysis became less. At the time of the seizure, the face was drawn to the right side, the tongue deviated in the same direction, and there were strabismus and partial ptosis and paralysis of the orbicularis palpebrarum muscle on the right side. Motility and sensibility in the right arm and leg were, at first, completely abolished, but at the end of ten days she was able to move about, by holding on to a chair. During three years she con- tinued to improve as regarded the paralysis, but for all that period did not sp'eak a word. In the summer of 1863 she became able to say the word "no," and a few months later she could say "yes." At my request, she allowed me to present her before the class of the Bellevue Hospital Medical College, in November, 1870, on the occasion of a clinical lecture on aphasia. She was then, and is now, enjoying good health, with the exception of frequent headache. Her countenance is remarkably bright and cheer- ful, and her whole expression is exceedingly intelligent. She compre- hends every word that is said to her, and attends to all her household duties. Yet she is unable to utter any words but "no," "yes," and " dado." The latter is seldom employed, but in her vocabulary signifies affirmation. She uses "yes "for affirmation, and "no" for negation, and both for doubtful or indifferent conditions. Thus, if asked how she is, she answers " Yes, yes, no, no," which means that she is tolerably well. Sometimes she employs these words quite indiscriminately. If asked what that is, pointing to a fan, she cannot tell, nor can she re- peat the word fan. She shows, however, that she knows, by making the gesture of fanning herself. She can neither read nor write, although on one occasion she succeeded, after great difficulty, in writing "no." Not long since she suddenly ejaculated, "I don't know ! " and a few days ago exclaimed, " How do you do ? " but she was not able to repeat either of these phrases, nor did she appear to be aware that she had said them. Her gestures are very intelligent and expressive. The right arm and leg are weaker than on the left side, and the sensibility is less. There is a murmur at the apex of the heart with the first sound.- Ophthalmoscopic examination showed the vessels of the retina of the left eye to be much larger than those of the right. In this case I diagnosticated embolism of the left middle cerebral artery. The aphasia was of both the amnesic and ataxic forms, and was ac- companied by right hemiplegia. Case VIII.—Mr. B. consulted me in November, 1870, for loss of the memory of words, and fullness and pain in the head, with occasional vertigo. Over a year previously, while in the woods of Minnesota buy APHASIA. 197 ing timber, he had suddenly lost consciousness for a few moments, and on recovering found that he had become hemiplegic on the right side, and had lost the power of speech. For a short time he could not utter a word, but gradually the memory of language, and the ability to coordinate the muscles of speech, returned to him, and he could articu- late sufficiently well to be understood. For several months, however, his recollection of words was bad. For some time he had been under the care of Dr. Hale, of Chicago, a homoeopathic physician, who advised him to place himself under my charge. When I first saw him, he could talk quite well, but there was still a hesitancy in his speech, and occasionally words were misplaced or miscalled. Articulation was distinct, and the hemiplegia had disap- peared. There was pain, almost entirely confined to the left temporal region. There was the history of acute articular rheumatism, and there was aortic insufficiency. In this case there had been at first amnesic and ataxic aphasia, with right hemiplegia. As the latter disappeared, the ability to coordinate the muscles of speech was increased, until at last articulation became perfect, and only amnesic aphasia remained. Case IX.—H. I., a merchant, consulted me in August, 1869, for hemiplegia, with inability to speak. While sitting at his desk, six weeks previously, he suddenly became vertiginous, and lost conscious- ness for a few moments. On recovering his senses, he discovered that he was paralyzed on the right side, and that he could not speak a word. He was exceedingly anxious to make known some wish, and one of his clerks brought him paper and a pencil, but he could not write a letter. An alphabet was then written, but he was unable to select the letters to form the words he wanted to use. A physician was sent for, and Mr. I. was bled to the extent of six- teen ounces, without any favorable result. He remained hemiplegic and completely aphasic for about two weeks. He then began to walk, and acquired the ability to say " what," " certainly," and " saw my leg off," which he contracted into " sawmelegoff," accentuating strongly the ultimate syllable. These words he used without apparent intelli- gence, though he clearly understood all that was said to him, and laughed at any joke as heartily as ever. His condition was about the same when I saw him. He could protrude his tongue and move it actively in all directions, but could not articulate any words but those mentioned. Thus, when I asked him to say "table," he said " Certainly; " and when I said "Well, say it then," he exclaimed, " Sawmelegoff!" at the same time, to show that he understood what I said, he went across the room, and put his hand on a table, uttering, at the same time, his full stock of words, "what," "certainly," "sawmelegoff." I then asked him if he could write; he replied, "Certainly." I 198 DISEASES OF THE BRAIN. placed paper before him, and gave him a pen with ink, but he was unable to write his name as I requested, although he could use his fingers for other things tolerably well. I asked him to draw a series of parallel lines, and he did so without difficulty. On my insisting that he should now make an effort to write his name, he made the attempt with this result: Fig. 19. I told him that was not his name, at which he gesticulated violently, exclaimed, " Sawmelegoff!" and gave me one of his visiting-cards. This gentleman continued under my care for some time, but with no perceptible change. He had had two attacks of acute articular rheu- matism, and had, when I saw him, both aortic and mitral insufficiency. Here, then, was right hemiplegia, with fully-developed ataxic and amnesic aphasia. My diagnosis was, embolism of the left middle cere- bral artery. Case X.—Miss C. R., of strongly-marked hysterical diathesis, sud- denly became aphasic while sitting at the breakfast-table. I saw her about two hours subsequently, when she drove to my office with her mother. There was no paralysis, the tongue could be moved freely in all directions, articulation was perfect, and she could pronounce any word mentioned before her. The memory of words was, however, entirely abolished. Case XI.—Mr. S., a retired merchant, consulted me in September, 1870, for the effects of cerebral hasmorrhage. He was hemiplegic on the right side, and unable to talk. His intelligence was good. He could read, but he was not able voluntarily to pronounce a word. The tongue was not in the least paralyzed, nor had it been. Occasionally ejaculations of various kinds would come forth. On one occasion, as he entered my office, he exclaimed—he was a German gentleman— " Guten Morgen, mein Herr," but by no effort could he repeat that or any other expression. His attempts to speak were continuous while he was with me; and his son who came with him said he was almost always trying to talk while he was not sleeping. This case was, therefore, one of ataxic aphasia, and was marked by the existence of right hemiplegia. Cerebral hasmorrhage, involving the corpus striatum, was the cause. Case XII.—Mr. L. N., a German gentleman,, came under my care in September, 1869, for symptoms indicative of cerebral softening. He was slightly paralyzed on the right side. His speech was affected both APHASIA. 199 amnesically and ataxically. Soon afterward, in consequence of maniacal symptoms making their appearance, I sent him, with the concurrence of my friend Prof. Flint, to the Lunatic Asylum, at Flushing. He re- mained there till September of the present year, gradually failing in mental and physical power, when, as he was no longer in a condition to injure himself or others, his friends, with my approval, removed him to their own home. At the present time he can scarcely remember a word, and his articulation is very defective. A remarkable feature of his con- versation is that he calls every thing " kazza," " cat." He appears to have forgotten every other word. The history of this case points to thrombosis as the probable lesion. Case XIII.—This was a very remarkable and instructive case, one which I have already mentioned under the head of embolism. The patient was a retired officer of the army, and consulted me in the autumn of 1869 for paralysis, vertigo, and slight difficulty of speak- ing, from which he had suffered for some months. Several years pre- viously he had been under the care of my friend Dr. Metcalfe, for acute rheumatism, with cardiac complications. The history of the case pointed strongly to embolism, and, as the paralysis involved the right side, I diagnosticated a previous attack of embolism of the left middle cerebral artery. The difficulty of speech was slight; there were both amnesic and ataxic aphasia. Under the treatment employed he improved very much in the ability to walk, to use his arm, and to speak, so much so that he and his friends considered him better than he had been for several years. But about six weeks after he came under my charge he had another attack. This time the left side was paralyzed, and there was no difficulty of speech. Galvanism was employed, as before, and he recovered sufficiently to go to Washington City. While there he had a third attack, characterized by right hemiplegia and aphasia. He soon recovered his power of speech, and soon afterward had a further attack, involving the left side, and unattended by aphasia. He recovered under the care of Dr. Basil Norris, of the army, and soon afterward came again to New York. A short time after his arrival I requested my friend Prof. Flint to see him in consultation, with the special view of having him examine his heart. This was done with thoroughness, but no abnormal sounds were de- tected. While in New York he had two other attacks, during both of which he was delirious; both were characterized by hemiplegia. That of the left side was unaccompanied by aberrations of language; that of the right was attended with ataxic and amnesic aphasia. He forgot the names of the most ordinary things, and there were many words that he could not articulate at all. Thus, when he wanted a fan, he called it " a large, flat thing to make a wind with." He forgot my name, and could not pronounce the words beetle, general, physician, and many 200 DISEASES OF THE BRAIN. others. I sent him to Newport greatly improved, but he had other attacks there, and finally died in the autumn of the present year, of, I presume, cerebral softening. The interesting features of this case are the concurrence of hemi- plegia and ataxic and amnesic aphasia, and the striking fact that there was no aphasia when the paralysis involved the left side. Thus, accord- ing to my views of the case, the patient had repeated attacks of cere- bral embolism. When the embolus lodged in the left middle cerebral artery, there was aphasia accompanied by right hemiplegia; when the embolus obstructed the right middle cerebral artery, there was left hemiplegia, but no aphasia. Case XIV.—In the early part of December, 1870, J. M., a patient of Bellevue Hospital, was, at his request, brought to my clinique at the college. His history, as given me by Dr. Judson, showed that he had repeated attacks of unconsciousness or semi-unconsciousness, which were accompanied with hemiplegia. Dr. Flint had also detected a bel- lows murmur, but it was at the apex of the heart. The patient had suffered from several seizures of acute articular rheumatism. Upon inquiry, I ascertained that he had had altogether eleven at- tacks of vertigo, unconsciousness, and hemiplegia. His intelligence was good, and he spoke tolerably well, though with hesitation and oc- casional difficulty of articulation. His speech was much better than it had been, and there was no well-marked hemiplegia. As in the case last mentioned, whenever the hemiplegia had been on the left side there was no aphasia, but when it was on the right side there was always well-marked difficulty of speech, both amnesic and ataxic. The only other case, similar to these last two, that I have been able to find, is one reported by Dr. Stewart,1 of a man who was admitted into the Middlesex Hospital, suffering from left hemiplegia, without aphasia. A week later he became affected with right hemiplegia and loss of speech. He died, and on post-mortem examination both middle cerebral arteries were found plugged with emboli. Case XV.—Captain C, an officer of the mercantile marine, was attacked in September, 1874, with sudden loss of the power of speech, attended with confusion of ideas, and vertigo. He soon recovered, but had several subsequent seizures, characterized by vertigo, impairment of language, and slight delirium. I first saw him on the 31st of October, and on the 28th of November he went with me to the University of New York, where he was one of the subjects of my clinical lecture on aphasia, delivered to the medical class. At this time, and for several weeks previously, he had constantly used words which were without re- lation to the things he wished to name. Thus, if he wanted his boots, he would ask for his top-sails, or would be apt to employ some other 1 Medical Times and Gazette, July 9, 1864. APHASIA. 201 word designating part of a ship. In his conversations with me he con- tinually exhibited this peculiarity. There was no want of memory for any other parts of speech than substantives. For instance, I held up a penknife before him ; he at once said it was to cut with, but, when I pressed him to name it, he called it a " boat." A thermometer was an " anchor," and a watch was a " capstan." When I asked him to say National Lntelligencer, he said " National intelligence-office," and, no matter how often I repeated the words, he always said " National intelli- gence-office." The reason for this was very obvious: he had frequently had occasion to say " intelligence-office," but had probably never before in his life been asked to say " National Intelligencer." After a time, he succeeded in acquiring the power to utter the final " e r," but then he placed it in the wrong position, and said " National intelligence- officer." Syllable by syllable, he could speak these words correctly, but they were at once forgotten. This was a typical case of the am- nesic form of aphasia. Many other cases of aphasia have come under my observation, but it is scarcely necessary to mention them in detail, as they present no features differing in any material point from those cited. The views which the cases I have observed have led me to form, have been confirmed by my recent study of the subject of aphasia. These have already been given in part, but the detail of the foregoing histories enables me to express the remainder with more confidence. It cannot have failed to strike the reader that, in all the cases of which hemiplegia formed a feature, the aphasia was of the ataxic form, while when there was no hemiplegia the aphasia was amnesic. In the one the individual was deprived of speech, because he could not coordi- nate the muscles used in articulation, in the other because he had lost the memory of words. This is a point which has not hitherto been noted. The phenomena indicate, I think, very clearly, the seat of the lesion, and the physiology of the parts involved. The gray matter of the lobes presides over the idea of language, and hence over the memory of words. When it only is involved, there is no hemiplegia, and there is no difficulty of articulation. The trouble is altogether as regards the memory of words. The corpus striatum contains the fibres which come from the ante- rior column of the spinal cord, and is besides connected with the hemi- sphere. A lesion, therefore, of this ganglion, or other part of the motor tract, causes paralysis of motion on the opposite side of the body. The cases I have detailed show, without exception, that the power of coordinating the muscles of speech is directly associated with this hemiplegia. A lesion, therefore, followed by hemiplegia and ataxic aphasia, indicates the motor tract as the seat. If amnesic aphasia is also present, the hemisphere is likewise involved. An analysis of the cases 202 DISEASES OF THE BRAIN. reported by Ogle, Jackson, and some other observers, shows that the association existed in their cases, although they have not noticed it as of any physiological or pathological bearing. Another important feature of the foregoing cases is the constant association of the aphasia with right hemiplegia where there was any paralysis at all. This indicates, perhaps, only the more frequent occur- rence of embolism on the left side, but the last two cases, as well as the one quoted from Dr. Stewart, show that the left hemisphere is more intimately connected with the faculty of speech than the right. In fact, it appears to me impossible to avoid this conclusion. Prof. Ferrierl has quite recently enunciated views relative to the patho-physiology of aphasia, which differ in several respects from those I have just expressed. The importance of the subject, and the de- servedly high position in cerebral physiology occupied by their author, must be my apology for quoting them in full : " Much has been written on the subject of aphasia, and many differ- ences of opinion still continue to exist among those who have directed their attention to it. It is not my intention to enter into any length- ened examination of the theories which have been advanced, nor to controvert the opinions of those who deny all localization of brain-func- tion including a ' speech-centre.' The researches of Broca, and the nu- merous confirmations of his observations which have been put on record, taken with the results of my experiments on monkeys, and the lower animals, seem to me to establish the fact of a localization of the faculty of speech, and to explain at least the broad features of the pathology of aphasia. I have shown that the region which governs the move- ments concerned in articulation is that which is the seat of lesion in aphasia. The region is symmetrically situated in both hemispheres, each one possessing the power of originating coordinate movements of the lips and tongue, in a bilateral manner. Broca's convolution is usually described as being the posterior third of the inferior frontal convolution of the left hemisphere. It would be more in accordance with the facts of experiments on monkeys, as well as with the cases which have come under my own observation, to localize the speech- centre in the operculum (Klappdeckel), which is included between the ascending and horizontal limbs of the fissure of Sylvius, and which im- mediately overlaps the island of Reil. While Broca's convolution is placed in the left hemisphere, the centre for bilateral coordination of the speech-muscles exists, as I have said, in both hemispheres. To this bilateral action of each centre is to be ascribed the peculiarity of loss of the faculty of speech without paralysis of the articulating muscles. For, as regards the mere muscular action, one centre is capable of carry- ing it on when the other has been disorganized. This contrasts in a 1 " Pathological Illustrations of Brain Function," " West Riding Lunatic Asylum Med- ical Reports," London, 1874, vol. iv., p. 54. APHASIA. 203 significant manner with the coincident hemiplegic paralysis of the arm and occasionally of the leg, which frequently exists along with the aphasia. The centres for the movements of the arm and hand are in close contiguity to the centre of articulation, and hence the lesion which causes aphasia usually involves these also. More rarely the leg is affected, owing to the fact that, being at a greater distance, the centres are less often invaded by the softening. These results are to be found when the cortex of the brain alone is implicated, the ganglia being intact, and furnish conclusive proof of the localization in the brain-cortex of the centres for voluntary motion. These centres, however, have another signification, in so far as they form the motor substrata of mind. Besides being centres for the accomplishment of acts of volition, they form the organic centres of the memory of accom- plished acts. The centres for articulation, besides their function of setting in action the complex and delicate movements involved in ar- ticulate speech, have the power of permanently recording the results of their functional activity. Words represent the movements of articula- tion, guided by impressions of mind. The memory of words must have organic basis in that part of the brain which is the centre involved in their execution, for the memory of words is nothing else than the memory of the articulating processes, which have been affected under the guidance of auditory sensations. The ideas of which words are the articulatory symbols have no relation to that part of the brain where words are remembered, except by associating fibres. The ideas, in physiological language, have their organic seat in those parts of the brain specially related to the nerves of common and special sensation, for all ideas are ultimately reconcilable to impressions of sense as their basis. The records of these in the brain cells furnish the material of all thought, and by their various combinations and associations constitute the foundation of all complex conceptions. The utterance of a word, with an appreciation of its meaning, involves the physiological activity not merely of the speech-centre, but also of those parts of the brain related to the various senses concerned in the perception of the quali- ties of the object signified. Thus the mention of the word ' orange' indicates not only the activity of the speech-centre, but also of the sensory centres of color, smell, taste, form, etc., all of which are con- cerned in our concept of the object. This is a concept of the simplest form, but the analysis of more complex ideas must necessarily be the same in principle. " In aphasia consequent, as it usually is, on disease of the left hemi- sphere, the memory of words is not lost, nor is the person incapable of appreciating the meaning of words uttered in his hearing. What is lost in aphasia is, as Hughlings Jackson so clearly discriminates, merely the power of voluntarily using words to express ideas. As both sides of the brain are symmetrical, and work conjointly, the memory of words 204 DISEASES OF THE BRAIN. may remain in the right hemisphere after the occurrence of lesion in the left. The explanation of the loss of the faculty of speech is to be attributed to the unequal preponderance of the left hemisphere in the inclination of voluntary actions. The left hemisphere, like the right side of the body, is the leading or driving side, so that lesion of the left side is like the loss of the right hand. It requires long education to enable the person to accomplish, with his left hand, all the delicate manipulations of which the right hand was capable. The leading action of the left hemisphere may, however, be merely an accident of education or necessity, and there is no reason why articulate speech should not be the function of tne right side. That such may be the case there are pathological grounds for believing, viz., in those where aphasia has resulted from disease of the right hemisphere, and in those rare cases where lesion of the left speech-centre has not caused the usual results." It is very evident, however, that the view of Dr. Hughlings Jack- son, thus enunciated and indorsed by Dr. Ferrier, is not of uniform application to the phenomena of aphasia; for, though in some cases there is no loss of the memory of words, but merely a loss of the volun- tary power to utter them, there are many other cases in which the patient has lost the memory of words, and has not lost the voluntary power to articulate them. Thus, the person who speaks of his boots as his " top-sails," has not lost the voluntary power of saying " boots," for he can utter the word when asked to do so, an act which would clearly be impossible if he had no voluntary power to say " boots." I have witnessed several cases in which the patients could say any word they were told to say, but who could scarcely articulate a syllable when not prompted. Of these, Case III., described in this chapter, is a remark- able instance, and others will, in this connection, attract the attention of the reader. The fact appears to be, that the only cases in which the voluntary power of articulation is lost, are those which are described in the present chapter as instances of ataxic aphasia. So much for some of the various theories which exist relative to the localization of the organ of language and for the clinical history of aphasia. I have not thought it necessary to discuss the view of Schroe- der van der Kolk,1 that the faculty of articulate speech resides in the corpora olivaria, because there is little if any physiological or patho- logical evidence to sustain it. Nor the hypothesis of Brown-Sequard,8 that speech is a reflex phenomenon, because there is no evidence in support of that opinion. Neither have I, though much tempted, ven- tured into the philosophy of the subject to any considerable extent. As to the causes, the prognosis, diagnosis, morbid anatomy, and 1 " On the Minute Structure and Functions of the Spinal Cord and Medulla Oblongata." "New Sydenham Society Publications," p. 140. 5 Seguin's " Memoir," already quoted. ACUTE CEREBRAL MENINGITIS. 205 pathology, they have been sufficiently considered in the remarks made, and the treatment is of course that of the pathological condition to which it is due, whether this be cerebral hasmorrhage, embolism, throm- bosis, softening, hysteria, wounds, the bites of poisonous serpents, syph- ilis, or other cause. One point, however, should be mentioned in this connection, and that is that constant efforts should be made to develop the uninjured speech-centre and to exercise the vocal organs, by constant attempts to speak. The application of the galvanic or faradaic currents to the tongue and other muscles concerned in articulation, is a measure of usefulness. CHAPTER VIII. ACUTE CEREBRAL MENINGITIS. By acute cerebral meningitis is understood inflammation of two membranes of the brain—the pia mater and arachnoid. Some writers have made the attempt to discriminate between inflammation of the arachnoid and inflammation of the pia mater, but there are no diagnostic marks by which such a distinction can be made, and we find from post- mortem examination that neither membrane can be inflamed without the other participating in the morbid process. Inflammation of the dura mater is never included under the term meningitis. The ancients made no distinction between the several inflammatory affections of the intra-cranial organs, but comprehended them all in one disease, which they called frenzy—(pprjv, the brain. Morgagni, however, showed that the membranes of the brain were the parts generally involved, and gave a very accurate account of the phenomena of an attack of acute meningitis. Since then, Rostan, Lallemand, Andral, Bouillaud, and others, have added to our knowledge. Symptoms.—The symptoms of acute cerebral meningitis may be divided into three groups, arranged in chronological order: the stage of invasion, the stage of excitation, and the stage of collapse. 1. The Stage op Invasion.—The most prominent initiatory symp- tom is headache, which may be diffused or confined to a limited part of the head. When this latter is the case, the frontal region is more gen- erally its seat; next in order of frequency is the occipital, and next the temporal. At the same time the face is flushed, the eyes are red and suffused, and there is a decided elevation in the temperature of the head, which is not only felt by the patient, but may be perceived by the hand of the physician. Vomiting is generally present. As might be expected, these symptoms are accompanied by fever. This, however, rarely runs high, so far as the force or the frequency of 206 DISEASES OF THE BRAIN. the pulse is concerned, or as regards the heat of the skin. It is mainly characterized by restlessness and insomnia. Occasionally there is a ten- dency to somnolence. This stage may last a few days or only a few hours, or may be so slight as not to attract attention. In general features it resembles the prodromatic stage of cerebral congestion. 2. The Stage of Excitement.—A chill ushers in this stage, and an increase in the intensity of several of the symptoms of the first stage and the development of others soon take place. Thus the fever becomes higher, the skin hotter, and the temperature of the body is elevated sev- eral degrees—the thermometer rising as high as 105°, 106°, and some- times to 107°. The pulse is frequent—rising to 120, or even 160—quick and hard, and the face becomes redder than in the first stage. The pain in the head augments in violence, and is increased by pressure on the scalp, or even the slightest movement. The eyes are bright, the pupils contracted and painfully sensitive to light. The hearing becomes morbidly acute, loud noises cause great agony, and even slight sounds are unbearable. The general sensibility of the body is increased, and hence the patient is rendered uncomfort- able by the contact of the bedclothes with the skin. Delirium is gen- erally present from the first, and is often of furious character. Hallu- cinations of sight and hearing are almost constant, and the irrationality of the ideas is marked by the incoherence of the speech. The patient when awake is continually talking, gesticulates violently, and weeps and laughs alternately over imaginary evils. It is sometimes necessary to use restraint to prevent him injuring himself or others, and the attendants should always be prepared for any emergency of the kind. As the disease advances, the delirium becomes more subdued, and the patient may exhibit some evidences of sanity. Even when there is no delirium, as occasionally happens, the influ- ence of the morbid action over the mind is shown in the irritability of the patient, and the change which he undergoes in character and dis- position. Convulsions rarely occur in adults, but motility generally is never- theless disordered. The limbs are in almost continual action, as are likewise the jaw and the eyelids. Twitchings of the facial and other muscles, such as those of the forearm, are usually well marked, and occasionally there are irregular movements of the eyeballs. Convul- sions, when they occur, may be either clonic, or tonic, or both. Thus there may be a gradually-increasing rigidity of some muscles, followed by relaxation and disordered movements. Sometimes there is opis- thotonos as well marked as in some cases of tetanus. Hemiplegia or paraplegia may occur, but are infrequent complications. I have seen two cases in which one lateral half of the body was paralyzed during the whole course of the disease. ACUTE CEREBRAL MENINGITIS. 207 Contractions of the limbs sometimes take place, and may be confined to one side or a single limb. In this case the forearm is usually strongly flexed on the arm. The muscles of organic life participate, and the bowels are obsti- nately constipated. There may be difficulty of swallowing, from spasm of the pharynx, and irregularity of breathing, from implication of the respiratory muscles. The most characteristic symptom of this stage is, however, the obsti- nate and violent cephalalgia, of which mention has already been made, and yet there are cases in which it is entirely absent from first to last. Several such instances have been under my own charge, and post-mor- tem examination has verified the existence of the evidences of menin- gitis. This stage lasts from a few days to two weeks. 3. The Stage of Collapse.—The beginning of this stage is marked by the occurrence of somnolence, which often shows a tendency to pass into coma, and by a subsidence of the delirium and muscular agitation. There are times, however, during which the stupor remits in profundity, and the patient appears to be somewhat conscious of his condition, but these periods only occur in the first part of the third stage. Ere long the coma becomes constant. Paralysis then supervenes, and is first manifested in the ocular or facial muscles. Thus from paralysis of one of the muscles of the eye- ball strabismus ensues, or the upper eyelid may drop from paralysis of the levator palpebrae superioris. The pupils dilate and become insensi- ble to light, and the mouth is drawn to one side from implication of the muscles of the face. Before long the contractions of the limbs relax, and paralysis takes place. The sphincters of the bladder and rectum also lose their power, and the urine and fasces escape involuntarily. The pulse becomes slow and irregular, but the temperature, as Jaccoud has shown, and as I have lately verified in several instances, does not fall. Some authors regard this reduction in the frequency of the pulse while the heat of the body remains high, as pathognomonic. The in- sensibility becomes more and more profound, and the patient dies in a state of coma, sometimes from asphyxia produced by paralysis of the respiratory muscles, but generally from the gradual engorgement of the lungs, and with a bodily temperature as high as at any other period of the disease. Such is the ordinary course of an attack of simple acute cerebral meningitis occurring in a young and healthy person. Though it is cer- tainly true, as post-mortem examinations have shown, that the mor- bid process may be general or limited to the convex or basilar surface of the brain, or to the ventricular lining, yet during life the distinction cannot be made, mainly for reasons which will be given under the head of pathology. But there are modifications often met with which require consideration. Of these, epidemic cerebro-spinal meningitis, though 208 DISEASES OF THE BRAIN. scarcely to be considered a disease of the nervous system, and tubercu- lar meningitis, will be discussed under other heads, but the differences due to acute rheumatism and old age may very properly be noticed in the present connection. RHEUMATIC MENINGITIS. Under the name of cerebral rheumatism, several very different affec- tions of the brain supervening during the course of acute articular rheumatism have been embraced. The relation of rheumatism to such secondary diseases has long been recognized, but very great confusion has existed in regard to the exact nature of the morbid processes set up in the brain and its membranes. That meningitis may, however, be one of these conditions, appears to be quite certain. Gintrac * has col- lected twenty-one cases of cerebral meningitis the result of rheumatism, or at least occurring in conjunction with that disease, the existence of which was established by post-mortem examination. Oulie2 con- tributes four others, and many more are to be found in medical treatises and periodicals. Although I have witnessed a number of cases of what in former editions of this work was designated cerebral rheumatism, I have only had one case in which the existence of meningitis as a consequence of rheumatism was demonstrated by post-mortem examination. The membranes of the brain are most liable to be affected during the latter stage of an attack of acute rheumatism, but there seems to be no doubt that the cerebral disease in question may supervene at any time during the course of the primary disease, and that it sometimes has all the appearance of being a true metastasis. The symptoms which indicate the supervention of cerebral meningitis are delirium, convul- sions, or more frequently choreiform movements in the limbs, tremor, especially about the lips and muscles of the face, paralysis in various parts of the body, and stupor. Pain and vomiting, which are such con- stant features of ordinary meningitis, are rarely present in the rheu- matic form of the affection. The bodily temperature is not elevated more than three or four degrees above the normal standard. Toward the last, coma, if already present, becomes more profound, or if not, makes its appearance, and death ordinarily ensues. Occasionally, how- ever, recovery takes place.3 1 Op. cit, tome iii., p. 77. 2 "Du rheumatisme cer^brale." These de Paris, 1868. 3 In a very valuable memoir on " Cerebral Rheumatism," just published, Prof. Da Costal has given the details of twelve cases in which cerebral symptoms supervened dur- ing the course of articular rheumatism. Dr. Da Costa expresses the opinion that all cases of what is called cerebral rheumatism are not characterized by the presence of meningitis, and the results of the post-mortem examinations which he obtained from his cases, cer- 1 American Journal of the Medical Sciences, January, 1875, p. 17. ACUTE CEREBRAL MENINGITIS. 209 SENILE MENINGITIS. In old persons, the symptoms of acute meningitis are rarely so pro- nounced as in individuals of middle age. The affection comes on more gradually, and may have made considerable progress before its existence is suspected. There is little or no pain, no fever, and no gastric or in- testinal derangement. The mental symptoms are very similar to those due to softening. The patient has imperfect articulation, his memory is impaired, and he does things which show that he is not in his right mind. The delirium is of the low muttering kind, and there is a ten- dency to coma even in the first stage. There is a more or less general paresis in all the limbs, and subsultus is commonly present. Death is usually due to pulmonary engorgement. Causes.—Among the predisposing causes of acute cerebral menin-* gitis, age is first to be considered. Guersant' asserts that the period of life between sixteen and forty-five is that during which acute menin- gitis is most liable to occur, not including children, who are far more prone to the disease than adults. Rilliet and Barthez2 have, however, shown that very young infants are not so subject to simple acute menin- gitis as children of from five to eleven years of age. The very oppo- site opinion is expressed by Drs. Meigs and Pepper.3 Thirteen cases of acute simple meningitis have come under my ob- servation. Of these, all were between the ages of thirty and forty. Men are more subject to it than women. Of my cases, ten were males and three females. Parent-Duchatelet and Martinet,4 however, think women are more predisposed to the affection than men. Temperature, either very high or very low, predisposes to acute meningitis. Eight of the cases under my care occurred in summer and five in winter. Certain professions and habitudes appear to favor the occurrence of the disease. Among the former are all those which require the head tainly support this view. But in Case I.—a very characteristic instance—the brain was not examined; Case V. recovered; in Case VI. the brain was not examined; in Case VIII., also a marked case, in which there were flushing of the face, occasional spasmodic contractions of the facial muscles, contracted pupils, undulatory motions of the body, and tossing of the arms, an examination was refused ; in Case IX., in which there were mental symptoms, facial paralysis, ptosis, and hemiplegia, the patient recovered; in Case XI. re- covery took place, as it did also in Case XII., so that in only six were there post-mortem examinations of the encephalon. Dr. Da Costa does not doubt the existence of rheumatic meningitis, but he contends, and I think successfully, that all cases of cerebral disorder, originating during the course of articular rheumatism, are not cases of meningitis, and that in some cases there are actually no abnormal post-mortem appearances. 1 Art. "Meningite," in " Dictionnaire de Medecine," Paris, 1839. 2 "Traite des maladies des enfants," Paris, 1853. 3 "A Practical Treatise on the Diseases of Children," Philadelphia, 1870, p. 464. 4 "Recherches sur l'inflammation de l'arachnoide," Paris, 1821. 14 210 DISEASES OF THE BRAIN. to be exposed to strong and direct heat; among the latter are excessive intellectual exertion, and abuse of alcoholic liquors. Tertiary syphilis, gout, and rheumatism, are likewise predisponents. Larreyx states that in the retreat of the French army from Russia, the soldiers, who had endured the most terrible sufferings from hunger and cold, were attacked, on their arrival in KOnigsberg, where they had ample food and warm quarters, with cerebral meningitis, which in gen- eral proved fatal. This result was probably due to the operation of many causes besides prolonged exposure to a low temperature, among which the sudden removal of the mental tension maintained by the exigencies of the situation in which the army was placed, was not the least. Of exciting causes, injuries of the head from falls or blows of differ- ent kinds stand first. Next is exposure to the direct rays of the sun, or other source of great heat, and then recession of an exanthematous affection, such as scarlatina, measles, or erysipelas, and the irritation of dentition, or intestinal worms. Acute cerebral meningitis sometimes prevails epidemically. Such was the case with the series of instances which came under Larrey's observation, and others have been noted. Diagnosis.—Acute meningitis may be confounded with partial or circumscribed encephalitis, but the distinction is made by considering that in the latter the headache is less severe, the delirium less marked, and the convulsions and contractions weaker. Moreover, the febrile excitement is much greater in acute meningitis than in partial enceph- alitis, and the whole disease more pronounced. The meningitis of the aged bears a considerable degree of resem- blance to cerebral softening; but the fact that the first-named affection is more rapid in its progress, and is not preceded by symptoms due to other morbid conditions, will generally enable the practitioner to make a correct diagnosis. From delirium tremens it may be distinguished by the history of the case, by the greater tendency to insomnia exhibited in alcoholism, and by the general character of the delirium. The febrile excitement of acute meningitis, the pain in the head, the heat of the skin, the ab- sence of clammy perspiration, and the increased temperature, as shown by the thermometer, are conclusive diagnostic marks. From typhoid fever meningitis is diagnosticated by the existence in the former of meteorism, abdominal tenderness, and petechia;, by bhe facts that the headache and febrile excitement are less, and that diarrhoea is present and vomiting is not. Prognosis.—This is always grave. Occasionally death takes place in a very few hours, and generally before the tenth day. When the disease is prolonged beyond this latter period, the prognosis becomes 1 "M6moires de chirurgie militaire et campagnes," Paris, 1817, tomeiv., p. 189. ACUTE CEREBRAL MENINGITIS. 211 more favorable. The occurrence of strabismus or other paralytic affec- tion, lessens the hope of a favorable termination. Prof. Flint, however, has cited two cases occurring in the hospital practice of himself and Dr. Thomas, in which there were strabismus, hemiplegia, and coma, both of which recovered. He also cites another case in which there was strabismus, and in which recovery took place. Hiccough is an unfavor- able event. Of the thirteen cases observed by myself, eleven died. In all of these fatal cases there was strabismus. In the two cases which recovered there was no squinting. The deaths in the fatal cases all occurred be- fore the tenth day, and two took place before the end of the third day. Morbid Anatomy.—If death occurs during the second stage of the disease, the most marked appearance found in the membranes is red- ness from increased hyperaemia. If, however, it is delayed till the third stage, thickening and opacity of the membranes and adhesions to each other, and of the pia mater to the brain, and effusion of serum, are the prominent features. In a case in which I made a post-mortem exami- nation in the summer of 1870, and which was caused by the great heat of the season, there was an extensive collection of bloody serum in the Cavity of the arachnoid, and the pia mater was so adherent as to bring with it a layer of the gray matter of the brain as it was stripped off. The fluid may consist solely of pus, or this may be mingled with serum in all proportions. The pus, with the fibrine of the exuded serum, often forms thin plates of membraniform texture, which are scattered over the surface of the inflamed region or may entirely cover it, and which are of the nature of false membranes. If death has taken place late in the course of the disease, evidences of the implication of the cerebral substance will generally be discerned. These consist in the gray matter becoming of a pinkish color, and the white, when cut, showing numerous puncta vasculosa. The ventricles rarely contain any considerable amount of fluid, and are often entirely empty. The latter was the case in the instance above mentioned. Pathology.—The symptoms of the first and second stages are due to congestion; those of the third mainly to effusion and consequent pressure. An important question connected with the pathology relates to the determination, from the symptoms, what part of the brain is the seat of the lesion. The upper convex portion-of the hemispheres is inti- mately related to the purely intellectual functions of the brain, while the under surface, or base, is connected with the motility of various parts of the body. Thus, if the inflammation be strictly limited to the upper surface of the brain, the predominant symptoms are those in- volving intellectuality, and consequently there is delirium, marked by incoherence of ideas and irrationality of language. If, on the contrary, the base of the brain alone is affected, the chief manifestations of dis- 212 DISEASES OF THE BRAIN. ease are seen in the muscular system, and there are contractions, spasms, convulsions, and paralysis. When the morbid action extends to both regions, there is a combination of these phenomena. But, as Jaccoudx states, there are some stubborn facts which stand in the way of the unreserved acceptance of the law laid down, for it occasionally happens that the symptoms are not in direct relation with the seat of the lesion. Thus, in the case the post-mortem examination of which I have referred to, there had been spasms and paralysis, yet the convex surface of the right hemisphere was alone involved, and that to an extent not exceeding a third the size of the hand. Jaccoud ex- plains such cases by attributing to the cerebral symptoms a double origin; one set being due directly to the part affected, the other result- ing from secondary reflex excitation. But a better explanation is to be found in the experiments of Fritsch and Hitzig,2 and of Ferrier,3 by which it is shown that there are distinct centres of muscular motion situated in the cortical substance of the brain, and that hence when this is irritated, as in the case referred to, by the occurrence of inflammation, spasms will be initiated in those muscles which are in direct relation with the centre implicated. It therefore is not necessary to frame an hypothesis to account for occur- rences which are readily explained by facts. Another fact should also be taken into consideration. In acute cerebral meningitis there is very frequently a large effusion of serum or an extensive formation of pus. If either be collected on the upper con- vex surface of either hemisphere, the pressure exerted through the in- tervening brain-substance upon the motor tract at the base must pro- duce more or less derangement of motility on the opposite side of the body. Guyot,4 who has given very careful study to the localization of the lesion from a consideration of the symptoms, declares that it is possible to define the seat very accurately, but his manner of looking at the sub- ject places it in altogether a different position from that which Jaccoud gives it, and which is not inconsistent with the investigations of Fritsch and Hitzig, and of Ferrier. Thus, tracing the fibres of the motor tract through the white substance to the convex surface of the hemispheres, he associates lesion of this region, not only with disturbances of idea- tion, but with derangement of motor functions. In this view he is supported by the experience of MM. Parent-Duchatelet and Martinet,5 1 Op. cit, p. 212. 2 " Ueber die electrische Erregbarkeit des Gehirns." Archiv fur Anatomie und Physi- ologie, von Du Bois-Reymond und Reichert, 1870, p. 300, et seq. 3 " Experimental Researches in Cerebral Physiology and Pathology," " West Riding Lunatic Asylum Medical Reports," vol. iii., 1873, p. 30. 4 " Du rapport des symptoms avec les lesions dans la m6ningite." Thdse de Paris, 1859. B Op. cit. ACUTE CEREBRAL MENINGITIS. 213 who state that in eight subjects who had exhibited hemiplegia, or the beginning of paralysis on one side of the body, they had discovered, on post-mortem examination, effusion on the convexity of the opposite hemisphere. When, however, the lesion is limited to the base, the functions of the hemispheres will not be affected, except upon the principle of reflex irritation, or of the transmission of pressure. It is evident, how- ever, that further researches, founded upon post-mortem examinations, are necessary to the satisfactory solution of the interesting questions involved. Treatment.—To afford any chance of a favorable result, the treat- ment should be energetic from the first. General bloodletting may be practised with advantage in subjects of good constitution and of the middle period of life. As many as twelve or sixteen ounces may be taken from the arm if the pulse is hard, the cephalalgia intense, or the delirium furious. Leeches applied behind the ears or to the inside of the nostrils are more generally of advantage. The same may be said of cups to the nucha. The hair should be cut off short, and ice kept constantly applied to the scalp during the first and second stages. It is better than the cold douche, for the reason that it is almost impossible to continue the latter without intermissions, during which the head again becomes hot. Com- presses wrung out of cold water will not answer; they soon get heated, and act as poultices. Irrigation, by a small stream of ice-water falling from a vessel placed above the head of the patient, is a useful means of applying cold, but is often inconvenient. The experiments of Dr. Benham* appear to show that cold applied to the head has no material effect in reducing the intra-cranial tempera- ture, or in lessening the amount of blood flowing to the brain. But it must be borne in mind that, though cold applied to the scalp may not reduce the normal intra-cranial temperature, it may exercise a very different influence over temperature which is abnormally high, and that his experiments wTith Ludwig's Strohm-uhr were but three in number, that the cold was only applied for thirty minutes, and that it is quite doubtful if the Strohm-uhr affords the best means, under the circum- stances, for determining the quantity of blood flowing to the brain. In actual experience, we find that the sedative influence of cold to the head is as well-established a fact as any other in therapeutics, and, though it may fail, as every other remedy does some time or other, to produce its expected effect, that fact should be no reason against our employment of it in cases in which it appears to be indicated. In acute cerebral meningitis, I have repeatedly seen the violence of the symp- toms mitigated by the agent in question, but, in order to obtain this 1 "On the Therapeutic Value of Cold to the Head," "West Riding Lunatic Asylum Medical Reports," vol. iv., 1874, p. 152. 214 DISEASES OF THE BRAIN. result, it should be kept persistently applied in the forms above men- tioned. Purgatives are generally advantageous and should be effective. Nothing is better than croton-oil, although calomel and podophyllin, grs. x with grs. ij, make a good combination for the purpose. My experience has satisfied me of the good effects of mercurializa- tion. I have administered calomel in doses of a grain every two hours until the breath became fetid, and I am sure the effect has been bene- ficial. The iodide of potassium is well spoken of by Dr. Flint,1 who says he has witnessed the good effects of the drug in several cases. Dr. F. R. Lymana has reported two cases in which it formed a prominent feature of the treatment, and in which recovery took place. Within late years in the few cases of acute cerebral meningitis that have been under my charge, I have found the greatest benefit from the bromide of potassium, and the three cases that recovered were instances in which it was administered in large doses. The theory upon which its employment is based has already been fully considered in the chapter on cerebral congestion. It should be administered in doses of at least thirty grains three or four times a day, from the very beginning of the affec- tion to the end of the second stage or the appearance of coma, should this symptom supervene. The head should be kept well elevated, the chamber cool, and well ventilated, the light in a great measure excluded, and the utmost quiet enjoined. The food, without being stimulating, should be nutritious. Nothing is superior to strong beef-tea, made either from fresh beef or from some one of the extracts in the market. In the third stage the treatment should be almost the reverse of that indicated as proper for the first and second stages. The mercury, iodide of potassium, bromide of potassium, ice to the head, and purgatives should be omitted, and attention should be given to the maintenance of the strength. To this end brandy, whiskey, or other alcoholic liquor, should be administered in such quantities as the occasion seems to require. It often happens in this stage that the delirium and exces- sive motility return. It must be remembered that this is not from any renewal of morbid processes within the cranium, but is entirely due to debility. At the moment of writing this, a young lady of this city is under my charge for acute cerebral meningitis, whom I did not see till the third stage was well advanced, and who for several days previously had exhibited a return of the delirium, for which depletive measures and hydrate of chloral had been employed. The free administration of brandy, champagne, and beef-tea, soon dissipated the symptoms of re- lapse, and she bids fair to recover. 1 Op. cit, p. 601. s American Medical Times, 1862, p. 334. CHRONIC CEREBRAL MENINGITIS. 215 Blisters may be used in this stage with advantage. They are best applied between the shoulders, and should be six or eight inches square. In the rheumatic form of the disease little special treatment is neces- sary. It is, perhaps, advisable to endeavor, by means of blisters or other revulsives, to bring back the disease to the joints. In the acute meningitis of the aged, active depletive treatment is not so generally admissible, and if apparently indicated should be carried out cautiously. It may even be proper to treat some cases with stimu- lants from the very first. CHAPTER IX. CHRONIC CEREBRAL MENINGITIS. Although it is scarcely possible, for reasons given in the preceding chapter, to determine from the symptoms the exact seat of the morbid process in an attack of acute cerebral meningitis, we are often able, in the chronic form of the disease, to make the differential diagnosis with sufficient accuracy. I shall therefore consider the affection according to its location under the heads of Chronic Verticalar Meningitis, and Chronic Basilar Meningitis, the terms being applied respectively to chronic inflammation of the membranes of the superior surface or vertex of the brain, and chronic inflammation of the membranes of the inferior surface or base of the brain. I.--CHRONIC VERTICALAK MENINGITIS. This disease may be the consequence of an attack of acute cerebral meningitis, or may originate without being thus preceded. The latter is the usual mode of development. Symptoms.—The symptoms of chronic verticalar meningitis are in some respects similar to those of general paralysis, an affection which will be fully described as one of the forms of insanity; and they also resemble those evolved during the course of softening, limited to the convex portion of the brain. Among the physical symptoms headache occupies a prominent posi- tion and is usually the first evidence of cerebral disease which attracts the attention of the patient. The pain is generally felt in the fore- head, in one or both eyes, or at the vertex, and is aggravated by men- tal exertion, by the mere act of reading or fixing the attention, by mus- cular effort, or by a dependent position of the head. It is not usually very intense, but is characterized by persistency. There are frequent attacks of vertigo. Somnolency is generally present, and there are 216 DISEASES OF THE BRAIN. trembling, defective articulation, weakness of the limbs, spasms of par- ticular muscles or groups of muscles, paralysis of the bladder or of the sphincters of the bladder and rectum, producing involuntary discharges of urine and faeces, weakness of the memory, especially as regards words, and a general enfeeblement of the mental faculties. Occa- sionally there are epileptic convulsions. Paralysis of the whole of one side of the body may ensue, or the loss of power may be confined to a single limb, or to a group of mus- cles. Anaesthesia may be present, either general or local, or there may be neuralgic pains in various parts of the body, sometimes of a very persistent character. The ocular muscles are not often implicated, .either by spasm or paralysis; and the special senses, except that of gen- eral sensibility, are not usually impaired. Convulsions of an epilepti- form character are not uncommon. Unless the cortical substance of the brain participates in the morbid action there is not ordinarily marked mental aberration, although there is a general failure of mental power. Under the name of " general paralysis,"1 and subsequently of "chronic, diffused periencephalitis,8" Calmeil described a disease which is now well known, and in which the cortical portion of the upper part of the cerebrum is in a condition of chronic inflammation, the membranes of the region being also involved. But the peculiarities of general paralysis are so well marked as to ne- cessitate separate description. The ophthalmoscope does not, in this affection, generally reveal any very notable changes in the fundus of the eyes. Occasionally, where there is reason to suspect its existence, there is ischaemia papillae, and still more rarely neuro-retinitis. As Dr. Allbutts has remarked, the optic nerves in drunkards affected with meningitis of the convex surface of the brain " are often degenerated, and the vessels injected, but these effects do not seem to be due to any meningitic process." When, however, the meningitis is complicated with inflammation of the cortical substance of the brain, neuro-retinitis is a frequent accompaniment. The general health participates more or less in the disturbance. The stomach is irritable, and vomiting is frequent, the bowels are usually obstinately constipated, and the urine is scanty and high- colored, often containing oxalate of lime and an excessive amount of uric acid. As the disease advances, the mental and physical symptoms become more and more pronounced. The mind is weaker, delirium is not in- frequent, convulsions occur oftener, and the paralysis extends and be- comes more profound. Blindness from pressure upon the optic nerves 1 "De la paralysed considered chez les alienes," Paris, 1826. 2 " Traite des maladies inflammatoires du cerveau," Paris, 1859. 8 " On the Use of the Ophthalmoscope in Diseases of the Nervous System," etc., Lon- don and New York, 1871, p. 108. CHRONIC CEREBRAL MENINGITIS. 217 may result. A state of continued coma now supervenes, during which the patient expires, or death takes place in convulsions. The duration of the disease varies from two or three months to one or more years. An interesting case of meningitis affecting the membranes at the convexity of the brain, is that of the eminent Swiss savant De Saussure, related by Dr. Odier.1 For many years M. de Saussure had been accustomed to great bodily fatigue, and to various degrees of atmospheric pressure, encountered in the many ascents of mountains he had made. He had been subject to an aggravated form of dyspepsia, and to repeated large losses of blood from haemorrhoids. At the end of the year 1793, after having lost his fortune, and ex- perienced a good deal of mental disturbance from the unsettled condi- tion of the national affairs, he was suddenly seized with vertigo, which was followed by distinct sense of numbness in the left arm and cheek. The vertigo did not last long, but nothing could relieve the feeling of numbness or torpor. Blisters, purgatives, tonics, and anti-spasmodics, were employed in vain. The affection of the arm seemed to be seated en- tirely in the sentient nerves, for the patient retained his strength, could perform all kinds of movements, but could not distinguish easily what he was touching. It seemed to him as if sand were interposed between his fingers and the bodies with which he brought them in contact. The sensation experienced was rather painful than otherwise, so that he was indisposed to use his hands unless they were protected with gloves. A similar feeling existed in the cheek and mouth on the same side, which, on passing his hand over his face, formed, in the most un- pleasant manner, a well-marked line of demarkation between the right and left side. In other respects he was well; his general health was not impaired, and he retained for a long time his presence of mind and the fullness of his intellectual powers. Many months were passed in this state, during which a great variety of remedies were tried, such as cold and warm bathing, electricity, arnica, valerian, blisters, embroca- tions, artificial and natural thermal waters, change of regimen, travel- ing, etc., but all in vain. The disease became worse and worse; always, however, by starts, the attacks being more or less violent and complete. One of the most violent was occasioned suddenly at Bourbon, by a shower-bath employed too warm. The attack produced by it was so complete that the whole of the left side, from the leg to the tongue, was affected. His articulation became by degrees indistinct and unintelli- gible. His legs, especially the left, became weaker, and his gait was staggering, and he found it almost impossible to maintain his equilib- rium and to direct his steps as he wanted. He experienced peculiar 1 " An Account of the Illness and Death of H. B. de Saussure, late Professor of Phi- losophy at Geneva," Edinburgh Medical and Surgical Journal, vol. ii., 1806, p. 393. 218 DISEASES OF THE BRAIN. difficulty in passing through doors, even when they were wide open, and no descent or ascent to make. As he approached a door he bal- anced himself, and quickened his motion as if he had to make a dan- gerous leap or a bad step to get over; when it was done he recovered his equilibrium, crossed the room, but had the same trouble in order to get to another apartment. Day by day the disease advanced; the intellectual faculties became perceptibly weaker; incontinence of urine supervened. The evening before his death he seemed to enjoy his sup- per, but was restless during the night; toward morning his head leaned to one side, he breathed with more difficulty than usual, and expired without agony. On opening the body thirty-two hours after death, the dura mater was found adherent to the cranium, particularly along the longitudinal sinus, but that deviation from the natural condition was not considered of importance, it being often met with unassociated with intra-cranial disease. Between the pia mater and the arachnoid there was found a considerable effusion of a bluish gelatinous substance. In various places there were circular spots of a gray yellowish color about two or three lines in diameter. These seemed as though they penetrated into the membranes, though susceptible of being detached from them like small separate spheres surrounded by a little circular margin of a dark- red color. At first sight these spots were taken for hydatids, but closer examination showed that the red margin was a blood-vessel connected with other vessels, and convoluted in the form of circles. There were no separate pouches or solutions of continuity in the membranes, only they were more transparent in those places than in others. The seros- ity underneath communicated freely with that which was diffused over all the surface of the brain, both having the same color and qualities. On opening the membranes the serous effusion ran off like water. The effusion existed not only over the surface of the cerebrum, but also over that of the cerebellum. The ventricles also were distended with a similar fluid. The examination of the brain presented nothing more of importance except that it was flattened on the surface and deeply furrowed by arteries. The total duration of the disease was five years, although the beginning may have been anterior to the apparent time of origination, as it was stated that Prof, de Saussure, long before his death, had often mistaken one word for another in conversation, and was so unconscious of his error as to get angry when not understood. Dr. Odier attributed the death of the patient to the effusion of a large quantity of serum into the ventricles and between the membranes of the brain. That this effusion resulted from chronic meningitis is scarcely a matter of doubt. Gintrac1 cites the following case: " A young man sixteen years old, 1 Op. cit, tome ii., p. 626. Quoted from Bruce, " Medico-Chirurgical Transactions," London, 1818, vol. ix., p. 280. CHRONIC CEREBRAL MENINGITIS. 219 very tall, was attacked in December with feebleness of sight, strabismus, dilatation of the pupils, diplopia, and headache ; pulse natural, consti- pation, epistaxis; convulsions, with foaming at the mouth; coma and stertor, which were relieved by bleeding from the temporal artery, but which returned twenty-four hours later. Delirium supervened, charac- terized by violent language, and attempts to strike and bite those around him ; pulse frequent. The wound in the artery being reopened, repeated losses of blood occurred, and the convulsions returned. Sight weakened, ideas confused, appetite voracious, general debility, but power of walking, of comprehension, and of speech, remained. Then somnolency, attended with spasmodic movements of the muscles, es- pecially of those of the face, appeared. The face was red and swollen, especially on the left side. Death occurred in violent convulsions two months after the beginning of the disease. " The cerebral blood-vessels were found to be very much injected. On the left anterior lobe there was a slight effusion of blood; a little serum in the ventricles; substance of' the brain firm; numerous puru- lent spots along the line of superior longitudinal sinus." M. Casimir Broussais * submitted to the Academie de Medecine a pathological specimen with the history, of which I give the main points: Lozeray, a sapeur pompier, twenty-two years old, entered the hos- pital Val-de-Grace August 1, 1840. Six days previously he had been attacked with headache and slight fever. The evening of his entrance he was bled. He improved, the pain disappeared, and his appetite re- turned. On the 7th of August he had a relapse; hardly answered the questions addressed to him; remained motionless in bed; was entirely paralyzed in the right arm and leg; was again bled. The next day, being comatose, venesection was again practised, and twenty leeches were applied to the temples. On the 9th the paralysis had disappeared, but, as he was still comatose, another venesection was performed, and fifteen leeches were applied to the neck over the jugular vein. On the 10th was bled again; still comatose, and the right arm contracted. On the 12th had epileptic paroxysms, during which it was remarked that one side was more convulsed than the other; coma profound; eighteen leeches to the jugulars; 14th, 15th, and 16th, same symptoms; an enormous bed-sore on the sacrum. On the 18th coma less complete; epileptic convulsions, especially in the night. From this time he con- tinued to improve till the 28th, when coma again supervened, and on the 29th he died. On post-mortem examination the dura mater was found healthy. On being incised, a quantity of sero-purulent fluid escaped. The mem- brane was adherent to the brain, principally on the convex surface, and especially on the right side, so that it was impossible to detach it 1 " Bulletin de l'academie royale de medecine," tome v., 1840, p. 564. 220 DISEASES OF THE BRAIN. entirely without rupture. On the right side it formed a sac extending over about three-fourths of the convex surface, containing from two hundred to two hundred and fifty grammes of a greenish-white sero- purulent fluid. Another sac, containing from fifty to sixty grammes of this fluid, existed on the left side. The dura mater was removed, and it was ascertained that this fluid came from the cavity of the arachnoid and from the meshes of the pia mater. In the case of a gentleman under my charge there was intense head- ache as the first prominent symptom, followed by epileptiform convul- sions, and varying degrees of paralysis, both of motion and of sensa- tion on one side of the body and again on the other. When I first saw him the optic nerves had been so injured by the pressure from effused fluid as to cause complete blindness. Light could not be dis- tinguished from darkness. The ophthalmoscope showed extreme atro- phy of both nerves, probably either the result of pressure or the conse- quence of neuritis from extension of the cerebral disease. The accumu- lation of fluid was so great as to force open the bi-parietal, the fronto- parietal, and the occipito-parietal sutures. Under treatment the excess of fluid disappeared, the pain ceased, and he acquired the power of vision to such an extent as to enable him to tell light from darkness, and even to make out the figures on a bright carpet. lie died, how- ever, about six months after leaving New York, of cancer of the stom- ach. There was no post-mortem examination of the brain, or none that was reported to me, but I am strongly of the opinion that the disease was chronic meningitis of the convexity of the brain, resulting in a large effusion of serum. Causes.—The etiology of chronic cerebral verticalar meningitis is often difficult to make out. Sometimes, however, the affection is the result of an acute attack. At times it clearly originates from blows or falls upon the head, and again it is caused by exposure to the heat of the sun or to artificial heat. There is certainly a form of chronic in- flammation of the membranes of the convex surface of the brain, which is due to the extreme heat of the sun, not necessarily to the action of the direct rays, and which is characterized by the symptoms I have speci- fied. I see some cases of this every year in New York, and have wit- nessed several similar instances in cooks and others whose occupations necessitated the exposure of the vertex to intense or long-continued heat. The affection in question may also be induced by mental influence, especially anxiety and other forms of emotional disturbance; and this category of causes is probably the most influential of all others, with the single exception of excessive alcoholic potations. So far as our knowledge extends, this last is the most common factor in the causation of chronic verticalar meningitis. CHRONIC CEREBRAL MENINGITIS. 221 Syphilis is another influential cause, though generally, as we shall see hereafter, it acts preferably upon the basilar portion of the mem- branes. It is probably sometimes induced by rheumatism and gout, and cer- tainly occasionally by tubercular deposit, but when arising from this last-named cause it is not to be confounded with tubercular cerebral meningitis, the seat of which is in the membranes at the base of the brain, and which is otherwise differently characterized. Diagnosis.—This is often impossible to be made out, with even a moderate degree of exactness, and is always more or less difficult. The affection may be confounded with inflammation and softening of the cortical substance of the cerebrum, and the most careful study will in many cases fail in discriminating between them. The difficulty is fre- quently heightened by the fact that the two diseases coexist. But we are much assisted by a thorough investigation, not only of the symp- toms, but of the causes. For instance, a category of phenomena such as has been given, resulting from exposure to intense heat, is generally due to chronic inflammation of the membranes of the superior surface of the brain, and the same may be said of syphilis. When, however, the symptoms follow undue mental exertion or emotional excitement, the distinction is more difficult, and indeed in such cases the substance of the cortex is usually also involved. In general, the pain which is so prominent a feature in inflammation of the membranes, is not so marked an accompaniment of softening, while in the latter the mental disturbance is greater than when the morbid process is confined to the meninges. From inflammation of the membranes at the base of the brain, the affection under consideration is distinguished by the almost constant absence of ocular paralysis, and by the fact that the seat of the pain is different, and that the mind is more decidedly involved. The ophthalmoscopic appearances will suffice for the diagnosis from anasmia or hyperaemia of the brain, or frcm megrim or neuralgia, even if the other points in the clinical history are not sufficient. Prognosis.—The prognosis in cases of chronic inflammation of the meninges of the convex surface of the brain is decidedly unfavorable, unless a syphilitic origin can be made out, in which event the prospect of recovery is good. But even in such a case the disease must be early subjected to proper treatment, for the disposition to extend to the sub- stance of the brain which the affection so often manifests, and the fact that new formations are liable to be produced and to exert an abnormal influence upon the nerve-tissue, very greatly increase the probability of an unfavorable result. Nevertheless, I am satisfied that even where there is no suspicion of syphilis, chronic verticalar meningitis is sometimes successfully com- bated. This point will be further considered under the head of treat- 222 DISEASES OF THE BRAIN. ment. In the mean time I quote the following case from Dr. E. L. Fox,1 of Bristol, England, in which a post-mortem examination gave evidence of the previous existence of the disease in question. It is possible there was a syphilitic taint in this case, though nothing is said on the subject: " The patient, a young man, had died of an attack of haemorrhage, from rupture of the right middle meningeal artery, but the dura mater, all over the convex surface of the hemispheres, was somewhat adherent to the subjacent arachnoid, while the arachnoid was thickened and yel- low all over. This patient had been under Mr. Parker's care a year be- fore, with great pain all over the upper part of the head, without any delirium, and had been treated, with entire success, with iodide of po- tassium. In this case, therefore, arachnitis had existed without any lesion of the cerebral matter itself, and without delirium." Morbid Anatomy and Pathology.—The essential features in the mor- bid anatomy of chronic cerebral verticalar meningitis are hyperemia of the vessels and a new formation of connective tissue by which the membranes adhere to each other and to the brain, and by which they are rendered opaque, and thicker than normal. In addition, there may be deposits of exudation on the convexity of the brain which, though intimately connected with the alterations of the membranes, are yet distinct from them. These, as characterized by Gintrac,8 may consist of serum effused under the arachnoid, of a thick, gelatiniform, discolored fluid in the same situation, of pus con- tained either in the cavity of the arachnoid or infiltrated into the meshes of the pia mater, of false membranes formed in the cavity of the arachnoid, non-adherent, adherent to one or other layer of this membrane, or double, composed of an external layer of the arachnoid, and an internal, adherent to the visceral lamina, thus constituting cysts, which may contain blood-serum or other matter. Of one hundred and sixty-seven cases of meningitis of the convexity of the brain collected by Gintrac—in which, however, the distinction between the acute and chronic forms of the disease is not drawn—the relative proportion of morbid conditions was as follows: Injection, opacity, or thickening of the membranes.................. 9 Serous exudation............................................... 33 Gelatiniform exudation.......................................... 14 Pus.......................................................... 30 False membranes............................................... 81 Total.................................................... 167 Fox3 has very clearly shown that tubercle may be associated with 1 "Clinical Observations on Acute Tubercle," "St. George's Hospital Reports," Lon- don, 1869, vol. iv., p. 61. s Op. cit., tome ii., p. 604. 3 Op. et loc. cit. CHRONIC CEREBRAL MENINGITIS. 223 chronic meningitis of the convexity of the brain. The following case, which I cite from him, is so interesting in several respects, that I quote it in full, so far as the description relates to the brain: "Case XXII.—Henry B., aged twenty-four, tailor; ill one month with pain in the forehead; no cough. When first examined in recum- bent position, a sharp, blowing, systolic murmur was heard at the base of the heart, traveling up toward the left shoulder; a little later he had sickness, then intense pain, chiefly at back of head. Head jerks back- ward at every beat of the heart; much cerebral throbbing. Temporary relief from blisters, cold to the head, and purgatives; but eventually more sickness, diplopia, which, however, Was intermittent, and in- creased headache. Then almost total freedom from pain, and all mor- bid symptoms, and he was able to be out; but he died suddenly in a fit, three months from the commencement of his illness. No bronzing of skin. "Post-mortem Examination.—Dura mater externally seemed healthy; internally it was firmly adherent to the subjacent tissues at the spots below mentioned; veins of convex surface of hemispheres tinged with blood. On left hemisphere, about middle of brain, was a spot of tuber- culous matter the size of a filbert, which seemed to be immediately con- nected with the vessels of the pia mater, to have become adherent on the one side to the dura mater, and on the other to have extended through the gray matter for a few lines into the white. The two lat- eral and third ventricles much distended with clear fluid, containing a few small, white flakes. Foramen of Monro enlarged sufficiently to contain a small nut. Walls of ventricles very soft; optic thalami tolerably firm. Corpora striata excessively pulpy; pons and medulla oblongata everywhere rather soft. On anterior lobe of right hemi- sphere, just on the lateral surface, was another tuberculous spot the size of a nut. On the external surface of the cerebellum, close to the floc- culus on left side, though not involving it, was a large mass of tubercule, dipping into the structure of the cerebellum, and uniting this organ to the posterior lobe of the left cerebral hemisphere. More than three- quarters of the left half of the cerebellum were occupied by large ves- sels of the same growth, which apparently had grown separately, and by gradual increase of size had at length become one mass. The dura mater was adherent over a great part of this side of the cerebellum, and the cerebellar structure that remained was almost diffluent. The other side of the cerebellum was also much softened." This case is remarkable, not only for the intermittence in the symp- toms, to which Dr. Fox calls attention, but also for the lightness of the phenomena when compared with the severity and extent of the lesions. Such remissions in the manifestations of cerebral disease as were ex- hibited in this case, though not unusual, are, in the present state of our knowledge, not easy of explanation. For it is very evident that there 224 DISEASES OF THE BRAIN. was a steady advance of the morbid processes up to the very instant of death, and yet the patient died suddenly, having up to that time passed through a period of almost entire freedom from pain and all morbid symptoms. I am tempted also to cite the next case from Dr. Fox's memoir, on account of a like slightness of symptoms existing in connection with extensive cerebral lesions. Case XXIII.—Catharine S., aged thirty-one, servant; single; pale, lean woman; has had vertigo and pain in back of the head for five weeks; no sickness, no rigors, pulse now very feeble and hurried. Tongue coated; skin hot; no sickness until eight days after admission, and she coughed first on the ninth day. Became delirious, but was always capable of answering questions reasonably, and the chief symptom was a gradu- ally increasing weakness of pulse. Sank quietly out of life, without coma, on the twenty-second day after admission, having had no convul- sions throughout, and no cerebral respiration until the last day of life. " Post-mortem Examination.—Cranium : Arachnoid, and subjacent tissues on convex surface of the hemispheres, contained much clear fluid, but were otherwise natural. Between the cerebral hemispheres and the longitudinal fissure were a number of small, miliary tubercles, and at the lower part of this fissure the opposed hemispheres were ad- herent to each other by means of a mass of tuberculous matter the size of a nut. A small portion of similar matter was found at the upper part of the cerebellum, connected with the arachnoid. The venous tissue around these tuberculous masses was very much softened arid ecchymosed. Two similar masses were also found in inner wall of pos- terior horn of each lateral ventricle. Ventricles full of turbid fluid, and their walls softened." It sometimes happens that chronic inflammation of the membranes of the vertex of the brain exists without the occurrence of notable symptoms. Several such cases have come under my own observation in which, after death, the membranes were found thickened, opaque, and adherent, and in which, during life, no complaint of cerebral disturb- ance had been made. It is probable, however, that symptoms of such disturbance have existed, but have not been mentioned by the patient. Treatment.—The treatment depends to some extent upon the cause, although the general management of the disease is not subject to any very essential variation, however it may originate. Thus the iodide of potassium is in all cases the agent "most to be relied upon. When the affection is due to syphilis, or has followed syphilitic infection, the iodide must be administered with much more persistency and in larger doses than when not so associated. In all cases, however, it must be given in what may be called large doses, and must be continued for several months. In uncomplicated cases the quantity administered may be at first ten grains three times a day, gradually increased to thirty grains CHRONIC CEREBRAL MENINGITIS. 225 for each dose; but in syphilitic cases the doses will often have to be carried to eighty or even a hundred grains thrice daily. The iodide of potassium should, in my opinion, always be given in gradually-increas- ing doses. This is best effected by using «a saturated solution of the medicine in water, each minim of which contains about a grain of the salt. For the first day ten minims may be given three times, for the second day eleven, and so on till the maximum dose, which it may be deemed proper to administer, is reached. I have several times had cases under my charge in which no sign of amelioration occurred till doses of from eighty to one hundred grains thrice daily were used. Some one of the bromides may be very advantageously given in addition to the iodide of potassium. The bromide of calcium is to be preferred in almost all cases. It acts more rapidly than the others, and, notwithstanding the recent opinion of a German physician, more effect- ually. The doses should be about fifteen grains daily, and each dose may be given with that of the iodide of potassium. It must not be forgotten that these medicines must, when taken, be administered in a large quantity of water (half a tumbler, for instance). They act better, and are less liable to irritate the stomach, when they are well diluted. Under the combined action of the bromide and iodide, the relief from all symptoms of intra-cranial disease is often very striking. This is especially apt to be the case when syphilis is at the bottom of the morbid process. Relative to the propriety of administering mercury in chronic cere- bral verticalar meningitis, much depends upon the nature and duration of the disease. In non-syphilitic cases it is not indicated, nor in those instances in which the syphilitic infection is remote, but, where the pri- mary disease is recent, mercury is of service as an addition to the other measures. It may be given in the form of the biniodide, or the bi- chloride, in doses of the sixteenth of a grain two or three times a day. For the relief of the pain, which is sometimes very severe, a pill con- taining half a grain of codeia may be prescribed with advantage, as often as required. In regard to local medication, I am inclined, from more recent ex- periences, to believe that blisters applied to the nape of the neck are occasionally beneficial. As a rule, however, I do not employ them, or any other revulsive or counter-irritant means. The patient should be instructed not to over-exert the mind, to avoid all causes of excitement, mental or physical, and live in strict accord- ance with- hygienic principles. CHRONIC BASILAR MENINGITIS. Chronic basilar meningitis is very seldom the consequence of an acute attack, probably mainly for the reason that acute inflammation 15 226 DISEASES OF THE BRAIN. of the membranes at the base of the brain is almost invariably a fatal affection. Symptoms.—Although there is generally pain from the very incep- tion of chronic basilar meningitis, the first very decided' symptom is sometimes an epileptiform paroxysm. Or there may be convulsive movements of a limb, a group of muscles, or a single muscle, unat- tended with loss of consciousness. Again, there may be tonic spasms of the muscles of one or more of the extremities, especially of the arms; or the muscles of the neck may be similarly affected, causing the head to be fixed in an abnormal posi- tion. The individual muscles of the face are not usually involved. But ordinarily the primary serious indication of intra-cranial dis- ease is paralysis. This may appear in the head, arm, the hand, or a single finger; or one side of the tongue may be affected, giving rise to defective articulation, and to a deviation toward the paralyzed side when the tongue is protruded, or the muscles supplied by the seventh nerve may be affected and facial paralysis be produced. In the great ma- jority of cases, however, some one of the motor nerves of the eyeball is first involved in the morbid process, and this is generally the third nerve of one side, resulting in ptosis, external strabismus, and diplopia, dila- tation of the pupil, and defective power of accommodation. Sometimes the implication of the-third nerve is not complete. Thus, there may be paralysis of the levator palpebrae superioris muscle, pro- ducing ptosis, or the internal rectus muscle of the eyeball may be par- alyzed, causing the globe to be rotated outward by the uncompensated action of the external rectus, and as a consequence producing double vision; or, what is more rarely the case, the superior or inferior rectus, or the inferior oblique, may lose the power to act. In a few cases, the only indication of the affection of the third nerve is dilatation of the pupil. The fourth nerve may be paralyzed, and then the loss of power is limited to the superior oblique muscle, and the ability to rotate the eye- ball outward and downward is impaired; and again, the lesion is only manifested as regards the sixth nerve and the external rectus muscle, so that internal strabismus is the result. Occasionally the first sign of the disease is aphasia, with or without vertigo, confusion of ideas, or loss of consciousness. It not infrequently happens that pain of a very severe character is for a long time the only symptom which disturbs the patient. It may be located in some part of the head, or may be referred by the patient to the face, and is often regarded and treated as ordinary neuralgia. The chief features of this pain are its intensity and persistency. I have known it to last, without interruption, night and day, for over four months, driving its subject to the \erge of insanity, and causing him to entertain serious thoughts of suicide. CHRONIC CEREBRAL MENINGITIS. 227 In a few of the cases which have come under my observation, the principal symptom was anaesthesia of certain portions of the cutaneous surface. The skin of the face appears to be particularly liable to this phenomenon, although I have seen it extend throughout the whole of one side of the body; again, confined to the lower extremities; and at other times to the trunk, or upper extremities. In one case this was unaccompanied by paralysis of motion anywhere, but in the others the muscles, or some of them supplied by the third nerve, were paralyzed. In a case reported by Petrequin,1 and cited by Lagneau,2 of syphilitic necrosis of the frontal bone, and in which there was certainly also chronic basilar meningitis, the lower limbs were deprived of sensibility for two months. Vertigo is almost always a prominent symptom, and may be so intense and persistent as to prevent the patient walking without support. At times it is impossible for the recumbent position to be abandoned, even for an instant, without the supervention of severe dizziness; at others it occurs unexpectedly, and may be the cause of the individual falling. The eyesight is often impaired from a very early period. This may be due to paralysis of the accommodation, resulting from loss of power in the iris and ciliary muscle, especially the latter; for, though the iris probably has some influence in effecting the adjustment of the lens for different distances, it is in the ciliary muscle, as Von Graefe has shown, that the function mainly resides. The defect in question is shown by the difficulty which the patient experiences in distinguishing near ob- jects. There is no trouble in seeing images at a distance, but the effort to read, for instance, is unsuccessful—the lines of print appearing blurred—and always increases the pain in the head, besides inducing temporary pain in the eye. The exact degree of impairment of accom- modative power may be ascertained by the use of Snellen's test-type, or still better by Galezowski's typographical scales.8 Or the asthenopia may be the result of the paralysis of the internal rectus muscle. Again, the defective vision may be caused by the disturbance in the special nervous apparatus of the eye. Examination with the ophthal- moscope almost invariably reveals the existence of hyperaemia of the optic nerve and retina, and not infrequently of optic neuritis, caused by extension of the morbid process from the cerebral membranes to the optic nerve. Sometimes, as in cases to be cited presently, vision may be entirely lost from this cause; but, again, it is indubitable^ as Dr. Hughlings Jackson has very definitely shown,4 that a great degree 1 Gazette Medicale de Paris, 1836, tome iv., p. 643. 2 "Maladies syphilitiques du systeme nerveux," Paris, 1860, p. 413. 8 "Echelles typographiques et chromotiques pour l'examen de l'acuite visuelle," Pans, 1874. * Among other places, in the AVest Riding Lunatic Asylum Reports, in a paper enti- 228 DISEASES OF THE BRAIN. of optic neuritis may exist, and yet the patient be capable of minute vision. The sense of hearing may also become impaired or lost by extension of the inflammation so as to involve the auditory nerve. Several cases of the kind have come under my observation; and in one, which will be more specifically referred to hereafter, the function was very suddenly regained under appropriate treatment.. Although mental exertion of all kinds adds to the severity of the symptoms, it is not usually the case that the mind is primarily affected to any considerable extent. There may be periods of depression but these are generally the result of the physical phenomena—the pain, ver- tigo, paralysis, etc., the sensations arising from or the contemplation of which are calculated to disturb the mental equanimity. When, how- ever, the mind is brought to bear upon any subject, the intellectual pro- cesses are as correct as ever, the only difference being that they cannot be long continued without the supervention of fatigue and an aggrava- tion of the symptoms. It quite often happens that the seat of chronic basilar meningitis changes, and with the transference there is an alteration in the locality of the symptoms. This is especially seen in the matter of paralysis. Thus, in the beginning, the third nerve may be paralyzed, and eventu- ally the extension of the lesion leads to the implication of the fourth, fifth, and sixth. Cases in illustration of this point, which have occurred in my own experience, will presently be adduced. In the mean time, the following example from Sir Charles Bell1 will prove of interest. The fact that Sir Charles mistook the real nature of the disease will not de- tract from its importance. It is reported as a " Case of Disease of the Nerves within the Orbit. " Martha Symmonds, aged forty-one, Northumberland Ward. This woman was admitted into the hospital for a disease apparently seated in the left orbit. Nine months ago she had a paralytic stroke, attended with the loss of power in her left arm, neck, and face, on the same side. She lost also her power of speech, excepting only to ' babble,' as she says. She recovered from this attack, and went into service. About eight or ten weeks ago, she was alarmed by a commencing dimness in both her eyes, and she was obliged to leave her place on account of this dimness of her sight. Both her eyes were equally affected, and there was no redness or opacity perceptible in either of them. She placed herself under a medical gentleman, because she dreaded a return of the palsy. About six weeks ago, the upper eyelid of the left eye fell, and tied " A Case of Recovery from Double Optic Neuritis." The case was probably one of chronic basilar meningitis, of syphilitic origin. 1 " The Nervous System of the Human Body. Embracing the Papers delivered to the Royal Society on the Subject of the Nerves," London, 1830. Appendix, p. cv. Edition of 1844, p. 343. CHRONIC CEREBRAL MENINGITIS. 229 she could not raise it. At that time she suffered great pain above the left eye, and the pain extended upon the left side of her forehead. She at the same time lost the vision of this eye, although she could dis- tinguish by it the light of day from darkness. She could direct the motions of this eyeball as well as of the other at that time, and the ap- pearance of the eye was natural. " Five days before she was admitted to the hospital she experienced a violent, deep, throbbing pain in her left eye, and from that time the eyeball, as she says, became enlarged, until it projected considerably beyond the orbit. Two days before her admittance, she was totally blind in that eye, and was deprived of sensation on the surface of the whole eye, eyelids, the internal corner of the nose, and upon the left side of her forehead. " At present her left eye is covered with its upper eyelid, and pro- jects greatly from its natural situation. The lower eyelid is everted as a consequence of the projection of the ball of the eye, and the conjunc- tiva is tumid and projecting. She cannot raise the upper eyelid, although when it is raised with her finger she can squeeze it down again, and winks with a motion which corresponds naturally with that of the other eye. It may be a question whether the globe of the eye is enlarged, or only protruded. The pupil is unnaturally large, and the iris is without motion. She cannot move the eyeball in any direction. The whole eye is insensible; she has just had her lower eyelid scarified, and she was not sensible of pain. She allows us also to press with our finger on the surface of the eye, without complaining of any pain, or winking; although, as we said above, she can still wink, and does wink with this eyelid when the other eye is threatened. " October 6th.—To-day some further examination was made of this woman's face and head, in order to ascertain the extent of insensibility. It was stated in our last report that she has lost sensation in the sur- face of the left eye and eyelids, in the corner of the nose, and upon the forehead. In these parts, she says that now the loss of sensation is less complete, because when she had her eyelid scarified, the other day, she felt pain, which she did not when it was scarified before. The eye also seems diminished in size. " Besides those parts which we have already described as being af- fected, she has, in a partial degree, lost sensibility to touch in that part of her cheek which is just under the orbit, and downward upon the side of her nose, and upon the left side of her upper lip, and also within the cavity of the nose on the left side. However, when the point of the pin was brought near to the ear, or upon the skin which is over the lower jaw, she then was sensible of pain. A piece of linen was twisted so that it might be introduced into the left nostril; she allowed us to push it upward as far as we could, and, during this operation, she only remarked that she was sensible of its presence. Turning it about with- 230 DISEASES OF THE BRAIN. in her nostril did not make her sneeze. When we tried the same ex- periment on the other nostril, she was unable to bear the tickling pro- duced by the loose threads of the cloth, before it was introduced into the nostril. Now she informed us that she is in the habit of taking snuff; and she is not only insensible to its usually agreeable effects, but unconscious of its presence in the left side of the nose. We next made her close her right nostril, and inhale strong spirit of ammonia; and then repeated the same experiment on the other nostril. There was a very obvious difference in the effects produced by the ammonia on the two sides of the nose. She told us she could smell the ammonia on both sides, but still she could not bear to hold the bottle containing the ammonia so long at the right nostril as we observed that she could at her left. When the bottle was placed under the right nostril, its pungency affected her almost immediately, so much that she could not bear it; on the other hand, she allowed it to remain for a consider- able time under the left nostril, and even snuffed it up strongly before she was inclined to remove it. During these experiments, we observed that the right eye became suffused with tears; the left eye, on the con- trary, appeared to be dry on its surface. " In order to ascertain further to what degree her sense of smelling was affected, we tried the effect of some substances which possess odor without pungency. On applying oil of anise-seed to her left nostril, while the right one was shut, she inhaled it powerfully, but was sen- sible of no smell. Then a piece of asafcetida was tried, but still she had no kind of sensation, either pleasant or the reverse. She was sensible to these odors in her right nostril. "The state of her mouth was examined; with the point of a pencil we pressed against the upper gums, on the left side of her mouth, and the inside of her cheek, where it is reflected off the gums, and she ap- peared to have very slight or no sensation at all. She volunteered to put a spoonful of mustard between her gums and her cheek, and she seemed very little incommoded by such an experiment. The sensibility of the other parts of her mouth was natural. "The circumstances of this case," continues Sir Charles, "make it difficult to determine exactly where the disease is seated, which thus produces the destruction of the optic nerve, the third and fourth nerves, the first and second divisions of the fifth nerve, and the sixth nerve. Among these nerves we might add the olfactory nerve; but it may be a question whether the function of that nerve is directly or indirectly affected: the issue of the case will probably determine this matter. However, from the condition of the parts without the orbit, we observe that the power of closing the eyelid and winking is retained, when the power of raising the eyelid is gone, and the sensibility of the eyelids and of the eye itself is completely lost. It is the portio dura which is distributed to the orbicular muscle of the eyelid, and bestows the power CHRONIC CEREBRAL MENINGITIS. 231 of winking. We see also that she can inhale powerfully, and can per- fectly move the muscles belonging to the nostril and upper lip of the left side, when at the same time the skin which covers these parts is insensible. Still, that power belongs to the portio dura. This nerve, passing to the face by a circuitous way, and being, therefore, uninjured by pressure within the orbit, permits her to move the left nostril and side of her mouth in a natural correspondence with the other side of her face, although both the first and second divisions of the fifth nerve are included in the disease, and are destroyed along with the first, sec- ond, third, fourth, and sixth nerves. " May 20,1829.—Since she left the hospital she has been a constant sufferer. The pain in her head has never left her; it is principally seated over both her eyes, and over the left in particular. For three years she has observed that this pain is aggravated for a fortnight be- fore her monthly periodical return-; she says she does not know what to do, her suffering is so great. The pain varies in a remarkable man- ner with the changes of the weather: she knows when rain is approach- ing by the increase of the pain, and immediately after it is over the pain is relieved. She has not had a return of the loss of speech, or of the paralysis of her arm, since she left the hospital, but she has had fits and she has suffered from cramps in the back of her neck and right breast. The arm, which was formerly paralytic, becomes, about once a month, numbed in such a manner that she cannot use her fingers, and this is accompanied with great pain. These attacks do not last for more than five minutes. She walks quite well. "The loss of sensation is principally in the forehead; when pricked with a sharp point in any part as high up as the crown of the head, she has no feeling; but in the temples, and below the orbits, and on the nose, she retains sensation. The left eye is blind; the pupil large and immovable; the motions of it are gone; the surface is insensible; it is clear, and it remains fixed in the centre of the orbit." This woman entered the Middlesex Hospital in October, 1824. In the third edition of Sir Charles Bell's work, published in 1844, the fore- going particulars are given, and the history is resumed by Mr. Shaw, as he observed her in June, 1836. At this time there was no marked change, except that, from an inflammation of the right eye, she had lost the sight, and had become entirely blind. That this case was not one of disease within the orbit is sufficiently apparent from a consideration of the symptoms, almost all of which point to intra-cranial lesion. The extensive paralysis of motion and of sensibility, the epileptic convulsions, the cramps, the aphasia, are so many circumstances against the correctness of Sir Charles Bell's diag- nosis. That the morbid condition was inflammation of the basilar surface of the cerebral membranes is extremely probable, as much so upon the principle of exclusion as from a consideration of the positive symptoms. 232 DISEASES OF THE BRAIN. In a case which I saw in consultation with Dr. H. Knapp, of this city, the patient, a young man, in whom there was no history or even suspicion of syphilis, was attacked with severe pain in the head, at- tended with dimness of vision in both eyes. In the next place the third pair of nerves became involved, causing paralysis of all the ocu- lar muscles supplied by these nerves on both sides, and of both eyelids, and also producing dilatation of both pupils. Next both fourth nerves were affected; then the fifth pair causing facial anaesthesia and paralysis of the temporal and masseter muscles on both sides; then the sixth, and eventually the seventh and eighth, resulting in paralysis of both exter- nal recti muscles, double facial paralysis, and loss of hearing in both ears. There was, therefore, in this very remarkable case, a gradual ad- vance of the morbid process, through a period of several weeks, along the base of the brain, from the anterior to the posterior region. With all these symptoms there was not the slightest mental derangement; neither was there paralysis of any other muscles than of those supplied by the nerves specified. Shortly after I saw him the pneumogastric nerves became implicated, and death soon ensued. Unfortunately, there was no post-mortem examination, but Prof. Knapp and myself agreed that the case was one of inflammation of the membranes cover- ing the basilar surface of the brain. In the case of a woman who came to my clinique in the winter of 1871-'72, the principal symptoms were deep-seated pains in the head, vertigo, and paralysis of the third nerve on the left side, as evidenced by ptosis, dilatation of the pupil, and external strabismus, the latter condition producing diplopia. Conjoined with these symptoms there was slight but decided paralysis of the muscles of the face, arm, and leg of the opposite side, together with cutaneous anaesthesia. Inquiry showed that these symptoms had been of very gradual development. There was no history of syphilis in the case. I was of the opinion that the disease was chronic basilar meningitis, and gave an unfavorable prognosis; prescribing, however, the iodide of potassium in large doses. The following year she returned, but this time the sixth nerve was affected, causing internal strabismus; and the ptosis, paralysis of the in- ternal rectus, and the dilatation of the pupil, had entirely disappeared. The other symptoms had for a time been very greatly relieved by the treatment, but had reappeared in considerable intensity about two months previously. In another instance, this migratory character of the disease was well shown. The case was that of a young man, a private .patient, but whom I showed to the class attending my clinique. He came to me originally with external strabismus, ptosis, and dilatation of the pupil of the left eye, together with defective accommodation. Examination with the ophthalmoscope showed the existence of optic neuritis, rather slight in character, but yet decided, in both eyes. He had also the most CHRONIC CEREBRAL MENINGITIS. 233 intensely agonizing pain in the head that has ever come under my ob- servation, with vertigo, frequent attacks of vomiting, and paresis if not paralysis of the left arm and leg. A consideration of his condition led me to the diagnosis of a cerebral tumor, and I accordingly gave a very unfavorable prognosis. I was led to this conclusion not so much from the motorial derangement, as from the atrocious cephalalgia from which the patient suffered. In this case there was some slight suspi- cion of syphilis, and I treated him with mercury and large doses of the iodide of potassium. In a short time the pain in his head disappeared, and in a few weeks there were no indications of paralysis anywhere; in fact, he was to all appearances perfectly cured. But at the end of two or three months he reappeared, with the corresponding set of symptoms in the right eye and right side of the body, and with pain in the head fully as severe as that which had characterized the previous attack. I again treated him with mercury and the iodide of potassium, and his symptoms again disappeared. He remained well for two years, when he had another attack, of which he was entirely relieved by the iodide of potassium. In this case, the history of which points strongly to a syphilitic origin, there were probably inflammation and thickening of the mem- branes at the base of the brain, and presumably gummy formations. The fact that the inflammation sometimes alternates with skin-erup- tions is interesting, and has been repeatedly noted. A case of the kind was not long since under my care. It was that of a gentleman who had attacks of acute pain in the head, accompanied with all the phenomena of paralysis of the left third nerve. There was effusion of lymph upon both optic disks, the result probably of old optic neuritis. Curiously enough, these attacks alternated with an eczematous affec- tion, involving the trunk and especially the breast. On the disappear- ance of the skin-disease under remedial measures, his head-symptoms immediately recurred, and, when they were relieved by the action of the iodide of potassium, he was again attacked with eczema. Of the forty-seven cases of basilar meningitis collected by Gintrac,1 several of them were distinctly chronic in character. As post-mortem examinations were made in these cases, they will be more appropriately considered under the head of morbid anatomy and pathology. Causes.—The causes of chronic basilar meningitis are generally sufficiently apparent. It may result from an acute attack, but this is not a usual mode of origin, for the reason already stated, that death is ordinarily the consequence of such an affection. The most common cause in my experience is syphilis; next, the inordinate use of alcoholic liquors; and next excessive emotional disturbance, such for instance as business anxieties. Then next in point of frequency come atmospheric vicissitudes, blows on the head, and attacks of other diseases, as scarlet 1 Op. cit., tome ii., p. 677. 234 DISEASES OF THE BRAIN. fever, and especially epidemic cerebro-spinal meningitis, and suppura- tive otitis. Men are more subject to it than women, and adults more than children. Frequently no cause can be assigned. Diagnosis.—Chronic basilar meningitis is not liable to be con- founded with any other cerebral affection except tumors, especially those of a syphilitic character, situated at the base of the brain, and chronic softening, arising from thrombosis of the basilar arteries, and diseases of the capillaries. From non-syphilitic tumors it may be distinguished by the fact that the paralysis is less extensive, that the pain is not usually so severe, that the vertigo is not so intense or persistent, and that the dis- turbances of vision are not so profound. In a word, the symptoms of chronic basilar meningitis are less pronounced than those of tumors at the base of the brain, while at the same time they are ordinarily de- veloped with greater rapidity. Another mark of difference is the fact that tumors, non-syphilitic in character, do not yield to remedial meas- ures, while chronic basilar meningitis often does, and is generally miti- gated by proper treatment. From tumors of a syphilitic nature, or gummata, as they are called, the diagnosis is difficult, if in fact there is any real distinction existing between them and basilar meningitis of syphilitic origin. A gummy tumor situated at the base of the brain can scarcely exist without the production of basilar meningitis, so that the symptoms such as have been described, present in a person having the clinical history of syphi- lis, are either the result of simple chronic meningitis, or of meningitis, associated with one or more gummy tumors. Virchowl goes so far as to doubt if even, where after death we find only meningitis, the condition has not been preceded by a gummatous affection which has disappeared. The further consideration of this point will be more proper under the head of morbid anatomy. Where there is no history of syphilis, of course the question of the existence or non-existence of syphilitic tumors will not arise. From thrombosis of the arteries at the base of the brain, and from such diseases of the capillaries in the same situation as have been de- scribed in the previous chapter, chronic basilar meningitis is scarcely distinguishable during the life of the patient. When these are syphi- litic in character, the two conditions generally coexist. Sooner or later, however, the former affections terminate in death, and the phe- nomena to which they give rise, though sometimes remitting in violence, are clearly not lessened in severity by medical treatment. As regards other affections, the history of the case will generally be a sufficient guide to a correct diagnosis. Prognosis.:—The prognosis is very much influenced by the etiology. Those cases which result from injuries generally terminate fatally, as do 1 "Pathologie des tumeurs, traduit de l'Allemand," Paris, 1869, tome ii., p. 440. CHRONIC CEREBRAL MENINGITIS. 235 those due to the excessive use of alcoholic liquors, especially if the habit be continued. When induced by mental influences the prognosis is generally more favorable, provided the patient can be subjected to the hygienic operation of rest, travel, change of associations, etc. Syphilitic basilar meningitis, if seen sufficiently early and subjected to proper treatment, usually terminates in recovery. Subsequent attacks, which are always liable to occur, do not in general run so favorable a course. In all cases a great deal depends upon the duration of the disease. When of long standing the morbid changes in the tissues involved have usually become so profound that recovery is not a probable sequence. The age of the patient is likewise an important point in the prog- nosis ; and, other things being equal, individuals of advanced years are not so apt to recover as those of middle life. In children a fatal termi- nation is to be expected. Those cases which are due to the extension of inflammation from the ear almost invariably end in death, as do those ensuing upon epidemic cerebro-spinal meningitis. Latterly, however, I have had under my charge two cases, resulting from cerebro-spinal meningitis, in which it has taken place, though with very marked impairment of vision from double optic neuritis in both, and of hearing in one. Morbid Anatomy.—The morbid anatomy of chronic basilar menin- gitis does not differ in many respects from the corresponding affection of the convex surface of the brain. It is, however, generally much more circumscribed in its extent, and may be restricted to a portion of the membranes not larger than a dime in circumference. In one form the affected tissues are thickened and opaque, and there is an exudation of serous or gelatiniform fluid ; in another the exudation is puriform ; and in a third it is thick and gummy, constituting the so-called gummy tumor of syphilitic origin. The serous or gelatiniform exudation often shows a tendency to be- come organized and to present a membraniform appearance, or even to assume a still more solid form. Gintrac cites from Simon : the case of a woman, thirty-five years old, who for six years had been subject to paroxysms of intense cephalalgia. Two years subsequently she became blind on the left side, and for two months afterward suffered still more severely from pain in the head ; then she lost the sight of her right eye. Both irides remained contractile. The sense of smell was lost, though the pituitary membrane retained its tactile sensibility. Hearing, taste, and touch, were unaffected. Coma supervened, in which she died. On examination, the diploe and the membranes were found congested. The arachnoid and the ventricles contained an excess of serous exuda- tion. In the pia mater there was a deposit of a whitish-gray fibrinous substance which followed the course of the middle cerebral vessels, and lay over the chiasma of the optic nerves, the tubercula mammillaria, and 1 "Bulletin de la soci6te anatomique," 1845, p. 196. 236 DISEASES OF THE BRAIN. the anterior perforated spaces. The optic and olfactory nerves were atrophied and the chiasma deformed ; the retinae were normal. Usually the membranes are, in some places, firmly adherent to each other, and not infrequently to the cortical substance of the brain, in which case the latter is softened to such an extent as to tear away when the attempt is made to separate the membranes from it. When the exudation is puriform in character it occasionally becomes thick, and appears as semi-solidified plates in various situations. The exudation, whatever its nature, may be deposited between the layers of the arachnoid, in the sub-arachnoid space, or in the meshes of the pia mater. Its seat may be any part of the base of the brain, but its usual situations are the chiasma of the optic nerves, along the course of these nerves, on the tuber cinereum, the corpora mammillaria, and be- tween the crura cerebri. Sometimes it extends anteriorly along the course of the olfactory nerves, laterally into the fissure of Sylvius, and posteriorly as far as the pons Varolii and medulla oblongata. In the syphilitic form of the disease it is a matter of some doubt whether the gummy exudation is the result of the specific inflammation of the membranes or whether the inflammation is excited by the pres- ence of the new formation. Gintrac * seems inclined to doubt the ex- istence of syphilitic meningitis, though he admits the possibility of its occurrence. For him there is no syphilitic meningitis unless its pres- ence be demonstrated by a post-mortem examination and its character- istics definitely established, while others give a specific nature to any inflammation of the meninges—and, in fact, to any other affection— occurring in a person who, at any time, has been the subject of syphilis. In my opinion, cerebral meningitis may be induced by the syphilitic diathesis, and thus be a syphilitic meningitis, and it may exist as a non- specific affection in an individual who has had an infecting chancre. Undoubtedly there are cases of meningitis occurring in syphilitic per- sons that are no more under the influence of anti-syphilitic treatment than the cases happening in otherwise healthy individuals. Fox,a however, states it as his opinion that it is at best an open question whether meningitis ever occurs independently of syphilis, rheumatism, alcoholic poisoning, tubercle, anaemia, or mechanical irritations. But, in regard to the morbid anatomy of chronic basilar meningitis of syphilitic etiology, Virchow8 has supplied very important data in his remarks on syphilitic tumors of the brain and its membranes. The gummy tumors are seen most frequently at the base of the brain. Sometimes they are very exactly defined in their boundaries, and then they are tumors in the true sense of the word ; but ordinarily they are more diffused, and are accompanied with the phenomena of inflamma- ' Op. cit, tome iii., p. 100. * " The Pathological Anatomy of the Nervous Centres," London, 1874, p. 65. * Op. cit, p. 437, et seq. CHRONIC CEREBRAL MENINGITIS. 237 tion, a fact which seems to distinguish them from the true tumor. As already stated, Virchow regards this condition as a " gummy inflamma- tion ;" and even when the exudation is not present, and the appear- ances are those of a non-specific inflammation of the membranes, the question may arise whether or not the gummy exudation has not been the first step in the morbid process, but, having been absorbed, has left only doubtful traces of its presence. With the true gummy tumor we are not at present concerned. The most common seat of syphilitic basilar meningitis is the region bounded anteriorly by the chiasma of the optic nerves, and posteriorly by the crura of the cerebellum. Hence it is that the nerves lying at the base of the brain, and especially the third pair, are so liable to be im- plicated. This latter, from its exposed situation, running as it does from the crura cerebri to the orbit, can scarcely escape being involved in the morbid process. Pathology.—The functions of the nerves at the base of the brain are so well understood that the connection of the symptoms of chronic basilar meningitis with the morbid condition constituting the disease is sufficiently apparent in the great majority of cases. The circumscribed character of the inflammation enables us also to determine its seat with accuracy, and its migrations can be marked with considerable certainty. Probably in the very earliest stage of the disease these points cannot always be clearly made out, for the principal phenomenon is centric pain, due to congestion, and it is difficult to locate the seat with exact- ness ; but, as the affection advances to its full development, effusion takes place, and then the eccentric symptoms become more prominent if they do not at this time make their appearance. These we have seen consist of disturbances of sensibility and of motility in those parts of the body supplied by the nerves at the base of the brain, or of aphasia from the extension of the inflammation along the fissure of Sylvius to the island of Reil, or parts of the brain in its immediate vicinity. It is only at a still later period, when the morbid process has directly or in- directly involved the substance of the basilar surface of the brain itself, that sensibility or motility is disturbed in the trunk and limbs. When the sense of smell is deranged, the lesion exists upon the same side as the symptoms, for, as we know, the olfactory nerves do not de- cussate. When vision is impaired from optic neuritis, we cannot be so sure as to the side upon which the disease exists. For we may have optic neu- ritis as the consequence of disease in distant parts of the brain, as well as from the direct implication of the optic nerves in the pathological condition ; and even when this latter is the case, owing to the in- complete decussation of these nerves, it is possible for optic neuritis to exist in conjunction with a homolateral or a heterolateral lesion. The symptoms due to the involution of the third pair of nerves are 238 DISEASES OF THE BRAIN. manifested as regards the upper eyelid, which becomes paralyzed and drops over the eye, the muscles of the globe, except the external rectus, and the pupil, which is dilated, owing to the paralysis of the circular fibres of the iris, which receive their motor influence, through the third nerve, from the ophthalmic ganglion. The third pair of nerves have their apparent origin in the crura cerebri, the right nerve from the right crus, and the left nerve from the left crus. If, however, the fibres be followed out by minute dissec- tion, as has been done by Vulpian' and others, they are seen to be ar- ranged into three groups. Of these the middle and posterior decussate after passing entirely through the crus, while the anterior group passes forward to the optic thalamus, in which ganglion the fibres are lost. None of the fibres of origin originate in the crus, and this latter may be entirely dissected away and the third nerve be left intact. Now, if Vulpian be right in his view—and there is no doubt now upon the sub- ject—that a considerable number of the fibres of origin of the third nerve decussate, any disease of the brain affecting these fibres must be manifested by derangements of motility of the muscles supplied by the nerve of the opposite side, and, as the motor and sensory fibres of the spinal cord decussate below the point at which the third nerves decus- sate, the disease, if causing paralysis of other parts of the body, would induce this condition also on the opposite side; or, in other words, on the same side with the paralysis of the muscles supplied by the third nerve. Each crus cerebri contains the motor and sensory fibres which come from the opposite side of the body, below the medulla oblongata. It also contains the fibres of the corresponding third nerve. Disease in- volving a crus would therefore cause derangement of motility in the muscles supplied by the corresponding third nerve, and of sensation and motion in the opposite half of the body ; alternate or cross paralysis would therefore be the result. As chronic basilar meningitis often in- volves the membrane covering a crus, cross-paralysis is frequently a phenomenon of the disease. In those cases in which there is no paralysis anywhere except in the muscles supplied by the ocular motor nerve, the lesion must exist ante- riorly to the crus, and affect the trunk of the nerve of the same side as that of the paralyzed muscles. It is not often the case that the fourth nerve, or trochlearis, is alone involved ; though one such case has come under my observation. In this the patient had no marked symptom of any kind, except that in a certain position of his head he saw double. On examination, I ascer- tained that, when he turned his head toward the left shoulder, he saw double, and hence I diagnosticated paralysis of the left inferior oblique muscle. Further experiments confirmed this opinion, and the diagnosis of chronic basilar meningitis was shown to be correct by the extension 1 " Essai sur l'origine de plusieurs paires des nerfs craniens." These de Paris, 1853. CHRONIC CEREBRAL MENINGITIS. 239 of the disease so as to involve the third nerve, and by the supervention of pain and other phenomena of the affection in question. The sixth nerve, or abducens, is not infrequently the only nerve implicated in the lesion, and then there is internal strabismus from paralysis of the external rectus muscle. Several such cases, in which there were the concomitant symptoms of chronic basilar meningitis, have come under my notice. The case of one of these, a woman, who formed the subject of a clinical lecture, has already been cited. An- other case was that of a man, the subject of syphilis, and in whom the lesion was only manifested as regarded the external rectus muscle. There were no head-symptoms of any kind. The paralysis had ensued during the night, and the patient awoke in the morning to find that he had internal strabismus and double vision. He recovered entirely under the use of large doses of the iodide of potassium. But on the 10th of January, 1875, he had an epileptiform paroxysm, and this was several times repeated during the following week. Under the influence of the iodide of potassium, conjoined with the bromide, he has for the past two months had no return of the convulsions ; but his mind is somewhat confused, and he has occasional severe pain in the head. The seventh, or facial nerve, is sometimes embraced in the morbid process, giving rise to paralysis of one or more of the muscles on one side of the face, which it supplies. In one instance, apparently the re- sult of syphilitic basilar meningitis, which came under my charge in December, 1874, both facial nerves were involved, and there was conse- quently double facial paralysis. The eighth, or auditory nerve, also occasionally gives evidence of loss or impairment of its function; but, unless special examination rela- tive to the hearing be made, or both nerves be involved, the lesion, as regards this nerve, may escape detection, as patients very often, even when the hearing is entirely destroyed in one ear, are unaware of the fact, and persist that it is unimpaired. The ninth, tenth, and eleventh pairs of nerves are not so apt to be affected in chronic basilar meningitis as some of the others, for the rea- sons that their relations with the interior of the cranium are not so in- timate, and that the seat of the disease is generally anterior to their situation. Should the ninth, or glosso-pharyngeal nerve, be involved, there would be loss or impairment of the sense of taste upon the corre- sponding side, and the implication of the pneumogastric would lead to a complicated series of phenomena, of which the chief would be pal- pitation of the heart, irregularity of the respiration, and derangement of the function of digestion; while, if the spinal accessory were reached by the morbid process, there would be difficulty of swallowing, and perhaps alteration in the timbre of the voice. The hypoglossal, or sublingual nerve, is occasionally affected, pro- 210 DISEASES OF TnE BRAIN. ducing paralysis of the side of the tongue corresponding to the situa- tion of the disease. When the fifth nerve is involved, the chief manifestations of its lesion are relative to sensation. Thus there are either intense neuralgic pains in some part of the cutaneous surface of the head or neck, or there is equally well-marked anaesthesia. The former condition is by far the more frequent. From some cause or other, the motor fibres of this nerve almost invariably escape, and thus the temporal and masseter muscles are not paralyzed. I have, however, already cited a case in which they were affected. The general relation of the symptoms of chronic basilar meningitis with the lesion constituting the disease is well shown in several of the cases cited by Gintrac. Thus he quotes one from Bossu,1 that of a man, twenty-four years old, who from exposure became affected with headache about the supra-orbital region, vertigo, noises in the ears, facial neuralgia, and muscular contractions. At the end of a year he had vomiting, want of appetite, general debility, and a continuation of the supra-orbital headache. There were also amblyopia, diplopia, ex- ternal strabismus, dilatation of the pupils, and painful contractions of the right side of the face. The pulse was full, regular, and not fre- quent; the mind was unaffected. Coma supervened, the right side of the face became insensible, the evacuations were involuntary, speech was impossible, and the movements of the tongue were imperfectly per- formed. The pulse was feeble and frequent, and death ensued. On post-mortem examination, a reddish serum was found to be infiltrated between the convolutions. At the base, under the third ventricle, a gelatiniform substance enveloped the commissure of the optic nerves and the tuber cinereum. It was reddish in color, and was closely ad- herent to the pituitary gland. The tubercula mammillaria were sepa- rated by a reddish mass, which extended into the ventricle, and which there had the size and form of a nut. The following case, cited by Gintrac * from Simon, is equally inter- esting : " A woman, thirty-five years old. For six years accessions of pain in the head. Two years afterward blindness of the left eye, and then for two months the most intense cephalalgia, followed by loss of sight in the right eye. Pupils still active. Anosmia, although the pituitary membrane preserved its tactile sensibility. Hearing, touch, and taste unimpaired. Skin warm; pulse freqnent, hard, and small. Failure of appetite; thirst, constipation, coma, death. "There.was congestion of the diplOe and of the meninges. The arachnoid and the lateral ventricles contained serum. There was a grayish-white deposit, of fibrinous appearance, in the pia mater, along 1 Gazette medicale de Lyons et moniteur des hopitaux, 1855, p. 853. 2 "Bulletin de la societe" anatomique," 1860, p. 143. CHRONIC CEREBRAL MENINGITIS. 241 the course of the middle cerebral vessels, on the chiasma of the optic nerves, the tubercula mammillaria, and the anterior perforated spaces. The olfactory and optic nerves were atrophied, and the chiasma was de- formed. The retime were normal. The tissue of the brain at the base was superficially softened." Treatment.—The principles which have been laid down for the man- agement of cases of chronic verticalar meningitis are equally applicable to the basilar form of the disease. The iodide of potassium, conjoined with some one of the bromides, should be administered; and, in syphi- litic cases, the former should be pushed to its extreme limit by gradu- ally increasing the doses. At the same time, there are other means of treatment, which are rendered necessary by the existence of paralysis, and these ordinarily consist of strychnia and some form of electricity. The details will, perhaps, be more clearly shown by the citation of a few cases from my note-book: A. W., married, aged thirty-two, consulted me, April 7, 1873, for pain in the head, accompanied by paralysis of the third nerve on the left side, producing ptosis, external strabismus, dilatation of the pupil, and double vision. On examination with the ophthalmoscope, both optic papillae were found to be congested, the left far more so, how- ever, than the right. He had had an epileptiform convulsion about two weeks before coming to me, and had suffered very often from at- tacks of vertigo. The first evidence of the disease was the cephalalgia, which had been very gradually developed during six or seven months, and which was mainly confined to the left temporal region. The pa- ralysis of the third nerve had been suddenly produced, on the morning of the 1st of April, while he was eating his breakfast. There was not the least evidence of syphilis in this case. The af- fection had obviously originated from long-continued anxiety of mind, the consequence of business troubles. I immediately began the administration of the iodide of potassium in the form of the saturated solution, in doses of ten drops three times a day, increased to twelve drops the second day, fourteen the third, and so on. After the fourth day, the intense pain in the head began to diminish; and on the tenth day, when the patient was taking thirty drops—equivalent to thirty grains—three times daily, it entirely disap- peared. The paralysis of the third nerve, however, continued, although the doses of the iodide were carried up to over two hundred grains daily, or seventy grains at a dose. The medicine was then discon- tinued, and the patient was treated with gradually-increasing doses of strychnia, and the interrupted primary or galvanic current applied to the closed eye, as nearly as possible over the internal rectus muscle on the upper eyelid. This treatment was persevered with for several weeks, without any marked effect upon the paralysis of the upper eye- lid, though the internal rectus muscle gradually recovered its power, 16 242 DISEASES OF THE BRAIN. and the diplopia disappeared. Nearly a year afterward, when I again saw the patient, the lid still drooped; but there had been no return of the other symptoms. A gentleman, aged about fifty, single, consulted me on the 11th of August, 1874, for intense pain in the right side of the head, with which he had suffered for several months, night and,day. Upon exam- ination, I discovered that he had experienced an attack of iritis of the left eye ten years previously, and that there was other evidence of syphilis. There was paralysis of the internal rectus of that side, which caused strabismus, though no diplopia, as the sight of the eye had been lost by extension of the inflammation to the capsule of the lens, causing opacity. In conversation with him, I observed that he was deaf in the right ear, a fact which he had not noticed till his attention was called to it and the hearing capacity tested. On examining the ear with the speculum, I perceived that the external auditory canal was closed by a growth of some kind, which was adherent to the anterior wall. The ophthalmoscope revealed the existence of marked optic neuritis of the right eye, and the patient could not read No. 3 of Galezowski. No ex- amination could be made of the left eye. On the following day, when he made his-visit to me, the right side of his face was paralyzed, as was also the right side of the tongue, and his speech was, in consequence, rendered very difficult and indistinct. I then began the administration of the iodide of potassium, in the form of the saturated solution, starting with the dose of ten drops three times a day, and directing it to be gradually increased. This was con- tinued till the 14th, when I removed the growth from the ear, by ex- cision, with a delicate bistoury. The effect of this operation was at once evident, so far as the hearing was concerned, and the patient de- clared that the pain in the head was decidedly mitigated. As it still, however, continued, I augmented the doses of the iodide by six drops a day, instead of three, and began the application of the interrupted primary current to the paralyzed muscles of the face and tongue. On the 20th he was taking twenty-one grains three times a day. The pain was decidedly less; but, as there were sharp lancinating pains along the course of the auricular branch of the lesser occipital nerve, I made an incision through the scalp, so as to divide it. The effect was, to abolish this pain altogether. The intra-cranial pain gradually diminished under the increasing doses of the iodide, and on the 27th of August had entirely ceased. The medicine was continued for several days after- ward, and was then omitted. The tongue gradually improved in motor power ; but several months subsequently was not protruded straight, although the speech was as good as ever. There has been no return of the other symptoms. The growth removed from the ear was examined microscopically by my friends Prof. Roosa and T. E. Clark, as well as by myself, and we CHRONIC CEREBRAL MENINGITIS. 243 agreed in the opinion that it was neuromatous in character. The whole tumor was somewhat larger than a large pea. The following very interesting case, which occurred recently in my practice, I quote from Dr. Lente's excellent paper " On the Neurotic Origin of Disease,"x read before the New York Neurological Society, December 7, 1874, Dr. Lente had frequent opportunities of seeing this patient in my consulting-room, and of witnessing the results of the treatment. Mr. W. was also kind enough to allow me to present him at my clinique at the Medical Department of the University of New York, and to describe his case to the class in attendance. " The treatment of the following case I had the opportunity of watching, through the courtesy of Prof. Hammond. The history I had from the patient himself: " Mr. W., a grain-inspector of Chicago, was attacked three years ago with epileptic convulsions; has had them once a month or oftener; also some threatening cerebral symptoms; had no treatment that he knows of except moderate doses of bromide of potassium and chloro- form inhalation. In June last he had a recurrence of cerebral symp- toms, insomnia, pain, double vision, etc. This lasted two weeks, and disappeared. On the 14th July, after some exposure to the sun, he was again attacked with the above symptoms, to a greater degree, and with complete inability to raise the eyeball or upper eyelid (left eye), also extreme internal strabismus, diplopia, and severe cephalalgia. These symptoms occurred suddenly in the night. Could neither read, nor distinguish the quality of grain. The strabismus disappeared slowly, and the ptosis also diminished somewhat, so that when he ap- plied to Dr. H., about the 13th of October, 1874, he could, by an effort, raise the lid so as to expose the cornea, but it fell back immediately; other symptoms the same. He was put upon increasing doses of the iodide of potassium, with the idea of relieving the basilar meningitis, presumed to be the cause of the symptoms, the application of the induced current to the brow and temple, and the hypodermic injection of strychnia. No immediate effect could be expected from the first two remedies; it is to the last that I desire to direct attention. Prof. Ham- mond proposed to inject the solution directly into the affected muscles, and accordingly did so, using gr. -£% in two drops of water; it is pre- sumed that it passed into the muscle, or most likely in its immediate proximity. In all, six injections, I think, were used. I watched the effect carefully and tested the eye and lid after each. They were done each alternate day. He declared that he perceived quite a decided ef- fect. After the second there was no doubt, as I could see the change within fifteen minutes, both on the ball and on the lid, but especially on the latter; after the third, the ptosis had entirely disappeared, and he could raise the ball to an horizontal plane; the diplopia had disap- 1 Psychological and Medico-Legal Journal, February, 1875, p. 82. 244 DISEASES OF THE BRAIN. peared, and he could read by holding the book low. After the fifth in- jection (gr. -^g-) no difference in the appearance of the eyes was distin- guishable, and he could read with the book held directly before him. He considered himself cured." In this case the iodide was carried to doses of sixty grains three times a day, before the pain began to yield; and eighty grains, equal to two hundred and forty grains daily, was reached, and continued for several days, before it was deemed advisable to omit its use. Mr. B. was sent to me, December 19, 1874, by Prof. M. A. Pallen. At the time he was suffering from agonizing pain in the left side of the head, paresis of the whole right side of the body, except the face, apha- sia, of the amnesic variety mainly, although the power to coordinate the muscles of articulation was greatly impaired, and from decided mental disturbance, characterized by the existence of hallucinations and marked dementia. The sight of both eyes was weakened, and examination with the ophthalmoscope showed the existence of double optic neuritis. There was a clear history of syphilis. I immediately began the administration of the iodide of potassium, in ten-grain doses, three times a day, gradually increased, as in the fore- going cases. By the time twenty-grain doses were reached the pain in the head had disappeared, the speech was much improved, the weakness of the right side had diminished, and the mind was altogether stronger. The iodide was continued up to sixty-grain doses, and then, as the patient was apparently cured, it was omitted, and he resumed his duties as cashier in a bank. Two months afterward, he had a relapse into his former condition. The accession was sudden. He awoke in the morning with pain in the head, weakness of the right side, and complete loss of speech. His aphasia was removed by a single application of the galvanic current from ten cells to the tongue, and I increased the use of the iodide as be fore. He again recovered his health. He is now (March 23d) quite well. It would be very easy to adduce many other cases from my private and hospital practice, but the foregoing are sufficient to indicate the main principles of treatment in chronic basilar meningitis. Occasion- ally, in cases of syphilitic origin, in which the infection has been recent, it may be advisable to administer mercury in some one of its forms. The bichloride, in the dose of the one-sixteenth of a grain, may be given with each dose of the iodide of potassium, or the biniodide in like doses, in the form of pill. Whether the affection has a syphilitic origin or not, antiphlogistic measures, as they are called, are not proper. On the contrary, wine and highly-nutritious food are frequently productive of amelioration. Should insomnia be present, some one of the bromides should be given, in doses of from fifteen to thirty grains, three times a day, till its full effect be produced. TUBERCULAR CEREBRAL MENINGITIS. 245 It may be stated that I have never observed any ill effects follow the administration of the very large doses of the iodide of potassium which I have recommended. Coryza is certainly not more apt to occur than with the small doses, nor is it more severe. Gastric irritation can generally be prevented by diluting each dose in a sufficient quantity of water. A dose of fifty or sixty grains should never be taken in less than half a tumbler of water. In the treatment of the paralysis which often remains, even after all active disease within the cranium has disappeared, electricity is almost indispensable; and I am entirely satisfied that the hypodermic injection of strychnia into the paralyzed muscle, or as near as may be to it, is a measure of the utmost importance. The good effects of it were very clearly seen in one of the cases cited. CHAPTER X. TUBERCULAR CEREBRAL MENINGITIS. Inflammation of the membranes of the brain, attended with or due to a deposit of miliary tubercles, was for many years considered as a disease peculiar to infancy, and was known as acute hydrocephalus be- fore its morbid anatomy and pathology were clearly comprehended. It is now well understood to be an affection to which adults are liable. By some authors, especially Robin and Bouchut, it is regarded as not being tubercular in character. It has hence occasionally been termed granular meningitis. Although mentioned by the ancient medi- cal writers, no clear and systematic description of tubercular meningitis was given till Whytt1 published his essay on the subject of dropsy of the brain. Since that time it has received the attention of many writers in this country, Great Britain, France, and Germany. Symptoms.—Whytt defined three periods of the disease, which he marked by the state of the pulse. I think the symptoms may be prop- erly arranged in four stages: 1. The prodromatic stage; 2. The stage of excitement; 3. The stage of depression; and 4. The stage of recur- rence. 1. The Prodromatic Stage.—This period may be altogether want- ing, or may be so slightly manifested as not to be noticed. Generally, however, it is well marked. If the child be sufficiently advanced in years, a change of disposition is among the first symptoms perceived. Thus the temper becomes irri- 1 " Observations on the most Frequent Form of the Hydrocephalus Internus, viz., Dropsy of the Ventricles of the Brain. Works of Robert Whytt, edited by his Son." Edinburgh, 1768, p. 725. 240 DISEASES OF THE BRAIN. table, caresses are disregarded, and dislike is shown for those amuse- ments which formerly gave pleasure. At the same time the appetite disappears, and the child loses flesh rapidly. This latter is not noticed about the face, but is mainly confined to the abdomen and limbs. The bowels are generally obstinately constipated, but occasionally there is diarrhoea. Headache is not often complained of; neither is vomiting a common symptom of this period. Fever is not continuous, although it is generally present at irregular times of the day. The prodromatic stage may last only a few days, or may be pro- longed for two or three months. 2. The Stage of Excitement.—This period is ushered in by obsti- nate vomiting, which is present in many cases, even though no food be taken. Intense pain in the head is a coincident symptom, and is so severe that the child puts his hands to his head and cries out or awakes screaming. Convulsions may also occur. They do not differ in gen- eral appearance from the ordinary epileptic paroxysms, and may be re- peated several times. Very early in this stage the fever becomes more persistent than in the first stage, although it may still be irregular. The pulse, however, is not hard and resisting, as in other inflammatory affections, but is soft and compressible. Trousseau' has called attention to a condition of the skin present in tubercular meningitis, which he at first regarded as peculiar to this dis- ease, but which subsequent investigation showed was likewise found in simple meningitis, in typhoid fever, and some other affections. If the finger-nail be passed lightly over the surface of the abdomen or the thorax so as to trace a series of lines, in about thirty seconds the skin becomes red—the color being at first diffused, but very soon the lines made by the nail are indicated by a still redder color, which persists a long time. Trousseau calls this appearance the "cerebral stain" (tache e'er cbr ale). The phenomenon he attributes to a profound modification in the vascularization of the skin; and, although it is not to be regarded as absolutely pathognomonic, it is a sign of very great importance. The intellectual faculties are not yet affected to any considerable extent, but the changes of character and disposition, and indifference to things which formerly excited interest, are still well marked. The physical strength, though lessened, is still not yet so far re- duced as to oblige the patient to remain in bed. The tongue is usually coated and red at the edges, the appetite diminished, and the bowels are obstinately constipated. The temperature of the body is elevated, but not to an extreme de- gree; the thermometer indicating from 101° to 103° Fahr. Sometimes there are distinct remissions in the violence of all the symptoms, but the disease nevertheless goes on to its full development. The transmission 1 Op. cit, Lecon lv., " Fievre C6r6bralc." TUBERCULAR CEREBRAL MENINGITIS. 247 from the second to the third stage is often marked by an amelioration which may last several days. From what has been said, it will be seen that the characteristic ■ phe- nomena of this stage are headache and vomiting. Its duration varies from seven to fourteen days. 3. Stage of Depression.—The pulse, which in the previous stage was sometimes as high as 140, and sometimes as low as 80, now becomes less rapid than is normal, and may even fall below 50. At the same time the beat is quick, but the interval between the pulsations is at times so great that the observer is, as Dance1 says, fearful that the action of the heart has stopped. The interval between the pulsations is often irregular, and this may be regarded as a sign of unfavorable im- port. In young infants there is a reduction in the temperature of the body below the normal standard, which lasts throughout the whole of this period. Roger regarded this reduction, preceded as it is by a higher temperature, and followed during the succeeding stage by another ele- vation, as pathognomonic of tubercular meningitis. The continued excitement of the previous stage is replaced in this by a strong tendency to somnolence, which alternates with a rather quiet delirium. The patient lies on his back, with the eyes fixed, but yet not looking at any object with attention. Events taking place around him no longer attract notice, and, though when addressed in a loud tone he may turn his gaze toward the speaker, it is very evident that the words convey no idea to his mind. The fingers are kept in almost continual motion, picking up threads and other small objects from the bedclothes, and occasionally clutching at imaginary things. Again, the fingers are alternately opened and shut without any real or apparent motive, and again the head is turned restlessly from side to side of the pillow. Convulsions are very gener- ally present from time to time during this stage, and may be so fre- quently repeated as to leave scarcely any interval between the seizures. Even if the attacks do not involve the body generally, the eyes scarcely ever escape; there being strabismus, convulsive movements of the pupils, and constant motions of the eyeballs. The facial muscles are likewise often affected. In the intervals of wakefulness, the cephalalgia continues, and causes the peculiar scream which is so characteristic as to have received the name of the " hydrocephalic cry." It is a sound such as might be produced by mingled emotions of terror and grief. Although probably excited by the pain, it is more or less automatic, and is not exactly such a cry as would be produced by unmixed physical suffering. It is ac- companied, however, by that contraction of the muscles of the face in- dicative of suffering. 1 " M6moire sur l'hydrocephale," Archives generale des medecine, 1830. 248 DISEASES OF THE BRAIN. The paleness of the countenance continues, but at times there is a sudden redness, which disappears as rapidly as it comes. The conjunctiva? are generally injected, and photophobia is present. M. Bouchut,1 who has given great attention to the subject of ophthal- moscopy in diseases of the nervous system, finds peripapillary con- gestion, dilatation of the retinal vessels, and deformation of the papilla?. There is often a general hyperaesthesia of the skin, for which, how- ever,' anaesthesia may be substituted. When this latter is the case the conjunctivae participate, and inflammation results. The limbs are weak, and, should the patient attempt to walk, the gait is staggering. The speech is hesitating, is rarely indulged in ex- cept in response to questions, and then with the least possible expendi- ture of words. The vomiting, which formed so prominent a symptom of the previous stage, has ceased, but the constipation still persists. The respiration is irregular, sometimes being rapid and sometimes slow. Occasionally there are deep sighs, followed by numerous quick inspirations, and again the respiratory movements may be so slight as scarcely to be perceived. This variation from the normal action, as well as the irregularity of the heart's movements, is due to the implica- tion of the pneumogastric nerves at their origins. This stage may last for from two or three days to two weeks. 4. Stage of Recurrence.—The characteristic phenomena of this stage are the return of the fever and the increase in the violence of the symptoms indicative of cerebral disturbance. Before its onset there may be a period of nearly complete intermission, so that the impression may be formed that recovery is taking place. This apparent cessation of the morbid action, however, only serves, with the experienced ob- server, to make the reappearance of the symptoms more striking. Convulsions are more frequent and violent than in the previous stage, and tonic contractions of the limbs are not uncommon. These contractions are more generally met with in the muscles of the neck and upper extremities, and vary from time to time in their intensity. The head is thus thrown backward, and, as the morbid action frequently extends to the muscles of the back, an appearance in the patient not unlike that present in tetanus is produced. Paralysis eventually supervenes. At first this is incomplete, affect- ing only a single limb or the muscles of the face, but it extends, and both limbs on one side, or an arm and a leg of opposite sides, become in- volved. Voluntary power is lost, but reflex movements can be excited by pinching or tickling. The delirium acquires increased intensity, and alternates with the somnolence, which likewise becomes more profound, and which gradu- 1 " Du diagnostic des maladies du systeme nerveux par l'ophthalmoscopie," Paris, 1866, p. 45, et seq. Plates iv., v., vi., vii., viii., ix., and xi., of the Atlas. TUBERCULAR CEREBRAL MENINGITIS. 249 ally masks all the other symptoms, till at last the coma is persistent and general, and spinal sensibility is lost. Before death the pulse rises in frequency, a cold sweat makes its ap- pearance, and the patient dies either by a slow process of asphyxia, or in convulsions. The fact that tubercular meningitis is not confined to infants is now generally admitted. Dance l was the first to recognize its occurrence in adults, and Gerhard,2 of Philadelphia, a few years subsequently reported several cases. Ledibuder3 also pointed out the analogy between the tubercular meningitis of infants and that of adults, and still later Val- leix4 gave the weight of his authority to the same effect. So far as the symptoms are concerned, I have never been able to perceive any essential points of difference between the tubercular men- ingitis of children and that of adults. The affection is, of course, modified, as are all other diseases, by the age of the patient, but, when allowance is made for this factor, the morbid process is one and the same in character. In adults, however, it generally supervenes in the course of tuberculosis of the lungs, whereas in infants it is ordinarily a primary manifestation of the tuber- cular diathesis. Causes.—Tubercular meningitis is an expression of a general state of the system. To enter at length into the question of its etiology would necessarily involve a discussion of the cause of the diathesis to which it is essentially due. Nevertheless, there are a number of deter- mining causes that may be appropriately considered. Age is an im- portant factor in determining the accession of tubercular meningitis. It is rare during the first year of infancy, but is more common during the period extending from the second to the seventh year than any other time of Hfe. From eight to ten it is much less frequent, and from ten to fifteen is rarely seen. In adults it is most common between the ages of seventeen and thirty. From thirty to forty it is rare, and after forty is scarcely ever met with. Males are more frequently the subjects of tubercular meningitis than females, and this holds good for all ages of life. The season of the year appears to exercise no influence. As to many other exciting causes alleged by authors, such as blows, emotional excitement, and previous diseases, nothing very definite is known. The same cannot, however, be said of the morbific influence of bad air, insufficient food, improper clothing, neglect of cleanliness, and a disregard of other sanitary requirements. 1 Op. cit. 2 American Journal of the Medical Sciences, 1834. 3 " Essai sur l'affection tuberculeuse aigue de la pie-mere," Paris, 1837. * " De la meningite tuberculeuse chez l'adult." Archives generates de medecine, 1838. 250 DISEASES OF THE BRAIN. Diagnosis.—Tubercular meningitis is liable to be confounded with several other affections, and can sometimes only be distinguished with difficulty. From simple meningitis it may be diagnosticated by the facts that the onset of the former is sudden, while the latter is insidious in its ap- proach, and slow in the development of its symptoms; the one goes on steadily through its course, the other halts and remits; in the one the temperature of the body rises several degrees, in the other the elevation is scarcely ever more than two degrees; in the one there is no hereditary tendency, while in the other inquiry will usually reveal the existence of hereditary tubercular predisposition. The mental symptoms show a marked difference. In simple menin- gitis the delirium is often furious, and is always very active; in the tubercular form of the disease the delirium is quiet, and alternates with stupor. In typhoid fever there may be vomiting and headache, but the bowels are not constipated, and there is tenderness over the right hypo- gastric region. Moreover, the epistaxis, the eruption, and the swelling of the spleen, which occur in typhoid fever, will aid in making the diag- nosis more certain. Worms in the alimentary canal may give rise to a set of symptoms very similar to those which form the prodromata of tubercular menin- gitis. As Jaccoud observes, therefore, it is well, whenever a child ex- hibits these symptoms, to administer one or two doses of a strong ver- mifuge. A peculiar affection, to which young infants are liable, may be mis- taken for tubercular meningitis. It was first described by Dr. Gooch,1 but derived its name—" hydrocephaloid disease "—from Dr. Marshall Hall. I have already alluded to this disorder under the head of cerebral anaemia. In it the child is irritable, restless, starting at every noise, moving in sleep, and often waking screaming. Vomiting is frequently present, but the bowels are loose. The whole appearance of the child betokens exhaustion, and, if due care be not taken, death may ensue. The absence of constipation, the history of the case, and the depressed state of the fontanelle, if this be yet open, will suffice to render the diagnosis clear. Trousseau considers the irregularity of the respiration the most im- portant sign indicating the presence of tubercular meningitis. " In no other disease," he says, "will you meet with this singular anomaly. You will not observe this unequal and irregular respiration either in the essential convulsions of infancy or in typhoid fever. I have reason, then, for insisting on the importance of the symptoms." Prognosis.—There is not much to say under this head. The ordi- 1 " On Some Symptoms in Children erroneously attributed to Congestion of the Brain." Gooch's Essays, New Sydenham Society, 1859, p. 179. TUBERCULAR CEREBRAL MENINGITIS. 251 nary termination of the disease is death. I have never seen a case re- cover; and, though instances with a favorable result have been reported, I am disposed to think the diagnosis of such has been erroneous. Drs. Meigs and Pepper,1 of thirty-one cases, had no recovery, though they report a case of tuberculosis of the meninges—not tubercular menin- gitis—in which recovery appears to have taken place, though the child died a year or two afterward with dysentery. It seems contrary to reason to expect a radical cure in a disease in which the cause cannot be removed. Do what we will, the tubercular deposit remains; and, as Jaccoud remarks, the reported cases of recov- ery were rather instances of a long remission in the intensity of the symptoms. Seitz," in his recent treatise, asserts that the time when cases of acute hydrocephalus were cured has gone by, and that former ap- parent success is to be attributed to false diagnosis. He declares that he has never witnessed a case terminate favorably. Morbid Anatomy and Pathology.—A question arises at the outset of an inquiry relative to the morbid anatomy of tubercular meningitis, which refers to the essential character of the disease; and that is, whether the gray semi-transparent granulations met with on post- mortem examination are tubercles, or whether they are an entirely dis- tinct morbid product ? Valleix, Rilliet and Barthez, Barrier, Grisolle, Meigs and Pepper, and others, regard them as tubercles. Grisolle ex- presses himself clearly on this point. " We have no doubt," he says, "that these granulations are tubercles in a rudimentary state; for we have many times, in the same subject, followed the morbid product in its different phases of evolution from the amorphous condition to the fully-developed tubercle." On the other hand, Bouchut, basing his conclusions mainly on the microscopical observations of Robin, is of the opinion that the granula- tions are formed: 1. Of fibro-plastic elements, consisting of free nuclei and fusiform cells, and ovoid cells. The nuclei are ovoid or spherical, and generally very small, not exceeding 0.008 to 0.009 in. in diameter. 2. Of a great quantity of granular amorphous homogeneous matter, which keeps the other elements strongly united. 3. Of a few vessels and fibres of connective tissue. Among all these elements the tubercu- lar corpuscles of micrographers are not to be found; and, therefore, the disease cannot be regarded as tubercular in character. M. Empis3 also contends that the microscopical analysis shows that the gray granula- tions are entirely distinct from tubercle. On the other hand, it is alleged—and I am disposed to think with force—that the most which the investigations of M. Robin and others in accord with him show, is, 1 " A Practical Treatise on the Diseases of Children," Philadelphia, 1870, p. 452. 2 "Die Meningitis Tuberculosa der Erwachsenen." Berlin, 1875, p. 377. 8 "Traite de la granulie," Paris, 1865. 252 DISEASES OF THE BRAIN. that there is no special characteristic of tubercle which will enable us to declare with certainty that it is present, and that it does not possess a structure which is the same in all stages of its development. The col- lateral evidence goes very far to support the view that the granulations are tubercular in character. The question which also arises, as to whether the inflammation pre- cedes the tubercular deposit, or vice versa, is generally decided in favor of the prior appearance of the tubercles. The granulations are met with in the course of the vessels of the pia mater. This membrane is always more or less inflamed, and is thickened by the infiltration of sanguine- ous, serous, plastic, or purulent exudations. The granular or tubercular matter is generally deposited at the base of the brain, and in this position is doubtless the cause of the derangements of motility which constitute so prominent, a feature of the disease. Its ordinary seat is along the course of the middle meningeal artery and its branches. Sometimes, though rarely, it is found on the convexity of the brain. The tissue of the brain is not generally much involved, although on section the red points, indicative of the situation of blood-vessels, are very much increased in number. Occasionally there are small extrava- sations of blood found in the gray substance. The ventricles are distended by serum, and this is sometimes so great in quantity as to cause the rupture of the septum lucidum. The liquid is either clear and limpid, milky from the presence of pus-globules, or bloody from containing red corpuscles. The morbid anatomy of the lungs and other organs, although inter- esting in the present connection, need not be dwelt upon; suffice it to say that tubercular deposits are always met with in some one or more of the viscera and especially in the lungs. Treatment.—In regard to a disease so uniformly fatal as tubercular meningitis, there is not much to say. The principal advice I have to give is, to refrain from blisters, antimonial ointment, leeches, and drastic purgatives, which have no other effect than to shorten the life of the patient, and to make his existence still more intolerable than it is made by disease. Iodide of potassium does less harm, but I have never known it do any good. Niemeyer, however, recommends it, and many will doubtless continue to employ it on his authority. Seitz,1 in a work of nearly four hundred pages, treating of tubercular meningitis in adults, devotes less than two pages to the subject of treatment, and speaks rather flippantly of all supposed remedial measures. When we have any reason to suspect an hereditary tendency to tubercular meningitis, prophylactic measures may be used with hope of success. These consist in providing for pure air, ample clothing, nutri- tious food, and in the administration of cod-liver oil, iron, iodine, and Op. et loc. cit. SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 253 quinine. A climate not subject to sudden vicissitudes, and of such a character as regards warmth and dryness that the patient can spend a great portion of the day in the open air, is also a matter of prime im- portance. CHAPTER XL SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. Suppurative inflammation of the brain is a very rare affection un- complicated with meningitis. In this latter connection it has already been sufficiently considered. In the present chapter, therefore, I shall discuss it solely as an independent lesion, and mainly in reference to the subsequent formation of abscess. Symptoms.—The symptoms of suppurative inflammation of the brain vary according to the seat of the lesion, and are rarely of such a charac- ter as to enable us to say, with any great degree of certainty, that we have a case of uncomplicated encephalitis before us. Nevertheless, cer- tain phenomena have been recognized, and, after death, the evidences of inflammation of the brain have been discovered. But these symp- toms are, many of them, met with in other cerebral disorders, and there- fore cannot be regarded as pathognomonic. It is difficult, if not impos- sible, to arrange them in stages; and therefore, after the prodromata, I shall consider the phenomena of acute encephalitis in accordance with their relation to the several functions of the organism liable to be affected. The premonitory symptoms are similar to those of cerebral con- gestion, and doubtless depend upon a like pathological condition. Thus there are vertigo, pain in the head, noises in the ears, troubles of vision, numbness, and difficulties of speech. They never, however, last as long as they do in simple congestion. Sometimes the first-observed symptom of approaching encephalitis is an epileptiform convulsion. In the fully-established disease the phenomena are very decided, but at the same time have no necessary or constant relation with the pa- thology, as similar symptoms are met with in other very different affec- tions. Disorders of Sensibility.—At first, there is generally hyperaesthesia; subsequently, anaesthesia. Headache is a common symptom, as it is in so many other cerebral diseases. There is no particular location of the pain—sometimes the frontal region, at others the occipital, and again the vertical or parietal regions, being its seat. It varies, likewise, as regards intensity and form, and may consist of a feeling of fullness or 254 DISEASES OF THE BRAIN. constriction only. It is present from the very beginning of the disease, and usually continues through its whole course. Pains are felt in various parts of the body, are sharp and lancinating, and often attended with cramps. Cutaneous hyperaesthesia is also oc- casionally met with. In the next place, there is anaesthesia, with all its accompaniments of formication, numbness, and other abnormal sensations of the kind, mainly affecting the face and upper extremities. As to the special senses, the sight is almost always deranged. There are bright flashes of light, iridescent appearances, and photophobia, all showing increased irritability of the retina. The pupils are contracted, the conjunctivae suffused, and the eyeballs are the seat of a dull, aching pain. Subse- quently, the pupils become dilated, and vision is lost. Ophthalmoscopic examination shows, in the early stages, papillary infiltration, with retinal congestion, and later, papillary atrophy and granular degeneration, the results of optic neuritis. There is also, generally, double vision, to which allusion will be more fully made directly. The hearing is at first very acute, and even slight noises are more or less painful. Noises in the ears, of various kinds, are present. As the disease advances, the hearing becomes much impaired, and is gradually lost, in one or both ears. The taste and smell are rarely affected. Disorders of Motility.—As with the sensibility, the motor organs of the body at first exhibit evidences of increased excitability. Thus, there are twitchings of the muscles, mainly of those of the face, and clonic or tonic spasms. Sometimes these last for several days. Subsultus is especially noticed in the flexor tendons of the wrist. General convulsions may take place, with or without loss of con- sciousness. Frequently the action is limited to one side of the body, or implicates one side of the face, or a single limb. Strabismus occurs, and double vision is produced, at this stage, from spasms of one of the ocular muscles. This period of muscular excitation corresponds very accurately with the stage of augmented sensibility. It is succeeded by a period of diminished motor power. Paralysis generally begins in a distant part of the body, and slowly involves one side. Thus, there may at first be a difficulty in raising the toes, or in grasping things with the fingers; then the knee becomes weak, the flexors of the thigh follow, and the whole limb drags. If the arm be the first member affected, the difficulty advances from the fingers to the elbow, and thence to the shoulder. Sometimes the morbid action ex- tends equally on both sides of the body, and then the gait becomes weak and shuffling. The legs are spread wide apart, so as to increase the base, and keep the centre of gravity more easily within it. The knees are bent, the pelvis is flexed on the thighs, and the whole body is SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 255 inclined forward. The face rarely escapes. It may be affected on one side only, in which case there is distortion, or there may be a gradual failure of muscular power on both sides. The muscles connected with the eyes almost always suffer. Ptosis is common, and external strabis- mus, causing double vision, accompanies it, both being produced by the implication of the third or motor oculi nerve. One side of the face sometimes becomes permanently contracted, and thus an appearance is produced somewhat resembling that which is caused by paralysis of the opposite side. It may be distinguished from this latter condition, however, by the fact that in it the eyelids are spas- modically closed, and the side of the face much more distorted than when there is paralysis of the opposite side. The tongue is always, in my experience, prominently affected. The first sign of diminished mo- tility is the frequency with which it is bitten, in conversation or masti- cation, and sometimes it is made quite sore, on one or both sides, or at the tip, from this cause. Then the patient discovers that long-continued speaking causes a sensation of fatigue, at the root of the tongue, and that a feeling as if this organ were too large for the mouth is expe- rienced. Then articulation becomes indistinct, the words are clipped or slurred over, so that at times it is difficult for others to understand what he says. Disorders of Intelligence.—The first indication of mental weakness is the susceptibility experienced to the influence of emotions. The patient will thus get uncontrollable fits of laughing or crying from very slight causes, and sometimes from no apparent cause. These paroxysms are frequently of mixed character, the patient passing from laughing to crying, and vice versa. The memory begins to fail at a very early period, especially as re- gards the names of things. The enfeeblement is by no means, however, confined to words, but facts and circumstances likewise fail to be remem- bered. Gradually a condition of complete dementia ensues, and finally coma, with or without previous or alternating delirium. Disorders of the Functions of Organic Life.—There is always febrile excitement in encephalitis. At first the pulse is frequent, rising to 120, but as the disease advances it falls, till toward the close it goes below the normal standard. It is characterized, according to Barras,1 by a characteristic tremulousness (tremblottemeni), which he compares to the unequal vibrations of a cord moderately stretched. This pecu- liarity he attributes to irregular arterial dilatation. According to my experience, the symptom is by no means constantly met with, and it certainly is not pathognomonic, for the same peculiarity of pulse is found in several other disorders. In a case, however, now under my care, in which there is reason to suspect encephalitis and abscess, the phenomenon is present in a marked degree, not only in the radial 1 "Bulletin de la soci^te mSdicale d'emulation," Juin et Octobre, 1823. 256 DISEASES OF THE BRATN. artery, but in the temporal and the angular, as it passes between the nose and the inner angle of the orbit. The respiration in the first stages is not materially deranged, but later it becomes irregular and stertorous, and finally asphyxia may take place. The temperature of the body is elevated till the fever abates, and paralysis makes its appearance. The thermometer rarely, however, goes above 103° Fahr., and is generally a degree below this point. The digestive organs usually show more or less evidence of derange- ment. Constipation is always a prominent feature, and the appetite is capricious. At times the patient refuses to eat, at others he will cram his stomach with all kinds of edibles. Deglutition is often troub- lesome, and occasionally dangerous, from paralysis of the pharyngeal muscles. Cases are on record in which death has occurred by the food becoming impacted in the throat, and several cases have come under my own notice, in which, from a like cause, a fatal result was barely pre- vented by the use of very energetic measures. Moreover, the secretions of the mouth are almost always altered either in quantity or quality, or both, and the sensibility of the tongue and faucial mucous membrane is often impaired. Hence, the patient is not aware that he has filled his mouth, and goes on cramming it with food, which makes an alimentary mass larger than can pass through the oesophagus. This, of course, even without the pharyngeal paralysis, interferes with the act of swallowing. The faeces are sometimes passed involuntarily, but this is almost entirely a feature of the last stage. Nausea and vomiting are present more or less from the very first. There may be either retention of urine from paralysis of the bladder, or incontinence from paralysis of the sphincter. Or both conditions may coexist, giving rise to a constant dribbling. These symptoms may be arranged in five classes, designated by the most prominent feature of each: the paralytic, the comatose, the epi- leptiform, the apoplectiform, and the maniacal. Complications may and often do arise. Thus there may be menin- gitis, temporary congestions, extravasation of blood, effusion of serum, or some intercurrent visceral affection. The tendency of acute encephalitis is to suppuration and the conse- quent formation of abscess, and many of the symptoms enumerated are due to the supervention of this condition. Death ensues gradually from exhaustion or asphyxia, or may take place suddenly from the bursting of the abscess into the ventricles, or upon the surface of the brain. Causes.—No age is exempt from the disease, although it is more common in old persons than in adults of middle age or young persons. It is probably more frequent in males than females solely from the fact that they are more subject to the exciting causes of the disease. SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 257 Among these are the inordinate use of alcoholic liquors, venereal ex- cesses, extreme intellectual exertion, great emotional disturbance, and exposure to extreme heat. It may also be induced by disease of the internal ear, by erysipelas affecting the head, or by severe attacks of scarlet fever, small-pox, or other eruptive disease. The most common cause, however, is injury of the brain. Diagnosis.—The diagnosis of suppurative encephalitis is, in the first stages, difficult if not impossible; the symptoms being common, as I have already said, to several other disorders. From cerebral haemor- rhage the distinction can be made without difficulty, for, although en- cephalitis may be developed with rapidity and by an apoplectic seizure, the tendency is for the subsequent phenomena to become progressively more marked, while in haemorrhage there is a gradual amelioration. The pulse in haemorrhage is from the first slow and regular, unless the medulla oblongata be the seat, while in encephalitis it is rapid and ir- regular. Meningitis is always associated with superficial encephalitis, and hence the symptoms bear a certain amount of resemblance to those of the affection under consideration. But the latter is, in general, charac- terized by the facts that the paralysis is more defined, both in intensity and location; that the delirium is less acute; that the cephalalgia is not so intense, nor the delirium so prominent or constant a phenomenon. In epilepsy the paroxysm is the main phenomenon of the disease. When this ceases, the patient in general recovers his ordinary mental faculties, but the epileptiform seizures of suppurative encephalitis are never followed by complete intellectual restoration. The disease with which it is most likely to be confounded is that which, from its obvious characteristics, is denominated general paralysis. I know of no diagnostic marks between the two conditions, except that general paralysis is usually of longer duration, and is ordinarily charac- terized by a peculiar form of mental aberration—the delire des gran- deurs of the French. The symptoms due to tumors are often almost identical in character with those attendant on abscess. The history of the case is our only safe guide. The fact that the brain has received an injury of some kind will indicate suppurative encephalitis as the probable difficulty. A lady is, at the moment of writing this, under my charge, who has been suc- cessively treated by several of the most skillful diagnosticians of this city, at times for abscess, and again for tumor, and I venture to say that no one, without the aid of a post-mortem examination, can say which lesion exists. Prognosis.—Suppurative encephalitis is invariably fatal, if the dis- ease does not terminate in resolution. As Jaccoud, however, remarks, cases of alleged cure before the stage of suppuration is reached must 17 258 DISEASES OF THE BRAIN. always have an element of uncertainty about them, and do not there- fore permit us to mitigate the unfavorable character of the prognosis. Drs. Gull and Sutton,1 while stating that there is nothing in the morbid anatomy of cerebral abscess which makes it necessarily an incurable affection, admit that practically it is irremediable. In this opinion I unhesitatingly concur. Morbid Anatomy and Pathology.—Suppurative encephalitis is a local disease restricted in its action, and hence affecting a limited and well- defined region of the cerebral tissue. This may vary from the size of a walnut to that of the closed fist, and is ordinarily irregularly spherical in shape. Although never of a diffused character, there may be, at the same time, several centres of inflammation. The part most frequently affected is the gray matter of the cerebrum—the morbid process in- volving the white substance in its progress. Next, the cerebellum ap- pears to be a favorite seat. The corpora striata, and the optic thalami, are also frequently involved. It sometimes happens that the pus which results from the inflamma- tory action is not collected in a cavity, but is infiltrated into the sub- jacent tissue. In such cases there is no well-defined abscess, but a pulpy mass is found on examination after death, consisting of the ele- ments of the brain-substance in a more or less disorganised condition, with those of the blood intermingled with pus—the whole of a greenish- yellow color. Again, there may be a collection of pus, but at the same time the walls are imperfectly formed, and there is infiltration to some extent. Lastly, the puriform deposit is entirely limited by a membrane consist- ing of connective tissue, and forming a cyst. The cerebral substance in contact with the walls of an abscess gradually breaks down, and hence the cavity undergoes constant enlargement in all directions, but espe- cially in the lines of least resistance. If the abscess is near the surface of the hemisphere, the tendency is to enlarge toward the external periphery ; if it is situated in the central part, in the corpora striata or optic thalami, the absorption of the peripheral tissue takes place in the direction of the ventricles. In the first instance, when the rupture en- sues, the pus will be extravasated into the cavity of the arachnoid; in the second, it will be poured out into the ventricular cavities. In either case, coma and death will result if the amount of pus be sufficiently large. It has happened that the pus has escaped from the cranium by the nose or ear. A lady now under my charge experienced this result several weeks since; a large quantity of purulent matter making its exit through the posterior nares. She is still alive, in full possession of her reasoning faculties, and her articulation perfect, but with the loss of sight in both eyes, paralysis of the right side of the face, the left arm, and leg, and suffering the most intense and constant pain in her 1 " Abscess of the Brain," Reynolds's " System of Medicine," vol. ii., p. 544. SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 259 head. The seat of the lesion is probably partly in the right half of the pons Varolii. The suppurative action is doubtless still going on, and I regard her death as inevitable.1 The substance of the brain in contiguity with the abscess, as already stated, undergoes disintegration. This is in the nature of softening. CHRONIC CEREBRAL ABSCESS. Suppurative inflammation of the brain, terminating in the formation of abscess, may be of a chronic character, the course of the disease ex- tending over several months. This is especially apt to result from dis- ease of the internal ear. Cases have been reported by Abercrombie,8 Lallemand,3 Toynbee,4 RibiSre,6 and others, and three have come under my own observation. Chronic abscess may also result from injuries of the brain or skull, and from suppuration set up around a clot due to extravasation of blood. As in the acute form of the disease, there are no very characteristic symptoms indicating the formation of abscess. Indeed, in some cases there are no symptoms at all referable to the brain for the whole period of the course of the disease, till a short time before death. A great part of a lobe may be destroyed, and even both anterior lobes almost entirely obliterated, and the patient continue to manifest his ordinary degree of intelligence. Ribiere8 has collected a number of interesting cases, several of which almost overturn some of our most definite ideas of cerebral physi- ology and pathology. Thus, he cites (Observation II.) the case of a man who entered the Hdpital de la Pitie, January 27, 1866. The pa- tient was depressed, answered questions with difficulty, and complained of a violent pain in the head. The symptoms were supposed to indi- cate the existence of typhoid fever. Two days subsequently a purulent discharge was noticed from the right ear, and, the pain in the head per- sisting, the diagnosis was changed to suppurative otitis, with probable caries of the petrous portion of the temporal bone. Leeches were ap- plied behind the ears and purgatives administered, after which the 1 This patient died shortly after the foregoing lines were written. She gradually passed into a state of profound coma, in which state death occurred. The pus continued to be discharged in small quantity up to the last, and microscopecal examination disclosed the existence of ganglion-cells containing granular matter, oil-globules, and other remains of broken-down nervous tissue. No post-mortem examination could be obtained. 2 " On Chronic Inflammation of the Brain and its Membranes," Edinburgh Medical and Surgical Journal, vol. xvi., 1818, p. 265, et seq. 3 Op. cit, p. 80, et seq. 4 " The Diseases of the Ear," etc., Philadelphia, 1860. 6 " Des abces de l'enc^phale consecutifs a la carie du rocher." These de Paris, 1866- 6 Op. cit. 260 DISEASES OF THE BRAIN. patient felt so far wTell that he determined to leave the hospital. He went to work again, and, on the 12th of February, attended a ball. The following morning, pus, mixed with blood, was discharged from the right ear, and, the tendency to stupor reappearing, he again presented himself at the hospital. It was then ascertained that the flow from the ear had begun several years previously, but had ceased for the two years immediately preceding his first entrance into the hospital. On the 14th he was in a state of not very intense stupor, since he was able to complain of the pain in the head; his pulse was 60, full and hard, and pus was passing from the right auditory canal. By the 16th of February the stupor had increased. There was no paralysis, devi- ation of the face, nor alterations of sensibility. The patient under- stood questions put to him, but answered slowly and imperfectly. The eyelids were closed, light appeared to be unpleasant, and the purulent flow still continued. He died at nine o'clock that night, without con- vulsions. The post-mortem examination of the head revealed the following condition: The external auditory canal was filled with desiccated purulent mat- ter; there was neither abscess nor abnormal redness about the ear. The superior longitudinal sinus was gorged with blood, the veins were black and dilated; the brain appeared congested, but a yellow tint of the right cerebral lobe was noticed. At the inferior face of this lobe, where a rupture had occurred in handling the brain, a quantity of pus estimated at one hundred grammes (about three ounces) flowed out. This was of a greenish color, and of offensive odor. The cavity left was about the size of a hen's egg, and was bounded by red, indu- rated, and thick walls. The pus, which during life had flowed from the auditory canal, had not come from the abscess, but from the carious petrous portion of the temporal bone. Around the abscess the substance of the brain was yellow and soft- ened. Three-fourths of the middle and posterior lobes were infiltrated with pus and softened in texture. The capillaries were not visible to the naked eye; the convolutions of the island of Reil were not recog- nizable, and the neighboring convolutions were not now distinct. The corpus striatum of the right side was healthy in its anterior fourth. In . the rest of its extent it was softened. The optic thalamus was also softened, as were likewise the roots of the optic nerve. We see that, in this case, as Ribiere remarks, a considerable abscess had destroyed, in great part, the corpus striatum and optic thalamus, and that, neverthe- less, the patient had been able to work till within a few days of his death, and was so slightly paralyzed as to be able to attend a public ball. Aside from a certain hebetude, the intellectual faculties were not deranged. SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 261 Another patient observed by Ribiere presented an entire absence of cerebral troubles, no paralysis, no contractions, no convulsions; the sensibility was intact, and the intelligence was active. Nevertheless, there was a degree of stupidity expressed in the countenance, and the expression was dull. Still there is almost always some pain in the head, which may be irregular as regards its location and character, or may be confined to one particular spot. In one of the cases under my observation, there was very acute pain, almost constant nausea or vomiting, a strong tendency to coma, and hemiplegia of the left side, coexisting with purulent discharge from the right ear. The patient, who had a short time previous suffered an attack of scarlet fever to which the ear-trouble was due, died suddenly, coma- tose, but without convulsion. Examination after death showed the existence of caries of the petrous portion of the temporal bone, and an abscess containing about two ounces of pus in the middle lobe of the right hemisphere. The right corpus striatum was softened in about half of its extent. In the other case there had been profuse discharge from the right ear for several years, unattended by any cerebral symptoms except occasional pain and headache, which were supposed by the family to be due to gastric derangement, and for which no medical advice was ever asked. One morning the patient, a young lady, twenty years of age, was suddenly roused from bed by an alarm of fire. In her hurry to dress herself, and in the confusion of the moment, she struck her head against the edge of an open door. She immediately felt a severe pain in the head and cried out, but almost instantly sank down to the floor in a stupor, from which she never emerged, death ensuing within five hours. On removing the calvarium a large extravasation of pus was discovered under the arachnoid, covering the right hemisphere, and it was ascertained that an abscess, the cavity of which was as large as a small orange, had occupied the middle lobe, and had burst through the convex superior surface by rupturing the cerebral substance. The petrous portion of the temporal bone of that side was carious, and com- municated by several very small openings with the abscess. When speaking of cerebral haemorrhage, I have referred to another case in which there was abscess of the cerebellum, produced by injury of the skull. In this instance there were notable symptoms, vertigo, convulsions, nausea, vomiting, and violent pain in the back of the head. At first there was no paralysis, but the patient subsequently became paraplegic, and died in convulsions. Examination after death disclosed an abscess, the cavity of which comprehended nearly the whole of the left lobe of the cerebellum. Prof. Roosa,1 while expressing the opinion that a suppurative pro- 1 " A Practical Treatise on Diseases of the Ear, including the Anatomy of the Organ," New York, William Wood & Co., 1873, p. 446. 262 DISEASES OF THE BRAIN. cess of the ear is probably necessary for the production of an abscess of the brain, reports a case which leads him to suspect that there may be such a thing as a chronic cerebral abscess leading to disturbing aural symptoms, such as tinnitus aurium, and pain in one side of the head, without any primary aural affection. He treated a gentleman, of about twenty-nine years of age, for some months for such symptoms as have been indicated, and when he died a cerebral abscess was found. He could hear the watch for but three inches from the left ear, which was the affected one, and the drum membrane was sunken. Prof. Roosa supposed the case to be one of chronic proliferous inflammation of the middle ear. The patient got no relief; he became very despondent on account of his tinnitus aurium, and gave up his business and died at Sag Harbor, Long Island, of malignant pustule, about two years and a half after Prof. Roosa first saw him, and three years and a half after his first aural symptoms. Dr. George A. Sterling made a post-mortem examination, and found great injection of the pia mater over the petrous portion of the temporal bone, and an abscess about the size of a ten-cent-piece in the brain-substance. It was bounded by inflammatory adhesions, and con- tained about ten drops of pus. The abscess was situated on the left side, in the superior lobe, one inch from the median line, and two inches from the coronal suture. In this case there had never been a suppurative inflammation of the ear. The fact that abscess of the brain may occur without being preceded or accompanied by suppuration of the ear is beyond doubt. Although recovery from chronic abscess of the brain never takes place, yet life is often prolonged for several years, even when there may be marked symptoms of cerebral disorder. And when death occurs it is generally suddenly, with or without obvious exciting cause. Treatment.—The treatment of acute suppurative encephalitis is alto- gether palliative. Symptoms, such as pain, vertigo, and vomiting, may be controlled to a certain extent. I have derived considerable benefit from the extract of Indian hemp, given in conjunction with the bromide of potassium. The doses of Squires's extract may range from half a grain to two grains three times a day, with from thirty to forty grains of the bromide, either of potassium or sodium. The pain and irrita- bility of the nervous system are greatly lessened by these remedies, and thus the patient's condition rendered more tolerable. When there is reason to suspect a syphilitic origin, mercury and iodide of potassium may be administered theoretically with some pros- pect of success, but practically with very little benefit. The medicines should be given in frequently-repeated doses—calomel being the prefer- able mercurial—so as to bring the system, as soon as possible, under their influence. Bloodletting, local and general, blisters, tartar-emetic, and other SUPPURATIVE ENCEPHALITIS OR CEREBRITIS. 263 measures calculated to depress the powers of the system, are worse than useless. In suppurative disease of the internal ear, probably due to caries of the petrous portion of the temporal bone, preventive measures against chronic abscess may do something. Leeches applied to the mastoid pro- cess, and blisters behind the ear, are indicated, and mercury with iodide of potassium will afford a chance of a beneficial result. The solution of the bichloride of mercury with iodide of potassium in water constitutes an eligible preparation. The flow of pus should be facilitated, and the propriety of trephining the mastoid cells may be a question for consid- eration. The management of injuries, with a view to preventing abscess, is to be conducted upon very obvious surgical principles. Note.—Under the name of Cerebria Dr. Charles Elaml has de- scribed an affection of the brain which he defines as "a spontaneous, acute general inflammation of the substance of the brain uncompli- cated with meningitis." Dr. Elam has, in my opinion, adduced very strong evidence of the existence of such a disease, but I am not quite sure that the symptoms and morbid anatomy are sufficiently character- istic to warrant at present its introduction into our nosology as a patho- logical entity. He says : " It is a disease which may, perhaps, occur at any period of life, although I have never seen it before eight nor after thirty-six years of age. It is certainly much more frequent between ten and thirty than at any other ages. It is uniform in its commencement as its termina- tion. It begins with Vomiting, and it ends with death. The inter- mediate phenomena are not very striking, and the duration is from thirty-six hours to twelve days. It differs in the most marked manner from the forms of encephalitis hitherto described, in its causation, its mode of invasion, its progress, and its morbid anatomy." I cite the following case, which will give a good idea of the affec- tion in question : " H. F., a boy, aged ten, previously in good health, vomited once on the morning of June 10th. In the evening I saw him, and was in- formed that he was then much better. He had complained slightly of headache at the moment of vomiting, but there was little or no remains of the pain afterward. He was not in bed, and seemed very much in his usual state, except some little languor. The pulse was about seventy, regular and moderate in tone. The tongue was slightly furred, and the bowels not quite so regular as in ordinary. He denied positively and repeatedly having any pain in the head, or feeling ill in any way. I could detect no such alteration in the pupils, nor such modification in any visible or perceptible organ or function, as to lead me to suspect 1 "On Cerebria and other Diseases of the Brain," London, 1872, p. 32. 264 DISEASES OF THE BRAIN. serious disease. My prescriptions were little more than formal direc- tions as to diet and general management. "For reasons unnecessary to mention, I called at the house the next day, about 11 A. M. The mother said, in answer to my inquiries, that her son must be better, he had slept so well, and was, in fact, asleep still. This at once excited my suspicions, and, going up-stairs, I found the boy pulseless, rather cold, and unable to be roused to any degree of consciousness. From this condition he never rallied, and he died the same afternoon, about thirty-two hours after the vomiting. " Post-mortem Examination, Thirty-five Hours after Death.— No trace of disease in the stomach, or any of the abdominal or thoracic organs. Head.—The sinuses a little more full than usual, but the membrane showing no signs whatever of disease. There was no effu- sion, except to a very trifling amount in the lateral ventricles. The brain-substance alone showed marks of pathological change, being very closely dotted with red spots ; the gray matter was darker than usual, and the white matter slightly rosy. The texture of the brain seemed to be almost normal, neither being softer nor harder than the average. There was no microscopical examination made of any part of the brain; but no doubt remained on the mind that this was a case of pure, un- complicated, idiopathic inflammation of the brain-substance." In another case "the whole mass of the brain was so altered in texture by inflammatory action that it could not support its own weight, nor hold together. No sooner was it removed from the head, and placed on a dish, than it gave way, falling prone together and flattening like an imperfectly-made form of jelly. The commissures were all ruptured by the weight of the hemispheres. The white mat- ter of the brain was throughout soft, and pinkish in color. On cutting it, it smeared the knife with a streaked stain. Microscopically ex- amined there was no pus, but an abundance of exudation corpuscles." My reasons for somewhat doubting that these were cases of "a special cerebritis, uncomplicated, general, and idiopathic," are : That the structural changes may have begun long before they were evi- denced by any notable symptoms, and hence may have existed for some time before coming under Dr. Elam's notice, and that the con- dition discovered after death may have resulted from occlusion of some one or more of the cerebral blood-vessels. Nevertheless I am inclined to think that Dr. Elam has made out his case; at any rate, he has made a very interesting and important contribution to cerebral pathology. DIFFUSED CEREBRAL SCLEROSIS. 265 CHAPTER XII. DIFFUSED CEREBRAL SCLEROSIS. By diffused cerebral sclerosis is to be understood a morbid condition of some part of the brain characterized by induration and atrophy of the tissue, and not distinctly circumscribed except by the anatomical limits of the region affected. It is not a disease which can be recognized with any great degree of certainty or even of probability during life. It is, however, a well- marked pathological condition, giving rise to very prominent symptoms. Of late years the affection has not been much noticed, except incident- ally, by a few writers of special treatises—though, under the name of " induration of the brain," it received considerable attention many years ago. The symptoms by which it is characterized are by no means peculiar to it, though, when taken collectively, they give us some reason to diag- nosticate sclerosis as their cause. A number of cases have come under my observation in which the lesion was probably diffused cerebral sclero- sis ; but I have never had the opportunity of verifying my diagnosis by post-mortem examination. The remarks, therefore, which I shall make on the morbid anatomy will mainly be based upon the studies and obser vations of other writers. Symptoms.—The symptoms of diffused cerebral sclerosis, like so many other brain-affections, are connected with the mind, with sensibility, and with the power of motion. It generally makes its appearance during infancy, and produces an arrest of development in the part of the brain affected, and consequently in certain parts of the body. The initial phenomena are those of congestion'and inflammation, during the course of which epileptic convulsions frequently ensue. These may be few in number, and may cease in a few days, or they may be very frequently re- peated and last for several years, or during the whole life of the patient. The mind remains undeveloped, speech, if already acquired, often becomes imperfect, and, if not yet present, may never be commenced. The limbs, usually only on one side of the body, become paralyzed, and do not grow with the same rapidity as those on the sound side. Contractions are very apt to take place, from the fact, probably, that the normal degree of antagonism between the muscles is destroyed, and that those not so much paralyzed as others draw the limbs in the direction of their action. It is quite common, therefore, in the affection under consideration, to find the fingers drawn into the palm of the hand, the wrist flexed on the forearm, the forearm on the arm, and the arm drawn backward by the 266 DISEASES OF THE BRAIN. action mainly of the latissimus dorsi. In the lower limbs, club-feet are produced in a similar manner. It is not uncommon, too, to find one or more senses weak or alto- gether lost, and the general sensibility of the body diminished on one side. The urine and faeces are often passed involuntarily, or else the patient, from never having acquired a sense of propriety or cleanliness, passes them whenever he chooses, at any time or place. With this general idea of the symptoms, I proceed to refer some- what at length to its history, in the course of which I shall quote several cases in illustration of its progress. The first to direct specific attention to the disease under consideration was M. Pinel,1 the younger, who, in a memoir read before the French Academy of Sciences, May 27, 1822, brought forward several cases in illustration of what he denominated " induration of the brain." I quote the first case in full as a typical example of the affection: Beler, aged eighteen years, an idiot from birth, was admitted into the Salpetriere Hospital, Junel, 1821. The patient was paralyzed in the left arm and leg. She could not use this arm, for the hand was strongly flexed on the forearm, and could not be extended. She walked with great difficulty, dragging the left leg. Her intellectual faculties were very much restricted ; she comprehended only the questions which were addressed to her relative to her health, her intelligence not extending beyond that point. She had also great difficulty in articulating the words yes and no, which were the only words she could speak. She had no particular habit, was always calm and tranquil, and had to be antici- pated in all her wants. She was subject to occasional attacks of epi- lepsy ; but, when the paroxysms came on, she had fits almost without intermission for thirty or forty hours. They returned about every twenty-five days. On the 4th of December, 1821, the patient was taken with a series of epileptic fits, almost continual in character, which lasted during four days, the paroxysms succeeding each other with inconceiv- able rapidity. During these continuous convulsions the right limbs were affected with violent movements. The left limbs, which had been paralyzed for a long time, were also strongly agitated, and the general sensibility was abolished. The face was red, the eyes were twisted, the dejections were passed involuntarily, the pulse was frequent and irreg- ular, and the respiration unequal and jerking. The patient died on the fourth day, without there having been any remission in the symptoms. Post-mortem Examination.—" General marasmus ; remarkable ema- ciation of the paralyzed limbs. The cranium was thick, eburnated, and very hard to break. The meninges were pale and healthy. The right lobe [hemisphere] of the brain was very much smaller than the left, it 1 " Recherches d'anatomie pathologique sur l'endurcissement du systeme nerveux," Journal de Physiologie de Magendie, tome ii., 1822, p. 191, et seq. DIFFUSED CEREBRAL SCLEROSIS. 267 was atrophied ; the convolutions were almost obliterated and very small, especially in the frontal and occipital regions. They were large and deep in the inferior part. The cortical substance was thicker than it generally is; the lateral ventricle was very small and dry. The sub- stance of the brain, throughout the whole extent of this right lobe [hemisphere], and notably above the ventricle, was of remarkable hard- ness, and it was torn with difficulty by the fingers, the tissue separating in longitudinal bands which converged toward the corpus striatum. "The left lobe [hemisphere] of the brain, much more developed than the right, was of the softness and consistence of the healthy brain- tissue, and this condition made the alteration in the right lobe [hemi- sphere] more obvious." The rest of the description refers to other organs. In regard to this case, M. Pinel remarks that to the pathological condition, the loss of the power of motion in the whole of one side, the almost complete annihilation of the intellectual faculties, and prob- ably the epileptic fits, are to be ascribed. The condition—which is fre- quent with idiots, but of which it is often difficult to estimate all the va- rious symptoms—is ordinarily revealed less by the paralysis of the limbs than by the distortions which it determines in the feet and the hands. Three other cases are adduced, in one of which the cerebellum was also in part indurated. M. Pinel, as the result of his observations of the morbid anatomy, states that the nervous tissue resembles a compact in- organic mass ; its consistence and density are those of hard-boiled white- of-egg; the cerebral substance is atrophied ; it appears entirely de- prived of blood-vessels—the eye perceiving no trace of capillaries. The induration appears to affect more particularly the medullary sub- stance than the gray substance; it was never observed in this last-named tissue. Griesinger,1 under the name of "diffused hypertrophy of the con- nective tissue of the brain," describes the affection now under consid- eration, and refers to an interesting case reported by Isambert,2 in which a microscopical examination of the altered tissue was made. It occurred in an idiotic child, two years of age. The ventricular walls, the great ganglia, the pons and peduncles, were solid and hard ; their tissue was elastic, like caoutchouc ; the nerve-tubes in the white sub- stance were almost completely destroyed and an amorphous granular substance occupied their place ; there also existed newly-formed fibrous connective tissue. In regard to such cases, Griesinger remarks that, when we are told that a hitherto healthy and well-developed child, about the period of dentition, or during the second or third year, suddenly became feverish, was attacked with convulsions and delirium, fell into 1 "Die Pathologie und Therapie der psychischen Krankheiten," Zweite Auflage, 1861, p. 301 Also " New Sydenham Society Translation," p. 359. 2 " Comptes rendus et memoire de la Societe de Biologie," tome ii., 1856, p. 9. 268 DISEASES OF THE BRAIN. a slightly soporific state, and soon afterward apparently recovered, but with the intellectual and physical development checked, the condition may be due to one of two morbid processes : either there are slight con- gestion and inflammation of the membranes, or there is encephalitis, which, after passing out of the acute stage, suspends further develop- ment in the affected parts. The mind, therefore, ceases to expand ; walking, if begun, is arrested ; speech remains as it is, or is altogether lost; one side of the body does not grow so fast as the other ; and con- vulsions, paralysis, and contractions, are present. A case in point, referred to by Griesinger, I quote from Calmeil:' " M. Alfred, born at Havre, single, aged twenty-two years, came to the Bicetre, where he resided twenty-two months : he had been an in- valid since infancy. " Until about three years of age, he had exhibited no peculiarity as regarded intelligence—resembling other children of his years. " At this period, however, he was attacked with measles, which was considered mild in form, and from which he had nearly recovered, when he was seized with a succession of severe eclamptic paroxysms. During twelve hours, it was impossible to rouse him from the coma, and gen- eral convulsions were present almost without interruption. " The day after, it was perceived that he was deaf, blind, and in- capable of articulating the least sound ; the convulsions had ceased. " At the end of fifteen days he recovered his hearing ; after a year he could say a few words ; but the retinae continued insensible to im- pressions of light. " It was now perceived that he walked with a certain degree of diffi- culty, and that he could hardly use the right hand. At times, also, he lost consciousness, but without falling, and it was subsequently recog- nized that these attacks were epileptic. " Until the age of thirteen, the intelligence of M. Alfred underwent scarcely any development, and he remained imbecile notwithstanding all the efforts made for his improvement. He nevertheless acquired a knowl- edge of a certain number of words, and he could make himself under- stood whenever he had a want to gratify. " At the age of nineteen he presented the symptoms of an almost complete state of idiocy. He comprehended some things, and could imperfectly articulate a few words. He was not evilly disposed,' but he was incapable of attending to his person, and even of eating without assistance. " He could take a few steps by supporting himself against the wall, on articles of furniture, or a cane, but he dragged his feet on the ground, and his right leg appeared to be weaker than the left. The right arm was contracted and almost immovable. Tactile sensibility was not af- fected, anywhere. He did not appear to perceive objects placed imme- 1 "Traite des maladies inflammatoires du ceryeau," Paris, 1859, tome ii., p. 411. DIFFUSED CEREBRAL SCLEROSIS. 269 diately before his eyes, and the pupils were dilated and insensible to the sudden accession of light. As regarded the bladder and rectum, he evacuated them without seeming to exercise the least restraint of clean- liness or propriety. " The epileptic paroxysms occurred with long intervals between them, and presented no characteristics worthy of special mention. The complexion was pale, and the body emaciated and notably weak. "During the month of January, 1827, there was frequent cough, combined with abundant expectoration, diarrhoea, and other symptoms of phthisis." He died in February of the same year. Autopsy.—The whole of the right side of the body was much less developed than the left side. The right arm and leg were especially emaciated and thin. " The face was free from distortion, and the cra- nium, without being deformed, was small and very narrow. The greater part of the cranium was abnormally thick, and contained an excessive amount of calcareous matter. " The dura mater was without change, and did not adhere to the osseous surfaces. " A very considerable quantity of serum was infiltrated into the meshes of the pia mater—principally toward the middle and convex surface of the two cerebral hemispheres. The pia mater was thickened, but was not adherent to the convolutions. " The left cerebral hemisphere was notably smaller than the right ; the posterior lobe being particularly remarkable for its diminution. The convolutions were flattened, and were as thin as the blade of a knife, were resistant to the touch, and were of a clear yellow color. The middle and anterior lobes were neither of them of ordinary size. " The posterior lobe of the right hemisphere was less developed than in a healthy brain, but the number of atrophied convolutions was small. " On cutting into the left posterior lobe with a bistoury, its tissue was found to be white, compact, homogeneous, and very resistant. It might be said that the cerebral substance had become doughy, and that an element, foreign to its nature, gave it an excessive degree of hardness. "On the right, the atrophied convolutions of the posterior lobes were difficult to cut; their structure was compact, but the induration of the nervous tissue did not extend deeply into the thickness of the lobe. " In all other parts of the brain the white and the gray substance, as well on the left as on the right side, were apparently, in all respects, in a healthy condition. " The corpora striata and the optic thalami were free from change, either as regarded their volume or their structure. " The pons Varolii, the tubercula quadrigemina, and the peduncles of the cerebrum, and cerebellum, were in a normal state. " The spinal cord relatively, and perhaps even absolutely, appeared to be larger than was natural. 270 DISEASES OF THE BRAIN. " The optic nerves were atrophied, of a glossy white color, and very hard." Other cases, similar in general features, are adduced by Calmeil. In the very interesting monograph of Cotard,1 to which reference has already been made, the relation of sclerosis to atrophy of the brain is clearly pointed out. As indicating a certain set of symptoms, in existence with a definite pathological state, I quote the following case, No. XXIX. of his series. " C, aged fifty-eight years, an inmate of the Salpetriere since 1828, entered the infirmary on the 25th of April, 1865, under the charge of M. Charcot. " She gave the following information, which she said she had from her mother, and from other persons who had brought her up : At the age of eighteen months she had three attacks of convulsions, which left her paralyzed on her right side. She had never had convulsions since. She had already begun to walk when the seizures took place, but she did not walk again till she was three years old. " According to the information given by the superintendent of her ward, who had known her since her entrance into the hospital, her intelli- gence had always been weak; she was incapable of attending to herself; she could read tolerably well, and could sign her name ; she had always spoken without difficulty. " She had been employed with coarse sewing, and had invariably been docile and attached to those who took care of her. " Her health had always been good, though she had, when about the age of twenty-five or thirty, several attacks of hysteria. Menstruation had been regular, and had ceased when she was forty-five. " For about a year the patient had been the subject of frequent at- tacks of vomiting, or of epigastric pain. At the time of her admission to the infirmary, she was very much emaciated and very cachectic. " Her intelligence did not appear to have been recently enfeebled ; she could read, sign her name, and speak without difficulty. " Her senses seemed to be intact; sight was good in both eyes, and the pupils were equal. There was no facial paralysis, and the tongue was protruded straight. " The right arm was emaciated, atrophied, and contracted ; the fore- arm was pronated and semi-flexed on the arm ; the hand was flexed on the forearm, and inclined toward the ulnar side ; the fingers were flexed in the palm of the hand, particularly the ring and little fingers ; the index-finger was semi-flexed, and the thumb was extended. " It was possible, without very great force, to bring the several parts of the limb almost into a state of extension, but, as soon as it was left to itself, it resumed its habitual position. The patient could execute a few movements with the shoulder and the elbow, but the wrist was ab- 1 " £tude sur l'atrophie partielle du cerveau," Paris, 1868, p. 49. DIFFUSED CEREBRAL SCLEROSIS. 271 solutely paralyzed, and the fingers could only be moved to a very lim- ited extent. " The right leg was less atrophied, and there was no other deformity than a talipes equinus. The patient walked with a cane. " The sensibility of the right side was intact, and no very notable difference of temperature was observed between the healthy and the paralyzed sides. " The patient died May 17th, after symptoms of acute peritonitis. " Autopsy.—Cancer of the stomach, circumjacent abscess, purulent peritonitis. " No exterior deformation of the cranium; on the left side its walls were thick, doubly and triply so at some points ; the frontal sinus ex- tended to the left of the mesial line, and communicated with a large cavity situated in the orbital arch, which was composed of two thin osseous lamellae. " The left middle fossa was smaller than the right, and the right cerebellar fossa was smaller than the left. " The dura mater being incised, a large quantity of serum escaped from the left side. The left hemisphere was very small, shriveled, and in length and breadth scarcely two-thirds the corresponding dimensions of the right hemisphere. The convolutions were pressed together, were hard, and of a whitish color. " On the external face of the middle lobe, behind the posterior mar- ginal convolution, and on the prolongation of the fissure of Sylvius, there was a deep depression running upward and backward, and three or four centimetres in length. At the bottom of this depression the convolutions were reduced to little ridges, which were hard, and of a yellow color. " The ventricle was considerably dilated ; the corpus striatum did not appear to be perceptibly diminished in volume, but the optic thala- mus was hardly one-fourth as large as that of the opposite side. There was considerable atrophy of the left crura of the fornix, and of the mammary tubercle. " The olfactory and optic nerves of the left side were apparently healthy; the tubercular quadrigemina were not atrophied. " The right hemisphere was healthy. " The right hemisphere of the cerebellum and the middle cerebellar peduncle of the same side were atrophied." Examined with the microscope, the indurated convolutions of the left hemisphere presented an enormous quantity of amyloid corpuscles and of nuclei of connective tissue : The following cases I select from others of similar character which have occurred in my own practice : Case I.—J. S., a boy, aged five years, was brought to me in the autumn of 1869, to be treated for epilepsy. The paroxysms occurred 272 DISEASES OF THE BRAIN. several times a day, and had originated when the child was two years of age, in consequence, as the mother thought, of a fall. At that time he could say a number of words, and was rapidly learn- ing to talk ; his intelligence was good, and he had been walking for several months. But after the first convulsion he ceased to speak and to walk, though he continued up to the time I first saw him to give his attention to very striking objects, such as noisy tops, bright-colored articles, and, above all, music and soldiers. During this period he had at least six exacer- bations, characterized by pain in the head, repeated convulsions, and coma. When he was about two years and a half old it was observed that he did not move the left arm and leg so freely as the right, and soon afterward he ceased to move them at all. The toes then began to be drawn under the sole of the foot, and the heel was raised. Then the leg became flexed on the thigh, and soon afterward the fingers of the left hand and thumb were gradually bent so as to press strongly against the palm. The wrist followed, and then the forearm. Both limbs were greatly atrophied. When he came under my examination he was having epileptic con- vulsions, both of the grand and petit rnal, every day. There was no deformity of the skull, though it was certainly small for his age. His mind was feeble, and he did not give attention to any remarks made to him, but bright objects at once attracted his gaze, and he made efforts to get hold of them. I examined the fundus of the eyes with the ophthalmoscope, and discovered an anaemic condition of the retinae and atrophy of both optic disks. I gave it as my opinion that the child was suffering from diffused cerebral sclerosis, involving the left hemisphere ; and that there was scarcely any prospect of material amelioration in his mental or physical condition. Case II.—A female, aged eight years, entered the New York State Hospital for Diseases of the Nervous System, June, 1870, having pre- viously been a patient at my clinic at the Bellevue Hospital Medical College. When quite an infant she had suffered from epileptiform con- vulsions, which had been almost immediately followed by paralysis of the right upper and lower extremities. The convulsions recurred at short intervals, and atrophy of the paralyzed limbs, with contractions of the fingers, hand, and forearm, supervened. She learned to walk, however, quite well, and also to talk without any very notable defects. Her mind was weak, and she was extremely silly in her behavior; she had never learned to read. Under the use of the bromide of potassium her epileptic paroxysms ceased, but the contractions and atrophy of the right arm resisted DIFFUSED CEREBRAL SCLEROSIS. 273 treatment by galvanism and mechanical appliances. The leg acquired much more power under the treatment than it had previously possessed. Case III.—W. W., a gentleman, aged forty-three, came to me, De- cember 11,1869, to be treated for what his physician and friends regarded as softening of the brain. About six months previously he had experienced, on awaking in the morning, great difficulty in extending the left hand and fingers, and through the whole day there was a decided tendency manifested for the latter to close, and the hand to be flexed upon the forearm; and this gradually, day after day, became stronger, till at last neither the hand nor fingers could be extended. Then the corresponding lower extremity became involved in a similar manner, and, about a month after noticing the first symptom, he had an epileptiform convulsion, and this was repeated twice the following day. Since then the fits have occurred at intervals of four or five days. With the contractions in the limbs of the left side, there was gradually- advancing paresis until, when he came under my observation, both arm and leg were almost completely paralyzed. Atrophy of both extremi- ties was present to an extreme degree, and sensibility and electro-mus- cular contractibility were almost entirely abolished. His mind was also notably impaired. He laughed immoderately at every question I put to him, and had a decided expression of imbecility. His speech was not affected to any remarkable degree, except as regarded extreme slowness of utterance. He had, previously to his illness, been a ready and quick speaker. My diagnosis was diffused cerebral sclero- sis, and I gave an unfavorable prognosis. The treatment, which will be considered under its proper head, was, however, successful to a very con- siderable extent. It will be seen, from the foregoing account of the symptoms, that diffused cerebral sclerosis is characterized mainly by weakness of intel- lect, paralysis, and muscular contractions. Causes.—The predisposing causes of the affection under considera- tion are not thoroughly understood. The disease appears to be much more frequent in infancy, although it lasts to the period of old age, and sometimes originates at an advanced time of life. The exciting causes are likewise imperfectly known. Injuries of the skull from falls or blows, and haemorrhagic cysts, appear to have some influence in originating the disease, but more generally it is developed, so far as we can perceive, spontaneously. Diagnosis.—The diagnosis of diffused cerebral sclerosis must always be more or less uncertain, for the reason that the symptoms are met with in other very different affections. In children a similar set of phenom- ena may be the consequence of arrest of development in the brain with- out any alteration of its structure recognizable by our means of obser- vation. In the case of an idiotic child affected with convulsions, hemi- 18 DISEASES OF THE BRAIN. plegia, and muscular contractions, I found, on post-mortem examination. the left hemisphere markedly smaller than the right, but I could detect no change of any part of its structure. Symptoms like those met with in diffused cerebral sclerosis may re- sult from brain-tumors of various kinds. In adults the disease is readily discriminated from cerebral haemor- rhage and embolism by the gradual character of its advance, and by the mental symptoms being more strongly pronounced. But from soften- ing the diagnosis cannot always be made out, and an opinion must be formed from the history and phenomena in each individual case. From thrombosis the diagnosis is equally difficult. Perhaps the dis- tinction may be made both as regards softening and thrombosis by the facts that, though contractions are met with in both these diseases, they are not such invariable accompaniments as they are in diffused cerebral sclerosis, and that they are never, as occasionally in the latter affection, a primary symptom. Prognosis.—The prospect of complete recovery is very gloomy, and even amelioration has hitherto been regarded as out of the question. I am inclined, however, to think, as the result of my own experience, that the condition of patients, apparently suffering from the affection in question, may be decidedly improved by suitable medical treatment. I have several times succeeded in arresting the convulsions, strength- ening the mind, increasing the strength and sensibility of the paralyzed members, and relaxing the contractions. My success has been much more decided in cases which had originated late in life—probably, for the reason mainly that the disease was seen earlier in its course. Morbid Anatomy.—This division of the subject has already been con- sidered incidentally, to some extent, in the remarks made under the head of symptoms, and in the detail of cases quoted. The most obvious feature detected by ordinary observation is the increased hardness and density which the cerebral tissue has acquired. This generally occupies a considerable portion of one lobe, or may ex- tend through the whole of it, or may even affect a whole hemisphere. It is not distinctly circumscribed, but diminishes in intensity from the centre to the periphery, and, according to Pinel, never invades the gray substance. The increased density is attended with atrophy when the disease affects the adult, and with atrophy and arrest of development when children are its subjects. In order to understand the essential nature of the morbid process which causes the brain to become indurated, a few words in regard to cerebral histology are necessary. Besides the nervous tissue of the brain, there is another anatomical element present which fulfills the function of binding the cells and fibres together, and giving the whole substance its normal degree of consist- DIFFUSE CEREBRAL SCLEROSIS. 275 ence. According to Virchow,1 this, although analogous to, is different in some respects from ordinary connective tissue. He gave to it the name of neuroglia or nerve-cement. Diffused cerebral sclerosis consists in the hypertrophy or increased formation of this tissue, and the atrophy or disappearance of the proper nervous substance. Atrophy of the brain may, however, be due to other causes than sclerosis, as in the case reported with great minute- ness by Schroeder van der Kolk,2 and several of those cited by Lalle- mand,3 Turner,4 and other writers. Pathology.—The symptoms which result from diffused cerebral scle- rosis are those which we might expect to be the consequence of a con- dition which essentially consists of a disappearance of that part of the brain-tissue capable of producing or transmitting nervous force, and the substitution of another histological element which is of secondary im- portance. They all indicate deficient cerebral power. It is with the brain as with a muscle undergoing atrophy: less force results from its action in correspondence with the advance of the process by which the characteristic anatomical elements disappear. Doubtless, if we had the opportunity of more thorough study of the symptoms of diffused cerebral sclerosis, and comparing them with the condition of the brain as found by post-mortem examination, we should find that they varied considerably in character, according to the part affected, and we should probably have reason to believe that the nerve-cells which had disappeared—motor, sensitive, or trophic—were in exact pathological relation with the symptoms observed. This spe- cial point has been well studied by MM. Duchenne de Boulogne and Jouffroy,6 in a recent paper, devoted to a somewhat different disease, and to which I have recently been enabled to add a few important data. Treatment.—This division of the subject has scarcely received any attention from authors. My experience, however, has sufficed to con- vince me that we can occasionally improve the condition of the patient. If there are epileptic convulsions, they may be prevented by the ad- ministration of the bromide of potassium, in doses of at least twenty grains, three times a day, to an adult. Larger doses may be necessary. On the cessation of the convulsions, it will sometimes be found that the intelligence at once begins to be developed. The paralysis and contractions may sometimes be lessened by the 1 "Cellular Pathology," Chance's translation, London, 1860, p. 277. 2 " A Case of Atrophy of the Left Hemisphere of the Brain," etc. New Sydenham So- ciety Translation, London, 1861. s Op. cit. 1 "De l'atrophie partielle ou unilateral du cervelet," etc., Paris, 1856. De l'atrophie aigue et chronique des cellules nerveuses de la moelle et du bulbe racbidien," etc.: Archives de Physiologie, No. 4, Juillet et Aout, 1870, p. 499. 276 DISEASES OF THE BRAIN. persistent use of both the induced and primary galvanic currents. The first named will often in the beginning fail to act upon the muscles, in which case the latter should be employed. This is always better for the contracted muscles than the induced current. For the relief of the pa- ralysis it should be interrupted, for the relaxation of contractions it should be constant. As regards the central lesion, I think it may occasionally be reached, when it has not had time to become very extensive or profound. And the best and really only means I know of are, the primary galvanic cur- rent passed through the brain, and the administration of the chloride of barium. In using the galvanic current, the electrodes—wet sponges—should be applied over the mastoid processes, and kept there for a period not exceeding: three minutes. Fifteen of Smee's cells will afford a current of sufficient intensity. The application should be made about every alternate day. The chloride of barium may be given in doses of about a grain three times a day. I usually administer it in solution, according to the follow- ing formula: $. Barii chloridi 3 j, aquae dest. § j, M. ft. sol.; dose, gtt. xij three times a day. I am unable to say that these measures have actually removed the supposed sclerosis of the brain, and caused the reformation of the atro- phied cells, but I am very sure that symptoms such as are attendant upon diffused cerebral sclerosis have several times been measurably dis- sipated by its influence. Thus, in the third case mentioned as occurring in my practice, the mind improved, the epileptic paroxysms ceased, the contractions were relaxed, the paralysis lessened, the affected limbs in- creased in size, and the further progress of the disease was arrested. At the present date (December 30, 1870) the gentleman is able to take care of himself, to walk tolerably well, and to use the formerly-para- lyzed arm for many purposes. In three other cases a like treatment has been productive of almost as marked a degree of benefit. CHAPTER XIII. MULTIPLE CEREBRAL SCLEROSIS. In multiple cerebral sclerosis the lesion involves several parts of the same ganglion, and consists of plates or nodules of sclerosed tissue scattered throughout its substance. It is only of late years that the affection in question has been par- tially recognized as a distinct pathological condition,. associated with certain symptoms. These symptoms were formerly, and still are to a MULTIPLE CEREBRAL SCLEROSIS. 277 great extent, confounded with other groups similar in several prominent features, but different altogether in anatomical relations, normal and ab- normal. Thus, under the designation of paralysis agitans, were comprehended the phenomena due to multiple cerebral sclerosis, multiple cerebro- spinal sclerosis, and muscular agitation, general or local—the result of very dissimilar lesions, or without discoverable morbid changes of any kind—the one symptom of tremor sufficing to bind them together. Even by late writers the distinction is not clearly made out. It is, in the present state of our knowledge impossible to say in all cases what part of the intra-cranial mass is affected. Still, we are not altogether without data on this point, and an attentive consideration of the symptoms will often, at least, enable us to say what ganglion of the encephalon is the main seat of the lesion. But, mindful of the fact that this work is intended to be practical, I shall not venture to deal with pathological refinements, but will point out, with as much succinct- ness as possible, one form of the morbid process under notice—a form which I think I am enabled to describe, from my own observations, with considerable accuracy. That form I shall designate— MULTIPLE SCLEROSIS MAINLY AFFECTING THE HEMISPHERES. Symptoms.—Among the first symptoms noticed in this affection is pain, which occurs in sharp paroxysms of short duration. Sometimes the sensation is as instantaneous as an electric shock. It is rarely the case that there is any extreme constant pain experienced, though a feeling of fullness or constriction is occasionally more or less perma- nent. In a few cases the first observed symptom has been an epileptic paroxysm. It is not uncommon to meet with disorders of sensibility in other parts of the body; and these may either be anaesthetic or hyperaesthetic in character. Probably the most common is a numbness of the ends of the fingers or toes, which gives the sensation of cushions when ob- jects are touched, and which is generally confined at first to a single upper or lower extremity. Shooting pains, something like electric shocks, are also sometimes experienced. The progress of the disease is almost invariably slow, and hence several months may elapse before any disorders of motility are experienced. These, however, are the next symptoms to make their appearance, and are generally first manifested by the occurrence of tremor or trembling. Tremor usually, but not always, is gradual in its development, and may be restricted to narrow limits. It may at first only be felt when the patient is unusually quiet, and has not his attention engaged. Thus a gentleman told me he had, for several months, only been sensible of 278 DISEASES OF THE BRAIN. a vibration in his arm when he lay down at night. It was then—from the description he gave me—limited entirely to the extensor indicis of the left hand, and was, in the beginning, not strong enough to move the finger. When I first saw him, several years afterward, both arms and one leg were strongly agitated. In another case, which I saw almost from the very beginning, the tremor was restricted to the same muscle for several months, and then gradually involved the extensors and flexors of the hand. And, in sev- eral other instances which have come under my notice, the onset was equally gentle. But, as I have said, this is not always the case. A gen- tleman consulted me in the summer of 1870, who, after having ex- perienced severe darting pains in the head and through the limbs on the right side, was suddenly, while in his field overlooking some work, seized with a violent trembling of the right hand, which continued for severs! minutes, notwithstanding his efforts to prevent it. A few days subse- quently, he had another accession of a similar kind in the same limb, and by degrees the intervals became shorter, until, in the space of a month, the tremor was constantly present except when he slept, and, when I saw him, had extended to the whole arm, and to the lower ex- tremity of the same side. In another case, a gentleman, much addicted to excessive mental exertion, was awakened one morning by a violent agitation in his right foot. He had been under my care several months previously for severe headache and inability to sleep, for which, believing them to result from inordinate intellectual labor, I had recommended mental rest and horse- back exercise. Under the use of these measures he had apparently quite recovered, but against my advice had resumed his literary labors. He was not very confident how long the shaking of the foot had lasted, but thought it was not more than a few seconds. Several days afterward, while writing, his right hand began to trem- ble slightly. He ceased his occupation, and rubbed his hand with the other. The tremor stopped for a moment only, again began, and has scarcely ever since been absent. The whole side eventually became involved. The tendency of the tremor is always to extend. Beginning in an extremity or a group of muscles, or only in a single muscle, it goes on attacking others, until at last all the limbs and even the head may be- come affected. By preference, the advance of the tremor is lateral, that is, if an arm be first invaded, the leg of the same side next suffers, then the other arm, and then the corresponding leg. Usually the head is the last part attacked; but this is not always so, as I have seen sev- eral cases in which the trembling began in it. For a long time the tremor is to some extent under volitional con- trol. A patient, for instance, will slap his tremulous hand on his knee and for a few seconds can manage to keep it quiet, but it soon begins MULTIPLE CEREBRAL SCLEROSIS. 279 to shake again, and, though perhaps a second time he may arrest its movements by a like process, the period of rest is shorter. Any change of position is calculated to quiet the tremor for a time, and thus the patient is every few minutes moving his arms or legs in the attempt to get a little respite. It is always increased by emotional disturbance of any kind. A limb which may ordinarily be but slightly tremulous, will shake vio- lently from the excitement or anxiety produced by making a visit to a physician. The effort to keep it quiet will also often increase the tremor. For a very considerable period after the beginning of the disease, the shaking ceases during sleep, but eventually this state affords no respite, and the patient is thus deprived still further of his physical strength. It is not often the case that the muscles of the face are affected very early in the disease, but they frequently become involved at a later period. In several cases I have seen a constant tremor in the upper eyelid of one or both sides, and in one instance this was the first mani- festation of the disease. In another very remarkable case the first indication of tremor was perceived in the left eyeball, which was, by clonic spasms of the inter- nal rectus muscle, kept in a state of motion producing a kind of nys- tagmus. The upper lid of the same eye next became affected, and then the tremor appeared in the corresponding arm. The upper lip I have several times seen tremulous, causing thereby an indistinctness in the articulation. I have never observed other muscles supplied by the facial, or third nerve, to be involved in the tremor. Occasionally the lower jaw is rendered tremulous from the seat of the disease being at the origin or in the course of the fifth nerve. The tongue is sometimes affected with tremor, generally at first on only one side, and I am inclined to think that the muscles of the phar- ynx and larynx do not invariably escape. The tremor is not, as some authors have asserted, only manifested when voluntary movements are performed. This is probably the case at least in the first instance with multiple cerebro-spinal sclerosis, but it certainly is not in the purely cerebral form now .under consideration. Jaccoud' calls attention to the error which has been committed relative to this point, and my own experience is uniformly in support of the opinion he expresses. The next symptom of importance to make its appearance is paraly- sis ; and, when the sclerosis is limited to the hemispheres or begins in them, it always follows the tremor. On this point I have insisted in my lectures to the class of the Bellevue Hospital Medical College, as an important indication of the fact that paralysis agitans is off;en a cere- bral disease, and I am glad to find so exact an observer as Jaccouda as- 1 " Traito" de pathologie interne," p. 194. Op. et loc. cit. 280 DISEASES OF THE BRAIN. serting that the paralysis is often preceded by muscular agitation or trembling. At first the loss of power is slight, and, like the trembling, is limited to a single muscle or group of muscles, but it gradually extends until it involves the limbs of one side, or even of both sides. According to my observations, it follows the course of the trembling, no limb being ever paralyzed till it has for some time been affected with tremor. In the face, however, the paralysis appears to be independent of the tremor. The period which elapses between the appearance of the tremor and the accession of the paralysis varies in different patients, and even greatly in the same patient. Thus some muscles may exhibit notable loss of power in a few weeks after they have begun to be agitated, while others remain free from paresis for many months. When the loss of power affects the extensors or flexors—especially in the former event—contractions may take place, as in diffused cere- bral sclerosis, and the limbs are thus more or less distorted. The most common seat of this phenomenon is in the upper extremity, and it gen- erally begins in the fingers, extending gradually to the wrist and elbow. But in some cases, even though the antagonism between certain groups of muscles be destroyed, there are no contractions. The muscles of the head, face, and trunk, do not escape. Strabismus, ptosis, and facial paralysis, are thus produced, and the muscles concerned in speech, in deglutition, and in respiration, likewise become involved. The sphinc- ters, according to my experience, are rarely paralyzed in the early stages of the disease, but I have several times witnessed paresis of the bladder among the primary symptoms. A marked symptom which I have observed, and which can only be distinctly shown by means of the dynamograph, is the inability of the patient to maintain a continuous muscular contraction, for even a short period. I have noticed this as among the very first indications of pa- resis, and I am disposed to think it exists even before the tremor is no- ticed. Thus, a gentleman occupying a prominent public position, and in whom I had diagnosticated multiple cerebral sclerosis mainly affect- ing the hemispheres, instead of making a straight line with the pencil of the instrument, traced one of which the following cut is & facsimile: Fig. 20. Repeated efforts only gave worse results. MULTIPLE CEREBRAL SCLEROSIS. 281 In another case, that of a gentleman referred to me by my friend Dr. Van Buren, the line made was as follows: Fig. 21. Here the patient was able to maintain the contraction at its original force for only about the sixth of a minute—the time required for the paper to traverse the pencil being exactly half a minute, and a third part of the line being horizontal. The ability to coordinate the affected muscles is always impaired, and thus in voluntary movements there is agitation independently of the esoteric tremor. This is seen not only in active movements, but in passive muscular contractions, such as those by which an article is held in the hand. In such a case the fingers cannot be kept in apposition with the object, but are moved about in a disorderly manner. The incoordination is manifestly connected with the inability to maintain a lengthened muscular contraction to which reference has just been made. Sometimes, by the strong effort of the will, assisted by the sense of sight, these last two difficulties may for a little while be overcome. A gentleman now under my charge, suffering from the affection in ques- tion, cannot, for instance, carry a glass of water to his lips except by looking at it fixedly, and concentrating all his volitional power upon the act. His lower limbs are not yet affected, and he consequently can coordinate them, in walking and other movements, perfectly well. In another case, a lady, affected with multiple cerebral sclerosis, un- dertook to help her invalid husband to rise from his chair; a band of music happening to pass the window, she turned to look at it, and, at once relaxing her hold, let him fall to the floor and injured him severely. Zenker1 reports a case in which there was a similar loss of the ap- preciation of the state of the muscle; and another is mentioned by Reynolds,5 under the head of "muscular anaesthesia." I am very sure that many cases of this last-named affection are instances of multiple cerebral sclerosis of other ganglia, and I shall presently more specifi- cally refer, under a different head, to two remarkable cases which have occurred in my own experience. Another phenomenon closely related with this incoordination is gen- erally present in multiple cerebral sclerosis, and that is, that the patient loses that innate or early-acquired knowledge of the exact situation of the several parts of his body. We can all of us, not thus affected, close our 1 "Ein Beitrag zur Sklerose des Hirns und Riickenmarks," Henle und Pfeufer's Zeitschrift fur rationelle Medizin, Bd. xxiv., 1865. 8 "System of Medicine," vol. ii., p. 330. 282 DISEASES OF THE BRAIN. eyes, and touch, with the end of the finger, any particular point on the face or rest of the body, with the utmost exactness. But a person with multiple cerebral sclerosis involving the hemispheres cannot do this. Thus, in attempting, with the eyes shut, to place the end of the index- finger on the middle of the eyebrow, he misses that point, sometimes by as much as two inches; and, no matter how frequently he tries, he suc- ceeds no better. It would appear that, in such cases, the normal instinct of topographical relation.between the fingers and the cutaneous surface generally, which all persons and many animals seem to possess, is im- paired. The electro-muscular contractility is never, according to my experi- ence, diminished in multiple cerebral sclerosis, uncomplicated with simi- lar lesions in the spinal cord. The attitude and gait of a person affected with multiple cerebral sclerosis are peculiar. In standing the body is generally inclined for- ward, the head falling toward the chest, the trunk flexed at the pelvis, and the knees slightly bent. In walking the action is similar to a jog- trot, the body being still inclined forward, and the patient often mov- ing with considerable rapidity. I have had several persons with the disease under my charge who could not walk at all, but who could run with surprising agility. One of these, a gentleman advanced in life, sent to me by my friend Prof. Sayre, was unable to take a step in my consulting-room. He was carried down-stairs by his attendants with some difficulty, and when he reached the front-door he was put on his feet. He then told his servant to give him a push, which the man did with all his might, and the old gentleman, being started, went at a full run and jumped into his carriage without the least difficulty. There is often a strong tendency to plunge' forward, and at times there is an impossibility of controlling it except by catching hold of some fixed object. Not long since I was walking down Broadway, when I saw in front of me a gentleman who was then under my charge, and in whom I had diagnosticated multiple cerebral sclerosis. Although aware of his peculiar impulsive gait, I had never seen it so strikingly manifested as it was then. He went at a full trot, threading his way among the numerous people in the street, until, apparently exhausted, he would lay hold of a lamp-post or awning-post and cling to it till he had recovered his breath, to start off again in a similar manner. This impulsion of the body forward makes it easy for the patient to ascend a staircase, but, on the contrary, very difficult to go down one. The first case of the disease in question which I saw in this city, over six years ago, was characterized by an extreme degree of festination. It was that of a maiden lady, over fifty years of age, who had been affected for several years. When she was going up-stairs no one could perceive the least irregularity in her gait, but to go down was impossible. MULTIPLE CEREBRAL SCLEROSIS. 283 Sometimes, however, the tendency is to go backward. This was the case, to a remarkable extent, in a gentleman, a resident of this city, who was sent to me by Prof. Van Buren. Every time he rose from his chair he was forced to take several steps backward, and it was only by constant mental effort that he was able to go forward at all. The tactile sensibility is generally impaired from a very early period in the course of the affection, and thus, the two points of the aesthesiom- eter must be more widely separated than in the normal condition of the system, in order to get two separate impressions. This anaesthesia bears no necessary relation to the region of skin covering the affected muscles. According to my experience, it is most marked at the termi- nal extremities of nerves. Numbness of different degrees, pains of various kinds, increased or diminished temperature, and excessive hyperaesthesia of the skin, may also exist. The special senses may be affected to a variable extent. Thus there may be amblyopia, or even complete blindness; the taste is very often impaired or abolished, and the hearing rendered less acute. The ophthalmoscope should always be employed to examine the fundus of the eye. The condition generally found to exist is white atrophy of the optic disk, which is identical in general features with sclerosis. The vessels of the retina will usually be found small, the branches of the veins few in number, and the choroid of a paler hue than is natural. The course of multiple cerebral sclerosis is progressive. The patient is finally unable to walk, the friction of his shaking body against the bed abrades the skin, the dejections are passed involuntarily, and he dies either in coma, in convulsions, or by a gradual process of asthenia, his mind participating in the general decay. The duration of the disease varies from a few months to eight or ten years. Generally it runs its course in about five years. Causes.—Age is certainly one of the most powerful predisposing causes of multiple cerebral sclerosis mainly affecting the hemispheres, and causing the symptoms heretofore classed as paralysis agitans. Thus, of thirteen cases in which I diagnosticated the disease in question, all were over fifty years of age, and six were over sixty. I have seen nu- merous cases of paralytic tremor in younger persons, but the morbid condition had scarcely any points in common with that now under notice. Cases, however, are on record in which young persons were the subjects. There is some evidence to support the theory that it is sometimes heredi- tary, but the whole subject is so confused in the minds of most authors, that it is difficult to make out clearly what they refer to under the des- ignation of paralysis agitans. Of the thirteen cases occurring in my own practice, private and hospital, five had immediate ancestors who had suffered from some form of tremor and paralysis. Whether the 284 DISEASES OF THE BRAIN. lesion was purely cerebral, cerebro-spinal, or whether the disease was en- tirely functional, I was not able to decide from the information given. The influence of sex is more readily ascertained and is very evident. Eleven of my cases were males and only two females. Of exciting causes there are many. In two of my cases it followed immediately on attacks of scarlet fever, in two it was a sequence of typhoid fever, in two it ensued after rheumatism, in two it was probably syphilitic, in two it was apparently excited by great emotional disturb- ance, in one by inordinate muscular exertion, and in three no cause could be assigned, or at least there was not, in my opinion, any sufficient ex- citing cause to be discovered. Diagnosis.—Multiple cerebral sclerosis has heretofore been con- founded with other diseases, and its very existence as an independent affection is very illogically questioned by some writers. There is, ot course, no anatomical reason wrhy the affection should not be confined to the brain as well, as it certainly is in some cases, as to the spinal cord. To this point I will return when the morbid anatomy and pathology are discussed, and, as in the foregoing account of the symptoms and causes, will base my remarks under the present head mainly on the results of my own experience. The occurrence of " head-symptoms" is sufficient to diagnosticate multiple cerebral sclerosis from the functional paralysis agitans, which is never a very serious affection, and the seat of which is not always centric. Besides, in the latter there are no festination, alterations of sensibility, incoordination, muscular anaesthesia, or inability to main- tain a continuous muscular contraction, while the paper of the dynamo- graph traverses the pencil of the instrument. The functional disorder is more liable to occur in persons under fifty than in those over that age. From the cerebro-spinal form of multiple sclerosis, which will be fully considered in another section of this work, it is distinguished mainly by the facts that the tremor makes its appearance before the paralysis, and that the agitation is present whether voluntary movements are be- ing made or not. With the purely spinal form it is not likely to be confounded by any one paying the slightest attention to the phenomena of the two diseases. From chorea it might in some cases not be readily discriminated without a thorough study of the clinical history and existing symptoms. But, though chorea sometimes occurs in adults, and is generally accom- panied by " head-symptoms," the two affections possess few other phe- nomena in common. In the first place, the mental symptoms in chorea are indicative of feebleness from the very first, while in multiple cerebral sclerosis imbe- cility supervenes late in the course of the disorder. In chorea there are no vertigo, pain in the head, or other evidences of congestion, while in MULTIPLE CEREBRAL SCLEROSIS. 285 the disease under notice these are among the very earliest symptoms. In chorea there is no actual tremor, but the disorderly movements are more extensive and irregular than in multiple cerebral sclerosis; neither is there festination or bending of the body forward. Tremor is sometimes met with after cerebral haemorrhage or other cause producing hemiplegia, but in such cases the clinical history, and the fact that the trembling comes on after the paralysis, will suffice to render the diagnosis sure. Prognosis.—The prospect of recovery is always unfavorable, but not, I am induced to think, absolutely hopeless if the patient be seen sufficiently early in the course of the disease and submitted to proper medical treatment. The probability of an arrest of the onward ten- dency is by no means small under like circumstances. Still, in the great majority of cases, all means fail, and the affection gradually and per- sistently goes on to its termination—death. Morbid Anatomy.—The membranes of the brain are sometimes opaque in patches, and occasionally contain an abnormal amount of serous fluid. The cerebral convolutions are occasionally flattened, and the gray substance is thinner than in the normal condition. It may also be changed in color, being pale, and scarcely, according to Jaccoud, to be distinguished from the white substance. On cutting into the tissue of the hemispheres, plates or nodules of hardened matter are found scattered throughout its extent. These are well defined, and vary in size from that of a cherry-stone to that of a small walnut. In the only case in which I have had the opportunity of making a post-mortem examination, they were confined entirely to the white substance of the hemispheres. Their color is white or grayish- white, and they are of varying degrees of consistency, from that of hard-boiled white of egg to that of cartilage. Examined with the microscope, they are seen to consist of the neu- roglia, which, to a great extent, has taken the place of the nervous tis- sue, and of the d&bris of this latter in the form of fibres, nucleated cells, and free nuclei. They are formed, therefore, by the hypertrophy of the connective tissue of the brain at the expense of the nervous tissue proper. Sometimes there are very few of these deposits—indeed, there may only be one—and at others they are present in large numbers. In the case examined by myself there were seven in the left hemisphere and eleven in the right, of sizes varying as previously stated. They may be found in other parts of the cerebral mass besides the hemispheres, though in the form under consideration these are their most prominent and constant seats. Thus, they may exist in the hemispheres and in the medulla oblongata, the pons Varolii, and the cerebellum, at the same time. When they occupy, likewise, the spinal cord, another disease is produced which differs anatomically and pathologically from multiple cerebral sclerosis. 286 DISEASES OF THE BRAIN. Sometimes large numbers of amyloid corpuscles are met with, but their presence is not constant. Pathology.—The first question to be considered under this head re- lates to the existence of multiple cerebral sclerosis as an independent affection—that is, without lesions of like character being at the same time produced in the spinal cord. The weight of authority is probably against the view expressed in this chapter, and, as I have, so far as I know, made the first attempt to identify a certain group of symptoms with multiple sclerosis limited to the cerebral ganglia, I am the more desirous to place the reasons by which I have been actuated before the reader. Andral,1 under the designation of partial induration of the brain, describes the morbid anatomy of an affection which is probably the same as that under present consideration, although his account of it is by no means full or precise. Valentiner,2 citing a number of cases observed by himself and Fre- richs, details one in which the lesions were limited to the brain, and in which the symptoms were similar to those I have specified in this chapter. Jaccoud declares that certain cases establish the possibility of scle- rosis limited to the encephalon. In a note he refers to several writers who have stated the parts affected, in some of which, however, the spinal cord was also involved. In the following it appears to have been re- stricted to the brain: Stcehr, hemispheres corpora mamillaria; Dumville, protuberance me- dulla oblongata and corpora olivaria; Pool, hemispheres centrum ovale; Cruveilhier, anterior face of the medulla oblongata, protuberance, cere- bral peduncles, corpus callosum, walls of the lateral ventricles, and the origins of the pneumogastric glosso-pharyngeal and hypoglossal nerves; Duplay, hemispheres, particularly in the vicinity of the ventricles, optic thalami, and corpora striata; Van Camp, protuberance; Obertimpfler, hemispheres; Barthez and Rilliet, hemispheres, particularly one convo- lution; Cohn, hemispheres in two cases; Gunsburg, hemisphere, gray substance of the convolutions; Valentiner-Frerichs, cerebellar pedun- cles, corpora olivaria, protuberance, and medulla oblongata; Meynert, cerebellum and protuberance.3 Bourneville and Guerard,4 while asserting that the existence of mul- tiple cerebral sclerosis as a separate and distinct affection rests on only one case—that of Valentiner—which they further declare was probably 1 "Precis d'anatomie pathologique," tome ii., 2e partie, Pari?, 1829, p. 810. 2 " Uber die Sklerose des Gehirns und Ruckenmarks." " Deutsche Klinik," B. xiv., 1856. 81 quote this note from Jaccoud, without vouching for its correctness, as, from the fact that he does not cite the works in which the details are to be found, I have not been able to verify his statements. 4 "De la sclerose en plaques diss6min6es," Paris, 1869, p. 58. MULTIPLE CEREBRAL SCLEROSIS. 287 imperfectly reported, admit that the cerebral form may be regarded as established. But none of the authors who have referred to it identify a form of paralysis agitans with a lesion characterized by the presence of bodies of sclerosed tissue in the brain, and especially in the hemi- spheres. Thus, Dr. Clymer expresses the opinion that, excluding the tremor, which may accompany hemiplegia and certain other disorders of which it is an altogether secondary phenomenon, there are but two varieties of paralysis agitans: 1. That which results from multiple (dis- seminated) sclerosis, affecting the encephalon and spinal cord; and, 2. A purely functional disorder, first fully described by Parkinson.1 Now, in my opinion, Parkinson has described two very distinct affections under the name of paralysis agitans. One of these is certainly func- tional so far as this: that the tremor shows no disposition to extend to distant parts of the body, that it is the only symptom present, that no lesion has been discovered, and that it is readily cured. The cases de- scribed by him, on pages 48 and 50 of his " Essay," were of this form, and Case IV was probably of like character. The other is charac- terized by the phenomena which I have detailed in this chapter, and which, though imperfectly described by other authors, have either been confounded with multiple cerebro-spinal sclerosis, or regarded as con- stituting an aggravated form of the functional disorder. Parkinson defines it as " involuntary tremulous motion, with less- ened muscular power, in parts not in action and even when supported; with a propensity to bend the trunk forward, and to pass from a walk- ing to a running pace, the senses and intellect being uninjured." Ordenstein2 is of the opinion that the true anatomical lesion of non-spinal tremor is yet to be found, although he refers to several cases in which there were organic changes in the pons Varolii, medulla oblongata, and crura cerebri. These he regards as accidental, and therefore as not being essential features of the disease. It is scarcely necessary to say that he does not make the distinction between mul- tiple cerebral sclerosis and the form of tremor to which I restrict the name of paralysis agitans, and the morbid anatomy of which is still undetermined. My own views of the true pathology of the cerebral form have been formed from careful observation of the course of the disease in thirteen cases, in one of which I was enabled to make a post-mortem examination. P. B., male, aged sixty-five, formerly a drummer in the army, and 1 "Essay on the Shaking-Palsy," London, 181V. In the previous editions of this work I have referred to my inability to obtain a copy of Parkinson's work, and that my cita- tions from it were therefore necessarily second-hand. Observing this statement, Dr. T. Windsor, of Manchester, England, was kind enough to present me with a copy, so that I am able in the present edition to refer to Parkinson directly. 2 "Sur la paralysie agitante," etc., Paris, 1868, p. 20, et seq. 288 DISEASES OF THE BRAIN. latterly an instructor of buglers, came under my observation at Cebo- leta, New Mexico, in the winter of 1849-'50. While milking a cow, one evening, he suddenly experienced a severe pain in his head, which lasted only a few seconds. He soon afterward had an epileptic paroxysm, dur- ing which he bit his tongue severely. He had no other fit, so far as was known, but the pain in the head recurred at different times, never, however, lasting longer than a minute or two. No other symptoms appeared for several weeks, and then he ex- perienced severe darting pains in the arms, and soon afterward the left hand began to shake. On examination I found the tremor limited en- tirely to the extensor communis digitorum, and that the motion was entirely in the line of extension and flexion. Little by little the other muscles of the forearm became involved, and then the disorder extend- ed upward, affecting the biceps, coraco-brachialis, triceps, deltoid, and the muscles of the shoulder generally. The arm was much weaker than the other, although he was left-handed. In about three months after first noticing the tremor in the left hand, the left foot was similarly affected, and, as in the first instance, the agitation gradually extended upward, until, so far as I could see, all the muscles of the extremity were involved. He now complained of numbness in the ends of the fingers of the affected extremity, and this slowly extended to the whole arm. The sensibility of the leg remained intact. Next the right arm went through a similar sequence of phenomena, then the right leg, and finally the head. There was no decided tendency to forward impulsion till both legs were involved, though there was difficulty in maintaining the erect pos- ture, and the body was inclined forward before either inferior extremity became affected. But with the accession of tremor in both lower limbs, a marked disposition to trot and a corresponding difficulty of walking slowly made their appearance. For over a year the tremor ceased whenever the patient went to sleep, and it generally became less troublesome as soon as he lay down and tried to sleep. But at last it continued night and day, and thus apparently hastened the termination of the disease, for he lost strength rapidly from deprivation of sleep. This debility was still further in- creased, by innutrition from proper food, it being impossible, in the then state of the country, to get any fresh vegetables. During the whole period from the occurrence of the first paroxysm of pain, there was a gradual but marked failure of the mental powers, until a condition of very decided imbecility was reached. Death finally took place about two years and one month after the epileptic fit, which occurred on the same day with the first pain felt in the head. I made the post-mortem examination with great care, but without any clearly-preconceived idea of what I should find, except that I ex- MULTIPLE CEREBRAL SCLEROSIS. 289 pected to discover lesions of some kind in the brain and spinal cord. On removing the calvarium, the membranes covering the surface of the hemispheres were found to be healthy. I removed the entire brain from the skullj and carefully examined the base. There was no appreciable lesion of any kind. No tumor, no induration, no softening of any of the ganglia. The membranes were dissected off, and the convolutions on the superior surface were, I thought, less distinctly marked than was normal. I then cut through the right hemisphere horizontally an inch from the surface, and was surprised to find the course of the scalpel re- sisted by a hard body. This I discovered to be a mass of dense tissue one inch and a quarter long, half an inch wide, and about half an inch thick. I then very thoroughly examined the hemisphere, not allowing any part of it to escape observation, and discovered eleven of these nod- ules of variable size—the smallest as large as a cherry-stone, the largest about the size of a walnut—in the white substance. In the left hemi- sphere I found seven similar masses. There were none in the peduncles, in the optic thalami, in the cor- pora striata, in the medulla oblongata, pons Varolii, cerebellum, or any other part of the encephalic mass. I then examined the spinal cord in like manner, making several hun- dred sections of it, but found no alteration anywhere. It was perfectly healthy in every respect, neither congested, softened, nor indurated in any part of its extent. The sclerosed bodies were, many of them, dense and as hard as car- tilage, others were like hard-boiled white of egg, and others like cheese. No microscopical examination was made. In this case the lesions were entirely limited to the hemispheres, a circumstance which I can well believe is not common—other ganglia of the brain generally participating and giving rise to corresponding modi- fications of, or additions to, the symptoms. Thus, when the medulla oblongata is involved, there is difficulty of swallowing and implication of the muscles of respiration; when the pons Varolii is affected, we have among other symptoms facial paralysis; when the corpora striata, more intense paralysis; when the optic thalami, de- rangement of vision and perhaps of hearing; when the crura cerebri, various unilateral convulsive movements and participation of the mus- cles supplied by the third pair of nerves; and when the cerebellum, es- pecially the crura, the tendency to go backward instead of forward; and so on with the other important parts of the encephalic mass. Other relations connected with the pathology will be considered when the subjects of multiple cerebro-spinal sclerosis, and what, for want of a better name, may be called paralysis agitans, are reached. Treatment.—To detail all the various methods which have been em- ployed in the treatment of the group of symptoms which I have classed together as multiple cerebral sclerosis mainly affecting the hemispheres, 19 290 DISEASES OF THE BRAIN. would be a fruitless piece of labor. Many of the cases of cure which have been reported were not instances of the disease now under notice, but of the milder, and, so far as we know, functional disorder; and, therefore, it would be useless to adduce them as guides in the present connection. I shall, therefore, confine my remarks to the results of my own experience. I am very sure that the condition of the patient is generally improved by the simultaneous administration of the chloride of barium and hy- oscyamus. The former may be employed according to the formula given in the immediately preceding chapter; that is, in doses of a grain three times a day; the other in the form of the tincture, in doses of from one to two drachms morning, noon, and night. Care should be taken that the latter preparation be fresh and properly made. As sold in the apoth- ecaries' shops, it is often inert. By these two remedies alone, the tremor is often markedly dimin- ished, and the paralysis and other disorders of motility and sensibility greatly lessened. Thus, in the case of a distinguished gentleman, a Senator of the United States, who consulted me in the spring of 1870 for what was designated shaking-palsy, but in whom I diagnosticated the disease under consideration, amendment was perceived from the very first day of the treatment. The tremor and paralysis diminished, the mind became stronger and more able to endure exertion, and the physical strength much increased. He was soon able to write and to attend to his official duties, and he has continued in his advanced stage of improvement to the present date. He still, however, takes his medicines, and will prob- ably be obliged to do so for a long time yet. In another case—that of a gentleman living in the interior of this State—no means have been so successful in improving the general health, and arresting the progress of the disease, as the chloride of barium and tincture of hyoscyamus. I have given these remedies alone or in con- junction with others, in nine cases, and never without a decidedly favor- able effect. Electricity is, however, a powerful adjunct, and I always employ it when the opportunity exists for so doing. The primary current, from not exceeding fifteen cells, should be passed through the brain antero- posteriorly and laterally, as previously described, and the sympathetic nerve should likewise be acted upon by a current of similar intensity. The tremulous muscles should also be subjected to the influence of a primary current of low tension. I am not sure that it makes any dif- ference in which direction the current be passed, but it is important that it should not be so intense as to cause any considerable pain. For the paralysis the induced current—not too strong—is to be rec- ommended, and for any contractions that may be present it is the pref- erable form to use. MULTIPLE CEREBRAL SCLEROSIS. 291 A gentleman, over sixty years of age, from Tennessee, consulted me in September, 1870, for tremor associated with paralysis. His physician, Dr. W. W. Yandell, came with him, and gave me much valuable infor- mation in regard to the progress of the disease. In the first place, there had been, several years previously, symptoms of a disordered cerebral circulation, indicated by pain and vertigo. Soon afterward tremor su- pervened in the left hand, and gradually extended to both limbs of that side. There were also paralysis and loss of sensibility. When he came under my notice, the upper extremity was more affected than the lower; contractions had taken place, and the fingers were strongly pressed against the palm of the hand, the hand was bent on the forearm, and the elbow was flexed to its utmost extent. The limb was somewhat atro- phied, but electro-muscular contractility was not sensibly impaired. The voice was exceedingly weak, but there was no paralysis of the tongue or facial muscles, and, though the patient could not speak above a whisper, every word was articulated distinctly, and was appropriately used. The body was greatly bent forward, the attitude being that of a person ascending a steep hill, and there was decided festination. The tremor and paralysis were much more marked on the left side than the right, and the agitation was altogether independent of voluntary move- ments. The mind, except as regarded the memory, was not essentially im- paired, and the sight and hearing were unaffected by the disease. There had never been any convulsive attack or loss of consciousness, and the course of the disease had been extremely gradual. Ophthalmoscopic ex- amination revealed nothing beyond an anaemic condition of the retinae and choroids. I diagnosticated multiple cerebral sclerosis mainly affecting the hemispheres, but probably involving also the right corpus striatum, and I prescribed the chloride of barium, tincture of hyoscyamus, and elec- tricity. He remained in New York a few days, and then returned to his home with the tremor abated, the contractions partially overcome, the muscles improved in strength, and the tendency to festination lessened. A month afterward Dr. Yandell, who had continued the treatment, wrote me, of the patient, that the improvement was more decided than his most sanguine friends had anticipated, and still continued; that the agitation was scarcely perceptible; that he could more than half extend the fingers of the left hand, could straighten his wrist and elbow, and could lift a chair, or put on his hat, with the right hand. From what I have since ascertained, he bids fair to recover entirely. If the general health be materially impaired, cod-liver oil, iron, and strychnia, may be administered with advantage. The food should always be highly nutritious, and a glass or two of wine, if not particularly contraindicated, may be taken daily with advan- 292 DISEASES OF THE BRAIN. tage. Passive exercise in the open air is always beneficial, but exces- sive walking or strong muscular exertion of any kind should be care- fully avoided. Emotional excitement or mental labor must be rigidly avoided. Under the treatment thus indicated, the patient may at least be re- lieved of a great deal of his suffering. CHAPTER XP7. TUMORS OF THE BRAIN. Though tumors of the brain differ greatly in character, they all, when they are accompanied by any notable symptoms, present many features in common. It will, therefore, be convenient to consider them under one head, and point out their differences when the morbid anat- omy and pathology are discussed. Symptoms.—It is possible for a person to have a tumor of the brain as large as an orange, and present no symptoms of it during life. One such case came under my observation several years ago, and many oth- ers are on record. In the instance referred to, the patient, a teamster, was twice shot in a quarrel, one ball grazed the skull, ploughing up the right parietal bone for the extent of an inch; the other entered the left breast, wounding the heart. Death ensued almost instantly. The brain was examined, and a tumor of an elliptical form, two inches in its long diameter, and one and three-quarters in its short diameter, was found, involving the white substance of the left posterior lobe. The character was that which Virchow has since called gliomatous, and contained no nervous tissue. Again, it sometimes happens that tumors of large size exist in the brain, and produce no symptoms till a few days before death. Then very violent manifestations ensue, and the patient dies convulsed or comatose. And it is always the case that the symptoms are entirely different, as one or other part of the brain is involved, or the tumor is large or small. Thus, we know very well that a morbid growth, seated in the pons Varolii, will cause very diverse symptoms from those pro- duced by a similar formation in one of the anterior lobes of either of the hemispheres. We may say, in general terms, that tumors situated in the medulla oblongata, the pons, the optic thalami, the corpora striata, the crura cerebri, the cerebellum, and the convex surface of the hemi- spheres, give rise to more decided manifestations than when the white substance of the hemispheres is the seat. Pain is probably the first symptom which attracts attention. It is generally confined to a definite region of the head corresponding to the TUMORS OF THE BRAIN. 293 location of the disease, but this is not always the case. It may be either a dull ache, lasting the greater portion of the day, or a sharp, lancinat- ing paroxysm, which ensues but for a few moments and recurs frequent- ly. As the morbid process goes on, the cephalalgia becomes more se- vere, and finally reaches a stage of great intensity. So great is the suffering that the patient cries out with the agony, and in a case under my observation suicide was attempted. Mental excitement, physical exertion, noises, and bright lights, aggravate the pain. The special senses rarely escape. The sight is among the first to suffer derangement, and vision may be irretrievably lost from pressure exerted upon the optic nerve, or through congestion of the retina and choroid and consequent disorganization of these structures, or, from what is more common, optic neuritis. Indeed, it has been recently as- serted by several pathologists that cerebral tumors, no matter what their situation, almost invariably give rise to this latter affection. The eyeball of the affected side is often rendered more prominent than the other, even when the tumor does not involve the orbit. The hearing is also often affected, and the taste not unfrequently perverted or lessened in acuteness. Disorders of sensibility in various parts of the body are common. These are either of the nature of anaesthesia or hyperaesthesia, and are usually experienced in the face or extremities. Vertigo is a very general symptom, and may be of all degrees of in- tensity, sometimes preventing the patient standing, walking, or even sitting. It is often observed very early in the course of the disease, and is frequently accompanied by nausea or vomiting. The disorders of motility are shown either as paralysis or convul- sions. In several cases under my observation the loss of muscular power was first exhibited in the muscles of the eyeball and its appendages, causing external strabismus, ptosis, and permanent dilatation of the pupil, from paralysis of the third nerve, or internal strabismus from the lesion involving the sixth nerve. In a case recently under my charge, the muscles supplied by the right facial nerve were alone affected, and in another the left side of the face and right side of the body were paralyzed. When there is paralysis, it is generally of the hemiplegic form, though occasionally it is paraplegic. Whatever its form, it is almost always of slow progress. Paralysis may be entirely absent. It is only a necessary attendant when the tumor involves some part of the motor tract. When the muscles concerned in articulation are implicated, the speech is rendered indistinct, and some sounds may be impossible of ut- terance, not from any defect in the idea of language or of its expres- sion, but simply from paresis of the vocal organs. Convulsions are other prominent symptoms, and they may be among the initial phenomena. It is not at all unusual for the first evidence of 294 DISEASES OF THE BRAIN. intra-cranial disturbance to be an epileptiform convulsion, and similar paroxysms may occur at intervals for many years. They may be gen- eral, or, what is more common, limited to one side of the body. Sometimes consciousness is not lost, but there are various convulsive movements of the limbs, tonic or clonic in character. Occasionally these are confined to the muscles of the face or eyeball. Disturbances of equilibrium, manifested by tendency to advance, to go backward, or to turn round to the right or left, are sometimes present. With these symptoms there are generally others not so palpably connected with the morbid intra-cranial process. Thus there may be disorders of the stomach, bowels, and kidneys, and of the respiration and circulation, which add much to the discomfort of the patient. As to the intellectual faculties, it is not uncommon to find that they do not become involved to any considerable extent till a late pe- riod of the disease. Then the change is usually a gradually-advancing imbecility. Death takes place either by convulsions or coma, or a combination of both. The following cases, which I select from my note-book, are interesting in several relations: J. H, male, aged thirty-seven, came under my observation January 15, 1856, at Fort Riley, in Kansas. A few months before he had re- ceived an injury of the left hip by being thrown from his horse, and was stunned for a few minutes. A few days afterward, as he was lying in bed, he suddenly became vertiginous, and at the same time had noises in his ears and some pain not very definitely located. He never had vertigo again, but the pain never left him night or day for several weeks. It then suddenly ceased, and did not recur till the morning of December 31st, when a sharp twinge was experienced in the front of the head, and he immediately saw every thing double. Ptosis and dilated pupil of the left eye soon supervened, and the arm of the right side became weaker. When I saw him the grasp of his hand was very feeble, and the ocular troubles very noticeable. The pain was almost constantly present, and was of the most intense character. He said it seemed as if a red-hot iron were being thrust through his brain. He had come several miles to see me, and went home after I had given him a palliative medicine. A few days afterward a messenger came for me in great haste, with the information that the patient was dying, and requesting my attendance. On my arrival, I found that he had been dead several hours, having had repeated severe convulsions. On post-mortem examination, a tumor, spheroidal in shape, with an average diameter of an inch and a quarter, was found occupying the middle third of the inner surface of the left middle lobe, so as to press on the left crus and third nerve. The points of interest in this case are the sudden cessation of the pain and its recurrence simultaneously with the paralysis of the third TUMORS OF THE BRAIN. 295 nerve, the slight paralysis of the body, and the absence of convulsions till just before the fatal termination. The ptosis, diplopia, and dilata- tion of the pupil, doubtless occurred at the very instant that the tumor encroached on the crus. The history of the following case, which I saw in September, 1864, at the request of my friend Prof. Van Buren, I take from the report of Dr. F. N. Otis,1 under whose immediate care the patient was : Miss E., aged twenty-six, was of healthy parentage, and, though of delicate organization, had enjoyed good health up to February, 1861, when she received a fall on the ice, striking violently upon her elbow. She was not conscious of receiving any other injury at the time. At 3 A. M. of the following day she awoke with an intense pain in the top of her head, of a throbbing, lancinating character, which continued throughout the day. By night she obtained relief. No further effect from the fall was experienced until about two weeks subsequently, when she discovered a small, firm, circumscribed swelling on the crown of the head at the point where the pain had previously been felt. This swell- ing, which was painless, increased gradually, until, after a year, it had attained the size of half a lemon. Soon after the appearance of the tumor, Miss E. began to suffer with severe pain, confined chiefly to the vertex, of the same character as that experienced immediately after the fall. This pain would continue almost without cessation for two or three weeks, after which for a like period she would be quite free from it. She had also occasional attacks of numbness, preceded by great drowsiness, and a cold, creeping sensation, succeeded by total loss of the power of motion, sometimes confined to a single extremity, and at others involving the entire body. These attacks usually came on at night, or after rest in a recumbent position, and generally, though not invariably, were precursors of severe headache. They were always fol- lowed by great nervous prostration. At first rare, they increased in frequency as the tumor enlarged, so that by February, 1863, she was seldom free from them for more than ten or twelve days, and the tumor had doubled in size within the year. She now began to be much an- noyed by tingling, crawling sensations in her face and through the head after any unusual exertion in writing, reading, or singing, but rode daily on horseback with apparent benefit. As time passed, she had fre- quent dizzy turns, with nausea, and sudden flashes like electric shocks passing over the entire body, lasting only for an instant, but leaving her much prostrated. The headache, which was always of the most agonizing description, came to be referred chiefly to the tumor, though often associated with pain through the temples and other parts of the head. The muscles of the neck sometimes became rigid, and the vision, as well as the sense of taste and smell, often became very imperfect 1 New York Medical Journal, vol. i., 1865, p. 26. 296 DISEASES OF THE BRAIN. and continued so for weeks. Sometimes the power of speech would be lost, but she always retained perfect consciousness. These attacks rarely lasted more than an hour or two. On the 23d of October, 1864, she was attacked with a peritoneal inflammation, from the effects of which she died on the ninth day there- after. Leaving out the details of the post-mortem examination of other parts of the body, we find that an incision was made across the vertex from ear to ear, and the skin dissected from the tumor, at the apex of which it was found to be firmly adherent. The calvarium was then sawn in a line one inch above the orbital margin around to the occipital protuberance ; the hemispheres of the cerebrum were then sliced, and the whole raised at the same time. On removing the two hemispheres, which were adherent above, a tumor one and a quarter inch in thickness and three inches in diameter, of a dull lemon-yellow color, a little softer than the cerebral substance, and separated into two lateral halves, was seen springing from the cen- tral surface of the dura mater. This intra-cranial tumor had insinuated itself into the sulci between the convolutions, and the dura mater could be traced between it and the bones. The situation of the tumor, and the relation to the exterior growth, are shown in the accompany- ing cut: Fig. 22. The microscopical examination by Dr. Gouley gave indications that both formations were encephaloid in character. Similar cases to the foregoing have been reported by Mr. Paget," 1 "Surgical Pathology," London, 1853, vol. ii., p. 221. TUMORS OF THE BRAIN. 297 of London, and by the late Dr. Isaacs,1 of this city. It will be noticed that, in the case just cited, there were neither convulsions, paralysis, anaesthesia, mental derangement, nor difficulties of speech. When I saw the young lady, not long before her death, there were no symptoms present from which it could have been inferred that a tumor occupied any part of the intra-cranial cavity. I. R., a general officer of volunteers during the late war, consulted me in the spring of 1870, through his brother, for what was thought to be softening of the brain. The patient was stout and well made, had no difficulty of speech, no derangement of sensibility, and no paralysis of any part of the body. His senses were remarkably acute. His memory, however, was almost entirely gone, he had forgotten the names of his children, did not even know what city he was in, and could not tell me where he had been just before coming to see me. Besides this, there was absolutely nothing. His strength was enor- mous, and his grip one that I shall not readily forget. His previous history was that he had served arduously through the war, and had, on being mustered out of service, resumed his business as a lumber-merchant. No syphilitic taint could be discovered. Six months before I saw him he had been suddenly seized with an epilep- tiform paroxysm which was followed by agonizing pain in the head. A second convulsion ensued in about a month afterward, the pain con- tinuing to be of the utmost severity, and almost without intermission. There was a third attack, and then the pain ceased ; but the failure of memory began to be manifested from that moment, and had gradually been becoming more pronounced. I diagnosticated a tumor involving mainly the white substance of one of the hemispheres, situated probably in the posterior lobe, and not affecting the motor tract, or the course of any of the cranial nerves. My principal reasons for not regarding the lesion as softening were the absence of paralysis or even paresis, the integrity of all the special senses, and the absolute perfection of articulation. At the same time I regarded the matter as extremely doubtful, and I cite the case here merely as one of interest in which the disease was probably a tumor. The patient died during the first week in January of the present year (1871), but I have received no details of any post-mortem examination. In May, 1870, I was requested by Dr. Hermann Knapp to meet him in consultation in the case of a gentleman suffering- from a cerebral tumor. The morbid growth apparently occupied the right anterior lobe of the brain, and involved also the temporal region of the skull on the same side. The sight of the right eye was destroyed, and that of the left so much impaired that only strong lights or shadows could be dis- tinguished. The lymphatic glands of the neck were very much enlarged. The pain was most acute night and day, with scarcely an intermis- • "Transactions of the Medical Society of the State of New York," 1859. 295 DISEASES OF THE BRAIN. sion. The right arm was numb and paralytic, but there was no abso- lute paralysis anywhere except in the ocular muscles. The mind was intact, and there had never been a convulsion. Under the use of the iodide of potassium and the protiodide of mer- cury the swelling of the cranium diminished, the swollen lymphatic glands were reduced, and the pain almost entirely abolished. I saw him several times afterward, and, when I discontinued my visits, he was doing wonderfully well. Subsequently, however, there was a re- turn of the symptoms, and death ensued. There was no history of syphilis in this case. The following account of a case, in which there was a tumor of the cerebellum, I have from my friend Prof. Austin Flint, M. D.: " In June, 1842, I was present, by invitation of Dr. James P. White, of Buffalo, at the autopsy in the case of W. R., aged about forty years. I noted at that time the following brief account of the history as stated by Dr. White, the attending physician: " The illness was dated from the preceding February (five months), but he had previously complained of pain in the head, and lassitude. In February he had had chills, which were at first attributed to malaria. Subsequently vomiting was a prominent symptom; it occurred in the morning immediately after rising from bed. Cephalalgia was a fre- quent, not a constant, symptom. He referred the pain especially to the occiput. In April he left Buffalo to visit friends in Rochester. He was prostrated by the journey, and, his condition now being alarming, he returned home. Notwithstanding the treatment adopted, he grad- ually failed, and died June 7th. " There had never been convulsions nor paralysis. "Post-mortem Examination.—The body was considerably emaci- ated. There was slight opacity of the arachnoid, and in some situations a small quantity of serum was effused beneath this membrane. The effusion within the ventricles was somewhat greater than usual. With these exceptions, there were no morbid appearances, except in the cere- bellum. Here was a tumor of the size of an English walnut. It was of fine consistence, and supposed to be tuberculous. There was no ap- pearance of inflammation or softening of the cerebral substance around the tumor, which was situated in the right lobe of the cerebellum. It was ascertained in this case that the venereal appetite had been wanting for many months before death. I recollect that Dr. White in- formed me at the time that vertigo was a feature in this case, and that it induced unsteadiness in the voluntary movements. Dr. White has since informed me that his recollection is now distinct as regards this point." A very important paper on intra-cranial tumors is that of my friend Prof. Roberts Bartholow, M. D.,1 of Cincinnati. Dr. Bartholow has dis- 1 " Report on Intra-cranial Tumors ; their Symptomatology and Diagnosis, with Illus- trated Cases," Columbus, 1869. TUMORS OF THE BRAIN. 299 cussed the relations of symptoms to lesions with great perspicuity and fullness. This able observer divides the symptoms produced by cerebral tumors into two orders: 1. Those common to morbid growths or adventitious products in general. 2. Those peculiar to tumors in special situations. In the first order are to be placed headache, vertigo, amaurosis, con- vulsions, and derangement of the intellectual and reflective faculties; in the second, alterations of sensibility, disturbances of the special senses, disorders of motility, vomiting, and urinary disorders. Causes.—The causes of cerebral tumors are so intimately connected with their character that a classification becomes at once necessary. Following Jaccoudx in this respect, I shall divide them into four groups: the vascular, the parasitic, the diathetic or constitutional, and the acci- dental. Even with this division we shall find that our knowledge of their etiology is not extensive. Vascular tumors are aneurisms of the cerebral arteries. The term does not include the capillary aneurisms of Bouchard and Charcot, re- ferred to under the head of cerebral haemorrhage, but applies only to dilatations of the larger arteries. According to Gouguenheim,2 they are more common between the ages of fifty and sixty than at other periods of life, though cases were met with under the age of puberty. Tables given by Durand8 are to the same effect, as is likewise the ex- perience of Lebert,4 Gull,5 and others. This is what might be expected from the known proclivity of the arteries to disease after the age of fifty. Sex appears to exert but little influence, though aneurisms of the cerebral arteries seem to be somewhat more frequent with men than women. As exciting causes, blows on the head, falls, sudden and great physi- cal exertion, intense emotion, or mental labor, embolism, and concentric hypertrophy of the heart, are to be mentioned. Parasitic tumors are caused by the migration of the embryos of the cysticercus and echinococcus from other parts of the body. Diathetic tumors are either cancerous, tuberculous, or syphilitic in character. The first named are more common during the adult period of hfe than any other, though they are met with at all ages. Although women are more subject to some forms of cancerous tumors than men, yet in the brain they are far more common in the male sex. Of forty- 1 Op. cit, p. 247. 3 "Des tumeurs anSvrysmales des arteres du cerveau." These de Paris, 1866, p. 12. 8 " Des anevrysmes du cerveau." Th&se de Paris, 1868, p. 87. 4 "Klinische Wochenschrift," Berlin, Nos. 20 to 42, 1866. 5 "Guy's Hospital Reports," third series, vol. v., 1859, p. 281, et seq. 300 DISEASES OF THE BRAIN. eight cases studied by Lebert, cancer of the brain was primary in forty- five, that is, made its first appearance in this organ. Ogle,1 of twenty-five cases of cerebral cancer, found that in thirteen the disease was confined to the brain, while, on the other hand, contrary to the generally received opinion, Dr. Mackenzie Bacona found but ten primary cases out of seventy-three. There is no doubt that cancer of the brain is sometimes the result of traumatic cause. Tuberculous tumors of the brain are generally met with in young children, though they do occur, as in the case related by Dr. Flint just cited, in adults. They are almost always secondary to similar products in the lungs. Syphilitic tumors are, of course, the result of the syphilitic infection of the system. Accidental tumors may be caused by injuries, as was probably the case in one of the instances cited. Jaccoud, however, expresses the opinion that such an apparent relation is purely fortuitous, and that all we know of their etiology is that they are more common after the age of forty than before that period. Diagnosis.—The diagnosis of cerebral tumors is sometimes almost self-evident, in others it is equally impossible. This difference is due, not only to the various situations they may occupy, but also to their diverse nature. The presence of severe pain in the head for a long time is of itself some indication of the existence of a tumor if it is unaccompanied by febrile excitement. Epileptiform convulsions, occurring after the age of forty, should excite suspicion that their cause is to be found in a mor- bid growth of some kind. The character of the convulsive seizures will aid us in forming an opinion of their etiology. When produced by a tumor they are generally unilateral, the loss of consciousness is not so complete, and there is rarely subsequent stupor. The diagnosis from epilepsy is rendered more evident by the fact that, in tumor, the con- vulsions are seldom accompanied by mental weakness, and never by periods of actual unconsciousness. From softening the distinction can be made without much difficulty in the majority of cases. The acute pain, the integrity of the mind, and the absence of general paresis, will usually suffice. But sometimes the discrimination cannot be made, for there are cases of tumors in which there is very little pain, in which the mind is involved, and in which the paralysis is not very strongly marked. The occurrence of very limited paralysis points to the existence of a tumor, rather than any other affection. A gentleman is now under my care, who, several years ago, had a cerebral haemorrhage, from which he 1 British and Foreign Medico-Chirurgical Review, July, 1865, p. 223. 2 " On Primary Cancer of the Brain," London, 1865. TUMORS OF THE BRAIN. 3Q1 was rendered hemiplegic. He regained to a great extent his mental and physical powers, but a few days ago suddenly had diplopia from paralysis of the external rectus muscle of the left eye, by which internal strabismus was produced. As yet there have been no other head-symp- toms except vertigo, with which he has suffered a great deal in the last two years, and which was excessive when the diplopia appeared. In other respects the health is good, and the mind gives no evidence of be- ing affected. The paralysis of the external rectus is on the same side with the general hemiplegia. In my opinion, though I express it, of course, without positiveness, there is an aneurismal tumor pressing upon the sixth nerve after its emergence from the medulla oblongata, and probably affecting the left internal carotid artery. If this view be correct, other symptoms will certainly arise ere long. These will probably consist in the more exten- sive implication of cranial nerves, and in the supervention of hemi- plegia.2 The diagnosis of the character of the tumor is of interest, and some- times of importance with a view to the prognosis. Aneurismal tumors are more common in persons of advanced age than in the young, they are more frequently accompanied by vertigo, and they are more generally indicated by paralysis of one or more of the cranial nerves. The mental symptoms are not often marked. Parasitical tumors usually first manifest themselves by the occur- rence of epileptiform convulsions, and the mental faculties do not long remain unaffected, for the reason that such products are more common- ly seated in the gray substance of the brain than in the white tissue or the ganglia at the base. As these latter generally escape, troubles of motility are rare. Diathetic tumors are more easily recognized than any others, for the reason that we have other evidence of the existence of constitutional infection in the great majority of cases. As regards cancer, however, this aid is not generally afforded, the affection being usually primary, and not producing the ordinary indications of the can- cerous cachexia. But, as in the case cited in full, and the others re- ferred to, the existence of an external tumor is some indication, in con- nection with head-symptoms, that there is a corresponding growth with- in the cranium. Tubercle may be suspected in cases presenting the symptoms of cerebral tumor, when there are indications of similar deposits in the lungs or other parts of the body, when the subject exhibits evidence of possessing the tuberculous diathesis, or when the history shows, heredi- tary tendency. In a patient presenting the symptoms of a tumor of the brain, its nature may safely be considered syphilitic if, in addition, his clinical 1 This patient was found dead in the water-closet of his residence shortly after the foregoing lines were written. There was no post-mortem examination. 302 DISEASES OF THE BRAIN. history shows that he is tainted with syphilis, or has, at some former period, suffered from it. In regard to accidental tumors or those of various anatomical char- acteristics, there is not much to be said of their diagnosis. There are no means by which one species can be distinguished from another, and no positive indications which can enable us to discriminate them from other tumors, except by the way of exclusion. Prognosis.—Cerebral tumors almost uniformly lead to a fatal result, except they be syphilitic in character. In these latter there is a very considerable prospect of recovery if the proper medical treatment be adopted ; and aneurismal tumors of the brain are occasionally sponta- neously cured, and are perhaps sometimes amenable to treatment. Morbid Anatomy and Pathology.— Vascular Tumors.—The most common seat of cerebral aneurisms is the basilar artery, and they are larger here than when any other vessel is affected. Gouguenheim1 gives the following table, based upon sixty-eight cases : Basilar.................................................. 17 cases. Middle cerebral........................................... 14 " Internal carotids.......................................... 12 " Anterior cerebral......................................... 8 " Posterior communicating................................... 5 " Cerebellar............................................... 4 " Anterior communicating................................... 2 " Posterior cerebral........................................ 3 " Middle meningeal......................................... 2 " Arterio-venous........................................... 2 " Cerebral aneurisms do not differ in any essential particular from similar formations in other parts of the body. They are, however, smaller, rarely being as large as a walnut, and generally ranging in size from that of a cherry-stone to that of an almond. Lebert ascertained that they were more frequently met with in the arteries of the left side of the brain than in those of the right. Gou- guenheim confirms this observation. Thus of forty-one cases in which the side was determined, twenty-seven were on the left, and fourteen on the right. This difference is doubtless, in part at least, due to the fact that one of the causes of cerebral aneurisms, embolus, is more com- mon on the left side than on the right, and in part to the circumstance that, the left common carotid arising directly from the arch of the aorta, the blood of that side has a greater degree of tension than the blood of the right side, and hence presses on the arterial walls with more force. In a very interesting paper, Prof. W. R. Smith4 calls attention to 1 Op. cit, p. 21. 2 " Cerebral Aneurism : Reports of the Dublin Pathological Society." Dublin Quar- terly Journal of Medical Science, November, 1870, p. 443. TUMORS OF THE BRAIN. 303 the fact that aneurisms of the encephalic arteries may be produced by embolism. The following figure, which I take from his memoir, gives an excellent illustration of such an aneurism in the left middle cerebral artery: Fia. 28. In regard to the post-mortem examination of the patient, from whom the preparation was taken, Prof. Smith says: " Upon tracing the left middle cerebral artery into the fissure of Sylvius, it was found to be obstructed (just where it branches into twigs surrounding the island of Reil) by a plug of fibrine of a yellowish color and oblong form, fully a quarter of an inch in length and about the eighth of an inch in breadth. At the seat of obstruction the vessel was dilated into an oblong tumor half an inch in length and a quarter of an inch broad,' the space intervening between the original plug and the arterial tunics being occupied by coagulated blood." The theory sustained by Prof. Smith was, as he freely states, first proposed by Dr. Senhouse Kirkes1 in the paper to which I have already referred under the head of embolism. The idea was formerly very generally entertained, that cerebral aneurisms were always true, that is, caused by the uniform dilatation of all the coats of the artery. Hodgsona sustained this view on the ground that the tunics of the encephalic arteries were of such extreme tenuity that they readily dilated, and Albers,3 Crisp,4 Gull,6 and others, held similar opinions, but the recognition of the fact that the arteries of the brain are peculiarly subject to disease in persons advanced in age, and the researches of Lebert, Virchow, and Kolliker, go to show that such a view is erroneous. Three other kinds are known to exist: the mixed external, in which the interior and middle coats are ruptured and the sac is formed by the external coat; the dissecting, in which 1 " Medico-Chirurgical Transactions," vol. xxxv., p. 852. ' "A Treatise on the Diseases of Arteries and Veins," London, 1815. 8 "Memoire sur les an6vrysmes du cerveau et ses meninges," Bonn, 1836. 4 "A Treatise on the Structure, Diseases, and Injuries of the Blood-vessels," London, 1847. 1 " Guy's Hospital Reports," 1857. 304 DISEASES OF THE BRAIN. the internal tunic is ruptured and the blood is to a certain extent forced between the layers of the middle tunic ; and the arterio-venous. This latter is seated in the cavernous sinus, and is produced by the rupture of a small carotid aneurism, or it is the result of wound or injury. x\neurismal tumors may cause death either by the pressure which they exert on important parts of the brain or by the giving way of the sac and the consequent extravasation of blood, producing pressure and disorganization. The rupture of an aneurismal tumor of course leads to the sudden development of a new set of symptoms, varying in character according to the situation of the disease and the course which the extravasated blood has taken. The extravasation may occur between the membranes, or into the substance of the brain, or into the ventricles, and is generally followed by sudden death. Occasionally, however, the patient survives to undergo a second rupture, or to die from secondary alterations of the cerebral tissue. Lebert has reported a case of aneurism of the basilar artery, in which there was a spontaneous cure; and another of the mid-1 die cerebral artery is cited by Durand2 on the authority of Bourneville and Fremy. The process in such cases is similar to that which occurs in like cases in the extra-cranial arteries; the blood in the aneurismal sac becomes solidified, the arterial canal at this point is obliterated, and the circulation is carried on by the collateral vessels. Parasitic tumors are of two kinds, those produced by the cysticer- cus and those caused by the echinococcus or hydatids. The former are small, scarcely ever being larger than a small bean. They are rarely encysted, as in other parts of the body, but are in close apposition with the brain-substance. They are generally met with in numbers ranging from ten to twenty. Cruveilhiera reports a case in which there were over one hundred. They are found in all parts of the cerebrum and cerebellum; fifty of those discovered by Cruveilhier, in the case just cited, were in the cere- bellum. Generally they are near the surface of the brain—often in the pia mater, in which situation they press upon the gray matter, and often in this latter substance. When situated in the ventricles, there is less impediment to the growth of the parasite, and hence it may be- come developed into a more or less perfect tape-worm. Cobbold3 states that there are about one hundred cases on record of cysticerci being found in the brain after death. Of these, Griesinger4 reports between fifty and sixty. Echinococci, or hydatids, though much larger than the foregoing- 1 Op. cit, p. 14. * " Anatomie pathologique g6ne>ale," tome ii., p. 83, Paris, 1852. 8 "Entozoa: An Introduction to the Study of nelminthology, with Reference more particularly to the Internal Parasites of Man," London, 1864. 4 " Cysticerken und ihre Diagnose," " Archiv der Heilkunde," 1862. TUMORS OF THE BRAIN. 305 described parasites, are less numerous. Generally there is only one, and rarely are there two cysts. Each cyst may contain a single hy- datid, as is usually the case, or there may be more in different stages of growth. In size, the cysts vary from that of a marble to that of an orange, and consist of a vascular membrane inclosing the parasite. Of one hundred and thirty-three cases occurring in the human sub- ject and analyzed by Cobbold, sixteen were situated in the brain. All were of course fatal. Both of these species of parasitical tumors may be primary, or they may be accompanied by similar growths in other parts of the body. Diathetic tumors are either cancerous, tuberculous, or syphilitic. Cancer may affect any part of the brain, though it more generally attacks the hemispheres, the cerebellum, the optic thalami, the corpus striatum, or the pons Varolii. It may begin in the bones of the crani- um, in the membranes, or in the brain itself. A common seat is the orbit. According to Dr. Mackenzie Bacon,1 of seventy-three cases of brain-tumors occurring in the London hospitals during the period from 1854 to 1863, ten were cancerous. Ladame,2 of three hundred and thirty-nine cases of cerebral tumors, collected from various sources, found that sixty-seven were cancerous. The dimensions of cancerous tumors are very variable. Generally they do not much exceed the size of an English walnut, though they may be twice as large. Either variety of cancer, encephaloid, scirrhous, or colloid, may have its seat in the brain. Primitive cancer is usually single; secondary, multiple. In a case reported by Dr. Webber,3 of Boston, in which there was a preexisting cancerous tumor of the vagina, the brain was found to contain several deposits- of cancerous growths—one quite large, situated in the left hemisphere, and two in the cerebellum. Ogle * has shown that the brain-substance surrounding the cancer- ous growth undergoes softening. Frequently it is not ckanged at all. The tumor itself does not often undergo softening, but a kind of fatty degeneration and atrophy occur, and the tissue becomes hard and compact, with no traces of blood-vessels remaining. Tubercular tumors may be either single or multiple. In the former case, they are often as large as a cherry ; in the latter, they may be as small as a grain of wheat. Very large tubercular tumors result from the fusion of two or more smaller ones. They are generally seated in the hemispheres or cerebellum, though the other parts of the encepha- lon are not exempt. They are the most frequently met with of all the forms of cerebral tumors. 1 Op. cit 2 " Symptom at ologie und Diagnostik der Hirngeschwulste," Wiirzburg, 1865. 8 Journal of Psychological Medicine, vol. iv., 1870, p. 569. 4 Journal of Mental Science, 1864, p. 229. 20 306 DISEASES OF THE BRAIN. Syphilitic tumors or gummata are in general seated in the mem- branes, or in these and the gray matter at the base of the brain. They are very rarely entirely confined to the substance of the brain, and are never encysted. They are, therefore, not distinctly circumscribed, but the elements of which they are composed are infiltrated into the surround- ing brain-tissue. In size they vary, rarely being as large as a walnut. Histologically they consist of nuclei and cells. The former contain nucleoli and occupy the periphery of the tumor, while the cells are found mainly in the centre. Syphilitic tumors are ordinarily accompa- nied by like growths in other parts of the body, especially the lungs and liver. Accidental Tumors.—Under this head are included all formations not diathetic or vascular. Among them are the fibro-plastic tumors, which may attain to the size of an orange, and which are generally growths from the dura mater at the external part of the base of the cranium. They are composed of fusiform cells, nuclei, and blood-ves- sels. They are of variable consistence, sometimes being almost fluid, and at others gelatiniform in character. Under the name of glioma, Virchow described a cerebral growth due to an abnormal development of the neuroglia or connective tissue of the brain. They are more generally found in the posterior cerebral lobes, and may attain to the size of an orange. Usually there is but one. There are two kinds of these tumors, one soft, being about the consistence of the brain-substance, the other much harder. They con- sist of cells and nuclei, but never contain any of the nervous elements. Cholesteatomata, sometimes called pearly tumors, may arise from the cranial bones, from the membranes, or from the brain itself. They rarely attain to the size of a walnut, and are generally very much smaller. Histologically they consist of a limiting membrane of ex- treme tenuity, the contents of which are disposed in concentric layers. These strata are epidermic cells which have undergone degeneration. There are no vessels either in the envelope or the contents, which, in addition to the elements just mentioned, consist of cholesterine and stearine. Virchow ' has applied the term psammomata to tumors composed of cerebral sand. The most common seat of these growths is the parietal dura mater at its anterior part. They are of firm consistence and are rarely larger than a cherry ; microscopically they are seen to consist of isolated grains of carbonate of lime, surrounded by concentric layers of epithelium held together by connective tissue. Similar tumors are met with in the choroid plexus of the fourth verticle. In addition to these there are osseous tumors (exostoses), growing from the cranial bones, and which may or may not be syphilitic, lipo- matous, enchondromatous, mucous, melanotic, and several other species 1 " Pathologie des tumeurs," tome ii., Paris, 1869, p. 105. TUMORS OF THE BRAIN. 307 of tumors, which are treated of fully in the special monographs on the subject, but which need not detain us in the present connection.1 Two bodies cannot occupy the same space at the same time. In a state of health, the brain so nearly fills the cranial cavity that there is barely room for those variations in the amount of blood and ventricu- lar fluid which occur within the normal limits. The growth of a tumor, therefore, is at the expense of the brain. As the former increases in size, the latter diminishes, and hence some of the symptoms resulting from tumors are similar to those which follow atrophy or sclerosis. Besides, we have other consequent effects, such as oedema, congestion, anaemia, haemorrhage, inflammation, or softening. When cerebral tumors press upon the cranial nerves they produce fatty degeneration and atrophy. This effect is manifested by altera- tions of sensibility or of motility in the parts supplied by these nerves. In the eyes, however, in addition, the changes can be seen with the ophthalmoscope. They consist in the main of atrophy of the optic disk, disappearance of the vessels, congestion of the retina, or haemor- rhage, or serous infiltration with detachment. As Jaccoud remarks, easily appreciated by the ophthalmoscope, these lesions have a real im- portance in clinical diagnosis. As to the relation between the symptoms and the seat of the lesion, the principles enunciated under the head of cerebral haemorrhage are applicable to cerebral tumors. Treatment.—An English surgeon, Mr. Coe," reports the case of a woman, aged fifty-five, who had enjoyed good health till on one occa- sion she had an altercation with her husband, during which she was ex- cited to very great anger, and in the course of which she received sev- eral severe blows on the head. About the same time she made severe efforts to lift some heavy burdens. A few minutes afterward she com- plained to a neighbor of a violent noise in her head—a sensation which she had never experienced before. She compared the sound to that made by the working of a fire-engine, and said that it was heard more distinctly in the left than the right ear. It was accompanied by a con- tinuous roar similar to that of distant thunder, and this was apparently situated at the superior and posterior angle of the right parietal bone. From the beginning of these symptoms she had not been able to lie down, but was obliged to sleep in a sitting posture. Her dreams be- came exceedingly frightful, and she often awoke starting and terrified. On examination nothing abnormal could be detected in the region of the heart or great vessels, but in the neck a strong aneurismal bruit, 1 For a very full and complete essay on the subject of Cerebral Tumors, the reader is referred to Dr. J. W. Ogle's cases illustrating the " Formation of Morbid Growths, Deposits. Tumors, Cysts, etc., in Connection with the Brain and Spinal Cord and their Investing Membranes," British and Foreign Medico-Chirurgical Review, 1864-65. a Cited by Gouguenheim, from Association Medical Journal, November, 1855. 308 DISEASES OF THE BRAIN. synchronous with the pulse, was discovered. It was heard distinctly over the whole surface of the head, but was louder over the left tem- poral bone. On compressing the right common carotid artery, no effect was produced in the murmur, but pressure on the left common carotid caused it to cease at once. There was slight strabismus of the left eye, and vision was not so perfect in this eye as in the right. The hearing was not affected, but the noise in the head was so great that it over- powered the sound of the carriages in the street. Mr. Coe diagnosticated an aneurism of the left internal carotid artery at its entrance into the cavernous sinus immediately after its emergence from the petrous portion of the temporal bone. On the 11th of December, 1851, Mr. Coe ligated the left common carotid artery. The bruit instantly ceased, but a soft and almost con- tinuous murmur succeeded, and could be distinctly heard on applying the stethoscope to a point just above the left ear. The patient kept the horizontal position for five hours after the operation. On the 13th there was no noise in the head, even when she concentrated her attention in the effort to hear it. From this time on- ward she continued to improve, and the bruit was never heard again. The probability of this case being one of cerebral aneurism is of course very great, and the result leads us to believe that such tumors are not entirely beyond the reach of remedial measures. So far, how- ever, as other tumors of the brain are concerned, there is no treatment calculated to cure the patient, unless a syphilitic taint can be ascer- tained to exist. It is well, however, even when there are no positive indications of the presence of such a diathesis, to act upon the pre- sumption that it does exist, and to administer mercury in some form with the iodide of potassium. By adopting this principle, I have sev- eral times succeeded in curing patients who exhibited the most positive indications of suffering from tumor of the brain. One very remarkable case was that of a gentleman who consulted me several months since for ptosis, double vision, dilatation of the pupil, vertigo, and cephalalgia. The opinion was expressed by other physicians that there was a cere- bral tumor, and I entirely accorded with the view. The gentleman had no recollection of ever having had a chancre of any kind, but I never- theless administered the bichloride of mercury and iodide of potassium, according to the following formula: 1£. Hyd. bichlor. (corros.) gr. ij, potass, iodidi 3 v, aquae 3 iv. M. ft. sol. Dose, teaspoonful three times a day. At the next visit of the patient he remembered that when in China, several years previously, he had contracted a chancre for which he was treated. I continued the treatment, conjoining it with the use of electricity to the eye so as to act upon the paralyzed muscles, and had the satisfaction to see a gradual but steady improve- ment take place, till eventually in the course of a few weeks the cure was complete. INSANITY. 309 Another case was that of a lady who consulted me in July, 1870, for agonizing pain in the head, vertigo, and paralysis of the third nerve of the left side, the latter producing ptosis, external strabismus, and consequent diplopia. I could discover no evidence of syphilis, but I nevertheless administered the bichloride of mercury and the iodide of potassium, as in the foregoing case. The induced or faradaic current was applied to the eye, and the patient soon began to mend. The headache disappeared first, then the vertigo, and eventually the paraly- sis. Subsequently I ascertained from the lady's husband that it was barely possible he might have infected his wife. I have no doubt what- ever that he did. The medication recommended can do no harm. There is, therefore no reason why the patient should not have the chance of being benefited by it. The prescription mentioned is a very eligible form for administering both the mercury'and iodide of potassium. Salivation is never caused by it, and the stomach generally tolerates it well. Of course the pro- portions of the ingredients can be altered, as may seem best in individ- ual cases. The induced galvanic current is beneficial in restoring contractility to the paralyzed muscles. When applied to the eye the lids should be closed, one electrode, a wet sponge, is placed on them, the other is held in the hand or placed on the nape of the neck, and a current not so strong as to cause any considerable pain is then allowed to pass through the intervening tissues. For the relief of the pain attendant on cere- bral tumors, morphia may be administered hypodermically, or, what I have found advantageous in several cases, the extract of Indian hemp, as recommended by Reynolds, may be used. Counter-irritation, as produced by the actual cautery or other less powerful means, can do no possible good, and only adds to the discom- fort of the patient. CHAPTER XV. INSANITY. GENERAL PRINCIPLES. The brain is the chief organ from which the force called the mind is evolved, and, so far as the present inquiry goes, may be regarded as the only one. For, though, wherever there is gray nerve-tissue, nervous force is generated, and though all nervous force partakes more or less of the character of that which we call mind, its qualities are not of such a nature as to bring its aberrations within the scope of this chapter. 310 DISEASES OF THE BRAIN. By mind, therefore, we understand a force developed by nervous action, and especially by the action of the brain. The modifications which this force, in its cerebral relations, undergoes outside of the limits of health, either as regards excess, deficiency, or variation of quality, are embraced under the term insanity. Some authors have doubted the connection between the brain and the mind. Though we all feel that the relation does exist, it is perhaps as well to state briefly the facts which tend to establish the dependence of the one upon the func- tionation of the other. They have been well set forth by Mr. Bain:' 1. The action of an organ, even within the limits of health, fre- quently gives rise to sensations of various kinds, and slight functional derangements are very distinctly felt. Thus, the pain of indigestion is referred to the stomach or bowels, as the case may be; difficulties with the urinary excretion cause uneasiness in the kidneys; derangements in the secretion of the bile cause pain in the liver; loud noises produce unpleasant feelings in the ears, and excessive or improper use of the eyes causes pain in these organs. So it is with the brain. Though ordinarily we are not conscious by any particular sensation that we are using it when we think (and the same is true mutatis mutandis of the other organs mentioned), yet inordinate mental exertion gives rise to headache, vertigo, and other derangements of sensibility, referable to the brain. I have had many patients under my charge in whom very slight mental action invariably produced pain in the head. It is well known that the brain becomes diseased when it is unduly taxed, just as does the spinal cord, the eye, or a muscle. 2. Injury or disease of the brain impairs in some way or other the powers of the mind. A blow on the head causes confusion of ideas, and, if hard enough, may abolish consciousness or the power of thought altogether. A piece of fractured bone, or a bullet, pressing on the brain, likewise destroys the ability to think; and though, as in cases cited in another part of this treatise, there are examples of terrible wounds of the brain without, for a time, notable impairment of the mind, there is some loss from the first, and eventually the patients die with head-symptoms. The various affections of the brain which have been considered in this treatise, without exception produce, at some time or other of their course, derangement in the evolution of mind. Insanity, too, very often is shown, after death, to have been accom- panied by structural changes in the brain. 3. The action of the brain, like that of other organs, results in the disintegration of its substance, and this destruction of tissue is in direct proportion to the amount of mental work done. We find, therefore, that the alkaline phosphates, which are mainly derived from the de- structive metamorphosis of the nervous tissue, and which are excreted 1 "The Senses and the Intellect," second edition, London, 1864, p. 11. Also "Mental and Moral Science; a Compendium of Psychology and Ethics," London, 1868, p. 5. INSANITY. 311 by the kidneys, are increased in quantity after severe intellectual labor, and are diminished by mental quietude. In a memoir published several years ago, I gave the results of a series of experiments performed upon myself, which show very conclusively that increased use of the brain causes increased decay.1 4. The size of the brain is well known to bear a direct relation to the intelligence of the individual; and, when all other conditions are alike, it may be said that the largest brain will produce the greatest amount of mental energy. Quality is, however, also an important fac- tor, and when with great size we also have a large amount of gray mat- ter, the intellectual capacity is at its maximum. Thus, Dr. Thurman a has shown that the average weight of the brain in Europeans is 49 ounces, while in ten men remarkable for their intel- lectual development it was 54.7 ounces. Of these, the brain of Cuvier, the celebrated naturalist, weighed 64.5 ounces, Spurzheim's 55.06, and Daniel Webster's 53.5. On the other hand, the brain is small in idiots. In three idiots whose ages were sixteen, forty, and fifty years, Tiede- mann found the weight of their respective brains to be 19f, 25f, and 22-£ ounces. Mr. Gore 3 has reported the case of a woman, forty-two years of age, whose intellect was infantine, who could scarcely say a few words, whose gait was unsteady, and whose chief occupation was carrying and nursing a doll. After death, her brain, carefully weighed, was found to weigh but 10 ounces and 5 grains. Mr. Marshall4 has also reported a case of microcephaly existing in the person of a boy twelve years old, whose brain weighed but 8£ ounces. The convolutions were strongly marked, though few in number and narrow. 5. Experiments performed upon the nerves and nerve-centres show that from the brain proceeds the force by which muscles are moved, and that it is the chief organ by which sensations are perceived—all the special senses, with the probable exception of touch, having their centres of perception in the brain alone. Thus, division of a nerve supplying a certain muscle cuts off the connection between the brain and that mus- cle, and hence the will can no longer act upon it. Division of the optic nerve, for instance, prevents the perception of visual images. From all of which considerations the connection between the brain and the mind is as clearly made out as any other fact in physiology.6 1 "Urological Contributions," American Journal of the Medical Sciences, April, 1856, p. 330. Also "Physiological Memoirs," Philadelphia, 1863, p. 17. 8 Journal of Mental Science, April, 1866. 3 " Notes of a Case of Microcephaly," Anthropological Review, No. 1, May, 1863, p. 168. 4 " Brain and Calvarium of a Microcephale." Transactions of the Anthropological Society of London, in Anthropological Review, No. 2, August, 1863, p. 8. B That the spinal cord is likewise the seat of certain elements of mind, or rather is capable of evolving them, can be satisfactorily shown by a parity of reasoning. For the illustrations and arguments in regard to this subject, the reader is referred to the author's 312 DISEASES OF THE BRAIN. The mind differs from forces in general, in being compound ; that is, in being made up of several other forces. These are perception, the intellect, the emotions, and the will. All the mental manifestations of which the brain is capable are embraced in one or more of these parts. Either one of them may be exercised independently of the other, though they are very intimately connected, and in all continuous mental pro- cesses are brought more or less into relative and consecutive action. As constituting the basis of my classification of the several forms of in- sanity, it is expedient to describe these four sub-forces of the mind: 1. Perception.—By perception is to be understood that part of the mind whose office it is to place the individual in relation with external objects. For the evolution of this force the brain is in intimate rela- tion with certain special organs which serve the purpose of receiving impressions of objects. Thus an image is formed upon the retina, and the optic nerve transmits the excitation to its ganglion or part of the brain. This at once functionates, the force called perception is evolved, and the image is perceived. If the retina be sufficiently diseased, the image is not formed; if the optic nerve is in an abnormal condition, the excitation is not transmitted; if the ganglion be disordered, the percep- tive force is not evolved. Like reasoning is applicable to the other senses—hearing, taste, smell, and touch. Perception may be exercised without any superior intellectual act— without any ideation whatever. Thus, if the cerebrum of a pigeon be removed, the animal is still capable of seeing and of hearing, but it ob- tains no idea from these senses. The mind, with the exception of per- ception, is lost. Perception is, however, the starting-point of all ideation. It is not seated exclusively in the brain, but is, under certain circumstances, especially in abnormal states of the system, as trance, somnambulism, etc., and in the lower animals evolved from the spinal cord. 2. The Intellect.—In the normal condition of the brain the excita- tion of a sense and the consequent perception do not stop at the special ganglion of that sense, but are transmitted to a more complex part of the brain where the perception is resolved into an idea. Thus the im- age impressed upon the retina, the perception of which has been formed by a sensory ganglion, ultimately causes the evolution of another force by which all its attributes capable of being represented upon the retina are more or less perfectly appreciated according to the structural quali- ties of the ideational centre. To the formation of the idea several im- portant faculties and modes of expression of the intellect contribute. Thus, if we suppose the retina to have received the image of a ball, a higher ganglion converts this into a perception, and a still higher one recent inaugural address as President of the New York Neurological Society, entitled "The Brain not the Sole Organ of the Mind." INSANITY. 313 into an idea; and this idea relates to the size, the form, the color, the material, etc., primarily, and the origin, uses, ownership, etc., seconda- rily. In gaining this conception of the thing impressed upon the retina, the memory, judgment, and other faculties of the intellect, are brought into action, and the process of reasoning is carried on. 3. The Emotions.—An idea in its turn excites another part of the brain to action, and an emotion is produced, or this last-named force may be evolved under certain circumstances without the intermediation of the idea, but solely from the transmission of a perception to the emo- tional ganglion. An emotion is that pleasurable or painful feeling which arises in us in consequence of sensorial impressions or intellectual action. Accord- ing to Bain, the word emotion is used to comprehend all that is under- stood by feelings, states of feeling, pleasure, pain, passion, sentiments, affection, etc. Within the limits of health the emotions act powerfully on certain organs of the body, and thus express their own activity. Thus grief is exhibited by the flow of tears from over-excitation of the lachrymal gland; extreme joy may also cause weeping; the jaw falls, and the angles of the mouth curve downward in mortification or sorrow, while in pleasure the face expands laterally. The eyes, the nose, and the mouth, are the three facial centres from which emotional expression is mainly produced. Other organs of the body, as the salivary glands, the heart, the mammary glands, the liver, the kidneys, and, in fact, nearly every viscus of the body, may exhibit the effects of emotion by the transmission of excitations through the sympathetic nerve. Most of the resulting effects are due to the fact that the sympathetic nerve especially presides over the vaso-motor system, and thus regulates the calibre of the blood-vessels. The Will.—By volition, acts are performed. Some acts are- auto- matic, but all done in consequence of intellection are the result of will- ing, and are for some specific purpose connected with an idea. Volition in the series of mental manifestations may precede emotion, but it al- ways follows ideation. To sum up these outlines: A person walking in the street sees a man on the opposite side of the way—Perception; he recognizes him as a friend whom he has not met for many years—Intellect; he determines to go across and speak to him— Will; he does so, and exhibits joy at the reunion—Emotion. Or, to alter the sequence somewhat: A person at a theatre sees and hears an actor on the stage—Percep- tion; the attitudes, gestures, and words of the player call up certain ideas—Intellect; he is moved to great joy or grief—Mnotion; and, de- termining to recognize the ability of the actor— Will, claps his hands, or throws him a bouquet. 314 DISEASES OF THE BRAIN. The mind, therefore, as before stated, is a compound force evolved by the brain, and its elements are perception, intellect, emotion, and will. The sun likewise evolves a compound force, and its elements are light, heat, and actinism. One of these forces, light, is again divisible into several primary colors, and the intellect of man, one of the mental forces, is made up of faculties. It would be easy to pursue the analogy still further, but enough has been said to indicate how clearly the rela- tionship between brain and mind is that of matter and force. In individuals whose brains are well formed, and free from structural changes, and are nourished with a due supply—neither excessive nor deficient—of healthy blood, the perception, the intellect, the emotions, and the will, act in a manner common to mankind in general. Slight changes in the formation or nutrition of the brain induce corresponding changes in the several parts of the mind, or in it as a whole. As no two brains are precisely alike, so no two persons are precisely alike in their mental processes. So long, however, as the deviations are not directly at variance with the average human mind the individual is sane. If they are at variance, he is insane. But within the limits of mental health marked irregularities are met with in different parts of the mind. Thus some persons are noted for never perceiving things as the majori- ty of people perceive them. Others have the emotional system inordi- nately or deficiently developed. Others are weak in judgment, defec- tive in memory, feeble in powers of application, or vacillating in their opinions. Others, again, are lacking in volitional power—-in the ability to perform certain acts, to refrain from others, or to follow a definite course of action which the intellect tells them is expedient and wise. Eccentricity.—Persons whose minds deviate in some one or more notable respects from the ordinary standard, but yet whose mental pro- cesses are not directly at variance with that standard, are said to be eccentric. It is not always easy to draw the line between strong ec- centricity and mild insanity. About the former, however, there is this marked characteristic: that its manifestations are according to a fixed system, are not founded on delusions, and are generally excited by those emotions or desires which are reflected back to the individual, such as vanity, pride, the love of approbation, or of notoriety, etc. Eccentric persons stand upon the verge of insanity with a decided pre- disposition to mental disease, and ordinarily do not pass the limit mere- ly for want of a sufficient exciting cause. Several instances of eccen- tricity passing into undoubted insanity have come under my observa- tion. In one of these, a lady had since her childhood shown a singular- ity of conduct as regarded her table-furniture, which she would have of no other material than copper. She carried this fancy to such an ex- tent that even the knives were made of copper. People laughed at her, and tried to reason her out of her whim, but in vain. In no other respect was there any evidence of mental aberration. She was intelli* INSANITY. 315 gent, by no means excitable, and in the enjoyment of excellent health. An uncle had, however, died insane. A trifling circumstance started in her a new train of thought, and excited emotions which she could not control. She read in the morning paper that a Mr. Kopperman had arrived at one of the hotels, and she announced her determination to call on him. Her friends endeavored to dissuade her, but without avail. She went to the hotel, and was told he had just left for Chicago. Without returning to her home, she bought a ticket for Chicago, and actually started on the next train for that city. The telegraph, how- ever, overtook her, and she was brought back from Rochester, raving of her love for a man she had never seen, and whose name alone had been associated in her mind with her fancy for copper table-furniture. She died of acute mania within a month. In another case a young man, a clerk in a city bank, had for several years exhibited peculiarities in the keeping of his books. He was ex- ceedingly exact in his accounts, but after the bank was closed for the day he always remained several hours, during which he ornamented each page of his day's work with arabesques in different-colored inks. His fellow-clerks amused themselves at his expense, but his superior officers, knowing his value, never interfered with him in his amusement. Gradually, however, he conceived the idea that they were displeased with him, and at last this became so firmly rooted in his mind that he resigned his position, notwithstanding the protestations of the directors that his idea was erroneous. Delusions of various kinds soon super- vened, and he is now hopelessly insane. Inquiry will frequently disclose the fact that the insane have been eccentric for several years before becoming affected with cerebral dis- ease to such an extent as to produce decided mental aberration. Definition Of Insanity.—Every medical witness, who appears in a case involving the mental capacity or responsibility of an individual, is expected to give a definition of insanity. It is extremely difficult to do this satisfactorily, as it is also with a great many other terms which are applied to complex forces. It is difficult to give such a meaning to the word as will cover all possible cases of deficiency or aberration of the mental faculties, and yet not include those instances of cerebral disease which cannot properly be classed under this head. For the purpose of showing how authors have varied in their ideas of the sig- nification of the word, as well as for the instruction of the reader seek- ing for information on the point, I quote a number of definitions from some of the most eminent authorities: Dr. John Haslam,1 who has written one of the most lucid treatises on insanity in the English language, and who was for many years one of the physicians to Bethlehem Hospital, confesses his inability to give a thoroughly comprehensive and yet a sufficiently exclusive definition of 1 " Observations on Madness and Melancholy," etc., second edition, London, 1809, p. 37. 316 DISEASES OF THE BRAIN. madness ; and Dr. Prichard ' frankly admits that it is better to give up the attempt to define insanity in general terms. Notwithstanding the reluctance of these and other medical authorities to formularize the phe- nomena of insanity, the attempt has frequently been made with more or less approach to completenesss. If the word can be even imperfectly defined in simple language without conveying erroneous ideas, it is cer- tainly advisable to make an effort in this direction. According to Hoffbauer,2 an individual is insane when the under- standing is diverted or changed in its operations ; when he is powerless to avail himself of his intellectual faculties, or to make known his wishes in a suitable manner. This definition, though embracing all cases of insanity, is not satis- factory, for the reason that it is applicable to certain cerebral disorders which are not properly classed under this head. Among these may be mentioned apoplexy, and concussion and compression of the brain. Dr. Bucknill, in his " Essay on Criminal Lunacv," defines insanity as " a condition of the mind in which a false action of conception or judgment, a defective power of the will, or an uncontrollable violence of the emotions and instincts, has separately or conjointly been produced by disease." This definition is a very excellent one, but still includes those diseases of the brain attended with unconsciousness which are not insanity. Dr. Guislain,8 an eminent Belgian authority, says that " insanity is a morbid derangement of the mental faculties unattended by fever, and chronic in. its character, which deprives man of the power of thinking and acting freely as regards his happiness, preservation, and responsi- bility." The objections to this definition, in addition to those applicable to the others given, are that insanity is not necessarily unaccompanied by fever, and that it is not always a chronic affection. Drs. Bucknill and Tuke,4 quoting from Maimon, say that " mental health consists in that state in which the will is free, and in which it can exercise its empire without obstacle. Any condition different to this is a disease of the mind, and if it is asked, What is the will ? it may be re- plied, according to the definition of Marc, that it is a moral faculty which originates, directs, prevents, or modifies the physical and moral acts which are submitted to it." The late Prof. Gilman, of this city, who had given a great deal of study to the subject, declared that the best definition he had been able to make was, that " insanity is a disease of the brain by which the free- dom of the will is impaired." This has the advantage of being short 'Article "Insanity," in "Cyclopaedia of Practical Medicine." 2 " Uhtersuchungen iiber die Krankheiten der Seele," Halle, 1803, p. 11. 8 " Lecons sur les phonopathies," tome i., p. 45. 4 "A Manual of Psychological Medicine," etc., London, 1858, p. 79. INSANITY. 31Y and of being to the point. Other diseases, however, are included in its terms. It would be easy to go on and quote numerous other authorities on this point, but enough have been cited to show the general import which physicians give to the word insanity. I will therefore dismiss the fur- ther consideration of this division of the subject, by stating that my own idea of insanity is based entirely on the fact that, as the healthy mind results from a healthy brain, so a disordered mind comes from a dis- eased brain. Insanity, therefore, strictly speaking, is only a symptom, and I would define it as— A manifestation of disease of the brain, characterized by a general or partial derangement of one or more faculties of the mind, and in which, while consciousness is not abolished, mental freedom is pervert- ed, weakened, or destroyed. An essential feature of the definition of insanity here given is, that it depends directly upon a diseased condition of the brain. This is the immediate cause, and may consist of structural changes due to injury, disease, or malformation, or malnutrition, the result of excessive intel- lectual exertion, the action of powerful emotions, irritations in distant parts of the body, the sudden stoppage of the digestive process, the in- troduction into the system of certain drugs, such as opium, alcohol, bel- ladonna, etc., the retention in the organism of substances poisonous in character, but which in health are excreted, and of other factors capa- ble of altering the quantity or quality of the blood circulating through the cerebral vessels, or of accelerating or retarding the metamorphosis of tissue which the brain undergoes in common with all the other organs of the body. These causes, with others, will be more fully considered hereafter. Classification.—Many classifications have been made of the several manifestations of insanity. As is well known, mental disease appears under different characters, just as does the healthy mind. Some authors have been exceedingly minute in their arrangement, making a type of the disease from each particular symptom or delusion the patient may show. Others, again, are metaphysical and unpractical. The classification of Esquirol * has been very generally adopted, with more or less modification according to the peculiar ideas of the authors. Although arbitrary, and based upon the principle of regard- ing the symptom as the disease, it is certainly the best of its kind; and, though made more than thirty years ago, is still followed by many writ- ers. The terms employed by Esquirol are so frequently met with in works on insanity, that I give his classification as a part of the history of the subject: 1. Melancholia.—Perversion of the understanding in regard to an 1 "Des maladies mentales," tome i., p. 11, Paris, 1838. 318 DISEASES OF THE BRAIN. object or a small number of objects, with the predominance of sadness and depression of mind. 2. Monomania.—Perversion of understanding limited to a single object or a small class of objects, with predominance of mental excite- ment. 3. Mania.—A condition in which the perversion of understanding embraces all kinds of objects, and is attended with mental excitement. 4. Dementia.—A condition in which those affected are incapable of reasoning, from the fact that the organs of thought have lost their energy and the force necessary for performing their functions. 5. Imbecility or Idiocy.—A condition in which the organs have never been sufficiently well-conformed to permit those affected to rea- son correctly. One of the latest and most able writers on the subject of mental de- rangement is Dr. Maudsley,1 and he classifies the several forms of insanity according to the mental symptoms as follows: I.—Affective or Pathetic Insanity. 1. Maniacal perversion of the affective life. Mania sine delirio. 2. Melancholic depression without delusion. Simple melancholia. 3. Moral alienation proper. Approaching this, but not reaching the degree of positive insanity, is the insane temperament. 1. General. a, Mania. II.—Ideational Insanity. acute, chronic. b, Melancholia 2. Partial. a, Monomania. b, Melancholia. 3. Dementia, \ -. ' ( secondary. 4. General Paralysis. 5. Idiocy or Imbecility. In 1867, an International Congress of Alienists was held in Paris, and a committee, appointed by that body to make a classification, re- ported the following : I. Simple insanity, embracing the different varieties of mania, mel- ancholia, and monomania, circular insanity and mixed insanity, delusion of persecution, moral insanity, and the dementia following these differ- ent forms of insanity. 1 "The Physiology and Pathology of the Mind," London and New York, 1867, p. 323. INSANITY. 319 II. Ejnlejitic insanity, or insanity with epilepsy, whether the convul- sive affection has preceded the insanity and has seemed to have been the cause ; or whether, on the contrary, it has appeared during the course of the mental disease only as a symptom or a complication. III. Paralytic Insanity.—This commission regards the disease called o-eneral paralysis of the insane as a distinct morbid entity, and not at all as a complication, a termination of insanity. It proposes, then, to com- prehend under the name of paralytic insane all the insane who show in any degree whatever the characteristic symptoms cf this disease. IV. Senile dementia, which we would define as the slow and pro- gressive enfeeblement of the intellectual and moral faculties consequent upon old age. V. Organic dementia; a term by which the commission means to designate a disease which is neither the dementia consequent upon in- sanity or epilepsy, nor paralytic dementia, nor senile dementia, but that which is consequent upon organic lesion of the brain, nearly always local, and which presents, as an almost constant symptom, hemiplegic occurrences more or less prolonged. VI. Idiocy, characterized by the absence or arrest of development of the intellectual and moral faculties. Imbecility and weakness of mind constitute hereof two degrees or varieties. VII. Cretinism, characterized by a lesion of the intellectual faculties more or less analogous to that observed in idiocy, but with which is uni- formly associated a characteristic vicious conformation of the body, an arrest of the development of the entirety of the organism. Outside of these typical forms there are others, such as— 1. Delirium tremens. 2. Delirium of acute diseases ; traumatic delirium. 3. Simple epilepsy. My own classification is much simpler than most that have been pro- posed, and is based entirely on the division of mind given. In part it has been brought forward by other authors, though with different ex- planations of the terms employed : I. Perceptional insanity, characterized by the tendency to the forma- tion of erroneous perception either from false impressions of real objects (illusions), or from no external excitation whatever (hallucinations). II. Intellectual insanity, characterized by the existence of delusions. III. Emotional insanity, characterized by the uncontrolled or im- perfectly-controlled predominance of one or more of the emotions. IV. Volitional insanity, in which there is an inability to exert the full will-power either affirmatively or negatively. V. Mania, characterized by the union of two or all four of these forms in the same individual. VI. General paralysis, a peculiar form of insanity, attended with progressively-advancing loss of mental and motor power. 320 DISEASES OF THE BRAIN. VII. Idiocy and dementia: the first due to the fact that there are original structural defects in the brain ; the second resulting from the supervention of organic changes in a brain originally of normal power. In a work like the present, embracing the diseases of the whole ner- vous system, it is, of course, impossible to consider at full length the very interesting subject of insanity. I shall endeavor, however, to give certain prominent features, referring the reader, for more complete information, to the monographs treating specifically of diseases of the mind.1 But, before proceeding to describe the several types mentioned, there are some important symptoms of mental disorder, the character and im- port of which must be clearly understood. These are illusion, hallucina- tion, delusion, incoherence, and delirium. Illusion.—An illusion is a false perception of a real sensorial impres- sion. Thus a person seeing a ball roll over the floor, and imagining it to be a mouse, has an illusion of the sense of sight; another, hearing the pattering of the rain on the roof, and perceiving in this sound the voice of some one calling him, has an illusion of the sense of hearing ; another, having some bitter substance placed upon his tongue, and forming the perception of a sweet flavor, has an illusion of the sense of taste ; and so on as regards the other senses. In all such cases there is a material basis for the perception, but this latter is not in exact relation with the former. Illusions are not always indicative of cerebral disorder ; indeed, they are very common with all of us under certain circumstances. It is, per- haps, never the case that the perception is precisely in accordance with the real properties of the substance making the sensorial impression. We never see, hear, taste, smell, or feel things exactly as they are. This imperfection may be due to surrounding circumstances not being favorable. Insufficient light may thus make our vision imperfect; loud noises may render us incapable of appreciating gentle sounds. A strong- ly-sapid substance previously rubbed over the tongue and fauces pre- vents our distinguishing delicate flavors ; a powerful odor may make such an impression on the Schneiderian membrane that other odors for a long time smell like it, and exposure to very cold weather interferes markedly with the discriminating power of the sense of touch. Imperfect perceptions are often formed in consequence of the per- ceptive ganglia being otherwise occupied. Thus, if we are looking in- tently at some object of interest, we are apt not to attend to the sounds which reach our ears, and consequently no clear perception of them is formed. Illusions of all the senses, but especially of sight and hearing, are 1 No work is better calculated to give philosophical views of the subject of insanity than the treatise of Dr. Maudsley, on the " Physiology and Pathology of the Mind." His little work on the " Body and Mind " is also admirable. INSANITY. 321 met with in insanity, and particularly in those acute forms characterized by the presence of delirium. Hallucination.—An hallucination is a false perception without any material basis, and is centric in its Origin. It is more, therefore, than an erroneous interpretation of a real object, for it is entirely formed by the mind. An individual, who, on looking at a blank wall, perceives it to be covered with pictures, has an hallucination ; another, who, when no sounds reach his ear, hears voices whispering to him, also suffers from an hallucination, and such false perceptions may be created as re- gards all kinds of sensorial excitations. The organs of the senses, in fact, are not necessary to the existence of hallucinations. Thus, if the eyes be closed, images may still be seen ; if the hearing be lost, voices may still be heard, and the reason for this is found in the fact that the erroneous perception constituting the hallucination is formed in that part of the brain which ordinarily requires the excitation of a sensorial impression for its functionation. A remarkable instance of this fact, as regards hallucinations of hearing, has recently come under my no- tice, in which an old lady absolutely deaf, not being able in fact to hear thunder or the noise caused by the discharge of a cannon, was constantly troubled by imaginary voices whispering in her ears. Hal- lucinations are always evidence of cerebral derangement, and are com- mon phenomena of insanity. They may be excited by emotions of various kinds, by which the character or quantity of the blood circu- lating in the brain is changed, by intellectual exertion, by certain drugs, and many other factors to be presently more fully considered. Delusion.—Illusions and hallucinations may exist, and the individual be perfectly sensible that they are not realities. In such cases the intel- lect is not involved. But, if he accepts his false perceptions as facts, his intellect participates, and he has delusions. A delusion is, therefore, a false belief. It may be based upon an illusion or an hallucination, may result from false reasoning in • regard to real occurrences, or be evolved out of the intellect spontaneously as the result of imperfect information, or of an inability to weigh evidence or to discriminate be- tween the true and the false. Delusions are not a test of insanity, as most lawyers and many physicians believe. If they were, one-half the world would be trying to put the other half into lunatic asylums ! They may be present without coexistent insanity, and many cases run their course without them. To be indicative of insanity, a delusion must be in regard to a mat- ter of fact and contrary to the customary mode of thought of the indi- vidual. Thus a believer in spiritualism is not necessarily insane because he sees and converses with the spirit of Benjamin Franklin, for his de- lusion is one not capable of proof or disproof ; it is a part of his mental- ity to believe in the existence of spirits and in the possibility of evoking them so as to see them and talk with them. But, if a non-believer in 21 322 DISEASES OF THE BRAIN. spiritualism should imagine that he was in the habit of seeing Franklin's spirit and of conversing with it, it would be good evidence of his insan- ity. And further, though the spiritualist might think he had interviews with Franklin, and still be sane, yet if he believe, without foundation and contrary to evidence, that his brother had tried to poison him, he would have a delusion sufficient to indicate his insanity. At a former period of the world's history, a belief in the possibility of seeing devils and demons of various kinds, and of suffering from their torments, was commonly entertained. Indeed, it is religiously held now by a great many otherwise sensible people. Such a belief is, according to my mode of thought, a delusion, and probably nine-tenths of those who read this treatise will agree with me in so regarding it. But it certainly would not be safe to consider every one holding such a creed as insane. A like reasoning applies to the holders of every other form of belief not in accordance with our own. A delusion, to be indicative of insanity, must be such a belief as would not be entertained in the ordinary norma! condition of the individual, must have been formed without such evi- dence as would have been necessary to convince in health, and must be held against such positive testimony as would have in health sufficed to eradicate it. Besides, as above said, a delusion, to be evidence of the existence of insanity, must relate to a matter of fact. Hence no matter how improb- able or absurd the religious belief of an individual may appear to us, it would not show him to be insane, for it would relate altogether to a matter of faith in regard to which certain knowledge could not be brought to bear. Thus in the recent case of Louis Bonard it was in evidence that the deceased had entertained the belief of metempsycho- sis ; and it was attempted before the Surrogate of the City and County of New York to set aside the will by which he bequeathed his estate to the Society for the Prevention of Cruelty to Animals, on the ground that metempsychosis was a delusion, and that an individual brought up in a Christian community who believed it was insane. My opinion on the subject was requested by the proponents of the will, and I stated before the Surrogate's Court that " no religious belief, no matter how absurd it may be, is of itself sufficient evidence' of a man's insanity. I base that answer upon the investigation of a large number of cases, and likewise upon a very thorough reading of the subject. As regards the doctrine of the transmigration of souls and the doctrine of metempsychosis—be- cause I think there is a distinction between them—both have been held at various times of the world's history by the most enlightened nations then on the earth. They were and are to the present day held by the Hindoos, by the people of Siam, by the people of Thibet, by the Chi- nese. They were held by the ancient Egyptians, Greeks, Persians, Scyth- ians, by the Druids and by the Celts generally to some extent. They are held now by the North American and South American Indians, as I INSANITY. 323 know from my own knowledge in regard to the North American Indi- ans. They were held by various heretical sects among the early Chris- tians, and then by the Gnostics and Manicheans, who were early he- retical sects. They have likewise been held by several distinguished European men— Pythagoras, Plato, Pericles, Plotinus ; by Origen, by Fourier, by Lessing ; and among writers of the present day by Pierre Leroux; and Fourier has written extensively on the subject. I know of my own knowledge that they are held at the present day by people in the city of New York. I may state that Mr. Alger, in his very learned work, ' The Doctrine of a Future State,' states from his own knowledge that these beliefs in some form or other are largely held in this coun- try and Europe at the present day." In deciding to admit the will to probate, the surrogate, the Hon. R. C. Hutchings, said : "It appears to me that if a judicial officer should assume that merely because a man believed in that doctrine " [metempsychosis], " he was insane or talked under an insane delusion or monomania incapacitat- ing him for making a will, if prompted by that faith, but, though con- sistent with it, wholly rational in its provisions, it would not fall far short in principle of assuming that all mankind who do not believe in the par- ticular faith which the judge accepts respecting the future state are more or less insane or the victims of an insane delusion. " This question is entirely within the domain of opinion or faith, and not of knowledge. A man may properly be assumed insane upon evi- dence that he is governed by hallucinations which are physically impos- sible to the knowledge of all sane men, and which are contrary to the evidence of the senses, or who is influenced by delusions which are the creation of diseased reflective faculties. " Hence the opinion as to a future state, of which no man has posi- tive knowledge, and in regard to which mankind have always differed, and do widely differ to-day even in the most civilized communities and among the most intellectual of men, cannot in any respect be deemed evidence of insanity, the only rule by which the insanity of one of cer- tain opinions can be determined being by some test founded on positive knowledge." 1 I have considered this point at some length, for the reason that I am aware that a good deal of misapprehension exists in the minds of phy- sicians and lawyers relative to the essential nature of a delusion which is to be evidence of an individual's insanity. The distinction between a belief founded on faith and one founded on fact is not always recognized, and we are all more or less apt, unless we guard ourselves closely, to look upon those who hold what we consider to be erroneous convic- tions as being the victims of insane delusions, when in reality the mat- 1 " Abbot's Reports of Practice. Cases determined in the Courts of the State of New York," vol. xvi., Nos. 2 and 3, p. 128, et seq. 324 DISEASES OF THE BRAIN. ter in question is entirely beyond the pale of investigation by the rules of evidence. Insanity may exist without delusions at any time being present. Thus there may be emotional insanity, the main feature of which gener- ally consists of mental depression, with an unreasoning tendency to suicide ; or there may be volitional insanity, characterized by an ina- bility to refrain from setting fire to neighbors' houses, or from com- mitting homicide. Incoherence.—A person is said to be incoherent when the words he utters are without proper relation to each other, or when his language is not in accordance with his ideas. As an example of incoherence I cite the following letter, which I received a few days since from a pa- tient : " In the Neck, January 7, 1871. " Dear Sir : I said he was in my own conscience that the book was confined I quote the long time with eccentricity in the common way. This is in memory to my upshot which was incorrect at the final oblivion. Dogs and money consistency with foundlings without ante bellum which was in statu quo. " This is passive in contiguity with the works met in the creation of existence. " Very commingle " in good faith «j. s. W---." This exhibits an extreme case, as there is not an idea to be ob- tained from the language used. Such instances are, however, common enough. Incoherence is a prominent feature of delirium, and is sometimes met with in the chronic insane. It is directly due either to the impossibility of keeping the attention sufficiently long on one idea for its full con- sideration, or to a like difficulty in coordinating those parts of the brain which are concerned in the formation and expression of thoughts. Delirium.—Delirium is that condition in which there are illusions, hallucinations, delusions, and incoherence, together with a general excess of motility, an inability to sleep, and acceleration of pulse. In acute delirium these phenomena are well marked; in the low and chron- ic forms they are less strongly indicated. Sometimes one or the other of these elements notably predominates. Delirium is present in the early stage of acute mania, and may exist as an accompaniment of cer- tain diseases of the brain which do not ordinarily cause insanity, such as cerebral congestion or anaemia. It is also common in fevers and in several other disorders of the system. INSANITY. 325 I.—Perceptional Insanity. In uncomplicated perceptional insanity, those parts of the brain only are disordered which are concerned in the formation of perceptions. It constitutes the primary form of mental aberration, and of itself is not of such a character as to lessen the responsibility of the individual, or to warrant any interference with his rights. It consists entirely in false perceptions ; and, if the intellect is for a moment deceived, the error is immediately corrected. As already stated, these are either illu- sions or hallucinations. In some cases these erroneous perceptions may coexist in the same individual. They may be related to all the senses, but are especially common as regards sight and hearing. Illusions, as already mentioned, are not necessarily due to any cen- tric difficulty, though such an origin is common. Thus, it is an illusion if a person on looking at an object sees two images. This result is due to some cause destroying the parallelism of the visual axes, and may be produced by a tumor of the orbit or by paralysis of one or the other of the ocular muscles. Even in such a case, if the paralysis were due to central lesion, the higher ganglia of the brain might escape implication. Illusions are often excited by emotional disturbance, and are then prob- ably directly due to some derangement of the cerebral circulation. The false perceptions called hallucinations are of more importance than illu- sions, in the symptomatology of insanity in general. In the purely perceptional form of mental aberration they are also exceedingly inter- esting, and are very often troublesome symptoms. Thus, a gentleman, who had overworked himself in financial business, was subject to hallu- cinations of hearing, which, however, did not in the least impose on his intellect. As he walked through the streets to his place of business, he heard a voice continually whispering to him, " Take care—take care ! " So strong was the impression made, that he often involuntarily turned round to see who was speaking to him. In another case, a gentleman saw images of various kinds as soon as his head touched the pillowj though they were never present when he was standing or sitting. The case of Nicolai, the German bookseller of the last century, is well known as a remarkable example, and others are afforded in the cases of Jerome Cardan, Pascal, and many other noted personages. Like illusions,1 the immediate cause of hallucinations is generally derangement of the cerebral circulation, either as regards quantity or quality. As is well known, they are frequently produced by alcoholic liquors, opium, belladonna, Indian hemp, and other drugs. They may also 1 For a fuller account of the subjects of illusions and hallucinations, the reader is referred to the author's works on " Sleep and its Derangements," J. B. Lippincott & Co., Philadelphia; and the "Physics and Physiology of Spiritualism," D. Appleton & Co., New York. 326 DISEASES OF THE BRAIN. result from mental exertion and emotional disturbance, from an over- loaded stomach, or may occur in the course of various diseases, espe- cially those of a febrile or exhausting character. They are very common in hysteria. Physical influences calculated to disturb the normal relation existing between the intra- and extra-cranial blood may give rise to illusions and hallucinations. Thus a gentleman, formerly under my professional charge, could always cause the appearance of images by tying a hand- kerchief moderately tight around his neck. There was one form, in particular, which was the first to come and the last to disappear. It consisted of a male figure clothed in the costume worn in England three hundred years ago, and bearing a striking resemblance to the portraits of Sir Walter Raleigh. This figure not only imposed on the sight, but also on the hearing, for questions put to it were promptly answered. De Boismont' refers to a case, on the authority of Moreau, in which an individual was able to obtain hallucinations of sight by inclining his head a little forward. By this movement the return of blood from the brain was impeded and the functions of the ganglia of vision were unduly exalted. A similar case was a few months ago under my own care. A gentleman while sitting at his table writing, happened to raise his eyes from the paper without moving his head, and was astonished to see before him the figure of an old woman \vith black cloak and hood. Throwing himself back in his chair in his amazement, he was again sur- prised to find that the image slowly disappeared; and as often as he repeated these movements a like series of phenomena occurred. A few days afterward he reported the circumstances to me, and on examining him I found that he wore a very high, old-fashioned stock, which, as he sat at the table with his head bent forward, compressed the large veins of the neck, and prevented for the time the return of blood from the brain. On changing his neck-wear for other of more modern fashion he was enabled to bend his head and raise his eyes without encountering the apparition. Dendya mentions the case of a gentleman of high attainments who was constantly haunted by a spectre when he retired to rest, which seemed to attempt his life. When he raised himself in bed the phan- tom vanished, but reappeared as he resumed the recumbent posture. In such cases as these it is entirely possible for the mind, if the hal- lucination persists, to become involved in some of its higher parts. It should, therefore, always be borne in mind that perceptional insanity is often only the starting-point of more profound mental disturbance, and that every effort should be made at this stage to overcome the incipient disease. 1 A " History of Dreams, Visions, Apparitions," etc., American edition, Philadelphia, 1855. 8 "The Philosophy of Mystery," London, 1841, p. 290. INSANITY. 327 Occasionally persons have the power of voluntarily producing hallu- cinations of various kinds—a practice fraught with danger, for the time is apt to come, sooner or later, in which they cannot get rid of their false perceptions. Goethe states that he had the power of giving form to the images passing before his mind, and upon one occasion saw his own figure approaching him. Abercrombie1 refers to the case of a gentleman who had all his life been affected by the appearance of spectral figures. To such an extent did this peculiarity exist, that, if he met a friend in the street, he could not at first satisfy himself whether he saw the real or the spectral figure. By close attention he was able to perceive that the outline of the false was not quite so dis- tinct as that of the real figure, but generally he used other means, such as touch or speech, or listening for the footsteps, to verify his visual impressions. He had also the power of calling up spectral figures at will by directing his attention steadily to the conceptions of his own mind, and these either consisted of a figure or a scene he had witnessed, or a composition created by his imagination. But, though he had the faculty of producing hallucinations, he had no power of banishing them, and, when he had once called up any particular person or scene, he could never say how long it might continue to haunt him. This gentle- man was in the prime of life, of sound mind, in good health, and en- gaged in business. His brother was similarly affected. Several like cases have come under my own observation. In one the power was directly the result of attendance at spiritual meetings, and of the efforts made to become a good "medium." The patient, a lady, was of a very impressionable temperament, and was consequently well disposed to acquire the dangerous faculty in question. At first she thought very deeply of some particular person whose image she endeavored to form in her mind. Then she assumed that the person was really present, and she addressed conversation to him, at the same time keeping the idealistic image in her thoughts. At this period she was not deceived, for she clearly recognized the fact that the image was not present. One day, however, she was thinking very intently of her mother, and picturing to herself her appearance as she looked when dressed for church on a particular occasion. She was reading a book at the time; happening to raise her eyes, she saw her mother standing before her exactly as she had imagined her. At first she was somewhat startled, and in her agitation closed her eyes with her hands. To her surprise she still saw the phantom, but yet, not being aware of the centric origin of the image, she conceived the idea that she had really seen her mother's spirit. In a few moments it disappeared, but she soon found that she had the ability to recall it at will, and that the power existed ' "Inquiries concerning the Intellectual Powers," etc., London, 1840, p. 380. 328 DISEASES OF THE BRAIN. in regard to many other forms—even those of animals, and of inanimate objects. During the spiritualistic meetings she attended she could thus re- produce the image of any person upon whom she strongly concentrated her thoughts, and was for a long time sincere in the belief that they were real appearances. At last she lost control of the operations, and was constantly subject to hallucinations of sight and hearing. She was unable to sleep, and complained of vertigo, pain in the head, and of other symptoms indicating centric hyperemia. The application of ice to the head, and other suitable medication, saved her from an attack of insanity, but her nervous system was for several months in a state of exhaustion from which she rallied with difficulty. A young lady once informed me that she was able to bring before her the images of the characters contained in any novel she may have been recently reading, or in any striking play she may have witnessed. It is probable that many of the visions of Jerome Cardan and Swe- denborg were voluntary productions. On this principle can be ex- plained many of the instances of spiritualistic hallucinations which have been detailed by inquirers willing to be deceived. Perceptional insanity may make its appearance suddenly, the first evidence of its presence being the illusion or hallucination. Usually, however, there are prodromata indicating cerebral derangement. These are pain in the head, irritability of temper, suffusion of the eyes, noises in the ears, a general restlessness, and some febrile excitement. The skin is generally dry, the mouth parched, the bowels costive, and the urine high colored and scanty. If not arrested, it may pass into one or the other of the following types of mental aberration: II.—Intellectual Insanity. The essential feature of intellectual insanity is delusion. It may be developed suddenly, or, as is generally the case, be preceded by evi- dences of cerebral disorder, which, though at the time of their occur- rence not attracting particular attention, are called to mind by the observers after the disease has become fully developed. In the first stages of intellectual insanity it is not often that the delusions are fixed, and they may succeed each other with such rapidity that the patient resembles one affected with mania. They may be based on illusions or hallucinations, or may arise from the reasoning of the patient from purely imaginary premises not connected with the senses. Sometimes they are spontaneous, and at others they appear to come from dreams. Thus, a gentleman, who had for several days been singular in his behavior, awoke in the night and imagined that he saw his wife stand- ing by his bedside with a phial of prussic acid which she was about to INSANITY. 329 empty into his mouth. The hallucination took such strong hold of him that he went into the adjoining room, where his wife slept, to see if she were there or not, and, though he found her sleeping quietly, he awoke her, and accused her of having attempted to poison him. No amount of argument or persuasion could eradicate the false belief from his mind. Another for several days had been spending money very freely in articles of little or no use to him, when one morning he announced to his family that for several days he had been thinking a great mistake had been committed in his conception, and that his soul had got into the wrong body. He was therefore convinced that he was not the man he should have been, and hence he had done a great many things which were altogether repugnant to his physical senses. So long as the antag- onism continued between his mind and his body, there was no hope of any happiness for him in this world. In this case there had never been any hallucination or illusions of any of the senses. The delusion was therefore entirely the result of the patient's own perverted thoughts. When rapidly following each other, delusions are clearly sponta- neous—are not the result of any series of thoughts, but come on the spur of the moment and upon very slight suggestions. As they are readily formed, they are not fixed in character. A lady, for instance, after receiving some very sorrowful intelligence relative to her husband, imagined that she had lost her eyesight. For a few hours she remained with her eyes shut, alleging that there were two deep cavities behind the lids. Suddenly she opened them, said she saw perfectly well, but that the top of her head had been cut off, and this was almost imme- diately changed to the belief that she was perishing with- cold, and so on, no one delusion lasting longer than a few minutes. In many cases like this the erroneous beliefs are excited by sensations in various parts of the body, but this was not so in the present instance. The connection between dreams and insanity is very close. Most of us have at times such vivid dreams that they have been removed from our minds with difficulty. There appears to be no doubt that many of the delusions of the insane have dreams for their cause. In the great majority of cases the erroneous beliefs of lunatics are connected more or less directly with themselves. Thus a person be- lieves that his leg is made of glass, that his head is reversed on his shoulders, that he is some great personage, that a large fortune has been left to him, or that some misfortune has deprived him of his prop- erty or his friends. He will often reason logically and forcibly from the premises he has assumed, and will give no evidence of insanity out- side of his delusion. Such cases are embraced under the term of rea- soning mania, and the skill and acumen exhibited by persons thus affected are often surprising. When it is important, in their estimation, for them to conceal their delusions, they will often do so for a long 330 DISEASES OF THE BRAIN. time, and stratagems of various kinds are necessary to their speedy detection. Sooner or later, however, the delusion comes out. The designation monomania can properly be applied to many of the cases of intellectual insanity. In the uncomplicated form of the disease it is rare, after it is fully established, that more than a single object, or a small class of objects, are the subjects of the delusions. The delusions of the insane may be comprehended under two cate- gories—those which are of a pleasant or exalted character, and those which are unpleasant or morbid. These usually leave their impress on the countenance of the patient, and his actions and manner are in accordance with them. It would be strange if this were not the case. The only guide which man has for his actions is his reason. He weighs arguments and mo- tives, and determines according to the bearing which they may have on his mental processes. A delusion is, in many cases, simply a false prem- ise ; the conclusions which the individual draws from it are entirely logical. Taking, for instance, the case of the gentleman who had imbibed the idea that his wife had attempted to poison him; and, ad- mitting that he was correct in this notion, his subsequent conduct—his denunciations, his refusal to live with her, his efforts to have her impris- oned, etc.—is perfectly reasonable. The line of conduct was such as most men would have pursued under like circumstances. In such cases, therefore, there is no fault in the intellectual processes after the first step is taken. It is this first step which constitutes the disease—it is the delusion which enslaves the mind. Intellectual insanity is often uncomplicated by any other form of mental derangement. There are no illusions, no hallucinations, no overpowering influence of the emotions, and no loss of control over the will. Even when the delusion is of such a character as apparently to be connected with some one of the senses, and thus to be based upon a false perception, full inquiry will often show that there is no error of the sensorial processes, centric or eccentric. Thus, a lady under my care had the delusion that she had lost her palate, as she called it. I held a mirror to her face, and, while she opened her mouth, I pointed out to her that all the parts were present. " Yes," she replied, " I see all that; the form is there, I know very well, but the substance is gone ;" and no arguments could convince her to the contrary. A gentleman conceived that his right hand was made of glass, and there- fore, to prevent its being broken, he kept it carefully inclosed in a stout case made to fit it accurately. On my calling his attention to the physical qualities of his hand, and pointing out how they differed from those of glass, he said : " I once thought just as you do. My brain was then incapable of appreciating minute differences as well as it can now; and, though I confess that my senses still convey to me the idea that my hand is like other people's, yet I know the conception is erroneous, INSANITY. 331 and I correct it at once by my reason. My hand looks like flesh and blood, but it is glass for all that. Nothing is more calculated to deceive than the senses." Persons affected with uncomplicated intellectual insanity may go through the world without giving any considerable evidence of mental derangement, unless the subject of their delusions be touched upon. Still, there is no telling to what extremes a delusion may carry its sub- ject. Like a sane idea, it may extend further with each day of life. A person, for instance, imagines that he is the Emperor of Russia. At first he does not comprehend the full importance of his supposed posi- tion, and, if of moderate reasoning power, possessing deficient informa- tion, and naturally of a quiet disposition, he may never go further than dressing himself in some tawdry finery, and strutting pompously through the wards of the hospital. But, under other circumstances, he reflects upon the greatness of his station, and thus, from time to time, he con- ceives new ideas of his powers and importance, and may thus become a very troublesome patient. He comes to believe, perhaps, that he has the power of life and death, and may attempt to exercise his imaginary prerogative. Delusions in regard to relatives and friends are very common, and hence the conduct of the person entertaining them is changed as it relates to the objects of his erroneous ideas. It is a usual thing, there- fore, for such an insane person to disinherit those who would naturally be heirs of his property. The following case, which came under my immediate observation, and which I quote from a former work,1 is important both in its pathological and medico-legal relations: " A gentleman, a widower, lived upon terms of great affection in the same house with his sister, who managed his establishment for him. For several years they had lived together without any thing occurring to disturb the sincere attachment which existed between them. He was as careful as possible to provide for all her wants, and exhibited a tender- ness and love toward her which were noticeable to all with whom they were thrown in contact. " One morning, at breakfast, without any premonitory indications of a change in his conduct having been observed, he removed his boots, took off his coat, and seated himself at the table in this condition. His sister, surprised at these acts in one who had always been remarkably punctilious in his social observances, inquired his reasons for such strange behavior, and made some laughing remark on the subject. He gave no answer, but, jumping up from his chair, began to swear and curse in the most violent manner. Becoming alarmed for her personal safety, she made her escape from the room, and sent for the family 1 " Insanity in its Medico-Legal Relations — Opinion relative to the Testamentary Capacity of the Late James C. Johnston," New York, Baker, Voorhis & Co., 1866, p IB 332 DISEASES OF THE BRAIN. physician. Gradually, however, her fears abated, and, approaching the door and hearing no noise within, she entered the room. To her great astonishment, she found her brother properly clothed seated at the table, as if nothing had happened, and waiting for her to pour out his coffee for him. At first he appeared to be in entire ignorance of his singular conduct, but at last he admitted that he believed he had taken off his coat and boots, and sworn a little. He excused himself by saying that his feet hurt him, and that he had felt very warm. " Nothing further evidencing any mental derangement took place till she began to notice a change in his demeanor toward her. He found fault with her personal appearance—said she arranged her hair badly, that her dresses were unbecoming, and that she was awkward in her movements. Then he accused her of neglecting the household, declared that she was ruining him with her extravagance, that he rcon- duct toward him was disrespectful and insulting, and that if she did not amend her ways he should be forced to send her out of the house. " She bore all his unkindness with great patience, and tried to con- vince him of the erroneous character of his impressions. But she might as well have attempted to change the course of the sun. His delu- sions had became fixed as a part of his mental being, and all efforts made to dissipate them only served to plant them deeper in his mind. Finally, it become very obvious that he had acquired a decided aversion to her. And at last so hateful had the very sight of her become that he ordered her to leave the house, giving her but three days in which to make her preparations for departure. Before she left his residence he had another attack of delirium which lasted several hours, and in which he made several attempts to cut his throat. Not till the occurrence of this second paroxysm did she have any idea that his conduct toward her was the result of insanity. After it passed off, she spoke of his condition to other relatives, but no action was taken in regard to put- ting him into an asylum. The day subsequent to this attack he came home with a common woman whom he installed as his house-keeper, and his sister took her departure. " Up to this period there had been no interruption in his business operations. In the interval between the two attacks of delirium his mind, except as regarded his sister, gave no evidence whatever of aberration. In all his relations with others he was as kind and con- siderate as he had ever been, and showed no diminution in his ability to manage all the details of his extensive mercantile transactions. " Soon after dismissing his sister from his establishment he made a will in favor of the woman whom he had introduced as his house-keeper. This will he read to me. It was perfectly correct in form and detail, and he conversed about it in a perfectly lucid and logical manner. He said that it had always been his intention to leave his property to his sister, but that she had behaved so badly toward him that he was de- INSANITY. 333 termined to cut her off altogether. I endeavored, but in vain, to dis- suade him from this purpose. He would not Hsten to argument, and the more I attempted to convince him of the erroneous character of his convictions, and of the great wrong he was perpetrating, the more obstinately he seemed determined to carry out his design, and finally he accused his sister of sending me to him, to induce him to change his will. As I did not believe him to be of sound and disposing mind, I refused to witness this document, and the servant whom he summoned also at my suggestion declined to attest it. He evinced no surprise at these refusals. On the contrary, he declared that they were just what he had expected, and that we were all in league with his sister to prevent him disposing of his property as he chose. "During the whole course of this interview, and in many others which I had with him before and after this event, I failed entirely to discover any signs of mental derangement except as related to his sister. On every other topic of conversation his opinions were such as showed that he possessed a sound and discriminating judgment, and his reasoning was such as would have convinced any one unacquainted with his delusion of the perfect integrity of his mental faculties. Even as regarded his sister there was no error in his intellectual processes. His premises were indeed false, but the arguments he based upon them and the deductions he drew from them were thoroughly logical. Certainly, if she had been the character he represented her to be, and had really been guilty of the conduct toward him of which he accused her, his aversion would have been perfectly natural. Previously to his third attack of delirium the severest charge he had made against his sister involved nothing of a criminal nature. He never went farther than to accuse her of a want of respect, of superciliousness and extravagant conduct, and of neglecting his comfort. After this last paroxysm, however, he told me one morning, in a very confidential manner, that she had made two unsuccessful attempts to poison him. A few weeks after this attack, he died suddenly of pneumonia. His will was found after his death written in his own handwriting, but neither signed nor witnessed. It bequeathed all his estate to his house-keeper. "In this case there were occasional paroxysms of delirium; a change in the feeling of affection he had always entertained for his sister; de- lusions in regard to the conduct of his sister toward him; and the desire to punish her by excluding her from his inheritance. "There can scarcely be a doubt that had a will been executed under these circumstances, it would have been declared null and void by any competent legal tribunal in the country ; the first element requisite for testamentary capacity, saneness of mind, was absent. The freedom of the will, so far as the patient's sister was concerned, was destroyed, for where there is delusion there is no freedom to act otherwise than as that delusion requires." 334 DISEASES OF THE BRAIN. Delusions may be of such a character as to affect the emotions secondarily. A very common delusion is that of having committed the unpardonable sin, and accordingly the patient suffers great emotional disturbance. This influence upon the emotions is perfectly natural and logical, for, if the person had really committed a sin for which there is no hope of pardon, and had thus incurred the punishment of eternal damnation, it would be strange if the emotions of sorrow and despair were not excited into activity. Such cases, however, are not to be em- braced under the head of emotional insanity; and, though at first sight they may appear to be of that type, inquiry will reveal the fact of the preexistence of the delusion. Intellectual insanity is often the sequence of an attack of acute mania, which form of mental aberration will be presently considered. I subjoin the accompanying portrait, engraved from a photograph, Fig. 24. of a typical case of intellectual insanity. The patient was, for many years, an inmate of the New York City Lunatic Asylum on Blackwell's Island. Her delusion was, that she was the wife of the late President Buchanan. She assumed his name, and was exceedingly tenacious of INSANITY. 335 her rights and dignities. All visitors were received by her with as much formality as though she were the real mistress of the White House. It will be seen, upon examination, that there is no trace of emotional dis- turbance to be perceived in her countenance. The expression of her face is intelligent and shrewd, and she might have walked Broadway every day of her life without exhibiting as much evidence of insanity as many of those who perambulate that thoroughfare and are consid- ered perfectly sane. III.—Emotional Insanity. The emotions are at all times difficult to control, but they may ac- quire such undue prominence as to dominate over the intellect and the will, and assume the entire mastery of the actions in one or more respects. This effect may be produced suddenly, from the action of some cause capable of disturbing the normal balance which exists among the several parts of the mind, or it may result from influences which act slowly but with gradually-increasing effect. In either case there is not necessarily either delusion or error of judgment, but it very generally happens that the intellect sooner or later becomes involved. Emotional insanity may be produced without there being any dis- coverable cause, and without the patient being able to allege a motive. Some emotions are more frequently disordered than others. Those of a sorrowful character are preeminent in this respect, and, when they are affected, the type of insanity called melancholia is the result. This may be either acute or chronic in its course. The first is rarely uncom- plicated, and hence will be more properly considered under the head of mania. Homicide, suicide, and other crimes, may be the result of emotional disturbance as well as of intellectual insanity. The most common of these is undoubtedly suicide, the individual committing self-destruction in order to escape from the depressing influences which act upon him. It more frequently happens, however, that the emotions are disordered through the morbid operations of the intellect. A person, for instance, to cite the example previously given, imbibes the delusion that he has committed the unpardonable sin, or that God has deserted him, and, in consequence, passes into a condition of settled melancholy, during which he may attempt self-destruction to escape from his harrowing thoughts, or commit a homicide, in order that the same end may be ac- complished by his being hanged for murder. Other emotions may of course be excited into morbid activity by derangement of the intellect. Delusional jealousy, anger, hatred, or love, may thus urge their unfor- tunate victim to the perpetration of crime, plunge him into a depth of unhappiness from which there is no escape, or lift him into an ecstasy of bliss far exceeding that derivable from the realization of all his wishes. 33G DISEASES OF THE BRAIN. Under the head of moral insanity, Dr. Prichard, several years ago, described a form of mental derangement which embraced several species which are now more properly placed under other heads. Several of these are clearly emotional in character, and most of them relate to altered modes of feeling or of the affective faculties, and therefore, in the largest sense of the word, may also be called emotional. Careful and thorough inquiry will, however, often show that the primary diffi- culty is one of defect, and not of aberration or exaggeration, and that, therefore, these instances of deficient moral sense, leading the subjects to the perpetration of crimes of various kinds, should be classed under the head of imbecility. Many cases of what are called temporary insanity, mania ephemera, transitory mania, and morbid impulse, are really instances of emotional insanity. That such a condition exists there can be no doubt, and it is important, both as regards the subject and society, to be able to recog- nize or to disprove its presence.1 A few words, therefore, on this point, will not be out of place. The state with which transitory emotional insanity is most apt to be confounded is that which has been designated heat of passion. Passion is emotional activity. It refers to that mode of the mind in which cer- tain impressions or emotions are felt, and which is accompanied by a tendency or impulse, often apparently irresistible, to act in accordance with these impressions or emotions irrespective of the intellect. An act performed in the heat of passion is one prompted by an emotion which for the moment controls the will, the intellect not being called into action. It is an act, therefore, performed without reflection. The passions are, to a certain extent, under the control of the will, and this power of checking their manifestations is capable of being greatly increased by self-discipline. Some persons hold their passions in entire subjugation, others are led away by very slight emotional disturbances. The law recognizes the natural weakness of man in this respect, and wisely discriminates between acts done after due reflection and those committed in the midst of passional excitement. The acts performed during temporary emotional insanity, in their more obvious aspects, and when viewed isolatedly, resemble those done in the heat of passion. But they are so only as regards the acts them- selves. Thus a person, entering a room at the very moment when one man was in the act of shooting another, would be unable to tell whether the homicide was done in the heat of passion, or under the influence of an attack of temporary insanity; he would be equally unable to say whether it was committed with malice aforethought or in self-defense. The act, therefore, by itself, can teach us nothing. We must look to 1 The best monograph on temporary insanity with which I am acquainted is that of KrafFt-Ebing, " Die Lehre von der Mania transitoria, fur Aerzte und Juristen dargestelt," Erlangen, 1865. INSANITY. 337 the attending circumstances, and to the antecedents of the perpetrator, for the facts which are to enlighten us as to the state of mind of the actor. Now, the conditions of temporary emotional insanity are so well marked that the act which indicates the height of the paroxysm may almost be disregarded, for it is always preceded by symptoms of men- tal aberration, while acts done in the heat of passion are not thus fore- shadowed. And, as regards the subsequent state of the individual, the dis- tinction is equally apparent. The one who' has committed a criminal act in the heat of passion soon subsides to his ordinary condition of equanimity, and generally begins to think of his safety. The one who has perpetrated a similar act during an attack of temporary emotional insanity never thinks of escape, nor even avoids publicity. He may even boast of his conduct, or deliver himself into the hands of the law. What is, however, of greater importance is the fact that, though he may subside into a condition of comparative sanity, the evidences of disease are still present, and remain in him for days, weeks, or even months and years. These symptoms are generally those of cerebral congestion, to which attention has already been directed. In heat of passion, the act follows immediately on the excitation of which it is the logical sequence. In temporary insanity, the act is the culmination of a series of disordered physical and mental manifesta- tions, and may or may not be in relation with the emotional cause. The distinction is, therefore, clear and precise. The case of Henriette Cornier, so fully detailed by Georget,1 is a striking instance of the action of emotional disturbance and morbid impulse. This woman was twenty-seven years of age, was of a joyous disposition and gentle in her ways, and particularly fond of young children. In June,- 1825, a notable change ensued in her ; she became sedate, seldom laughed, sighed often, was taciturn, and neglectful of her work. She was accordingly discharged from her service as domestic, and re- turned to her friends. She soon afterward made an attempt at suicide by throwing herself from the parapet of a bridge, but was prevented. She then entered the service of a Madame Fournier, still being dis- posed to melancholy, notwithstanding all efforts made to restore her. On the 4th of November, her mistress went out, leaving Henriette at her work, and directing her to go to a shop kept by a woman named Belon, and get some cheese. This woman had a very beautiful little daughter not two years old, for whom Henriette had always manifested a great liking. On this occasion she fondled the child as usual, and per- suaded her mother to let her take it out to walk. Henriette took the child to Madame Fournier's house, and going first to the kitchen, ob- tained a large knife, with which, and the child, she went to her own room. On the staircase she met the porteress, and, before her, em- 1 "Discussion m6dico-16gale sur la folie, ou alienation mentale," Paris, 1826. 22 338 DISEASES OF THE BRAIN. braced with every evidence of love the little child she held in her arms. Arrived at her own chamber, she laid the infant on its back on the bed, and, seizing its head with one hand, she with the other drew the knife rapidly across the neck and severed the head from the body before her victim could utter a cry. Before, during, and after this crime, she had, as she declared, no emotion or feeling of horror. On the contrary, she was calm, collected, felt neither pleasure nor sorrow, but apparently acted mechanically. Two hours afterward the mother came for her child; Henriette stood at the door. " Your child is dead," she exclaimed, and then, en- tering the room, seized the head of the murdered infant and threw it into the street. On the arrival of the officers, she was found sitting in the room with the dead body, gazing at it, her hands covered with blood and the knife near her. She did not deny her crime, and exhibited neither penitence nor remorse. " I intended to kill it," she said, and, on being further interrogated, declared that she had no particular motive ; that she had experienced the inclination, and she was destined to perpetrate the act. She was suspected of insanity, and was examined by a commission consisting of Adelon, Esquirol, and Leveille, who reported that they were unable to determine whether she was sane or not. This report not being satisfactory, a second examination was ordered, but still no definite opinion could be obtained from the commission. She was tried and found guilty, very illogically, of voluntary but unpremeditated homicide, and was sentenced to hard labor for life. It not unfrequently happens that, so far from the individual at tempting to combat any morbid impulses which he may entertain, he takes positive pleasure in obeying them. Such cases may properly be classed under the head of emotional insanity. The element of pleasure enters with predominating force into the etiology of his actions, and he experiences delight from the perpetration of crimes remarkable for their cruelty and for their apparently motiveless character. As Ray1 says: " The sentiments of truth, honor, honesty, benevolence, purity, have given place to mendacity, dishonesty, obscenity, and selfishness, and all sense of shame and self-control has disappeared, while the intellect has lost none of its usual power to argue, convince, please or charm. I once asked a patient, who was constantly saying or doing something to annoy or disturb others while his intellect was apparently as free from delusion or any other impairment as ever, whether in committing his aggressive acts he felt constrained by an irresistible impulse contrary to his convictions of right, or was not aware at the moment that he was doing wrong. His reply should sink deeply into the hearts of those who legislate for or sit in judgment on the insane: ' I neither acted 1 " A Treatise, on the Medical Jurisprudence of Insanity," fifth edition, Boston, 1871, p. 223. INSANITY. 339 from an irresistible impulse, nor upon the belief that I was doing right. I knew perfectly well I was doing wrong, and I might have refrained if I had pleased. I did thus and so because I loved to do it. It gave me an indescribable pleasure to do wrong.' This man, when well, is kind and benevolent, and in his whole walk and conversation a model of propriety." A few years ago a young man was arrested in this city for assault- ing a young lady in the street. He was identified as a person who had committed many previous offenses of a like character. His plan was to rush up to a lady, seize her, throw her down, and take off her shoes, which he carried away with him. He did not attempt otherwise to injure her or to take away any other article from her. On searching his trunks and drawers they were found full of women's shoes. He said he had no use for them, and was actuated by an irresistible impulse which it was pleasant for him to gratify. In 1828 Papavoine killed in the forest of Vincennes two little boys, who were there on a holiday with their mother. He had never seen these children before, and when seized with the impulse to kill them went and bought a knife for the purpose. Returning he murdered them before their mother's eyes, and made his escape. On being arrested and identified, he at first denied the charge, but subsequently admitted its truth. Confined in prison he set fire to his bed, and attempted to mur- der a fellow-prisoner. When interrogated during his trial, he declared that at the time of the double murder he was in bad health, had been unable to sleep, and was nervous. He asserted that he had no motive whatever to kill the two children. Inquiry into his antecedents showed that, though he had been quiet and taciturn in his habits, he had never exhibited any indications of insanity, but had discharged with fidelity the duties of an office he held under the government, and had retired with a pension. The plea of insanity was put forward by his counsel, but it was disregarded by the jury, and he was found guilty and ex- ecuted. The force of habit, undoubtedly, has much to do with the repetition of criminal or insane acts originally due to the gratification of a morbid impulse—itself the offspring of a powerful emotion. This was evidently the case with Helene Jegado, who in France, between the years 1833 and 1851, killed twenty-eight persons by poison, besides making several un- successful attempts. In none of her murders was any cause alleged or discovered, though undoubtedly the gratification derived from the per- petration of crime, and the fact of being additionally impelled thereto by habit, were the determining factors. Her victims were her masters and mistresses, her fellow-servants, her friends, for whom in their dying moments she displayed the utmost tenderness and care. The plea of monomania was set up in her defense, but no evidence of insanity was brought forward by her counsel, save the apparent want of motive for 340 DISEASES OF THE BRAIN. her crimes. She was found guilty by the jury after a short deliberation, and was in due time executed. Her last words on the scaffold were directed to accusing a woman as her instigator and accomplice whose name was not even mentioned during the trial, and who, upon inquiry, was found to be an old paralytic, whose, life had been of the most exemplary character. The case of Dumollard is in some respects similar to the last. This man, a peasant, of a low order of intellect, had & penchant for murder- ing servant-girls whom he pretended to hire, and then conducting them to unfrequented places, put them to death. Six thus disappeared, and nine others barely escaped. Indeed, it is probable that many more than these were murdered, for on searching his premises twelve hundred and fifty articles of women's apparel were found, of which only fifty were identified. As some one said at the time, Dumollard ought to have had a cemetery of his own. And yet there was no such motive for his crimes as would adequately account for them. He did not sell the clothing and other things of little value which he obtained from his victims. Indeed, it was shown that he had burned and otherwise de- stroyed many of them, and the rest were hidden in out-of-the-way places about his dwelling. There was no evidence to show that he had outraged any of them whom he had murdered, and he was found not guilty of the accusation to this effect. He appears to have been wholly actuated by morbid impulse and the force of habit—a habit which had become a part of his being, and which it afforded him pleasure to in- dulge. Insanity was urged in his defense, but he was found guilty and was executed. The recent case of Jesse Pomeroy, the particulars of which, being generally known, need not be .dwelt upon here, is another similar in its general features to the foregoing.1 The legal relations of this particular form of mental aberration scarcely fall within the scope of the present work, but they are so im- portant that I do not hesitate to say a word on the subject. That individuals thus affected are insane, that is, of unhealthy minds, is undoubtedly true, but there is none the less any reason why, when convicted of crimes, they should not be made to suffer the full penalty which the law awards. There is no evidence to show that a crime committed through a morbid impulse based upon a still more morbid emotion of pleasure, could not have been prevented had the individual chosen to combat the desire of self-gratification. Those mor- bidly-constituted persons, who commit crimes because it is pleasant for them to do so, such as Helene Jegado, Dumollard, Pomeroy, and others, whose cases have been cited, should be treated exactly like other 1 For further instances and remarks on this subject the reader is referred to the au- thor's Memoir on " Morbid Impulse," read before the New York Medico-Legal Society, May 28, 1874. INSANITY. 341 offenders against the laws. The absence of motive is apparent only. The fact that the criminal experiences pleasure from the committal of the act is as strong a motive as any other that can be alleged, and is entitled to no more extenuating force than the pleasure of revenge or acquisitiveness or other passions. " Lord, how I do love thieving!" said a London vagabond. " If I had all the riches of the world I would still be a thief." The plea, " I could not help it," is one which every member of the criminal classes can urge with as much force as the subject of emotional morbid impulse, and, when it stands alone in an otherwise sane individual, should be absolutely disregarded by juries and judges. Fro. 25. Emotional insanity of a very intense character, putting on the form of melancholia, may, as I have said, exist without the intellect par- ticipating—that is, without the existence of delusions. Dr. Dickson1 cites the case of a young man under his care in St. Luke's Hospital, in whom neither hallucinations nor delusions were ever developed. At ' "The Science and Practice of* Medicine in Relation to Mind," etc., New York, 1874, p. 188. 342 DISEASES OF THE BRAIN. the outset of his attack he got out of health, had losses in business, and began to grow low-spirited ; this state continued till the depression began to incapacitate him for business. He then became strongly impressed with the idea of suicide, which he afterward described as an awful, overpowering, and fiery sensation which seemed to prompt him to make away with himself. The portrait (Fig. 25) is that of a woman affected with pure emo- tional insanity, of a depressing character, but without delusions of any kind. She could assign no cause for the intense melancholy with which she was affected, and which caused her to pass the greater part of the day crying and wringing her hands. She had twice attempted suicide before she came under my care, not from any delusion, but solely that she might escape from her overpowering emotions and the mental anguish they caused her. She was fully sensible of her situation, knew how groundless was her grief, and constantly lamented her in- ability to control her feelings. IV.—Volitional Insanity. In uncomplicated volitional insanity, there are no delusions and no emotional disturbance, but solely an inability to exert the will in accord- ance with the intellect. Many cases of morbid impulse are instances of volitional insanity, in which an idea suddenly flashing across the mind is immediately carried out by the individual, although his intellect and his emotions are strongly exerted against it. Thus, a person who previously has not exhibited any very obvious symptoms of mental derangement— though careful inquiry will invariably show that slight evidences of cerebral disease have been present for some days—instantaneously feels a morbid impulse to commit a murder or perpetrate some other criminal act, and is forced to yield, notwithstanding all the efforts he may make. Numerous cases of the kind are on record, and they are readily distin- guished from such as those cited in the immediately preceding section by this fact of their being against the wishes and desires of the culprit, who has for the time lost the control of the will. Thus Esquirol' relates the case of a man thirty-two years old, of a nervous temperament and quiet disposition, who had been well educated, and who was fond of the fine arts. He had suffered from a brain-disorder, but had been several months'cured. After being in Paris for about two months, during which time he led a perfectly regular life, he one day entered the Palais de Justice and attacked an advocate with great fury. The next morning, when seen by Esquirol, he was perfectly tranquil and composed, showed no anger whatever, and had slept well all night. The same day he designed a landscape. He recollected what he had done the previous day, and spoke of it with coolness. He declared that 1 "Des maladies mentales," Paris, 1838, tome i., p. 380. INSANITY. 343 he had entertained no ill-will against the advocate, had never even seen him before, and had no business with him or any other lawyer. He could not understand, he said, what had actuated him to make the assault. Subsequently he exhibited no indications whatever of being insane. In morbid impulse due to volitional insanity, the individual who is its subject is perfectly aware of the incongruous act he is about to commit, but perpetrates it because he is compelled thereto by a force which he feels himself powerless to resist. He acts calmly and deliber- ately very often, but again manifests agitation and excitement. He does not for a moment lose consciousness—as does the epileptic, who may also commit acts of violence under the impulse of a paroxysm— and when his impulse has been acted upon or his purpose changed by any for the moment more powerful cause, he recollects distinctly all the circumstances of the occasion. It frequently happens that the patient struggles successfully against these impulses, even when on the very point of yielding, or when he takes such measures of prevention as are sufficient for the purpose; or the impulse disappears apparently spontaneously, or as a consequence of appropriate medical treatment. Georget' relates the case of a woman, the wife of a shoemaker, who felt herself impulsed to murder her four children. She sought medical advice for a disease, which, as she said, was driving her to despair. She had the appearance of health, slept well, was regular in her men- strual function, had no pain and no disturbance of the circulation. But she complained of being subject to a morbid impulse to kill her children, although she declared that she loved them better than she did herself. When the paroxysm was at its highest her face became red, and she trembled violently. She was cured by the use of baths, valerian, and a blister applied between the shoulders. The same author quotes from Michu the following case : "A countrywoman, twenty-four years old, having simple manners and good habits, but rather taciturn, was safely delivered of her first child ten days previously, when she suddenly, while looking at it in- tently, experienced a desire to strangle it. The idea of such a thing made her shudder with horror. She placed the infant in its cradle and rushed out of the house, hoping to divert herself from her fatal impulse. Returning home to nurse her child, she again experienced the sensation of being forced to kill it. Again she left the house, and going to the church prayed to be delivered from the sin of murder. Soon afterward she met the priest, who, being a sensible man, advised her to consult a physician, and in the mean time promised to'watch her. Michu was con- sulted. He observed nothing abnormal in the appearance of the woman. When asked if she loved her babjT, she replied: 'I know well that a 1 "Discussion medico-16gale sur la folie," etc., Paris, 1826. 344 DISEASES OF THE BRAIN. mother ought to love her child; if I do not love mine it is not my fault.' Michu very wisely insisted on removing the child from her, and in the course of a few days the impulse disappeared."1 Very slight causes are often sufficient to destroy or overcome the morbid impulse. Marc2 cites the case of M. R., a distinguished chemist and an amiable man, who, feeling himself compelled to commit murder, and fearing his inability to resist, voluntarily placed himself in a maison de sant'e of the faubourg St.-Antoine. Tormented by the desire to kill, he often prostrated himself before the altar and implored the Almighty to deliver him from his atrocious impulse, the origin of which he could not explain. When he felt that his will was yielding, he went to the superintendent of the asylum, and had him tie his thumbs together with a ribbon. This weak band was sufficient to calm the unfortunate man for a time; but eventually he attempted to kill one of his keepers, and finally died in a paroxysm of acute mania. Again, all the efforts of the affected individual are apparently un- successful, and the fatal deed is committed. I say apparently, because we never can be sure that the patient has exercised all his will-power. When he effectually resists, there are not wanting those who will de- clare that the case is not one of morbid impulse; while, when he yields, at once or eventually, these same persons will just as strongly affirm that the impulse was irresistible. Several cases have come under my observation in which patients have confessed to me that they have had impulses to commit various kinds of crimes, which they have been barely able to resist. These people have passed through life attending faith- fully to their several duties, and entirely unsuspected of contending with themselves in so terrible a manner. A few weeks ago a young man consulted me for symptoms indicat- ing cerebral congestion. He had pain in his head, dizziness, and was unable to sleep. He informed me that he had been for several months constantly troubled by a force, which was inexplicable to him, to kill a friend, who was employed in the same office with him. Upon one occa- sion he had gone so far as to secretly put strychnia into a mug of ale, which he had invited the young man to drink; but, just as the intended • victim was raising the vessel to his lips, he had, as if by accident, knocked it out of his hand. Every morning he awoke with the impulse so strong upon him that he felt certain he would carry it out before the day closed; but he had always been able to overcome it. This young man reasoned perfectly well, in regard to his impulse, and very candidly admitted, and I entirely agreed with him, that if he had yielded and committed the murder, he ought to have been punished to the full extent of the law. The following extract from a letter which I recently received is like- wise to the point: 1 Op. cit, p. 50. * " Consultation medico-legale pour Henriette Cornier," etc. INSANITY. 345 " In the New York Sun of the 30th inst. I noticed the proceedings of the Medico-Legal Society, in the College of Physicians and Surgeons, on emotional insanity, etc., and I was impressed particularly with your re- marks on ' Morbid Impulse.' Some two weeks since I was at work in my garden, with a spade, and one of my little girl children, just three years old, came in where I was, and I was suddenly seized with an impulse to kill the child with the spade that I was at work with, and in order to prevent my doing so I had to make her leave the garden. Now, I love this child better than I do the apple of my eye, and why I was seized with that impulse I can't say. Since that time I have been feeling strange, and I am afraid to trust myself with my own family, though I know perfectly well what I am doing, and only feel actuated by these impulses. I have consulted a physician, and he laughed at me. If you can suggest any remedy for these strange impulses, I will pay you what you charge, and will consider that you have done me a favor that will cause me to bless your name forever. I don't consider that I am in any danger of murdering any one just yet: but the idea of such a thing is horrible, and I fear it may grow on me unless remedied." In my reply I called his attention to the admitted fact that he had his impulse under control; that he was able to reason calmly and intel- ligently in regard to it; that he had applied to me for advice, and that I urged him, without delay, to place himself under the restraint of an asylum. I further told him, that if he disregarded this advice, and finally yielded to his impulse, he would be fully as guilty of murder as if he had killed through deliberate malice, and that he ought to be just as surely executed as any other murderer. A morbid impulse of the kind under consideration is sometimes ex- cited by a suggestion which the individual suddenly receives. The action of this principle is well shown in the following case: A young man, a member of a highly respectable family, consulted me for what he called insanity. It appeared that a few weeks pre- viously, while walking down Broadway, he had been struck with the appearance of a lady in front of him, who wore a very rich black-silk dress. Suddenly the impulse seized him to ruin this dress by throwing sulphuric acid on it. He therefore stopped at an apothecary's shop, and purchased a small vial of oil of vitriol. Hastening his pace, he soon overtook the lady, and walking by her side he managed in the crowd to empty his vial over her dress without being perceived. He derived so much satisfaction from this act that he resolved to repeat it at once. He therefore purchased another supply of vitriol, and, singling out a lady better dressed than others around her, poured the contents of the vial over her dress, and again escaped detection. He then went home, and, reflecting upon what he had done, determined to persevere in the practice ; but a night's rest put him in a healthier frame of mind, and he concluded to abandon the idea. Indeed, he was so distressed by 346 DISEASES OF THE BRAIN. what he had already done, that he wrote out an advertisement for the newspapers, in which he requested the ladies whose dresses he had spoiled, to reply through the same channel, giving their residences, so that he might recompense them for the loss he had caused them to sus- tain. But on his way to the newspaper offices he again felt the impulse at the sight of a handsome dress to throw vitriol on it, and again he purchased a supply and repeated the act of the day before. He now began to consider more fully than he had yet done the nature and consequences of his conduct, and the next morning came to me for advice. He stated very frankly his entire conviction that his acts were in the highest degree immoral and degrading, but expressed to me his utter inability to refrain. " A handsome dress," he said, " acts upon me very much as I sup- pose a piece of red cloth does on an infuriated bull; I must attack it. The bull uses his horns, while I use vitriol. I do not know why the idea ever came into my head. I certainly should never have conceived of such a thing if I had been blind. I was altogether excited by the sight of that handsome black-silk dress the first day, and it was impossible for me to resist it after it had once had a lodging in my mind. But I have often seen fully as handsome dresses in the street before, but never previously was the sight followed by such an impulse." Upon the most careful examination I could discover no evidence of disease anywhere, except in the one point of wakefulness, with which he had suffered more or less for several months past. I therefore pre- scribed bromide of calcium for him, and insisted on his removing him- self from further temptation by taking a sea-voyage in a sailing-vessel upon which there were no women passengers. He at once expressed his acquiescence in my views. He went to sea in a fishing-schooner, and returned in three or four months perfectly free from his morbid impulse. A gentleman who came about once a week to consult me for cere- bral congestion, the result of excessive application to business, and who lived in a neighboring town, informed me that during his journeys by rail he invariably experienced an impulse to throw himself from the train. Finally he was so strongly impelled that he stated the case to an acquaintance in the cars, and begged him to sit near him, and restrain him, if he made any such attempt. After that he never came without bringing a friend with him, who had instructions not to lose sight of him for an instant. In telling me of his impulse he described it as almost overwhelming, and that it seemed to be excited by the rapid motion, and by the fact that he had heard of people throwing themselves from railway-trains. It is well known that persons standing on great heights often expe- rience an impulse to jump off. So many individuals committed suicide by leaping from the Colonne Venddme and Arc de Triomphe in Paris, INSANITY 347 and from the Duke of York's Monument in London, that precautions had to be taken to prevent further acts of the kind. Marc relates the case of a nurse who felt the impulse to murder the infant she took care of, whenever she saw its naked skin. She threw herself on her knees before her mistress, and begged to be discharged, declaring that the whiteness of the child's skin excited her to murder it, and that she could no longer resist the impulse. Several years since, I had a lady under my charge who, whenever she saw the naked shoulders of a young child felt an impulse, which she declared she could not resist, to bite the skin. She had thus inflicted very disagreeable wounds on the children of her friends, and was finally arrested on the charge of assault, but the matter was hushed up on her promise to abstain, and she kept her promise. Morbid impulses are often excited by the sight of a suitable weapon with which an act of violence may be committed. Persons have hanged themselves on the suggestion of seeing a rope; others have committed murder or suicide from seeing knives, pistols, etc. Even a word spoken in jest may be sufficient. Dr. Oppenheim, of Hamburg, having received for dissection the body of a man who had committed suicide by cutting his throat, but who had done this in such a manner that his death did not take place until after an interval of great suffering, jokingly re- marked to his attendant, " If you have any fancy to cut your throat, don't do it in such a bungling way as this; a little more to the left here, and you will cut the carotid artery." The individual to whom this dan- gerous advice was given was a sober, steady man, with a family and a comfortable subsistence. He had never manifested the slightest ten- dency to suicide, and had no motive to commit it. Yet, strange to say, the sight of the corpse and the observation made by Dr. Oppenheim suggested to his mind the idea of self-destruction, and this took such firm hold of him that he carried it into execution, fortunately, however, without profiting by the anatomical instruction he had received, for he did not cut the carotid artery. Closely allied to suggestion, and probably a more powerful cause of morbid impulse, is imitation. Thus many crimes have been committed by persons who have had this impulse excited by reading accounts of the trials of other persons, or the detailed recitals of all the particulars of offenses which the age requires the public press to contain. Epi- demics of murder, suicide, arson, and other crimes, are thus produced. " Some years ago," says Dr. Forbes Winslow,1 " a man hung himself on the threshold of one of the doors at the H6tel des Invalides. No suicide had occurred at the establishment for two years previously; but in the succeeding fortnight five invalids hung themselves on the same cross-bar, and the governor was obliged to shut up the passage." Epidemics of suicide spread, according to Plutarch, among the 1 "The Anatomy of Suicide," London, 1840, p. 120. 348 DISEASES OF THE BRAIN. women of Miletus, and, as is well known, in later days among the young women of Marseilles. A careful attention to the cases of suicide recorded in the daily news- papers of a large city shows that they are to a great extent influenced in character by the principle of imitation. A case of suicide by Paris- green is published, and straightway half a dozen others due to this poison are the result. Or a man or woman jumps from a ferry-boat while it is crossing the river, and then this mode becomes the fashion for a while, to be followed in its turn by some other method. When I was a medical student of the University of New York, a young gentleman from Georgia was on one occasion dissecting the same body that I was. He had drawn one of the lower extremities as his part of the subject, and he was assiduous and careful in his duties. So far as my observation of him extended, he did not differ essentially from other medical students. He was cheerful in disposition, and gave no evidence whatever of mental derangement, or even of excitement or depression of mind. One morning we were told that he had been found dead on the floor of his bedroom, and examination showed that he had divided his femoral artery, and had died from hemorrhage. It was then ascertained that he had, the evening before, received a letter which had apparently caused him much unhappiness. Now, suicide from division of the femoral artery is certainly a very unusual mode of self-destruction. I doubt if any case of the kind had previously occurred in New York. Yet within a week there were two others, one of which was Horace Wells, the alleged discoverer of the anesthetic properties of sulphuric ether. Here we have the principle of suggestion acting on the first victim, and then that of imitation on the others. Imitation is of more force when the intellect is less fully developed. Even in the normal condition we find it more strongly exercised in children and women than in adult men. In the former the influence may be so powerful that actual disease is acquired. Thus a child imi- tates the movements of another affected with chorea or with stammer- ing, and immediately acquires the disorder. Even squinting has been contracted in this manner. A lady had received such a vivid impression at seeing her maid throw herself down a well, that she never passed a well without feeling a strong impulse to throw herself into it.1 An idiot, after having killed a pig, felt impelled to kill a man, and obeyed the impulse on the first one he met. A melancholic person was present at the execution of a criminal, and was immediately seized with an impulse, of which he was fully conscious, and could scarcely resist, to murder some one. A child six years old strangled its younger brother. The father and 1 Gall, "Fonctions du cerveau et de chacune de ses parties," tome x., p. 199. INSANITY. 349 mother entering the room at the moment the act was in process of ac- complishment, demanded the cause. The child threw itself, weeping, into their arms, and answered that it was imitating the devil, whom it had seen strangle punchinello. Such cases as these are at least of value if they cause us to recognize the force of the principle of imitation, and to render less public than they are now the executions of criminals and the slaughter of animals. In the month of February, 1846, three hundred and fifty French sol- diers were encamped together in Algiers, when one of them wounded himself in the wrist. Within twenty days thereafter thirteen others had injured themselves in precisely the same manner. The commandant, frightened at this series of mutilations, removed his camp to a distance of eight leagues ; but what was his astonishment to find that within a week eight others had voluntarily wounded themselves in the same way ! The well-known tendency of many women to become affected with hysteria at the sight of another suffering from a paroxysm of the dis- ease, and the similar fact of the extension of epidemics of demonomania, trance, ecstasy, the impulse to mew like a cat or to bleat like a sheep, and, it may be added, crusading, both of mediaeval and of more recent times, may also be cited as illustrations in point. The legal relations of volitional insanity are of so much interest that I do not hesitate to give my views relative to the principles which should in this connection be taken into consideration. A person aware of the existence of an impulse to commit crime, and which he fears he may not be able to resist, is bound to do every thing in his power to render the accomplishment of his propensity impossible. It is his duty to immediately place himself under restraint. If he does not, he is morally and legally in no better position than a ruffian who feels an impulse to acquire other people's property, and accordingly murders the man most convenient for his purpose. The individual who is clearly shown to have yielded to a previously unfelt impulse to commit crime, and who accordingly perpetrates an otherwise motiveless offense, or one which in his normal condition would evidently not have been committed, is too dangerous to society to be allowed to go at large. He ought to be placed under permanent re- straint. I say permanent, because experience shows that this form of mental aberration is exceedingly apt to recur. Many cases might be cited in illustration of the fact of crimes against the person being com- mitted after discharge from confinement, and there are hundreds of similar instances on record. Many instances of the so-called moral insanity may properly be placed under the head of volitional insanity, for they are characterized by an inability to so exert the will as to refrain from the perpetration of acts known to be crimes. Of such are cases of kleptomania, dipso- mania, pyromania, etc. 350 DISEASES OF THE BRAIN. The will in insanity is often secondarily affected through disturbance originating in the intellect or the emotions, and acts are hence per- formed which give evidence of the existence of mental aberration. In mania of all kinds, and especially in dementia and general paralysis, there is either a loss of volitional control, or an inability to exert the normal will-power. V.—Maxia. In mania the mind is affected in several, generally all of its parts. There are illusions, hallucinations, delusions, emotional disturbance, and loss of volitional power or control. The patient is either morbidly ex- cited or depressed, and is often violent in his language and actions. Acute mania is the more common species of mental aberration, and in its two types of exaltation and depression constitutes the .form which it is most important for the physician to understand. I shall therefore consider them at some length, so far as their symptoms and cause are concerned. Acute mania with exaltation has its prodromatic stage, the symp- toms of which are very similar to those which precede an attack of fully-developed cerebral congestion. These in the main are pain or full- ness in the head, confusion of ideas, increased irritability of the mind, and, above all, wakefulness. In addition, there are restlessness of body and a singularity of behavior, which strike those thrown into intimate relations with the subject, and cause them to suspect that something is wrong with him. The character and disposition undergo a change, and it is very common for unfounded prejudices to be formed against persons for- merly highly esteemed. Before very long there are illusions and hallucinations. At first the patient struggles against them, but eventually he accepts them as true, and hence becomes subject to delusions. These are rarely fixed in the earlier stages, and may not be so through the whole course of the dis- order. With these symptoms there are evidences of derangement in other organs besides the brain. Thus, the appetite is lessened, the bowels are torpid, the kidneys fail to eliminate the normal quantity of urine, the heart becomes irregular in its action and beats with increased fre- quency, a certain sign of a weak and excited nervous system, and the skin is either bathed in perspiration or is dry and hard. With the full development of the disorder the patient becomes inco- herent and rambling, showing a great disposition to talk, to laugh, and to sing, and indulging in antics of various kinds. His delusions mainly have reference to himself: he imagines that he is some great personage, that he has suddenly become very rich, or that he has been specially singled out for some other piece of good fortune. INSANITY. 351 Not unfrequently he is exceedingly troublesome, destroying the fur- niture of his room, tearing his clothes, attacking those around him, and making all kinds of attempts to escape from restraint, but at the same time there is rarely any serious effort to do great bodily harm either to himself or others. Sometimes, however—and this fact should always be borne in mind by the attendants—there is a disposition to perpetrate acts of extreme violence, and such a tendency, even when not previously manifested, may very suddenly be developed. Thus, a lady under my care, who had a few days before become in- sane, behaved with propriety, merely making continual efforts to get into the street to attend court, where, as she believed, she had an im- portant lawsuit. Without any warning, however, she went into an adjoining room where her infant child was sleeping, and threw it out of the window before she could be stopped in her act, exclaiming, " Well, if I can't go out, my baby shall." Fortunately, the child fell on a thick grape-vine, and was not injured. In another case, a gentleman, whom I saw in consultation with my friend the late Prof. George T. Elliot, became affected with acute mania of the most hilarious and exalted character. While playing on the piano and singing with the utmost glee, he expressed a wish for a cracker, and went to the dining-room to get one. While apparently looking for something to eat, he suddenly seized a knife and attempted to cut his throat. The close proximity of his attendant alone prevented his inflicting serious injury on himself. As a rule, patients with acute mania lose all sense of decency, and become exceedingly filthy in their habits and obscene in their language and conduct. At times such lunatics exhibit a surprising degree of cunning, and are able to exercise great control over their conduct when they have an end to accomplish. They may thus readily deceive the young and in- experienced physician, and induce him to forego the idea of putting them under permanent restraint, or they may so impose on him as to induce him to relax his vigilance, and thus allow of their committing some outrageous act. It must be remembered that acute mania is not suddenly cured, but runs a definite and allotted course. It is rare that the memory of patients suffers to any considerable extent in acute mania. They are perfectly conscious of their sur- roundings, and are seldom deceived by the subterfuge so frequently and so unjustifiably employed that they are to be taken to an hotel or a country-seat when about to depart for an asylum. If the stratagem does for the moment impose upon them, they recollect the fraud, and will not again repose confidence in those who have perpetrated it. Their appetites are generally unchanged. If in the habit of smok- ing or drinking, they still want their tobacco and their wine, and are usually able to eat a full allowance of food. 352 DISEASES OF THE BRAIN. After their entrance into the asylum, the main object of their lives is to get out again as soon as possible. They often recognize their con- dition, and will call attention to any indications of improvement they may exhibit. They are not for a moment deceived by the delusions of their fellow-lunatics. " Doctor," said a patient to me whom I had sent to a lunatic asylum, and was visiting, " this is the best place in which to study the infirmities and humbugs of human nature of which I have any knowledge. Everybody here is insane except myself. There is a fellow I used to know before he lost his mind, a good, clever fellow he was too, and as sharp as a steel-trap. Now he is a d—d fool, and thinks he takes his breakfast off the top of the capitol every morning. And there is a lady holding that bunch of rags to her breast and thinking it's a baby. These lunatics are funny, very funny, but I've had about enough of them, and would like to go somewhere else." At the time, this gentleman thought he was General Grant, and was going.to be inaugurated President in a few days. It is rarely the case that the sleep is regular and sound. Often they Fig. 26. INSANITY. 353 will lie awake all night, talking of their plans, or else will annoy their attendants in every conceivable way. Although having usually uncom- fortable feelings in the head, they rarely suffer from acute pain in that part of the body. The preceding woodcut represents a case of acute mania, with general mental exaltation. No one can fail to perceive the expression of happiness on the face. Acute Mania, with Depression.—The acute melancholia of many authors is a very terrible form of mental aberration. Like that just described, it is generally preceded by prodromata, which indicate, by their character, the type of insanity which is about' to be developed, but it often appears with great suddenness. In the case of a lady now under my charge, the first evidence of mental disorder was a violent scream, due to the fact that an idea had instantaneously flashed through her mind that she had committed the unpardonable sin, and had conse- quently lost all hope of saving her soul. For several days she con- tinued, with scarcely an intermission, to scream, to cry, and to sob, at the same time showing the greatest terror from the apprehension that the devils were approaching her. Gradually this extreme state became less violent, but she still continued to be actuated by intense fear, and paced the floor night and day, wringing her hands, weeping, and ex- claiming, " Lost, lost, lost forever ! " In another case of a lady from the West, the idea suddenly occurred to her that she was about to be killed. She screamed, and begged, and prayed, to those around her not to allow her to be injured. In the fur- niture and attendants she saw her murderers, and to escape from them made several attempts to throw herself out of the window. Then she believed that she was to be poisoned, and refused all food with the utmost pertinacity—closing her teeth so firmly together that it was only by the use of all my strength that I could succeed in prying them open. Of all the forms of insanity, this is the one in which illusions and hallucinations of the senses are most common. These are particularly so as regards sight and hearing, and do not, as a general thing, refer to the body of the patient—although generally in direct relation with his delusion. A gentleman, who, within a short period after becoming affected with the present variety of insanity, came under my care, was controlled by the delusion that he had committed so many sins that atonement must be made. He had, therefore, several times attempted suicide, and, when I entered the room where he was, he was in the act of strug- gling with his friends, who were using all their strength to prevent him throwing himself out of the window. As soon as he saw me, he fell on his knees, held up his hands in the attitude of prayer, and mumbled out a few words which showed that he took me for a priest, and was asking 23 354 DISEASES OF THE BRAIN. for intercession with the offended Deity. On arriving at the asylum, to which I recommended him to be immediately sent, he went at once to an open coal-fire, and, before any one knew what, he was about, thrust his hand into the mass of burning coals, and succeeded in injuring it terribly. Fig. 27. In all cases of acute mania with depression, too great care cannot be taken to prevent self-injury or suicide. It must be constantly kept in mind that the idea is a very common one with this class of patients, and that frequently they manifest great astuteness in concealing it till they are ready to make the attempt. The physician, in general practice, should always urge that patients affected with the form of insanity under consideration should, as soon as possible, be placed in an asylum, for it is almost impossible to man- age them in ordinary houses, or with their friends about them. The preceding woodcut (Fig. 27) is an admirable likeness, taken from a photograph of a young woman in the New York City Lunatic Asylum, suffering from acute mania, with depression. Apprehension and terror are plainly depicted on her countenance. INSANITY. 355 Fig. 28 represents a female inmate of the same asylum, whose his- tory I have not been able to obtain, but whose expression of counte- Fig. 2<*. nance, though less pronounced than that of the preceding, is nevertheless sufficiently indicative of the existence of mania with depression. VI.—General Paralysis. The affection now known as general paralysis was first described by Delaye,1 in 1822; then by Bayle,2 in the same year; and then, with much more thoroughness and exactness, by Calmeil,3 in 1826. It is a very common form of mental derangement, and, aside from the implication of the mind, presents the very striking feature of a gradually-advan- cing paralysis, which derives its name of general from the fact that it 1 "De la paralysie gen6rale incomplete," Th&se de Paris, 1822. 9 "Recherches sur les maladies rhentales," Paris, 1822; and "Traite des maladies du cerveau et des membranes," Paris, 1826. 1 " De la paralysie consid6ree chez les ali6nes. Recherches faites dans le service de feu M. Roger-Collard'et de M. Esquirol," Paris, 1826. 356 DISEASES OF THE BRAIN. involves, sooner or later, nearly every muscle of the body. This paral- ysis may show itself at the same time that the insanity is manifested ; it may precede the mental derangement, or it may be subsequent thereto. The latter is much the more usual order. The mental symptoms differ, in several important respects, from those which occur in other forms of insanity. The first indication of disease is generally an excessive anxiety in regard to matters which are really of no great importance. Of the cases which have come under my care, one was first made apparent by a morbid apprehension on the part of the patient that he was not managing some trust-funds in the best possible way ; another by the idea that he was constantly wound- ing the feelings of his friends; and another was continually changing his mind about the most trivial things, and apparently thinking that the world watched, with great anxiety, all his movements. At first the general mental type is that of depression. The emo- tions are easily excited, and the delusions which soon make their ap- pearance are of the melancholic form. The idea of propriety in the every-day affairs of life seems to be lost, and the patient will commit all kinds of indecent acts without appearing to be aware that he is doing any thing unusual. His memory fails rapidly, and his intellectual vigor declines from the very first. Hence he is not able to argue in defense of his delusions, but attacks with physical force those who venture to differ with him. His acts are in other respects eccentric and absurd. He spends money in things which are of no manner of use to him, and at the same time refuses to pay his small debts ; he harasses in every possible way those who are about him, gives them impossible orders, and then abuses them if they are not at once obeyed; he is whimsical at the table, his likes and dislikes are changed, and he either eats and drinks voraciously, or declares that nothing is cooked to suit him, and leaves the table in a rage. Gradually the form of his mental aberration changes ; he becomes more cheerful, forms all kinds of impossible schemes for suddenly acquiring great wealth, and these are quickly abandoned for others equally impracticable. Thus delusion after delu- sion rapidly succeed each other, and these, in the great majority of cases, relate to the grandeur, the wealth, the physical strength, or some other great quality of the patient, constituting the delire des grandeurs of the French. One will tell of his immense palaces built of gold and inlaid with precious stones, and in the next breath will descant of his great weight or his extreme lightness, or of the number of children he has, or of the millions of operas he has composed. Another urges his great importance in the political world, tells us that he has elected all the members of Congress himself, that he has paid off the national debt, and that in consequence he is to be made Emperor of the United States, with a salary of a thousand millions a year; that he is going to have a thousand physicians, who are to be clothed in blue-velvet uniforms em- INSANITY. 357 broidered in gold and diamonds ; that he has chartered the Great Eastern for a pleasure-trip, and engaged ten thousand musicians and a similar number of ballet-dancers to go with him. The next day he has forgotten all these fancies, and is off on another series of absurd ideas. In no respect is he restrained in the extent of his delusions. Impossibilities are not regarded. While scarcely able to drag one leg after the other, he will brag of his great fleetness of foot, and in the very death gasp will mutter about his extreme strength and en- durance. The symptoms connected with sensation are equally well marked. In the early stage headache is often very severe, so much so that, as Westphal' has remarked in his excellent monograph on the subject of general paralysis, the patient often dashes his head against the wall. At other times the feeling in the head is that of fullness or tightness, and these sensations are often accompanied with vertigo. Neuralgia in various parts of the body is common, and some of my patients have complained of the different degrees of numbness, especially in the hands and feet. But still more strongly manifested are the disorders of motility, due to the progressive paralysis. According to my experience, the first sign of loss of power—one which is very often observed before any evidence of mental derangement is perceived—is a slight defect of articulation due to paralysis of the lips. At first this is scarcely perceptible ; there is merely a little trembling, an action such as that seen in persons who are endeavoring to restrain their emotions, but it is sufficient to give indistinctness to the utterance of those words which contain labial letters. The tongue is the next to be affected. Examination shows that there are fibrillary contractions of its muscles, and it is moved with less facility. The articulation is slovenly, words are slurred over, and there are both stammering and stuttering. The patient notices these difficul- ties, and in endeavoring to obviate them makes matters worse, by his inability to be exact, contrasting strongly with his efforts. The paral- ysis of the tongue gradually becomes more complete, and at last this organ can only be moved with great difficulty. The other facial mus- cles participate, and a blank, somewhat sorrowful expression is con- stantly present. The voice loses its fullness, and there is difficulty of swallowing. The muscles of the eye are also generally involved, producing ptosis from paralysis of the levator palpebral superioris diplopia, from implica- tion of the internal rectus, and contraction of the pupil—all of these effects, except the last, being due to lesion existing at the point of origin, or in the course of the third nerve. The pupils are often un- 1 " Ueber den gegenwartigen Standpunct der Kenntnisse von der allgemeinen pro- gressiven Paralyse der Irren," Griesinger's Archiv, Heft i., p. 44. 358 DISEASES OF THE BRAIN. equal, and Austin' declares with all seriousness that contraction of the right pupil is associated with melancholic delusions, and contraction of the left pupil with elation. Further investigation has not confirmed this theory. The gait of patients affected with general paralysis is very peculiar, and is of two distinct kinds. In the one it is similar to that of a person suffering from sclerosis of the posterior columns of the spinal cord (locomotor ataxia). The feet are lifted high, and are thrown down with a good deal of force, the heel striking the ground first. As Westphal remarks, patients with this gait cannot stand with the eyes shut and the feet close together. In the other kind the feet are scarcely lifted from the ground, but are shuffled over it, and the action is somewhat like that of a person attempting to balance himself on a tight-rope. Patients with this gait can without difficulty stand with the eyes shut. As regards the upper extremities, the fingers lose their strength and delicate coordinating power. The handwriting is shaky, and there is awkwardness in buttoning the clothing. The grip of the hand is still strong, but there is an impossibility, as shown by the dynamograph, of maintaining a continuous muscular contraction for even a few seconds. The following is one of the tracings made by a patient affected with the disease under consideration : Fiq. 29. In analyzing this tracing, we see that it is not from feebleness of the muscles that the line is descending, for there are spasmodic ele- vations which show considerable force. It proves, however, that, no matter at what point the pencil is placed, the patient cannot keep it there. The ability to write well, if previously possessed, is lost, and the patient not only exhibits a bad chirography, but omits letters from the words he uses, and appears in some cases to have forgotten how to spell. The following facsimile of a letter I received recently from a gentleman of education and intelligence, affected with general paral- 1 "A Practical Account of General Paralysis, its Mental and Physical Symptoms, Statistics, Causes, Seat, and Treatment," London, 1859, p. 31, et seq. INSANITY. 359 ysis, shows both these points, and also very strikingly the disposition to insist upon the ideas which have been acquired. Fio. 80. W*v-«fn/$C tA~VS^ Jwc 'frw-C -~ des maladies de l'enfance," Paris, 1853, tome ii., p. Parish? kebJ°madaire> 1845> and "Trait6 de 1'electrisation localised," 1" edition, £52 DISEASES OF THE SPINAL CORD. toward the natural standard. It thus becomes important to have some means by which a very slight increase of heat may be noticed. A deli- cate thermometer graduated to tenths of a degree will generally suffice, but much more exact indications may be obtained by Lombard's thermo- electric differential calorimeter, described in the introduction to this treatise. One of the thermo-electric piles is placed on the sound limb, the other on the corresponding part of the paralyzed limb. Both are in connection, by delicate silk-covered wire, with the poles of a gal- vanometer. If the temperature of both limbs be the same, the needle of the galvanometer remains quiet. If either be warmer than the other, the needle is deflected to the north or the south, according as one or the other limb has the higher temperature. By this apparatus, very small fractions of a degree of temperature can be determined with absolute certainty. Sensibility is not materially, if at all, lessened, though the reflex excitability is diminished, and often entirely abolished, from the very first. The faradaic current almost always fails from the earliest period to cause contractions in the.paralyzed muscles, but the galvanic current will, even when of low tension, produce movements in the most thoroughly paralyzed muscles, before the stage of atrophy is reached. This first period of infantile spinal paralysis, in which the loss of power is the most obvious symptom, may last a month, or even six months, before the second period, characterized by atrophy, begins. It is then usually the case that the paralysis gradually disappears to a great extent, if the loss of motor power has in the first place been extensive. Even when the paralysis has been restricted to a single limb, some muscles regain their function, and in either case complete restoration may occur. In those parts, however, in which there is no retrogression of the disease, atrOphy ensues, and advances sometimes with great rapidity. The temperature falls still lower, till, in some cases, it is scarcely higher than that of the surrounding atmosphere. In a patient from Maine, a little girl of about ten years of age, in whom both the lower extremities remained paralyzed, and were atrophied to a very marked degree, the temperature of the legs below the knee was only 75° Fahr. in an atmos- phere of 72°. The skin is of a livid hue, and pressure with the point of the finger causes a white spot to appear, which does not again be- come colored for some time, owing to the torpidity of the capillary circulation. With this atrophy, the electric contractility of the muscles disap- pears, although it has begun to be lost at an earlier period, and hence the strongest induced currents fail to cause the slightest contraction, and in some cases even powerful primary currents are equally ineffica- cious. Indeed, in no other disease is the electric excitability so thor- oughly abolished as in that under consideration. INFANTILE SPINAL PARALYSIS. 453 Owing to the atrophy and consequent weakness of the muscles which surround the articulations, as well as to relaxation of the ligaments of the paralyzed limbs, the bones entering into the composition of the joints become separated. This condition is especially manifested when the upper extremity is the affected part, as regards the shoulder, the head of the humerus sometimes falling away from the glenoid cavity to the extent of an inch or more. The passive mobility of the joint is therefore very greatly increased, and dislocation is readily effected. If, as is often the case, certain muscles of a limb regain their power, while others remain paralyzed, the normal equilibrium is destroyed, and distortions of various kinds are consequently produced. Hence, infan- tile spinal paralysis is among the most important causes of club-feet. The bones are also subject to atrophy and to arrest of growth, and therefore the paralyzed and atrophied limb eventually is shorter than the corresponding sound member. In the case of a boy, six years old, who, several years since, was under my charge, the left arm, in conse- quence of infantile spinal paralysis occurring in his second year, was two inches shorter than the right. This arrest of growth was not very evident when the child was dressed, and the limb, by its own weight, hung by the side, for the reason that the head of the humerus was sep- arated nearly two inches from the glenoid cavity, but, when the bones were brought into apposition, the shortening was of course apparent. This extension of the atrophy and arrest of development to the os- seous system is by no means an invariable accompaniment, and is per- haps never produced unless the original central lesion is profound, and the muscles, generally, of an extremity are involved. Unless death should occur during the first stage of the disease, it is not probable that spinal infantile paralysis will in any case tend to shorten life. Tho tendency is for the spinal lesion to limit itself, and hence, when the second stage of the disease appears, there is no proba- bility that any extension of the morbid process will take place. The consequences are entirely restricted to the parts which are in nervous relation with the region of the cord in which the central lesion exists. At no time during the course of spinal infantile paralysis is either the bladder or its sphincter paralyzed, neither is the sphincter ani de- prived of its contractile power. The muscles most apt, according to my experience, to become the ultimate seat of the paralysis and atrophy are the tibialis anticus, the peroneal, the deltoid, the gluteal, the extensors of the toes, and the quadriceps femoris. I have never seen a case in which any muscle of the head or neck was involved. Seguin 1 states that the temporal has been found paralyzed once. Bed-sores or atrophic ulcerations of the skin rarely occur. I have never observed a case in which they were present —a fact which goes to show that, notwithstanding the appearance of the 1 " Infantile Spinal Paralysis," Medical Record, January 15, 1874. 154 DISEASES OF THE SPINAL CORD. surface over the paralyzed parts, the nutrition of the skin is not essen- tially lessened. Causes.—Little is known of the etiology of infantile spinal paralysis. In two cases under my observation, occurring in brothers, it was ap- parently induced by the nurse allowing the infants to lie on the damp ground for an hour or more ; in several other cases, it came on while the children were suffering from teething, and in others it has followed diseases of various kinds, such as whooping-cough, measles, scarlet fever, etc. In the great majority of the cases that I have witnessed, no cause could be reasonably assigned. More than half of the cases occur during the first two years of life. M. Duchenne (de Boulogne), the younger,1 of fifty-six cases occurring in the private practice of his father, finds the proportion of cases, for the several ages up to ten years, as follows : Twelve days after birth.......................................... 1 At the age of one month........................................ 1 At two months................................................. 2 At from four to six months..................................... 6 At from six months to a year.................................... 6 From one year to eighteen months................................20 From eighteen months to two years............................... 11 From two to three years......................................... 6 From three to four years....................................... 2 At seven years.......... ....... ............................., 1 At ten years................................................... 1 Total............................................. 56 Diagnosis.—The symptoms of infantile spinal paralysis in the early part of its first stage are rarely so characteristic as to admit of a rational diagnosis being given. They are such as are met with in many other affections, and the early age of the patient is usually an obstacle to ex- act inquiries. I shall, under the head of morbid anatomy, cite cases in ' which spinal haemorrhage has produced symptoms in some respects simi- lar to those of infantile spinal paralysis, but such cases are extremely rare, and they are not characterized by the progressive atrophy and marked reduction of temperature so characteristic of the affection under notice. Setting them aside, it is not probable that, having in view the phenomena of the disease, the intelligent physician of the present day will blunder ^ in his diagnosis. The absence of _cerebj;al symptoms, the cessation of the fever when it has existed, and the general good health of the pa- tient, will go to render the diagnosis still more certain. The only con- dition with which the disease in question may be confounded, is the temporary paralysis due to reflex irritations, and probably the direct 1 Duchenne (de Boulogne), " De l'electrisation localisee," troisi&me Edition, Paris, 1872, p. 417. INFANTILE SPINAL PARALYSIS. 455 consequence of spinal anaemia. But the fact that such irritations are generally sufficiently evident, and that the paralysis disappears with their removal, will not permit us to remain long in doubt. As the dis- ease advances to its full development, the symptoms become more and more characteristic, until doubt is scarcely any longer possible. In fact, in its entirety, infantile spinal paralysis cannot be mistaken for any other affection. Prognosis.—Infantile spinal paralysis is not an affection liable to terminate fatally. Death may possibly, occur in the very inception of the disorder from the irritation and general disturbance due to the in- flammation of the cord, but, though I admit the possibility of such an event, none such has ever come under my observation, nor have I been able to 6nd any such recorded. The prognosis is therefore only of im- portance as regards the consequent paralysis and atrophy. And here it depends very much upon the fact as to whether the disease has ad- vanced so far as to have resulted in the abolition of the electric con- tractility of the affected muscles. If this is lost to the induced current, the cure will be difficult, and the treatment protracted ; if the primary current is also powerless, a cure is impossible. I believe I was the first to use the primary current in the treatment of infantile paralysis, and to insist on its great value as a curative agent, and as an element in the prognosis.1 If the muscles can be made to contract with either the in- duced or primary currents, the cure is often merely a matter of time and patience. But regard must also be had to the extent of the pa- ralysis and atrophy. If all the muscles of one or more of the limbs are involved, and if contractions in the non-affected muscles have interfered to any considerable extent with the conformation of the joints, a cure will be next to impossible. While, therefore, recognizing the severity of the lesions in infantile spinal paralysis, and the tediousness of the meth- ods of cure, I cannot look upon the affection with the hopelessness of Volkmann.1 For with Dr. Radcliffe3 I am every day more and more convinced that muscles which I should once have looked upon as hope- lessly paralyzed, may be resuscitated by proper treatment. Again, it must not be forgotten that the most extensive paralysis, in the disease under consideration, may in great part, or entirely, spon- taneously disappear before the atrophy begins to make its appearance. It is not, therefore, safe to venture on a prediction as to the ultimate result at any time anterior to the stage of atrophy. Morbid Anatomy.—The morbid anatomy of infantile spinal paralysis is to be studied in the spinal cord, the nerves, the muscles, and the bones—the lesions in the three latter tissues being secondary to those 1 New York Medical Journal, December, 1865. 1 " Ueber Kinderlahmung und paralytische Contracturen-Sammlung," Klinische Ver- b-age, No. 1, Leipzig, 1870. 3 Reynolds's " System of Medicine," vol. iii., p. 666. 456 DISEASES OF THE SPINAL CORD. existing in the cord. Previous to the recent investigations of Vul- pian and Prevost, Dr. Lockhart Clarke, and Charcot and his pupils, there was no approach to uniformity relative to the essential character of the disease, many observers denying that there was any structural central lesion. Even since this last-named distinguished observer, in conjunction with Joffroy, published the report of his notable case, with a detailed statement of the post-mortem appearances, and since his results have been confirmed by others, we find so prominent a teacher and physician as Dr. West1 ignoring them altogether, and concentrating his attention entirely on the eccentric lesions in a few brief sentences. It is not to be denied that paralysis of spinal origin may exist in children and be a very different affection from the one under notice. Paralysis, like cough, is only a symptom which may be due to many very different lesions. Thus, in a case of paralysis in a child six years of age, which had begun four years previously, and which involved the left lower extremity, I had the opportunity of making a post-mortem examination—death occurring from pneumonia. On examining the spinal cord, I found in the lower part of the dorsal region, and in the left anterior column, a cicatrix partially filled with a very small clot. No microscopical examination was made, and hence the condition of the anterior cornua was not ascertained. The atrophy of the paralyzed muscles was very slight, and it is therefore possible that there was no primary lesion of the nerve-cells of the anterior horns. The paralysis had ensued suddenly, and may have followed a fall or a blow—no ac- curate history could be obtained. I then, and for some time subse- quently^ regarded this case as one of infantile spinal paralysis as at present understood, but I am now entirely satisfied that, beyond the loss of motor power, it had little in common with this affection. The slight atrophy which existed was possibly the result of secondary de- generation of a few cells of the left anterior horn, and not a conse- quence of any primary lesion of this region. A histological examination would have done much toward the elucidation of this interesting case, but it was at the time impossible. Dr. Clifford Allbutt2 has reported a case in which the symptoms were more clearly the result of haemorrhage. The patient was an infant in good health, seven months old. One evening the mother lifted the child rather suddenly, and was astonished to see the body fall heavily forward. There were no evidences of pain, but she shortly afterward perceived that it was paralyzed in all four limbs. Death ensued in a short time from implication of $he respiratory nerves. The spinal cord was submitted to careful examination, and two haemorrhagic clots were discovered in the cervical region. One of these, of small size, was in the 1 " On some Disorders of the Nervous System in Childhood "—being the Lumleian Lectures for 1871, Philadelphia, 1871, p. 87. * The Lancet, vol. ii., 1870, p. 84. INFANTILE SPINAL PARALYSIS. 457 left posterior horn; the other, larger, was in the right posterior horn and lateral column. If these clots had been formed in the lower dorsal region the infant would probably have survived, and the case might have been regarded as one of infantile spinal paralysis. In a case reported by Hayem,1 the patient was attacked with pa- ralysis of the lower extremities at the age of two years. Death took place twenty-two years afterward, of phthisis. The gray substance of the cord contained blood-pigment disseminated through its substance. Such instances, as I have said, only go to show the similarity of symp- toms which may result from very different causes, and like examples will readily occur to the reader as being afforded by unlike lesions in other parts of the body. The first attempt to associate spinal infantile paralysis with lesion of the anterior horns of the spinal cord was made by Cornil,1 who re- ported the case of a patient affected with the disease in question, who died of cancer of the mammary gland at the age of forty-nine. The affection had been contracted by the subject, when an infant two years old, being left to lie for a long time on cold and damp ground. The muscles of the inferior extremities, especially those of the left, were paralyzed and atrophied. The post-mortem examination, which ex- tended to the muscles, the nerves, and the spinal cord, revealed the ex- istence in this latter organ of atrophy of the anterior horns of gray matter and of the antero-lateral columns—in those parts of the cord from which emanated the nerves going to the affected muscles. This case was the first published, in which lesion of the cord was noted in connection with infantile spinal paralysis, though the author states that he had previously, in 1863, observed an increased development of con- nective tissue in the anterior columns. The case of haemorrhage coming under my own notice, previously cited, occurred in 1858. Prevosta described, in 1865, the case of a woman, aged seventy-eight, in whom there was paralysis of the left leg, with deformation of the foot, evidently, in the opinion of M. Vulpian, whose patient she was in the Salpetriere, the result of infantile spinal paralysis. The muscles of the left leg and foot, as well as those of the lower part of the thigh, were much atrophied. The patient was demented, and died of phthisis. Post-mortem examination showed the left anterior horn of gray matter to be atrophied. On microscopical examination, it was seen that all the external part of this horn had undergone an alteration, the nerve- cells being replaced by a cellular and nuclear tissue evidently the pro liberation of the neuroglia. This was colored red by carmine. Amy- loid corpuscles were also present. The ganglion-cells of this part had almost entirely disappeared, and the one or two that remained were |" Comptes rendus des seances, et memoires de la societe de biologie," 1869, 1870. Ibid., tome v., serie III., 1863, p. 187. 45S DISEASES OF THE SPINAL CORD. atrophied. The cells of the internal group were also diminished in number. The right anterior horn was normal. This was the first case in which atrophy and disappearance of the cells of the anterior horn were found associated with infantile spinal paralysis. In 1868, Dr. Lockhart Clarke,1 in collaboration with Mr. Z. Johnson, published, under the head of muscular atrophy, the details of a case which was clearly one of infantile spinal paralysis. The disease had ensued in early infancy, immediately after inoculation with small-pox virus, and involved both upper extremities, which, besides being para- lyzed, were greatly atrophied. Examination of the cord showed atrophy and softening of both anterior horns, with atrophy and degeneration of nerve-cells. In many places the cells had disappeared. Then in 1870,2 Charcot, in conjunction with his pupil Joffroy, gave the results of his examination of a case which may be considered as defi- nitely settling the question of the morbid anatomy of infantile spinal paralysis. The patient, a woman named Wilson, died at the age of forty-five years, of phthisis, having been the subject of paralysis since childhood. The disease had suddenly made its appearance when she was seven years old, and had at first involved all four limbs. At the end of a year the upper extremities had in a measure regained their power, the lower remained atrophied and nearly altogether paralyzed. On post-mortem examination the spinal cord was found to be affected from the cervical to the lumbar enlargement. The alterations were chiefly in the gray matter, and especially in the anterior cornua. These were atrophied and distorted, and the cells had disappeared to a very great extent. In some places entire groups of cells had disappeared, without leaving any traces of their former presence. In the immediate vicinity of some of the points of cellular atrophy, the neuroglia had un- dergone sclerous transformation, but there were places where the lesion of the cells was the only alteration which could be discovered. Since the publication of the details of Charcot's case, several others have been reported, and a number of excellent monographs have been written in illustration of the morbid anatomy of infantile spinal paraly- sis. Among these may be cited those of Parrot and Joffroy,3 Roger and Damaschino,4 Dujardin-Beaumetz,5 Petitfils,8 Seguin,7 Putnam-Jacobi,' 1 " On a Remarkable Case of Extreme Muscular Atrophy, with Extensive Disease of the Spinal Cord," " Medico-Chirurgical Transactions," Second Series, vol. xxxiii., 1868, p. 249. 2 " Archives de Physiologie," tome iii., 1870, p. 135. 8 Ibid., 1870, p. 310. 4 " Recherches anatomo-pathologiques sur la paralysie de l'enfance," Gazette Medicate de Paris, 1871, Nos. 41, 43, 45, 48, and 51. B " De la myelite aigue," Paris, 1872. s "Considerations sur l'atrophie des cellules motrices," Paris, 1873. 1 "Infantile Spinal Paralysis," Midical Record, January 15, 1874. 8 American Journal of Obstetrics, May, IS74. INFANTILE SPINAL PARALYSIS. 459 Fio. 87. and Charcot,1 who has quite recently traversed the whole ground, and who has admirably summed up what is known of the whole subject. Fig. 88. 1 Revue photographique des hopitaux, Janvier et Fevrier, 1872, and "Lecons sur lea maladies du systeme nerveux," fascicule iii., Paris, 1874. 460 DISEASES OF THE SPINAL CORD. They all go to show that the essential lesion in infantile spinal paraly- sis is situated in the anterior horns of gray matter, and that it consists of a myelitis, in consequence of which there is an atrophy of the part affected, a degeneration of its structure, and a disappearance of its cell- elements. This contraction or atrophy is well shown in the accompa- nying woodcut from Charcot (Fig. 37), which represents a magnified section of the spinal cord taken from the cervical region of a woman, aged fifty years, who died in the Salpetriere, of general paralysis of the insane, and in whom there was infantile spinal paralysis affecting the right superior extremity. The atrophy of the right anterior horn is well marked, and the emaciation of the right antero-lateral and poste- rior columns, probably a secondary complication, is also notable. The atrophy and disappearance of the nerve-cells are sometimes ex- ceedingly limited. In the accompanying figure (Fig. 38), also from Char- cot, an enlarged view is given of a section of the spinal cord taken from the lumbar region in a case of infantile spinal paralysis, affecting the right lower extremity : A, the left anterior horn, healthy ; a, healthy group of ganglion-cells ; B, right anterior horn ; b, median ganglionary nucleus, of which the cells are destroyed, and which is represented by a foyer of sclerosis. In Fig. 39, a still more enlarged view is given of the Fig. 39. right anterior horn : a, cervix of the posterior horn ; b, postero-external group of nerve-cells ; c, antero-external group, the cells of which have entirely disappeared, while they are intact in groups b and d; d, inter- nal group ; e, the commissure. The myelitis is parenchymatous in character, that is, it begins in the INFANTILE SPINAL PARALYSIS. 461 nerve-cell structure, and, if the neuroglia be found involved, it is from the extension of the morbid process, and not from any primary implica- tion. This is sufficiently established, not only from an examination of sections of the cord, such as that represented in the last figure in which the lesion is restricted to the nervous elements, but from a consideration of the physiological relation which exists between the cells of the anterior horn and the functions which they have to perform—func- tions which are interfered with in cases of infantile spinal paralysis. Roger and DamaschinoJ have had the opportunity of making histo- logical examinations in three cases of infantile spinal paralysis, in which death took place from intercurrent affections while the^ disease was still in its early stage. As the result of their observations they conclude that— " 1. The characteristic alteration of infantile paralysis is a lesion of the spinal cord, of which the atrophy of the nerves and muscles is the consequence. "2. This lesion is more particularly seated in the anterior portion of the gray spinal substance, where it is seen in the form of centres of softening. " 3. This softening is of an inflammatory character, and the disease is a myelitis. " 4. Infantile paralysis ought therefore to be called infantile spinal paralysis, and moreover its nosological position is certainly among the affections of the cord, and among the myelites." As regards the cell-alterations they found them to consist in atro- phy, with pigmentation. Charcot" has figured the changes which the cells of the anterior horns undergo in such cases : A represents the normal state ; B, a cell hypertrophied ; C, pigmentary alteration of the last stage of pigmen- tary change ; E, a cell in a state of sclerous atrophy ; and F, vacuolary alteration, which latter may be the result of the processes used in pre- paring the specimens—Fig. 40. The anterior roots of the nerves coming from the affected region have been found atrophied, the myeline having disappeared, and only the axis-cylinder remaining. In other cases the nerve-tubules have been found to be very attenuated, and separated from each other by large spaces filled with connective tissue. The ganglia of the sympathetic have been examined by Roger and Damaschino, but exhibited no change •from their normal structure. The bones of the paralyzed parts undergo atrophy with the muscles, though, when the lesion is not extensive, the bony atrophy may escape recognition. "We have already seen that the affected extremities are often submitted to an arrest or retardation of growth. Besides this con- 1 Op. cit. * Lecons sur les maladies du systeme nerveux, troisidme partie, Paris, 1874, p. 184. 462 DISEASES OF THE SPINAL CORD. dition, there is a cessation in the development of the bone laterally, and consequently its shaft remains smaller than is natural. The articular ex- tremities of the affected bones lose their cartilages, and are more or Fig. 40. i less arrested in their development. Examined microscopically, as has been done by Laborde1 and others, the osseous tissue is found to present a deficient number of bone-cells and an excessive amount of medullary elements and adipose matter. It does not appear that the normal rela- tion of earthy to animal matter is disturbed to such an extent as to render the bones either especially liable to fracture or distortion. But, of all the peripheric lesions, those of the muscles have attracted the most attention, and have been the most carefully studied. It ap- pears to be settled without doubt that the first stage of atrophy is char- acterized by a diminution of the diameter of the muscular fibrillae, and that there is not then any histological evidence of a tendency to fatty degeneration. At this time there is an increased formation of connective tissue— a process which appears to persist for a considerable period. Eventually the atrophied muscles tend, in the great majority of cases, to break down into fat. The transverse striae disappear, and the degeneration, at first granular and bony, becomes unmistakably fatty. Eventually the muscle consists of nothing but fat and connective tissue, and in time the former disappears, leaving only a mass composed of the sarcolemmae and connective tissue. The nature of the morbid process is well shown in the accompanying woodcuts, made from my own drawings of the microscopical appear- 1 "De la paralysie essentielle de l'enfance," These de Paris, 1864, p. 30. INFANTILE SPINAL PARALYSIS. 463 ances of portions of diseased muscles removed by Duchenne's trocar. Fig. 41 represents a portion of the upper part of the tibialis anticus muscle of a boy who had suffered from organic infantile paralysis for over two years, and in whom the progress of the atrophy was exceed- Ftg. 41. ingly rapid. Oil-globules are seen along the course of the fibrillae. These latter are irregular and torn, and the transverse striae are becom- ing dim. In Fig. 42 a still more advanced stage is shown. This cut repre- Fio. 42. sents a portion of the same muscle taken from the lower part. The transverse striae have nearly disappeared, oil-globules are seen in large numbers, and fat-corpuscles are also abundant. In Fig. 43 the progress of the disease is well shown. The upper Fig. 43. margin of the specimen is a mass of fat-globules, and throughout the whole the transverse striae are absent. In Fig. 44 is shown a portion taken from the same muscle one month after the preceding specimens were removed. The transverse striae are entirely gone, and the muscle is a mass of oil-globules and fat-vesi- cles. 464 DISEASES OF THE SPINAL CORD. Fig. 44. Fig. 45 represents a piece of the same muscle six weeks later. It is now nothing more than a mass of connective tissue, the fat being almost entirely absorbed ; no transverse or longitudinal striae are to be perceived. Fig. 45. But there is not, as Duchenne affirms, this degeneration in every case of organic infantile paralysis. In two cases, which had lasted over four years, I found the structure of the muscle unchanged. There were atrophy, loss of electric contractility, and reduction of temperature, but every specimen of the affected muscles that I examined showed no change from the normal character. In every other respect the symp- toms were similar to those observed in ordinary cases of the disease. Improvement was very slow, but finally every muscle except the rectus femoris in one, and the tibialis anticus in the other, recovered, and the children were enabled to walk. The affection in both cases was con- fined to the left lower extremity. I am hence led to the conclusion that fatty degeneration of muscles, though the ordinary result of organic infantile paralysis, is not an inva- riable consequence.1 Pathology.—Whether all the cells of the anterior horns of gray matter are motor, or whether there are both motor and trophic cells, are questions which the histological examination of the normal struct- 1 Journal of Psychological Medicine, No. 1, 1867, p. 57. Since the observations then published, other observers have arrived at the same conclusion. Thus, M. Charcot (Op. cit, p. 161) says: "The surcharge of fat, although habitual in old cases of infantile mus- cular atrophy, is nevertheless not necessary. By the side of the muscles distended with fat, there are often others which are reduced to a very small volume, and in which the adipose tissue is almost entirely absent. In these last are found primitive fasciculi of very small diameter, but possessing their characteristic striation." INFANTILE SPINAL PARALYSIS. 465 ure seems to be quite incapable of satisfactorily answering. Samuel1 has contended for the existence of a distinct system of nerves, the function of which is to preside over the nutrition of the parts to which they are distributed, and there is not wanting physiological evidence to support his theory ; as, for instance, the troubles of nutrition which result in the eye when the fifth pair is divided, and which Vulpiana admits are due neither to irritation of the divided nerve-fibres nor to paralysis of the vaso-motor fibres contained in the nerve. Waller3 has also expressed his opinion relative to the existence of distinct trophic centres in the cord. He regarded the ganglion of the posterior root as the trophic centre for this root, while the gray substance of the an- terior horns is the trophic centre for the anterior root. In regard to this theory, Weir Mitchell4 expresses the opinion that it is still a matter of doubt, in which view all will unite till actual demonstration settles it affirmatively or negatively. But pathology points still more clearly than does physiology to the existence of trophic cells in the spinal cord. In infantile spinal pa- ralysis the peripheric disturbance is, in the first place, solely one of motility ; there is paralysis without atrophy. After a time, which may be as much as six months, or even more, the trophic changes be- gin. These, as we have seen, are not of that mild character resulting from disuse, but are active and intense, leading to the certain destruc- tion of whole groups of muscles, and even to arrest of development and degeneration of the bones. It is impossible, it appears to me, to ac- count satisfactorily for this atrophic process on the supposition that all the cells of the anterior horns of gray matter are motor, and that they alone are involved in the lesion. Charcot, however, constantly speaks of the affection in question as essentially consisting in an atrophy and disappearance of motor nerve-cells, and the majority of French writers adopt his view. Indeed, he argues very strenuously against the exist- ence of spinal trophic cells, in which, it appears to me, he ignores some of the most valuable contributions which he and others of his country- men have made to the pathology of the nervous system. A very impor- tant memoir of MM. Duchenne and Joffroy 6 throws much light upon this interesting subject, and will be fully considered under the head of pro- gressive muscular atrophy, when additional evidence in support of the theory of the existence of trophic cells will be adduced. But, whether we admit the existence of trophic cells in the anterior horns of gray matter or not, there is no doubt of the dependence of the , ' " Die tropischen Nerven," Leipzig, 1860. ' " Lecons sur l'appareil vaso-moteur," Paris, 1875, tome ii., p. 377. ' "Proceedings of the Royal Society of London," vol. ii., 1860-'62. 4 "Injuries of Nerves and their Consequences," Philadelphia, 1872, p. 78. "De l'atrophie aigue et chronique des cellules nerveuses," etc., Archives de physU ologie, No. 4, 1870, p. 499. 30 466 DISEASES OF THE SPINAL CORD. peripheric troubles on the central lesion. Some authors have assumed that the essential feature of the disease was some disturbance in the sympathetic nervous system; but there is no evidence to support this view. On the contrary, examination has shown that there is no appre- ciable lesion of this system, and the fact that all the functions of the organism are generally well performed in cases of infantile spinal pa- ralysis militates strongly against the hypothesis. No examination of the cord of a patient dying during the very ear- liest stage of infantile spinal paralysis has yet been made. Judging, however, from the character of the symptoms, and from their diffusion, and subsequent retrogression, it is extremely probable that, as in other inflammatory affections, there is congestion, and that this condition is not limited to the anterior tract of gray matter. As we have seen, pains not only in the cord, but in the limbs, are occasionally met with, and Vulpian1 refers to an instance in which there was complete anaes- thesia. In the case of a little girl whom he examined a few days after the invasion of the disease, and in whom the electro-muscular contrac- tility of the muscles of both inferior extremities was entirely abol- ished to strong faradaic currents, sensibility was equally annihilated, so that the electric brush could be passed over the skin without pain being produced. The pathology of the deformations so generally met with in cases of infantile spinal paralysis is very obviously the result of the destruc- tion or impairment of that normal equilibrium which exists between the muscles. Thus, if the extensors of the hand are affected while the flexors remain unparalyzed, these latter will in time cause a flexion of the hand upon the forearm ; if the muscles of one side only of the spine are paralyzed, the muscles of the other side will produce a lateral curva- ture ; if the extensors of the foot are alone deprived of their power, the strong gastrocnemius and soleus cause a talipes equinus; while, if these latter are the seat of the derangement while the extensors are healthy, a talipes calcaneus is the result; and these conditions are more or less modified according as other muscles are more or less involved. Treatment.—The fact that infantile spinal paralysis is due to an organic affection of the spinal cord is no bar to treatment addressed to the peripheric lesions—it having been very definitely shown by numer- ous investigations that the integrity of nerve-centres is affected either favorably or unfavorably by eccentric nerve-conditions. It is therefore perfectly practicable, in favorable cases of the disease in question, so to improve the nutrition of the cord, by proper measures directed to the relief of the peripheric trouble, as to arrest the morbid process in the cells of the anterior horns, and even to effect their regeneration. The fact that cases of long-standing infantile spinal paralysis are cured— cases in which there can be no doubt of the existence of the spinal 1 " Lecons sur l'appareil vaso-moteur," Paris, 1873, tome ii., p. 410. INFANTILE SPINAL PARALYSIS. 467 lesion—is of itself sufficient evidence to establish the correctness of the view advanced. The investigations of MM. Masius and Van Lair,1 relative to the regeneration of the spinal cord, also show how great is the reparative power of the organ. They divided the cord in frogs, and at the end of from two to four months obtained indubitable evi- dence that the animals had regained voluntary movements and sensi- bility in the posterior extremities. In other frogs, histological exami- nation showed the more or less complete regeneration of the cord. The conditions which lead us to expect a favorable or an unfavorable result from treatment are stated under the head of prognosis. The treatment of the disease, however, consists both in the use of general and local means. Of the former, ergot is chief, and should be given as soon as we can determine the nature of the disease under which the child is suffering. Young children bear this remedy well. Infants of six months may take as much as ten drops of the fluid-ex- tract three times a day, and this may be increased to half a drachm for children of from one to two years. It is rarely the case, however, that we have the opportunity of giving this valuable agent from the very inception of the disease. But even after the first or febrile stage has subsided, when the affection is solely manifested by paralysis, be- fore the atrophic stage has begun, ergot is of great service—not to be surpassed, in my opinion, by any other medicine, and the only one capable of cutting short the disease, or lessening its extent. After the stage of atrophy is reached there is no longer any benefit to be derived from ergot ; strychnia is then useful because it is ca- pable of acting as a general stimulant to the nervous system, is pos- sessed of undoubted value in cases of degeneration of nervous tissue, and is, moreover, a tonic to the muscles. I generally prescribe it in union with iron and phosphoric acid, according to the following form- ula: IjL Strychniae sul. gr. j, ferri pyrophosph. 3 ss., acidi phosphorici | ss., syrupus zingiberis § iijss. M. ft. mist. Dose, a teaspoonful or less, according to the age of the patient. A child of from three to five years of age can take half a teaspoonful of this mixture thrice daily; or, the strychnia may be given advantageously in the form of hypodermic injections in doses suitable to the age. In children under one year old, the ninety-sixth of a grain is as much as should be given at a dose, and under six months it should not be administered at all. I am quite sure that strychnia, hypodermically introduced in very gradually-increased doses, is more efficacious than when taken into the stomach. The immediately local means of treatment are those which are cal- culated to promote the nutrition of the muscles, and restore or augment their contractile power. The first end is effected by causing a greater ' " Recherches experimentales sur la regeneration anatomique et functionnelle de la moelle epiniere," analyzed in Archives de Physiologie, tome iv., p. 268. » 468 DISEASES OF THE SPINAL CORD. amount of blood to flow through the diseased parts; the second is best accomplished by the persistent use of electricity, and active and passive exercise. Under the first head are embraced heat, friction, and kneading. Heat is best applied by means of hot water. A temperature of from 110° to 120° Fahr. may be used, and the limb should be thor- oughly immersed, and allowed to remain so for half an hour; salt may be added to the water, with the view of augmenting the stimulant effect. Frictions with a dry towel, a flesh-brush, or the hand, are also ex- ceedingly useful; they should be practised several times in the course of the day, to the extent of reddening the skin. Kneading the muscles affords a means of exercising them, and of in- creasing the amount of blood in the vessels. They should be pinched firmly between the fingers of both hands to the extent of producing some little pain; every paralyzed muscle should be gone over in this way daily. Jounod's boot, when the inferior extremity is the one affected, or a similar apparatus for the upper extremity, is an efficacious means of causing an increased flow of blood to the parts, and of producing a per- manent enlargement of the vessels. Care, however, should be taken that the exhaustion of the air be not carried too far. Under the second head, electricity comes first. If the induced cur- rent will produce contractions in the affected muscles, it should be em- ployed; but if, as often happens, it should fail to do so, the primary current interrupted must be brought into service. In the communica- tion x already cited, I called attention to this valuable agent in the treatment of organic infantile paralysis, and adduced several cases in illustration of its beneficial action. If a contraction can be induced by it, recovery is merely a matter of time, so far as that particular muscle is concerned. As soon as the muscle is so far developed as to contract to the induced current, this latter should be employed. Every alter- nate day is often enough for a sitting. The time necessary for each is, of course, dependent on the extent of the paralysis. During the period from December, 1865, to December, 1870, I treated ninety-eight cases of organic infantile paralysis. Of these, the disease was so far advanced in eleven as to render it very evident, after thorough examination, that success was out of the question. In the remaining eighty-seven, no contractions could be caused in the affected muscles by the strongest induced currents in thirty-nine; while in all of these the primary current produced decided contractions. Of the eighty-seven cases, fourteen were entirely cured; twenty-eight were greatly improved; thirty slightly improved, and the remainder—fifteen —discontinued treatment before sufficient time had elapsed to ascertain • ' New York Medical Journal, December, 1865. INFANTILE SPINAL PARALYSIS. 469 the effect. Since then I have kept no very full record of my cases, but I am enabled to state that the proportions do not vary essentially from those above stated. At the best, however, the treatment must be of long duration, and even when the muscles are entirely restored they must be reeducated to the performance of their functions. Few parents, comparatively, have the patience to wait and to devote the necessary time to doing their part ofthe work; unless there is a reasonable assurance in regard to these points, it is better not to undertake the case. It is not, except in recent cases, a matter of days, or of weeks, but of months, and some- times of years. But, even when fatty degeneration is going on, the disease may be arrested by the proper use of the direct current. Fig. 46 shows the ap- pearance of a portion of muscle as examined by the microscope, October Fig. 46. 21, 1866. This specimen was removed from the belly of the gastro- cnemius muscle before any treatment whatever had been employed, and after the disease had existed, with gradually-advancing atrophy, for about four and a half months. Fig. 47 represents a piece of the same muscle from the same part, on December 3d, six weeks after the treatment was begun. In the first, oil-globules are seen to have displaced the muscular tissue to a Fig. 47. great extent; the transverse striae have disappeared entirely from some parts, and are faintly seen even where they are present. In the second, the quantity of fat is perceived to be very much lessened, and the striae are much more numerous and distinct. This case, which was one of pa- ralysis of the left leg and foot, entirely recovered. I feel that I cannot insist too strongly on the use of the primary or galvanic current, when contractions cannot be obtained by the faradaio 470 DISEASES OF THE SPINAL CORD. or induced current. If the electric contractility of the muscles is not utterly destroyed—as Dr. Radcliffe1 remarks—there appears to be no limit to the prospect of recovery. Whichever form of current be employed, it must be applied directly to the skin over the affected muscles, or, in some cases, to the nerves which go to them; and the current should be as strong as is necessary to cause contractions. Applying it through the hand of the physician is worse than useless. Along with the electricity, passive motions of the joints should be made, and the child should be encouraged to direct the will to the affected muscles as often and as powerfully as possible. A very valuable aid to the treatment, in cases of deformities, is af- forded by the use of apparatus calculated to take the tension from the paralyzed muscles. An overstretched muscle is in the worst possible state to react to the electrical stimulus, for the strain is of itself a most efficient agent in destroying its contractility. India-rubber cords may be very advantageously employed in this connection. As to tenotomy, the question of its propriety must be determined by the circumstances of each individual case, and may be left to the good sense of a competent orthopaedic surgeon. b. Spinal Paralysis of Adults. Duchenne,2 to whom we owe the identification of several other affections of the nervous system, was the first to insist upon the fact that there was a form of paralysis met with in adults which presented great analogies with infantile spinal paralysis. He recognized two forms of this disorder, one he designated acute anterior spinal paralysis of adults, the other subacute general anterior spinal paralysis of adults. As these have the same patho-anatomical features and differ in their symptoms only as regards a few not very material points, there is nothing to be gained by considering them separately. In the third and last edition of his great work,3 under the head of spinal paralysis in the adult, he sums up his earlier and more recent investigations on the subject. But, though Duchenne has shown by the cases recorded in the first edition of his work published in 1855, and the remarks therein made in regard to them, that he was acquainted with a form of spinal paral- ysis occurring in adults characterized by loss of voluntary power, 1 Article " Infantile Paralysis." Reynolds's " System of Medicine," vol. ii. a As these pages are passing through the press, the death of this distinguished phy- sician is announced. Probably no one man has done so much as he for the advancement of neuro-pathology and therapeutics. The keenness of his observation was only equaled by his indomitable spirit of investigation and immense capacity for work. In him scien- tific medicine has lost a follower whose place will not soon be filled. 3 "De l'electrisation localise," Paris, 1872, p. 437. SPINAL PARALYSIS OF ADULTS. 471 atrophy, and diminished electric contractility in the muscles, " as when the anterior columns of the cord are altered," Meyer,1 of Berlin, is entitled to the credit of being the first clearly to state in a publication his belief in the existence of an affection holding intimate relations with infantile paralysis and to employ the term spinal paralysis of adults. Thus, after describing the first named disease he says : " A similar paralysis of the lower extremities occurs also in adults, occasioned by the existence of some exanthematous action or other unknown cause. The disease in such cases is of course subject to such modifications as the completed structure of the body would induce. Among these are the following : 1. As the bones of the adult are fully developed, that retardation in the structural growth of the affected members, which may occur in cases of infantile spinal paralysis, has here of course no place. 2. In consequence of the adult's greater energy of will impelling him to bring into action muscles which can be made to perform the duties of the paralyzed ones, as well as in consequence of the greater firmness and resisting power of the ligaments of the adult, secondary deformities are not developed to the same extent as in the spinal paralysis of children. 3. As in no case, so far as my observation goes, is the power of locomotion removed, there cannot be so great a disturbance in the circulation of the blood, nor, consequently, so remarkable a reduction of temperature. 4. On the other hand, as a result of the double amount of work devolved upon the muscles that perform the duties of the paralyzed ones, a striking hypertrophy of these muscles is induced. " Among other cases the following have fallen under my observation: "The two Barons von H., twin brothers, well-built, fine large men, uniformly healthy, in their eighteenth year, simultaneously fell sick with the measles. These having run an apparently favorable course, were followed in both with a paralysis of the legs inducing a constantly increasing emaciation of those parts. When I visited them, which was not till they had reached their twenty-fourth year, the circumference of the thighs of each measured respectively twenty and twenty-one inches, the circumference of the calves ten and ten and a half inches ; the latter dimension, if the normal relation of the thighs to the calves be as three to two, was accordingly four inches below the true stand- ard. The glutei muscles, on the contrary, as the patients made all loco- motory movements from the hip-joint, were developed to colossal proportions, contrasting strongly with the emaciated legs. Their walk was, therefore, very peculiar. As the legs could only be used as stilts, at every step of the right or left foot there occurred a rotary movement from behind forward of the right or left thigh, which communicated 1 "Die Electricitat in ihrer Anwendung," etc., Berlin, 1868. See also my translation of this work, "Electricity in its Relations to Practical Medicine," second American edition, New York, 1874, p. 229. 472 DISEASES OF THE SPINAL CORD. itself to the whole body, causing it to turn at every step toward the one or the other side. The extensor power of the leg was very limited; the dorsal extension of the foot and the flexion of the toes were not in the power of the patients, and but a slight adduction of the toes was possible; the patients trod upon the outer borders of the feet, and in the mm. tibiales, consequently, contorted forms were exhibited. The adductors of the thigh as well as the muscles of the foot were normally developed; on the other hand, the extensors of the knee-joint and all the muscles of the leg had suffered greatly in assimilative power. The sensibility of the skin and muscles was perfectly preserved. The electro-muscular contractility was reduced in the quadriceps femoris, and altogether wanting in the mm. peronei, the extensors digit, com., the gastrocnemii, etc.; but the adductors of the knee-joint and the toes showed a weak reaction." It is, therefore, quite apparent that Meyer had a very distinct con- ception of the disease in question. Since then a number of cases have been reported under different names, which are clearly instances of the affection in question, and no small amount of confusion exists in regard to the whole subject, from the fact that unnecessary refinement has been shown in classifying them. Thus, as we have seen, Duchenne describes two varieties—an acute anterior spinal paralysis of the adult and subacute general anterior spinal paralysis of adults. This latter has, by others, been designated acute ascending paralysis. After a full survey of the sub- ject and careful study of several cases of each, I am very decidedly of the opinion that these two varieties do not essentially differ from each other. The affection called by Duchennex subacute diffused general spinal paralysis—a name calculated to add greatly to the already existing confusion—is evidently acute general myelitis. This view rela- tive to the identity of the two morbid states I have taught for two years past to the medical classes at the University of New York. It is sustained by very cogent reasoning by M. Petitfils,2 and is held also with some reservation by Dr. E. S. Seguin8 in his excellent little mono- graph on the affection in question. Symptoms.—The onset of the disease is generally sudden, and is usually characterized by pains in the back, which radiate to the limbs, and by the various sensations of numbness, especially in the extreme peripheric parts of the body. There may or may not be fever, and when it is present it is not ordinarily excessive. At the same time there is loss of the power of motion, varying in character and degree from the sudden and complete paralysis of all the limbs, to the gradual 1 " L'electrisation localisee," troisiSme edition, Paris, 1872. 2 " Considerations sur l'atrophie aigue des cellules motrices," Paris, 1873, p. 83. 3 " Spinal Paralysis of the Adult: Acute, Subacute, and Chronic—(Inflammation of the Motor Tract of the Spinal Cord "), New York, 1874. SPINAL PARALYSIS OF ADULTS. 473 extension of the akinesis from a part of an extremity to one or more. At this early period, as I have recently had an opportunity of determin- ing, by means of Dr. Lombard's instrument for measuring differences of temperature, there is an increase of heat in the affected extremities amounting to from 2° to 4° Fahr. From the very first and throughout the whole course of the disease, the sensibility ordinarily remains intact, and the pains which are com- monly phenomena of the initial part of the primary stage disappear within the first two or three days, or even earlier, and sometimes are not present at all. The bladder and the sphincter ani generally remain unaffected. There are usually no cramps or spasmodic contractions of any of the muscles. Neither is any feeling of constriction experienced around the body. The electric contractility of the muscles is impaired at a very early stage, and generally goes on diminishing till at last very strong induced currents fail to cause any reaction. It is rare, however, that the excitability to the galvanic current is entirely abolished, except in long-continued and neglected cases, and, even in these, currents of great intensity will often cause contractions. At the same time the cutane- ous sensibility to all kinds of electrical stimulation remains unimpaired. Reflex contractions in all the paralyzed parts are difficult, and some- times impossible to excite from the very beginning. The face is rarely involved. In one of my own cases, however, one side was completely paralyzed, so far as the seventh pair of nerves was concerned, and Dr. Seguin * has reported an instance in which the third and facial nerves were both affected. Some of the other symptoms go to show that this was not an uncomplicated case, and Dr. Seguin's diagnosis was " myelitis or degeneration of the anterior horns of gray matter of cord ; the motor part being involved from the third cerebral nerve downward, with probably recent extension of myelitis to deeper parts of cord at some points." In the majority of cases, the paralyzed parts, after a period varying from two or three weeks to several months, begin to recover their pow- er, but it usually happens that the loss of motility remains in some mus- cles as in the infantile form of the disease. Atrophy may occur before the retrocession of the paralysis. Generally, however, its appearance is first seen in those parts which remain paralyzed, and occasionally it is absent altogether. In all the cases collected and observed by Seguin, it was a prominent feature ; it was wanting in one of my own cases, that above referred to ; as it was likewise in a very interesting instance reported by Dr. Labadie-Lagrave,2 in which the muscles of respiration were involved, but yet in which recovery took place. 1 Op. cit., Case XXI., p. 19. Observation de paralysie ascendante aigue." Brochure, extrait de la Gazette des Hopitaux, 1870. 474 DISEASES OF THE SPINAL CORD. The reduction of temperature, though marked, never, in my ex- perience, reaches the low point observed in the infantile form. The atrophy likewise is rarelyso profound. But in the case of a gentleman of New Jersey, in whom the paralysis began slowly in the left lower extremity and gradually extended upward till the medulla oblongata was involved, and death produced from asphyxia, the wasting was rapid and extensive, till at last apparently nothing of the muscular tissue re- mained in the limb first affected. In this case the right side continued free from the least sign of paralysis so long as the patient was under my observation. In some cases which have been observed, the paralysis is first mani- fested in the lower limbs, and progressively advances upward till the superior extremities are affected. Still, in some cases continuing its progress, the medulla oblongata is reached, and death takes place by asphyxia. Or it may follow a descending course, the superior extremi- ties being first attacked, and subsequently the inferior. The muscles in some of these instances are very rapidly and pro- foundly atrophied, and can be seen to waste from day to day in groups. Such cases may be regarded as representing the subacute form as described by Duchenne. Other examples designated by the names of acute progressive pa- ralysis, acute ascending paralysis,1 etc., are in reality like those de- scribed by Duchenne under the title of subacute general diffused spinal paralysis, and are cases of general myelitis. Of such notably is the instance reported by Harley,3 in which the post-mortem examination was made by Lockhart Clarke, and the lesion found to implicate not only the anterior horns but the posterior, and the antero-lateral and posterior columns. In no case that has been reported or that has come under my own notice was there any tendency exhibited to the formation of bed-sores. From the foregoing account it will be seen that the more prominent phenomena observed in cases of spinal paralysis in the adult are strik- ingly like those which characterize the infantile form. Even as regards the results there is no essential variation, except that due to difference of age. There is, of course, in the adult no arrest of development, and the disposition to deformities is not so great as in the infant, but nev- ertheless, as in the first case reported by Charcot,3 they may occur. Occasionally, hyperaesthesia exists. This was the case in two of Seguin's cases4—XX. and XXII.—and to a marked degree in that of Labadie-Lagrave.5 Thus, as the latter remarks : 1 Landry, " Note sur la paralysie ascendante aigue," Gazette Hebdomadaire, 1850, pp. 470, et seq. 2 Lancet, October 3, 1868. 3 " Lecons sur les maladies du syst&me nerveux," fas. iii., 1874, p. 173. * Op. cit, pp. 17, 22. 6 Op. cit, p. 6. SPINAL PARALYSIS OF ADULTS. 475 " Besides the cutaneous hyperaesthesia, there was a still more de- cided muscular hyperaesthesia. The lightest pressure on the muscles was very painful, and caused the patient to cry out. In addition, lan- cinating pains were felt in the lumbar region, when the flexed thighs were suddenly extended. Passive movements of the lower extremities also caused a certain amount of pain." It is very certain that many cases of spinal paralysis and atrophy occurring previously to the last two or three years, and reported under other designations, were in fact instances of spinal paralysis of adults. This is probably true, for instance, as regards the " case of acute mus- cular atrophy," * occurring in the London Hospital in the service of Dr. Ramskill, relative to which it is stated that " electro-motility was ab- sent," a circumstance not present in progressive muscular atrophy. A case which forms the subject of a clinical lecture by Jaccoud 3 is clearly one of inflammation of the anterior tract of gray matter. The patient, a man seventy years of age, was seized with pains and numb- ness in the extremities, with incoordination. Shortly afterward there was loss of power in all four limbs, which progressively increased till at last he was unable to walk or to use his arms. At the same time atro- phy began in the paralyzed parts. Reflex movements were abolished and reflex excitability was either lost or impaired, in the affected mus- cles. There were pains and some loss of sensibility. Death ensued : on post-mortem examination the spinal arachnoid was found studded with fibrous plates, which pressed upon the roots of the nerves, causing their atrophy. Hence the name of progressive nervous atrophy which Jaccoud gives to the case. The spinal cord was pronounced healthy, but, as no microscopical examination was made of it, the opportunity was lost for discovering the real and essential lesion, the disease of the anterior horns, which undoubtedly existed. Some of the cases which I have, previous to the recognition of the affection under notice, regarded as instances of spinal congestion, pro- gressive muscular atrophy, and antero-lateral spinal sclerosis, were, I have now no doubt, examples of inflammation of the anterior tract of gray matter. Several of these I have reported. Among them is the case of Rose Peyton, who formed the subject of a clinical lecture I delivered at the Bellevue Hospital Medical College3 in the autumn of 1870, and of which my clinical assistant, Dr. Cross, prepared at the time the following report: "Rose Peyton, twenty-seven years of age, born in Ireland, mother of two children, both of whom are 1 Quoted from the Lancet in the Quarterly Journal of Psychological Medicine, vol iii 1869, p. 198. "' "De l'atrophie nerveuse progressive," "Lecons de clinique medicale," second edi- tion, Paris, 1869, p. 372. " Clinical Lectures on Diseases of the Nervous System," Quarterly Journal of Psy. etiological Medicine, January, 1871, p. 22. 476 DISEASES OF THE SPINAL CORD. living; the older has talipes valgus, while the younger is a fine, hearty child. Her family is very healthy, and there is no evidence of nervous diseases either in it or in any of its branches, so far as she is aware. The patient was a strong, active woman, and always did her own work until twelve weeks ago. In May there was a cessation of menstruation, and in July last she was seized with a deep, dull, aching pain in both legs, and which appeared to her to be in the bones. There is no syphi- litic taint in her history. There succeeded, shortly after, a severe pain in the back, which has continued up to the present time, but which has varied in intensity. Soon, loss of motility, numbness, and anaesthesia, made their appearance in both legs, and in the course of two months she was totally unable to walk. At first, her bowels were very costive, but soon this condition was succeeded by incontinence of the rectum, which lasted for two weeks, varying in degree. There was also reten- tion of urine. Sensations of formication alternating with numbness, of heat and cold, of pricking by pins and needles, were present not only in the feet and toes, but also in the hands and fingers. Patient noticed that on rising in the morning, after a night's rest, her limbs were weaker, and that she had greater difficulty in moving about. The paralysis, after commencing in the lower extremities, rapidly extended to the upper. August 25th.—Was able to get out of bed for the first time in five weeks, and by means of a chair could move about a very little. Since then she had improved only so much as to be able to come to the out-door department of the New York State Hospital for Dis- eases of the Nervous System, by being supported by a person on each side, and only then with extreme difficulty. She was admitted Septem- ber 22, 1870, when she was found in the following condition: Motility and tactile sensibility in both legs greatly impaired, but the right leg is the weaker of the two. Left hand, as measured by the dynamometer, is much feebler in power than the right, and this to a more marked degree than any normal disparity. Sensations of formication, alternating with numbness, of heat and cold, pricking by pins and needles, and tingling, still continued in the feet and toes, as also in the hands and fingers. Pain in the back increased by pressure and percussion, but no burning sensation on applying heat and cold. The anaesthesia is more marked in the thighs than in the legs; soreness in the soles of the feet; bowels constipated; bladder normal; electro-muscular contractility and sensibility greatly diminished. No band around the waist. No spasms, twitchings, or reflex movements in the legs. Pain in the lower ex- tremities as at first. Changes in the degree of paralysis from time to time. Temperature diminished. The circumference of the legs is dimin- ished to a marked extent owing to the atrophy of the muscles. Heart and lungs healthy; urine not examined." At the time, I regarded this case as one of spinal congestion, and this was probably an associated condition, but it is very evident that it SPINAL PARALYSIS OF ADULTS. 477 was an instance of inflammation of the anterior tract of gray matter chronic in character. The treatment by my direction consisted of elec- tricity and ergot, and a complete recovery was the result. The case of Elbert Baxter, detailed in the same lecture, was prob- ably one of inflammation of the right half of the cord involving the anterior tract of gray matter and right posterior column. There were paralysis with atrophy of the right lower extremity, and marked anaes- thesia and incoordination in the left. This patient also recovered after having been under treatment with ergot and electricity at the New York State Hospital for Diseases of the Nervous System for over a year. Another case, likewise a patient in this hospital, and the subject of another clinical lecture, was at that time, February 18,1871, regarded by me as an instance of progressive muscular atrophy beginning with con- gestion. It is Cases X. and XVn., of those collected by Dr. Seguin,1 who saw the patient two days before I did, and who then considered it an example of spinal congestion. It is also briefly cited in the former editions of this work," and in full in a subsequent publication.3 The affection began with pain in the back and sharp, shooting pains in the legs, attended with weakness. There was also, at first, some headache, vertigo, confusion of ideas, etc. Numbness and loss of power existed in both the upper and lower extremities. Subsequently, the anaesthesia and paralysis of the upper extremities disappeared. Six months afterward the head-symptoms recurred, and there were super- added fibrillary contractions in both arms and legs, with a return of the numbness. The paralysis of the lower limbs increased to such an extent, that the patient was obliged to use crutches, and six weeks later he was confined to bed, unable to move any part of his body but his head. The bladder and its sphincter were also weakened, though he did not lose control of them. The paralysis of the arms again disap- peared, but it remained in the legs, and he now noticed that they began to be atrophied, and this condition went on advancing. For three years he did not walk at all, and during this time the fibrillary contractions continued in the legs, though to a diminished extent. He then gradu- ally reacquired the power to walk with a crutch. At the time of his admission to the hospital his condition, as ascertained by Dr. Cross, was as follows : * " In the legs the extensors, together with the gastrocnemii and so- lei muscles, were found to have almost disappeared, while the atrophy in the thigh was distinctly visible, and this loss of power had been 1 Op. cit, pp. 8 and 10. See note of Dr. Seguin appended to p. 11 of his Memoir. 8 Former editions, p. 666. Lectures on Diseases of the Nervous System," New York, 1874, p. 147—history prepared by Dr. Cross. 4 " Clinical Lectures," p. 150. 478 DISEASES OF THE SPINAL CORD. directly proportioned to the extent of the atrophy. The gait of this patient was also highly characteristic of the disease from which he was suffering. In walking he lifted his feet high from the ground through the action of the flexors of the thigh upon the pelvis, in order to clear his toes, which drooped to an extreme degree—and his knees were in this way bent to a greater extent than usual. The legs were very much reduced in size, and the loss of muscular fibre was quite apparent from the greatly diminished electric contractility in these parts. There was no atrophy to be discerned in any other part of the body, nor did the patient have any head-symptoms whatever, nor had he any loss of motil- ity, or any abnormal sensations in his upper limbs. His bowels were regular, and he had no trouble with his bladder. There was no loss of sensibility, nor were there any sensations of numbness in the legs. His heart and lungs were in a healthy state. The reflex excitability was diminished in the lower extremities, as was likewise the temperature, and the capillary circulation was very sluggish, as was demonstrated by the decrease of temperature, which was several degrees below the nor- mal standard, and the effect of pressure. There were no fibrillary con- tractions present, nor had the patient experienced any electric-like pains, cramps, jerkings, or other abnormal sensations for some time. The outlines of the fibulae and tibiae, together with the knee-joints, were distinctly visible, owing to the destruction of the muscles on the ante- rior surface of the leg, while the posterior aspect of the calf was flat- tened from a like cause. His back-ache had completely disappeared, but, although he felt well and suffered no pain, he appreciated the gradual loss of power in his lower extremities. His appetite was good, and his mind was very active." In his recent memoir, Dr. Seguin classes this case as one of spinal paralysis of the adult, in which opinion I entirely coincide. At the time I described it, the disease under notice was not distinctly recog- nized, and certainly the resemblance to progressive muscular atrophy was very great. With locomotor ataxia, to which affection Charcot' assigns it, it has scarcely any thing in common. The cut (Fig. 48), owing to the position of the patient when the photograph was taken, does not show very well the effect of the disease in the legs, but the atrophy of the thighs is distinctly indicated. Two cases which I had regarded1 as instances of "antero-lateral spinal sclerosis" were very probably examples of inflammation of the anterior tract of gray matter. In one of these, a gentleman whom I first saw in consultation with my friend Dr. Walter F. Atlee, of Phila- delphia, and who was, subsequently, for a long time under my imme- diate charge, the lesion was in the beginning confined to the very lowest part of the spinal cord. Gradually the disease extended upward 1 " A Treatise on Diseases of the Nervous System," New York, 1871—and subsequent editions, pp. 475, 476. SPINAL PARALYSIS OF ADULTS. 479 until at last, after three years, the muscles of respiration and of deglu- tition became implicated, and death took place. But for several months before this the patient was unable to use either legs or arms, or even to sit up. At no time, however, was the bladder deranged in any respect, Fig. 48. and at no time were there pains or spasmodic action of the muscles. The cutaneous sensibility was scarcely affected, and the atrophy, though extensive, was not profound, and did not strike me at the time as being very active in character. The other case was that of a distinguished legal gentleman of New Orleans, sent to me by my friend Dr. Cabell, of the University of Vir- ginia. There was a gradual extension of the disease without any at- tendant pains, anaesthesia, or muscular contractions, except to a slight extent at first. In this instance also the bladder and rectum escaped. This case resisted all treatment. The patient finally went abroad, and died soon afterward in London. The atrophy was not a prominent feature. In another case, that of a gentleman from New Jersey, there was a similar condition of paralysis, involving, however, only one lateral half of the body, and beginning in the leg. In this case the atrophy was of 480 DISEASES OF THE SPINAL CORD. the most active character, advancing pari passu with the paralysis. The flexors and extensors of the foot, and the flexors of the leg, were almost entirely destroyed when the patient came under my observa- tion. Before I saw him, however, he had consulted several distinguished medical gentlemen, who had treated his case as one of tumor of the cord or of the vertebral column. This case has already been cited on page 474, and is noticed in the previous editions of this work.1 In regard to these three cases, I stated in 1871,a " Such cases as the foregoing, and several others which have come under my notice, are doubtless to be classed with many of those placed under the head of what Duchenne has called general spinal paralysis." Since 1873 I have had the opportunity of witnessing many cases of spinal paralysis of adults. Some of the more striking of these will be noticed under other divisions of this section. Causes.—In many cases of spinal paralysis of adults, the disease is clearly the result of cold, either applied directly to the back as in lying on cold, damp ground, or from refrigeration of some part of the surface of the body. Relative to this last influence, Frinberg8 has performed an experiment which, if confirmed in its results, will be of a very in- structive character. He shaved off the hair from the skin of a rabbit and on the unprotected skin threw a jet of the vapor of ether by means of Richardson's apparatus. Three days subsequently he repeated this operation. About a month afterward the animal was attacked with in- continence of urine and paraplegia, and died in a few days. On post- mortem examination the whole length of the spinal cord was found in- flamed. There was in fact general acute myelitis. In regard to this experiment, I can adopt the language of Vulpian,4 who says : " This experiment would be very valuable if the results obtained had been observed with a certain number of other animals treated in the same manner. Till then we may be permitted to doubt if there really was the relation of cause and effect between the refrigeration of the skin by the ether-spray and the paraplegia which made its appearance a month later." Bernhardt's6 case ensued upon exposure to cold, as did several of Seguin's, and five in my own experience. Meyer's' two cases followed close on measles. In Rose Peyton, whose case I have related, sudden suppression of menstruation appeared to be the cause ; in a number of others, blows and falls were alleged as causes, and in others venereal 1 Op. cit, p. 476. 2 Previous editions of this work, p. 476. 3"Ueber Reflexlahmungen," Berlin, klin. Wochenschrift, 1871, Nos. 41, 42, 44, and 45. 4 " Lecons sur l'appareil vaso-moteur," Paris, 1869, tome ii., p. 88. 5 " Ueber eime der Spinalen-Kinderlahmung ahnliche Affection Erwachsener," " ArchiT fur Psychiatrie und Nervenkrankheiten," B. iv., 1873. 6 Op. cit, p. 229. SPINAL PARALYSIS OF ADULTS. 481 excesses, dysentery, syphilis, and violent muscular efforts, seem to have been the exciting agencies. In the majority of cases, however, no cause can be discovered. Such at least has been the fact with the instances that have come under my own observation. Diagnosis.—Spinal paralysis of adults is to be recognized by the facts that the paralysis is often extensive in the first place, and then becomes restricted, or that it begins in a limited portion of the body, usually in one or both of the lower extremities and then advances ; that the paralysis always precedes the atrophy ; that the reflex excitability is somewhat impaired ; that the electro-muscular contractility is di- minished ; that there are no bed-sores ; that the disturbances of sensi- bility are not usually prominent features ; and that the bladder and rectum generally escape. It has been often confounded with progressive muscular atrophy, but attention to the features above stated will prevent mistakes of the kind. In progressive muscular atrophy, it must be borne in mind that the atrophy is the essential feature, and that the loss of power results from the diminished size of the muscles. In acute general myelitis the paralysis of the bladder and sphincter ani, the tendency to bed-sores, the spasmodic movements of the limbs, the great disturbances of sensibility, the sensation of constriction around the body, and the greater constitutional commotion, will serve for the identification of the disease. In the partial form of acute myelitis the distinctive features are equally as marked. Hallopeaul has reported a number of cases under the head of chronic diffused myelitis, which were undoubtedly instances of spinal paralysis of adults, judging both from their symptoms and morbid anatomy, and the author admits as much when he says :2 " The remarkable lesions [brown discoloration, no microscopical ex- amination being made] which we found in the anterior horns permit us to think that, as in the cases of MM. Charcot and Joffroy, histological alterations would have been discovered." The distinction between the acute, the subacute, and the chronic forms of spinal paralysis of adults is not one of kind but only of de- gree, and the same may be said of the acute ascending paralysis of Lan- dry, on which I have already insisted. The fact that in the latter form of the disease the respiratory muscles are affected, is of course only due to the circumstance that the morbid process has reached the medulla oblongata. In regard to this variety, Dr. Seguin says : " There is an affection running its course in ten or twenty days, characterized by symptoms almost identical with those of subacute spinal palsy. There is an akinesis, without much anaesthesia, first appearing in the feet and *egs, then ascending and involving the entire trunk and limbs, produc- 1 "Etudes sur les myelites chroniques diffuses," Archives Generates, 1871-72. 8 Op. cit, tome i., 1872, p. 72. 31 482 DISEASES OF THE SPINAL CORD. ing, in nearly all cases, death by asphyxia. It is upon this palsy of the respiratory muscles that the diagnosis of this most fatal disease, acute ascending paralysis, is to be made from spinal paralysis." Now, if in any case the progress of the disease had been arrested at a point of the spinal cord half an inch below the decussation of the an- terior columns, the diagnostic mark of Dr. Seguin would have been absent, and the distinction between the form in question and spinal pa- ralysis of adults could not have been made. The mere fact of the im- plication of the respiratory nerves cannot, in my opinion, be made a ground for assuming a separate nosological position for acute ascend- ing paralysis any more than the circumstance of the brachial plexus be- ing reached in any case should make a distinct form. Dr. Seguin does not appear to recognize the fact that the acute ascending paralysis of Landry is identical with the subacute general anterior spinal paralysis of adults, although he very distinctly admits the relationship. Petitfils J has entered at length into the consideration of the question of the identity of the acute and subacute forms, and has very satisfac- torily shown, both from the symptoms and the morbid anatomy, that no essential difference between them exists. From spinal congestion the spinal paralysis of adults is discriminated by the facts that, in the former the sphincters are usually affected, that the paralysis is not generally complete in any part of the body, by the absence of atrophy, and by the general presence of disturbances of vis- ceral functions. In the first stage, however, of either affection, it must be admitted that very striking resemblances exist, and time may be necessary for the diagnosis to be made with accuracy. Thus, in a case which I saw a few days since, in consultation with Dr. Newcomb of this city, there had been, in the first place, a set of symptoms present which, had I then seen the patient, would have induced me to regard it as one of spinal congestion. When the man, a stage-carpenter, came to me, however, the paralysis and atrophy of the right lower extremity, the diminished temperature of that limb, and the absence of bladder- troubles, left no doubt on my mind relative to the case being one of spinal paralysis in the adult. A case reported by Dr. Cuming,''1 of Belfast, which presented all the essential features of spinal paralysis of adults, was regarded by him as one of spinal congestion. The patient, a man aged forty, observed on a cold night that his hands had become numb and white, and when he reached home he had not the use of them. A few days afterward he fell asleep on a cold wall, and when he awoke found the numbness in- creased. In a few days he was entirely deprived of the power of mo- 1 " Considerations sur l'atrophie aigue des cellules motrices," Paris, 1873, p. 83. 2 " Case of Extensive Paralysis from Morbid Condition of the Spinal Cord, probably Congestion," Transactions of Ulster Medical Society, Dublin Quarterly Journal of Medi- cal Science, vol. xlvii., 1869, p. 471. SPINAL PARALYSIS OF ADULTS. £§3 tion in all parts below the neck. But he soon began to regain the use of his limbs, and at the end of two years could walk well. The upper extremities were, however, wasted, and he had the main en griffe. The diagnosis, therefore, should not be hastily made. Prognosis.—So long as the lesion does not attain to the height of the respiratory nerves, the prognosis, as regards the life of the patient, is not unfavorable. Indeed, recovery, with a more or less extensive loss of power, with atrophy and deformity, is the rule, and in some cases there is a complete restoration of motor power and muscular integrity. Even when the morbid process reaches the height of the respiratory nerves, life may be preserved, and complete restoration may take place. This was the case with the instance already cited reported by M. La- badie-Lagrave, and in two in my own experience, which will be fully cited under the head of treatment. Sometimes the process of recovery begins within a few days, and goes on uninterruptedly till complete restoration is the result. When seen at a later stage, when the paralysis and atrophy are limited, the prospect of cure or improvement depends altogether on the condition of the muscles as regards their electric contractility. If the affected muscles can be made to contract with either the induced or primary current, recovery will, in all probability, take place. But, when this action cannot be brought about, there is no hope. The principles of the prognosis are, therefore, identical with those which exist in the infantile form of the disease. Morbid Anatomy and Pathology.—There is not much to add under this head to the remarks made on the same subject in regard to infan- tile spinal paralysis. The characteristics of the disease have, as we have seen, sufficed to place the lesion in the anterior tract of gray matter, and this theory, based upon physiology and the analogy of the affection with infantile spinal paralysis, has been definitely confirmed by post- mortem research within the past three years by Gombault,1 one of the pupils of the Salpetriere. The patient, aged sixty-seven on the 1st of January, 1865, was seized suddenly with a paralysis of all four extremities, beginning in her legs and extending to the arms as a numbness and heaviness. Within half an hour she could not stand. There were no antecedent phenomena, she having been in perfect health up to the moment of the attack. There was no paralysis of the tongue, muscles of deglutition, or respiration. The bladder and rectum were also unaffected, and the cutaneous sensibility remained intact. The paralysis of the limbs soon became complete, and in fifteen days she was taken to the hospital. There was slight febrile disturbance, but at no time were there bed-sores. 1" Note sur un cas de paralysie spinale de l'adulte suivi d'autopsie," Archives de Phy- tiologie, tome v., 1873, p. 80. 484 DISEASES OF THE SPINAL CORD. After two years passed in complete immobility, the patient recov- ered, to some extent, the use of her limbs. The amendment began in the upper extremities. When she entered the Salpetriere, five and a half years after the inception of the disease, she could walk imper- fectly with a cane. During the first year of her stay in the hospital she improved so that she was able to dress herself, and to take short walks in the court-yard. On the 13th of May, 1872, examination showed that the thenar emi- nences had entirely disappeared, the interosseous muscles were atro- phied, there was the main en griffe ; the muscles of the forearms, arms, shoulders, neck, and chest, were atrophied. In the lower extremities the left calf was most atrophied, and was soft and flabby ; the thighs were unaffected. The electro-muscular contractility was entirely abolished in the hands and forearms, impaired in other parts of the upper extremities, and in the legs. The cutaneous sensibility was preserved. The patient soon afterward died of another disease. On post-mortem examination the membranes of the brain and cord were found to be healthy, and to the naked eye there was no lesion of either of these organs. The histological examination of the spinal cord was made after hardening in solution of chromic acid and coloring with carmine. The white substance throughout all its extent exhibited no traces of disease. Only the columns of horizontal fibres which emerge from the anterior horns to form the fibres of origin of the anterior roots showed a notable diminution in size. The posterior commissure and posterior horns were normal. The lesion was almost entirely confined to the area of the anterior horns, and here it only concerned the large nerve- cells called motor-cells. The walls of the vessels had suffered no change; they were of normal thickness, and the sheath was free 'from granular bodies. Moreover, there was not in the neuroglia any trace of the ex- istence of an irritative process such as a proliferation of the neuroglia. As to the alteration of the nerve-cells, it was such as is met with in progressive atrophy of these elements—yellow pigmentation. The le- sion was diffused; it had struck here and there the nervous elements, of which a certain number had disappeared, for in some sections only fif- teen or twenty could be counted. The cells which did not exhibit this yellow pigmentation were nevertheless reduced in size. This was the first full investigation made relative to the morbid anatomy of spinal paralysis of adults; but, previous to Gombault's re- searches an examination of a patient who had died of ascending paraly- sis, and in whom lesions of the anterior horns were discovered, was re- ported by Chalret.1 1 "These de Paris," 1872, cited by Gombault. SPINAL PARALYSIS OF ADULTS. 485 The data are, therefore, quite sufficient to enable us to place spinal paralysis of adults in a definite patho-anatomical position as depending upon inflammation of the anterior tract of gray matter and the conse- quent atrophy and disappearance of the cells constituting its nervous elements. In regard to the questions entering into the pathology of the dis- ease under notice there is nothing to bring forward in addition to the facts and arguments already adduced under the head of infantile spinal paralysis. Treatment.—The treatment of spinal paralysis of adults admits of division into two parts, that which is proper for the first or acute stage, and that advisable for the second or chronic stage. I have had the opportunity of treating four cases of the disease in question from the very beginning, with the result in each case of arrest- ing the progress of the disease and preventing any subsequent atrophy of the limbs. Two of these were of the most severe type of this affec- tion, and I therefore report them with some degree of fullness, as ex- emplifying the therapeutical principles which in my opinion should govern. A. G. S., aged about thirty-five, after rising one morning and moving about the room, felt a slight degree of weakness in both lower extremities. This increased through the day, and by night he was un- able to stand. The next morning he felt similar weakness in both arms and in a few hours was deprived of their use. He was out of the city at the time, but he was brought here, and I saw him on the fourth day. He was then perpectly helpless from complete paralysis of all four limbs. There were no aberrations of sensibility, no paralysis of the bladder or sphincters, no motor spasms anywhere. Reflex excitability was abolished in all the paralyzed parts, and the electro-muscular con- tractility was greatly diminished especially in the muscles of the legs. The breathing, deglutition, articulation, and motility of the neck and face, were unaffected. The mind was as clear as ever. There had been slight fever, but this had disappeared when he came under my observa- tion. There was no history of syphilis. I immediately began the treatment with the iodide of potassium in doses of ten grains three times a day, increased gradually, and the fluid-extract of ergot in doses of a drachm, to be taken also three times a day. On the following morning there was some difficulty of respiration and of deglutition, and the movements of the tongue were a little awk- ward. The irregularity and shortness of breathing increased through the day and night, and when I saw him the next morning there was great discomfort on this account. The action of the heart was also considerably disturbed, and there were frequent interruptions in the pulse. On the seventh day of the disease he suddenly became para- 486 DISEASES OF THE SPINAL CORD. lyzed on both sides of the face, the right being more severely af- fected. During all this time the iodide of potassium and ergot had been per- sistently given, the latter, on the appearance of the bulbar symptoms, having been increased to two drachms four times daily. On the ninth day of the disease there was a slight amelioration in the phenomena due to the implication of the medulla oblongata. The respiration became easier, the deglutition less difficult, the articulation more distinct, and the facial paralysis of the left side began to disap- pear. He was able to close the eye of that side and to elevate and corrugate the brows. On the tenth day the facial paralysis of both sides had nearly disap- peared, and the patient was able to breathe freely, to talk well, and to swallow without inconvenience. There was also a slight return of motility in the lower extremities. The toes could be moved and the feet flexed. The galvanic current, interrupted rapidly, was now applied to the muscles of both upper and lower extremities for half an hour every day, at the same time that the internal medication was continued. The limbs were also well kneaded, and passive motions made with them frequently. On the thirteenth day his condition was as follows : He could move both lower extremities while lying in bed—performing with slowness, but yet with precision, all the movements of which the parts were capable. The arms could not yet be moved, but he could slightly extend and flex the fingers of both hands. The bulbar symptoms had entirely disappeared. Reflex excitability and electro-muscular contrac- tility were good, except that it required strong galvanic currents to cause contractions in the anterior tibial and peroneal muscles of both legs. All the other muscles reacted well to the faradaic current. The ergot and iodide of potassium were now discontinued. His improvement went on, and by the end of the fourth month he could walk a mile or more, and use his hands and arms well. There was slight atrophy of the muscles of the calves, but nowhere else. The faradaic current was still employed daily, and under its use he became stronger, till at the end of a year he was not conscious of any weakness in any part of his body. He has continued and now is perfectly well, and was kind enough to allow me to make him the subject of a clinical lecture a few days ago at the University Medical College. B. B., aged forty-five, was attacked with gradually-increasing pa- ralysis of the right side, beginning in the leg, and gradually advancing during several months, till it involved the whole of the lower extremity and arm. At no time, however, was the loss of power complete. He went to the Warm Springs of Arkansas, but did not improve. Return- ing to New York in April, 1875, and his disease becoming worse, I was requested to take charge of his case. SPINAL PARALYSIS OF ADULTS. 487 When I saw him there was such a degree of paralysis of the right lower extremity that he was unable to walk without assistance—the arm of that side was nearly useless. The respiration was labored and irregular ; he was almost unable to swallow, and would not eat, on account of the great distress produced by all attempts at deglutition— the tongue could not be protruded, and his articulation was unintelligible. Owing to his inability to swallow, the saliva ran in streams from his mouth, and, as he could not cough without great and painful effort, the mucus accumulated in his air-passages, and caused danger of suffoca- tion. It was removed from time to time from the pharynx by the fingers of his nurse. There was moderate febrile excitement. Although the paralysis was more marked on the right side, I ascer- tained that the left was also affected. Tickling the soles of the feet caused no reflex movements. Electro-muscular contractility was greatly impaired on the right side, and weakened quite notably on the left. There was no facial paralysis ; no bladder or sphincter trouble ; no bed-sores ; no derangement of sensibility ; no pains, and no muscular spasms. At no time had there been any mental disturbance, except great emotional weakness and irritability of temper. The intellect was per- fectly intact; the memory perfect. The iodide of potassium was given as in the previous case, but was combined with the bromide in doses of fifteen grains. Ergot, in the form of the fluid-extract, was also administered. I requested my friend Dr. Clinton Wagner to make a careful examination of the throat, and to take charge of him, so far as the immediate management of his throat-symptoms was concerned. He found the fauces, pharynx, and larynx congested, and the vocal cords partially paralyzed. He recom- mended steam inhalations, and they were used, with the effect of giving great relief by detaching the mucus and rendering it more fluid. As the difficulty of swallowing increased, I made preparations to feed the patient through a stomach-tube. The efforts at respiration became more painful, and at times I thought death by asphyxia immi- nent. The tongue was now immovable, lying like a flabby, reddened mass in the mouth, and the patient lay in bed entirely helpless through the paralysis of his limbs. But now amendment began, and, as in the case just cited, with the gradual disappearance of the bulbar symp- toms. Little by little improvement took place. Faradization was now brought into use, and was employed daily to the tongue, throat, and extremities, while the internal medication was continued. By the first of June he was able to use his legs in standing, and his arms and hands to support himself. He could not yet, however, employ them in feeding himself. About the first of July he could walk with a cane, and used his hands well. He went to Saratoga the middle of July, and while there had a relapse, consisting in a sudden paralysis 488 DISEASES OF THE SPINAL CORD. of the left lower extremity, by which he was again deprived of the ability to walk. He was there attended by Drs. Whiting and Lente, and I also visited him. The iodide of potassium, which had been dis- continued, was resumed. Under its use, with ergot, hypodermic injec- tions of strychnia, and faradism, he has again acquired the power of walking, though his improvement, owing to considerable atrophy of the muscles of the legs, especially the gastrocnemii, is slow. It may be mentioned, incidentally, that after he began to lose power in his legs, he fell, upon one occasion, and struck his right side violently against the edge of a wooden bucket. After he was able to go out, I made a careful examination, and, detecting fluctuation in the liver, I removed about a pint of pus with the aspirator. No unpleasant symp- toms followed, and there was no reaccumulation of the pus. The treatment, therefore, which in my opinion is best adapted to the initial or advancing stage of spinal paralysis in the adult, is that which consists in the persistent use of the iodide of potassium and ergot, both given in large doses. The former I carried, in both of the cases cited, to half an ounce daily, and the latter to an ounce. Dr. Seguinx reports a case, as occurring in the practice of Dr. T. A. McBride, and which he saw in consultation, in which the fluid-extract of ergot was given in like quantity daily, and in which recovery ensued. This treatment is based upon the theory that the first stage of the dis- ease in question is characterized by a congestion limited to the anterior tract of gray matter. As soon as the muscles show the slightest sign of regaining their power, electricity should be employed. The form in which it should be used depends entirely on the requirements of each individual case. If the faradaic current will cause contractions in the paralyzed muscles, it is the preferable form, but if not, then the interrupted primary or gal- vanic current must be applied and used in such a degree of intensity aa will cause muscular contractions. In one of the other cases of the four which I have treated, while the disease was advancing, I used the actual cautery to the spine—applied over the seat of the disease, as near as could be determined from the extent of the paralysis. The effect was apparently excellent, the lesion ceasing to advance. But one such case cannot be regarded as afford- ing more than an indication. From what I have seen, however, of the power of the actual cautery in other affections of the cord, I should be disposed to employ it in future like cases of spinal paralysis of adults. In the later or chronic stage, as will be presently shown, it is certainly of great value. After the progress of the disease is arrested, the treatment which is most advisable consists in the persistent use of electricity to the para- lyzed muscles, with the view of restoring motility and preventing or 1 Op. cit, p. 22, Case XXII. SPINAL PARALYSIS OF ADULTS. 489 curing atrophy ; the hypodermic injections of strychnia in gradually- increasing doses, till the physiological effects of the drug are produced, when the doses should be diminished, and again increased, and so on ; and repeated applications of the actual cautery to the spine. Relative to this latter agent, my method consists in first applying the ether-spray over the part to be cauterized, and using the platinum- tipped iron brought, by means of an alcohol-lamp, or a Bunsen's burner, to a white heat. Three or four applications are made at one sitting on each side of the spinous processes, and over the part which is in physio- logical relation with the paralyzed regions. I have never seen a case of spinal paralysis of adults which was en- tirely unamenable to this treatment, and the majority recover completely. In the accompanying woodcut (Fig. 49) is the exact appearance of the legs of a woman who consulted me September 20, 1874, and who had Fig. 49. suffered an attack of the disease under consideration some three years previously. As will be seen, the calves are atrophied to an extreme degree, and her walking was correspondingly impaired. She was treat- ed with the galvanic current in the first place, and subsequently with the faradaic. Strychnia was injected into the limbs daily, according to the method mentioned, beginning with the thirtieth of a grain, and the actual cautery was applied to the lower dorsal and upper lumbar region of the spine six times. In less than three months she could walk as 490 DISEASES OF THE SPINAL CORD. well as she ever did, and her calves, from having measured each only eleven and a half inches at their largest circumference, had increased to fifteen inches in the right, and fifteen and a half in the left. Electricity has been very generally employed by those physicians who have recognized the disease in question. Thus BernhardtJ reports a case of recovery mainly through its agency, as do also Eisenlohr," a case from Friedreich's clinic ; Frey,3 three cases from Kussmaul's clinic in Freiberg ; Seguin,4 several cases, in which electricity was a part of the treatment, and with good results ; Lincoln,5 complete recovery after marked atrophy ; Ley den,* a bad case with partial recovery, so as to be able to walk with crutches a little better than he could before treatment ; and cases mentioned by Duchenne.7 In my own practice, I have treated a good many cases with electri- city alone—cases in which the paralysis and atrophy were limited, and have rarely been disappointed in the results. In one very notable case, sent to me by my friend Dr. Christopher Johnston, of Baltimore, the gastrocnemius was rapidly regenerated through the agency of the inter- rupted galvanic current, so that the strength could be measured daily by means of an apparatus devised by the patient, and the improvement accurately ascertained. With the electricity, passive movements and kneading are always useful, and the patient should be encouraged to use the affected mus- cles up to the point of fatigue, at repeated times during the day. c. Pseudohypertrophic Spinal Paralysis. In the former editions of this work I considered this disease under the head of hypertrophy of muscular connective tissue, although treating of it as one of the affections of the motor and trophic cells of the cord. Although previously noticed, the first to thoroughly investigate the condition was Duchenne,8 who described it under the name of paraplegie hypertrophique de Venfance de cause cerebrale. He has since designated it paralysie pseudo-hypertrophique, ou myo-scUrosique." Jaccoud 1 " Ueber eine der spinalen Kinderlahmung ahnliche Affection Erwachsener," Archiv fur Psychiatrie und Nervenkrankheiten, Band iv., Heft 2, 1873, p. 370. * " Zur Lehre von der acuten spinalen Paralysie," Archiv fur Psychiatrie u. s. vs., Band iv., 1874, p. 219. 3 " Ueber temporare Erwachsener, die der temporaren Spinallahmung der Kinder analog sind, und von Myelitis der Vorderhorner auszugehen scheinen," Berliner klinische Wo- chenschrift, Nos. 1-3, 1874. 4 Op. cit, Cases XIX., XX., XXII. * " A Case of Spinal Paralysis in an Adult, resembling the so-called Infantile Paraly< sis," Boston Medical and Surgical Journal, March 25, 1875. 8 "Klinikder Nervenkrankheiten," zweiter Band, Berlin, 1875, p. 199. ' Op. cit, p. 458. 8 "De 1'electrisation localisee," etc., Paris, 1861, p. 353. 9 Archives Generates, etc., 1868. I0 Op. cit., p. 365. PSEUDO-HYPERTROPHIC SPINAL PARALYSIS. 491 calls it sclerose musculaire progressive (progressive muscular sclerosis). Dr. Fosterl terms it paralysis with apparent muscular hypertrophy, and Bartha fatty muscular atrophy. Regarding the affection as consisting essentially in disease of the motor and trophic nerve-cells, and as being manifested by hypertrophy of the muscular connective tissue at the expense of the muscular fibres, I have provisionally placed it in the present chapter. My personal ac- quaintance with the disease is limited to two cases, and I am of the opinion that it is exceedingly rare in this country—seven other cases only having been reported, one by Drs. William Ingalls and S. G. Web- ber, of Boston,3 the latter of whom, in connection with the history of the case, has written a very excellent memoir on the disease ; one by Dr. William Pepper,4 of Philadelphia ; one by Dr. S. Weir Mitchell ;5 one by Dr. C. H. Drake ; * one by Dr. C. T. Poore,7 of New York, who, in an exhaustive essay, has summed up almost all that is known on the subject, and two by Dr. George S. Gerhard,8 of Philadelphia. The American cases are thus nine in number. Symptoms.—The first symptom observed is weakness in the lower extremities, which causes an inability to stand steadily, or to walk with- out stumbling or falling. The legs are separated widely in standing or walking, and thus a peculiar character is given to the gait, which some- what resembles that of a duck. Very soon an enlargement of the calf of one of the legs is perceived, the other before long is affected, and then the muscles of the thighs and gluteal region become involved. As the child stands or walks, a remarkable incurvation of the spine in the lumbo-sacral region is perceived, so that, if, as Duchenne remarks, a plumb-line be allowed to fall from the most posterior part of the spinous process of a vertebra, it passes far behind the sacrum. He con- siders this phenomenon to be due to weakness of the erector muscles of the spine. The muscles of the trunk may become involved, as may also those of the upper extremities—the deltoids being the first affected in the majority of cases, and the progress being much slower than in the lower extremities. With the advance of the hypertrophy the paralysis becomes more 1 Lancet, May 8, 1869. 2"Beitrage zur Kenntniss der atrophia musculorem lipomatosa," Archiv der Heil- htnde, 1871, p. 120. 3 " A Case of Progressive Muscular Sclerosis, with a Paper on the same," Boston Med- ical and Surgical Journal, November 17, 1870. 4 " Clinical Lecture on a Case of Progressive Muscular Sclerosis," Philadelphia, 1871. Also Philadelphia Medical Times, June 15 and July 1, 1871. 6 Photographic Review, October, 1871. 6 Philadelphia Medical Times, August 29, 1874. " New York Medical Journal, June, 1875. ■ Philadelphia Medical Times, October 16, 1875, p. 29. 492 DISEASES OF THE SPINAL CORD. strongly marked, and finally the child is confined to the recumbent post- ure. Distortions from disturbance of muscular equilibrium may take place, and the attempt at flexion or extension becomes painful. Occasionally the skin over the affected parts presents a peculiar mottled appearance, such as would be produced in the healthy skin by exposure to cold. After a period which varies in duration from two to five or six years, the hypertrophied limbs may begin to diminish in size, and eventually they put on very much the appearance exhibited in infantile spinal pa- ralysis. This does not appear to be a constant occurrence, but is mark- edly exhibited in a case now under my care. Sometimes the muscles which are attacked, as the disease advances from the lower extremities, do not become hypertrophied, but on the contrary diminish in volume as in infantile spinal paralysis. We thus have in the same individual, some muscles paralyzed with coexistent hypertrophy, while others are paralyzed and atrophied. Electric contractility is always lessened to the induced current, but, according to some observers, is increased to the primary current. In the cases under my care, both currents failed to cause the normal amount of contraction in the affected muscles. The cutaneous sensi- bility is not affected. The course of the disease is slow, its average duration being about five or six years. As it advances, there are symptoms indicating loss of mental power, and cerebral disturbance is sometimes also indicated by ocular troubles and pain in the head. Death takes place by the respiratory muscles becoming implicated, by exhaustion, or by some intercurrent affection. Weir Mitchell, in the Philadelphia Photographic Review, for 1871, reported a case which has recently been reexamined by Dr. George S. Gerhard.1 The most remarkable feature of the case, that of a boy now thirteen years old, is that the tongue and all of the facial muscles, but particularly the temporals, are hypertrophied. His speech is altered from the enlargement of the tongue, and he has some difficulty in taking his food. There is also a somewhat more than normal cardiac impulse. As regards the hypertrophy of the facial muscles this case is remarka- ble, and would be unique, but for the occurrence of a like condition in a case of my own, in which the left side of the face is hypertrophied. In the case which came under my notice March 7, 1871, the patient, a boy seven years old, exhibited great disinclination to learn to walk. At three years of age he could not stand longer than a few seconds, and even for this time he was obliged to spread the legs apart and to hold on to some article of furniture. It was not noticed till he was five years old that his legs were larger than was natural. The hypertrophy 1 " Pseudohypertrophic Paralysis," Philadelphia Medical Times, October 16, 1875, p. 31. PSEUDO-HYPERTROPHIC SPINAL PARALYSIS. 493 began in the right calf, then attacked the left, and then the glutei mus- cles, before affecting the muscles of the thighs. The upper extremities are as yet unaffected, but the spinal curve is very evident. The accom- panying woodcuts (Figs. 50 and 51) give a posterior and profile view of this boy, from photographs. He was unable to stand alone while the photographs were being taken, but the spinal curve is well shown, Fia. 50. fig 51. and the positions are those he spontaneously assumed. He died in the spring of 1875, with pneumonia, having been for the previous three years unable to stand or even sit. The muscles of the upper extremi- ties were paralyzed for two years before his death, but underwent rapid atrophy instead of enlargement. The other case, that of a bright, intelligent boy, six years of age, 494 DISEASES OF THE SPINAL CORD. was brought to me May 3, 1871, at the suggestion of my friend Dr. Trask, of Astoria, who accompanied the patient. Several months pre- viously the child had been noticed to fall frequently while at play in the house, and to show weakness in the legs when ascending a staircase. The parents were unable to account for this debility, for, as the father assured me, the legs were exceedingly well developed. As the boy stood in my consulting-room, I observed that he separated his legs to a greater than usual distance, and that as he walked he also kept them far apart, and that his gait was staggering. As soon as his trousers were removed, I at once perceived the nature of his disease, for the calves of both legs were hypertrophied to an enormous extent, and the incurva- tion of the spine was well marked. The electro-muscular contractility was almost entirely abolished in the gastrocnemii and solei muscles, and notably lessened in the muscles of the thighs, the gluteal region, and the back. These latter were not hypertrophied. On the contrary, they appeared to be rather under than above the normal size, and they were in a very decided paretic condition. Thus, when I requested him to cross one leg over the other as he sat on a chair, he was unable to do so without seizing hold of the leg with his hands, and thus assisting with their strength, and, as he lay at full length on his back on the floor, he could not draw up his legs without great trouble, though he could flex the thighs with readiness. On measuring the calves at their greatest dimensions, I found the right to have a circumference of twelve and a quarter inches, and the left of eleven and a half inches. The right thigh, at its point of greatest circumference, measured but eleven and a quarter inches, and the left ten and three-quarters inches. I saw this patient again in the course of two months. The paralysis of the lower extremities had in- creased to such an extent as to cause walking to be very difficult. At every step he lifted the thigh almost to the line of a right angle with the body, for he had no power to raise the foot. The flexors of the thigh, upon the pelvis, did not therefore appear to be much weakened. The calves were of about the same size as before. The upper extremi- ties were still unaffected. I did not see this case again for nearly two years. The paralysis had then so far extended as to render walking impossible, but the arms were still strong, and by their means the patient dragged himself along over the floor. The calves had diminished in size, and the extensor muscles of the foot had become atrophied to such an extent as to allow of the permanent elevation of the heels by the uncompensated action of the still incompletely-paralyzed gastrocnemii and solei. The thighs were now hypertrophied, as were also the glutei muscles. Accurately measured, the circumference of the calves was, for the right, eight and a half inches, a loss of three and three-quarters inches; and for the left, eight and a quarter inches, a loss of three and a quarter PSEUDOHYPERTROPHIC SPINAL PARALYSIS. 4.95 inches. On the other hand, the right thigh measured, at its largest part, fifteen inches, an increase of three and three-quarters inches; and the left fourteen and three-quarters inches, an increase of four inches. I saw this patient again in the summer of 1874, a year after the last visit, when, in order to allow of his wearing a shoe, I divided the right tendo-achillis, with the result of bringing down the heel and perma- nently relieving the extreme condition of talipes equinus which existed. The calves had undergone still further atrophy, and the thighs were likewise beginning to shrink. There was a slight disposition to a con- traction of the flexors of the thighs, and the upper extremities were be- coming paretic. A year subsequently (July, 1875) I again saw this patient. He had then been using a steel apparatus, which enabled him to stand, or rather the apparatus stood, and, being strong, supported the completely-para- lyzed patient. The calves now measured, the right eight inches, and the left eight and a quarter inches in circumference—a loss from the first measurements of four and a quarter inches and three and a quarter inches respectively. The thighs had also lost greatly from their hyper- trophied condition of two years before. The right now measured, at its largest part, ten and a half inches, a loss of five inches, and the left ten inches, a loss of four and three-quarters inches. The upper extremities were decidedly weaker than they were a year ago, but there was as yet no hypertrophy. The patient could not even sit without support, and there was notable weakness of the muscles which maintain the erect position of the head. Throughout the whole of the period during which this patient has been under my observation, the mind has remained clear, and the gen- eral health has been excellent, circulation, respiration, digestion, and urination, all being well performed. The cutaneous tactile sensibility and the sensibility to pain have not been in the least weakened. While these pages are going through the press, I have again (De- cember 2, 1875) examined this patient in conjunction with Dr. C. T. Poore, who expressed a wish to see the case. To our astonishment a feature presented itself which thus far is entirely exceptional. A second stage of hypertrophy is going on ; the calves now measure, the right ten inches, and the left ten and a quarter. The thighs were not meas- ured, but were very considerably larger than when I last saw them ; and the father, a very intelligent gentleman, said that the enlargement in the lower extremities had been going on for two or three months. The left side of the face was decidedly larger than the right. The pa- tient was still unable to walk, stand, or sit alone, but was comparatively strong in the arms, and in good general health. His mind was remark- ably bright. At all my examinations except the last two, I removed, by means of Duchenne's trocar, portions of the hypertrophied and atrophied 496 DISEASES OF THE SPINAL CORD. muscles, the results of the examination of which will be given under the head of the morbid anatomy. Causes.—The disease is one which is almost entirely confined to chil- dren, and boys are more liable than girls. Nevertheless, it is not a dis- ease peculiar to very early infancy. Of thirteen cases observed by Du- chenne, six are stated to have begun in first infancy, while in seven the inception occurred at from two to ten years. Cases have also been re- ported as, occurring in adults. From a table containing an analysis of forty-one cases given by Dr. Webber, in his paper already cited, it ap- pears that in one case the patient was twenty-six when the disease be- gan, in one a few years under forty, and in one about twentv- eight. Poore,1 of eighty-five cases analyzed by him, ascertained that in thirty-eight the disease was first manifested before the age of five years; in twenty-six between the fifth and tenth year, in six between the tenth and sixteenth year, and in six after that age—one at twenty-four, one at twenty-six, one at twenty-eight, one at thirty-seven, and one at about forty. Duchenne expresses the opinion that an hereditary tendency some- times exists, and this appears to be the fact. Of the cases analyzed by Poore, in two a maternal uncle and aunt had the disease ; in one, three maternal uncles and aunts were affected ; in one, one maternal uncle and one half-uncle ; in one, three maternal half-brothers ; and in one a maternal half-brother, three maternal uncles, and other members on the mother's side. The disease does not appear, therefore, to be transmitted directly from parent to offspring, but is a marked example of atavism. The descent is always from the mother's side. As to exciting causes, little or nothing is known. In both my cases no reasonable explanation of its etiology could be given. There is some reason for ascribing it occasionally to exposure to cold and dampness, and to antecedent febrile diseases. Diagnosis.—The only affection at all resembling that under consid- eration is simple muscular hypertrophy due to an excessive supply of blood being sent to a part of the body. The histories and phenomena of the two disorders are, however, so very different, that I do not see how any error can arise in making a diagnosis between them. Never- theless, it is tolerably certain that mistakes on this point have been made. Thus, such cases as the one reported by Mr. Maunder4 which was clearly one of muscular hypertrophy possessing no analogies with the disease under consideration, have to my knowledge been regarded as instances of the disease under notice. 1 " Pseudohypertrophic Muscular Paralysis, with an Analysis of Cases," New York Medical Journal, vol. xxi., 1875, p. 569. 8 Medical Times and Gazette, March 27, 1869. PSEUDOHYPERTROPHIC SPINAL PARALYSIS- 497 Duchenne,1 under this head, gives very elaborate directions for the discrimination of cases of pseud o-hypertrophic paralysis from those of progressive muscular atrophy occurring in infants, infantile paralysis, and the tardy development of the coordinative and motor functions in young children. But it appears to me that very slight inquiry and ex- amination will suffice to make errors in regard to any of these condi- tions almost impossible on the part of any one capable of distinguish- ing one disease from another. Prognosis.—The prognosis is unfavorable. Two cases of recovery are related by Duchenne, and other observers have reported improve- ments, but the tendency is to death, though life may be prolonged many years notwithstanding the gradual advance of the disease. And yet the fatal result is rarely directly due to the disease itself.- Some intercurrent affection ensues, and the vital power being enfeebled can- not resist effectually the new disorder. Thus death occurred in mv first case by pneumonia; and of thirteen cases referred to by Poore, in which the termination is given, not one died directly of the disease. Morbid Anatomy and Pathology.—Five years ago, in the first edi- tion of this work, I wrote as follows : " The spinal cord has only been examined in one case—that of Eulenburg, by Cohnheim—and no lesion was discovered. We are not, from this negative result, to infer that changes had not taken place. About the same time observers were everywhere declaring that in progressive muscular atrophy, organic in- fantile paralysis, and locomotor ataxia, there were no central lesions. I have no doubt that careful microscopic examination of the spinal cord, after the manner of Dr. Lockhart Clarke, will result in the detection of atrophy and degeneration of nerve-cells in cases of hypertrophy of muscular connective tissue." Since that time examinations of the spinal cord have been accom- plished by several observers, and I think it will be rendered apparent from the following remarks that the prophecy then ventured has been measurably fulfilled and notably by the distinguished physician and histologist to whom reference was specially made. I shall endeavor to place the results of these examinations before the reader, and to state the conclusions which, in my opinion, are to be derived from them. Eulenburg's case, above referred to, was the first in which the spinal cord was examined; the investigation was conducted by Cohnheim,1 and the spinal cord was found to be healthy. But as Charcota admits, in bringing forward this case, the method of examination was imperfect and of such a character that " delicate lesions such as atrophy of the motor cells and sclerosis of the anterior horns of gray matter might Op cit, and "De l'electrisation localisee," troisieme edition, Paris, 1872, p. 608. 9 Verhandlungen der Berliner medicinischen Gesellschaft, Berlin, 1866, H. ii., p. 191. Also Canstatt's Jahresbericht, H. ii., 1866, p. 261. " Lecons sur les maladies du systeme nerveux," troisieme fascicule, 1874, p. 260. 198 DISEASES OF THE SPINAL CORD. have escaped observation." We may, therefore, with entire propriety set the results aside, as teaching us nothing definite on the subject. W. Mllller1 reports the examination of the spinal cord in a case of the disease under notice, which, however, was complicated with pro- found cerebral disease. He found gray degeneration of the lateral columns and atrophy of the nerve-cells of the anterior horns of gray matter. Mr. W. B. Kestevan, who had previously reported2 three so-called cases of pseudo-hypertrophic paralysis associated with imbecility, subse- quently examined the brain and spinal cord of one of them who, besides the mental weakness, was subject to epilepsy. The investigation was almost entirely confined to the brain and is reported3 in such general terms that it is difficult to ascertain to what part of the cerebro-spinal axis the remarks apply. And the plate which accompanies the paper is so imperfectly described that it is impossible to determine what part of the brain or spinal cord it represents, or even to which of these organs it relates. Nevertheless, it is stated that the perivascular canals were enlarged, that there was granular degeneration, and that the nerve-cells of the brain and spinal cord were normal. On account of the insufficiency of the details, as well as for the reasons that the brain-disease was evi- dently the primary affection, and that it is exceedingly, doubtful from the description given that the case was one of pseudo-hypertrophic paralysis at all, it is not in this connection entitled to much if any weight. Then Dr. Barth4 had the opportunity of examining the cord in the case of a man forty-four years old who had suffered from the symptoms of pseudo-hypertrophic paralysis. The loss of power was first mani- fested in the lower extremities, and was in the early stage accompanied with atrophy as in Dr. Pepper's case. After a time, however, the shrunken muscles began to enlarge, and when the patient died had at- tained to a great size. Examination made of them established the fact that, they exhibited the lesions characteristic of the disease—lesions to which attention will presently be directed. The lateral columns of the cord were in a state of sclerosis from the upper border of the cervical enlargement to the lower part of the lum- bar region. The anterior horns of gray matter were greatly atrophied 1 " Ein Fall vom umschriebener Muskel-Atrophie mit interstitieller Lipomatose," Bei- irage zur pathologischen Anatomie und Physiologie des menschlichen Rue ken marks, Heft u., Leipzig, 1870 2 " Cases of Mental Imbecility associated with ' Duchenne's Paralysis' or Pseudo-hy- pertrophic Muscular Paralysis," Journal of Mental Science, April, 1870, p. 41. 8 " Microscopical Anatomy of the Brain and Spinal Cord in a Case of Imbecility asso. ciated with Duchenne's Paralysis," Journal of Mental Science, January, 1871, p. 563. 4" Beitrage zur Kenntniss der Atrophia musculorum lipomatosa," Archiv der Heih kunde, Leipzig, 1871, p. 120. PSEUDO-HYPERTROPHIC SPINAL PARALYSIS. 499 and many of the nerve-cells had disappeared, while those that remained were shrunken. Still later Charcot1 minutely examined the cord in the case of a patient of Duchenne's, who had died of an intercurrent affection while the subject of pseudo-hypertrophic paralysis. The results were absolutely negative. The antero-lateral and posterior columns were in a state of perfect integrity, and the gray matter which was made the special object of investigation presented no trace of altera- tion. The anterior horns were neither atrophied nor deformed, the neuroglia possessed its ordinary transparency, and the motor cells, in number normal, exhibited no deviation from the physiological type. Last of all, Dr. Lockhart Clarke2 has given the details of his inves- tigation into the morbid anatomy of the spinal cord in a case of pseudo- hypertrophic paralysis. He ascertained that "the spinal cord pre- sented various changes throughout the cervical, dorsal, and lumbar re- gions. The most important was the disintegration of the gray sub- stance of the anterior, lower, and central portions of each lateral half. In some places this had occurred, chiefly around the vessels, but in others it involved extensive areas ; about the level of the last dorsal nerves it had amounted to almost total destruction of gray matter on each side between the posterior vesicular columns. Other changes, as disintegration of the nerve-roots, commencing sclerosis of the lateral and posterior columns, destruction of the white commissure in various places, dilatation of vessels and extravasations, were noticed." We therefore perceive that in two cases—Cohnheim's, which, for reasons stated, we may disregard, and Charcot's—there were no lesions found in the cord ; while in three—Muller's, Barth's, and Clarke's— the anterior horns of gray matter were found more or less diseased. Charcot argues very unphilosophically against the legitimate deduction to be drawn from these cases, and, basing his opinion on his own inves- tigations, which led to negative results, contends that the spinal cord is not the seat of the lesion which causes the symptoms of pseudo-hyper- trophic paralysis. But what weight is to be attached to his isolated case when we con- sider the results obtained by Miiller, Barth, and Lockhart Clarke, and compare them with the phenomena of the disease in question, may be determined by reference to a memoir, published in a number of the same journal for the same year that contained his own paper. No one has contended more energetically and with greater success than M. Char- cot, for the view that infantile spinal paralysis is a disease, the seat of which is in the anterior horns of gray matter of the spinal cord. Now, 1 "Note sur l'etat anatomique des muscles et de la moelle epiniere dans un cas de para- lysie pseudo-hypertrophique," Archives de Physiologie, Mars, 1872, p. 228. 3 "On a Case of Pseudo-Hypertrophic Muscular Paralysis," Medico-Chirurgical Trans- actions, vol. xlvii., 1874, p. 500 DISEASES OF THE SPINAL CORD. the memoir' in question details very minutely the state of the muscles of a patient affected from birth with double talipes varus, and it is shown that they were in precisely such a condition as are the affected muscles of a patient the subject of infantile spinal paralysis, and yet the most thorough and careful examination of properly-prepared sec- tions of the spinal cord, taken from the whole lumbo-dorsal region, failed to show the slightest deviation in any respect from the normal standard. In another memoir, on a similar subject,1 with a like condition of the muscles, one whole lateral half of the cord was atrophied and the nerve- cells of the antero-external group had entirely disappeared. Doubtless M. Charcot will admit that the positive evidence of M. Dejerine is more convincing in the matter of intra-uterine infantile pa- ralysis than the negative testimony of MM. Coyne and Troisier. In this he would certainly be logical, and I am disposed to accord like pre- cedence to the investigations and affirmative results of Mllller, Barth, and Clarke, in comparison with the negative results of M. Charcot's ex- amination. In Muller's, Earth's, and Clarke's cases, the lesions were not limited to the anterior tract of gray matter, but neither were the phenomena those of simple uncomplicated pseudo-hypertrophic spinal paralysis. I think, therefore, that, in the present state of our knowledge, we are warranted in at least provisionally accepting the view that the anterior tract of gray matter is the seat of lesion in pseudo-hypertrophic spinal paralysis. Another very important point in the morbid anatomy of pseudo- hypertrophic spinal paralysis relates to the condition of the affected muscles. Here there is a tolerable uniformity of views. In the first stage there may be—as Pepper has shown, and as my second case likewise exhibits—atrophy of the muscles instead of hyper- trophy. A microscopical examination shows the transverse striae to be in process of disappearing, and in some of the fibrillar, to have altogether gone. The connective tissue already shows a tendency to proliferation, but there is as yet no trace of that fatty degeneration and deposit which afterward becomes the most striking patho-anatomical feature of the disease. In the case which I have detailed, a portion of the primarily- atrophied left rectus femoris muscle was removed by Duchenne's trocar, and, examined with a fourth-inch objective, presented the appearance above described. In Pepper's case not a single fibril of the deltoid muscle which he examined exhibited evidence of fatty degeneration, though the connective tissue was very greatly in excess of the normal 1 " Pied hot varus congenital double. Examen de la moelle epiniere," par MM. Coyne et Troisier, Archives de Physiologie, 18*71—'72, p. 655. ! " Note sur l'etat de la moelle epiniere dans un cas de pied bot equin," par J. De- jerine, Archives de Physiologie, No. 2, Mars, Avril, 1875, p. 253. PSEUDO-HYPERTROPHIC SPINAL PARALYSIS. 501 proportion, and in places there were small collections of minute fat- globules or refracting granules. But in the hypertrophied muscles there is not only fatty degenera- tion of the muscular tissue, but there is fatty deposit between the fibrillae, and a still more notably-increased development of the connective tissue. As the process advances, the fibrillae in great part disappear, fat and connective tissue crowding them out as it were, and eventually even this latter is in a great measure replaced by fat-vesicles. The muscle is now at its most advanced stage of hypertrophy. But the process is not yet complete, for a stage of secondary atrophy begins, the fat is absorbed, and finally nothing is left but a few degenerated muscular fibrillae and a mass of connective tissue. There is thus in the first place simply a change in the muscular fibrillar characterized by a disappearance of the transverse striae. This is probably the first stage of the fatty degeneration, which is afterward manifested unmistakably. At the same time the connective tissue be- tween the bundles of fibrillar and the fibrillae themselves, is increased in amount. Then the disintegration of the muscular fibrillae becomes more evident, the connective tissue is still more increased, and fat-vesi- cles make their appearance between the fibrillae and the bundles of fibres. Finally, the muscular tissue mostly disappears, the fat is ab- sorbed, and connective tissue, with perhaps a few fibrillae, in a more or less advanced stage of degeneration, is all that remains. In those cases in which there is no primary atrophy of the muscles, the first stage, as described above, is of course wanting. Relative to the pathology of pseudo-hypertrophic spinal paralysis, there is, as already stated, very decided difference of opinion. Du- chenne is undecided. Charcot regards the muscular lesion the essential one—the spinal, when such has been discovered, being accidental. Fried- reich J is of like opinion as regards the seat of the disease, but consid- ers the affection in question identical in character with progressive mus- cular atrophy ; and Pepper, who, at the date of his writing, had only Cohnheim's imperfectly examined case before him, is apparently dis- posed to look upon the condition of the muscles as primary; and on the other hand, Mailer, Barth, and Lockhart Clarke, consider the spinal lesion the primary, and the muscular the secondary affection. In this view I have already expressed my concurrence. And I am disposed to agree with the view of Friedreich above re- ferred to, which affirms the similarity existing between pseudo-hyper- trophic spinal paralysis and progressive muscular atrophy. This simi- larity I would not, however, attribute to the mere circumstance that there is an analogy between the states of the muscles in the two dis- eases, but rather to the fact that the spinal cord is the primary seat of 1 "Ueber progressive Muskelatrophie; ueber wahre und falsche Muskelhypertrophie " Berlin, 1873. 502 DISEASES OF THE SPINAL CORD. the morbid process in both, and that this process is inflammation of the motor and trophic cells of the anterior tract of gray matter. At the same time, as the diseases are not identical, there is an element of ori- ginal difference, the mature of which science has not yet been able to unravel. Treatment.—Duchenne, as we have seen, succeeded in curing two cases in their incipiency, with the faradaic current. Authors are agreed that if any thing is likely to prove successful, it is electricity in some one of its forms, and all cases have been treated with this agent. Thus far, however, not only is there no record of another cure, but there is scarcely the mention of even slight improvement. The disease has gone on slowly but certainly in its progress, unchecked by therapeutical measures. Still we are not, on that account, to despair. I would recommend the primary or galvanic current to the spine, the actual cautery to that part of the spine corresponding to the diseased portion of the cord as determined by the muscular troubles, faradization of the affected mus- cles with as strong currents as the patient can bear—kneading, the application of heat, and in general those measures which have been recommended for infantile spinal paralysis. Benedict1 has treated five cases with the primary current to the back, and three of them with the induced current to the affected muscles. These cases were improved. In neither of my cases was there any check to the advance of the dis- ease, though both forms of electricity were assiduously employed. Internally, strychnia, iron, and phosphorus, may be used, and bene- fit may be derived from their tonic virtues. 2. Inflammation of the Motor Cells. Thus far, only one disease of this class has been differentiated, and it is characterized by paralysis of the parts involved, without atrophy. a. Glosso-Labio-Laryngeal Paralysis. The first explicit account of this very remarkable disease is that of Duchenne,8 who, in consideration of "the tendency of the morbid pro- cess to advance unchecked, and of the parts affected, designated it " progressive muscular paralysis of the tongue, the veil of the palate, and the lips." The consequences of this condition, as pointed out by Duchenne, are difficulties of articulation and of deglutition, and at a late period of the disease frequent attacks of strangulation, during one of which the patient may die ; or death may result either from in- anition or syncope. But, although Duchenne was the first to give a systematic descrip- 1 " Electro-therapie," Wien, 1868, p. 186. ! "De 1'electrisation localisee," etc., deuxieme Edition, Paris, 1861, p. 621. GLOSSO-LABIO-LARYNGEAL PARALYSIS. 503 tion of the affection, it was observed by Dr. F. W. Robinson, in 1825, who thus writes to Sir Charles Bell: * "In consequence of your impor- tant discoveries relating to the nerves, I am particularly desirous to have your opinion in the following case: The invalid is an unmarried lady, nearly seventy years of age, who has enjoyed uninterrupted good health up to the present illness. She has had occasional short attacks of gouty rheumatism in both feet and also in the knees, of very short duration. From the first of her complaining up to the present moment, she has been free from headache, and from pain, numbness, or debility of the limbs. The vision and hearing are natural, the appetite good ; the bowels regular, and the sleep natural. In short, there is not the slightest deviation from sound health except in the particulars I shall relate. " Some few months ago she had some difficulty in using the tongue, and in expressing particular words. This difficulty has gradually in- creased, and now she cannot protrude the tongue or even move it. She has lost her speech altogether. The tongue itself is soft and pulpy, but it retains its sense of taste and of feeling. The deglutition is impaired, and occasionally she is distressed with a sense of suffocation in attempt- ing to swallow food, which now she is obliged to do with great care. She cannot hack up any thing from the throat nor draw any thing from the posterior nares by a back draught. The features of the face are quite natural, and the skin retains its feeling. The saliva occasionally flows from the mouth." This is certainly a very accurate description of a case which, although its real nature was not recognized at the time, was undoubtedly an in- stance of the disease under notice. Then Trousseau in 1841, just twenty years before the publication of Duchenne's account, recognized it as an affection he had not previously seen, and wrote a memorandum of the existing phenomena.3 Trousseau named the disease glosso-laryngeal paralysis, in his lecture on the sub- ject, and this was afterward amplified by Duchenne into glosso-labio- laryngeal paralysis. Many cases have been subsequently reported, and descriptions of the affection given, but no one has added any thing to the graphic symptomatology of Duchenne. Fifteen cases of the disease have come under my observation during the past ten years. Symptoms.—It rarely happens that patients seek medical advice for the initial symptoms of the disease under notice. We are therefore, in general, obliged to rely on their accounts of the order and progress of the symptoms. In one instance only—and this patient is still under treatment—have I had the opportunity of observing a case from a very early point in the course of the disease. The first evidence of disease, which in the majority of instances at- 1 " The Nervous System of the Human Body," London, 1830, p. cxvii. 9 "Lectures on Clinical Medicine," Bazire's translation, p. 117. 5(14 DISEASES OF THE SPINAL CORD. tracts the attention of the patient, is a slight difficulty of articulation, due to a want of rapidity and exactness in the movements of the tono-ue. This circumstance occurred in eleven of my cases. In the others the symptom first noticed was a tendency in the lips to remain separate, and the consequent necessity of using some degree of mental action to keep them closed. In a short time the restraint in the motions of the tongue becomes more distinctly marked, and it is especially character- ized by an inability to raise the extremity to the roof of the mouth, or to press it against the upper teeth. The words, therefore, which the patient experiences most difficulty in pronouncing distinctly are those which begin with lingual or dental consonants. The gutturals he can articulate without trouble ; and the labials, except when the affection begins in the lips, do not yet give him inconvenience. The next symptom to make its appearance is difficulty of swallow- ing. The food is not promptly grasped by the constrictor muscles of the pharnyx, and the tongue does not press it strongly against them. At times it enters the pharynx, and, not being carried onward by the muscles of deglutition, may slip into the larynx and occasion suffocation. Liquids are especially difficult to swallow, and are often ejected through the nostrils. As the result of this paralysis of the muscles of deglutition, the saliva, instead of being swallowed as fast as secreted, accumulates in the mouth. Here it becomes stringy from its mixture with the buccal mucus, and when the patient opens his lips it runs out in streams. After a time the orbicularis oris becomes so far paralyzed that the lips cannot be kept closed without continual exertion, and then the viscid saliva is constantly flowing out of the mouth. In four of the cases mentioned as being under my charge, there was from the first some flow of saliva from the mouth, not apparently from any difficulty of swallowing, but from the existing paralysis of the orbicularis oris allow- ing the mouth to be almost constantly open. The other muscles sup- plied by the facial nerve in the lower part of the face, singularly enough, do not become involved. The food, it is true, accumulates between the gums and the cheeks, and has to be removed with the finger, but this is not due to any paralysis of the buccinator muscles, but to the want of power in the tongue to move the alimentary bolus around the cavity of the mouth. When the disease is thus fully developed by the paralysis of the tongue, the veil of the palate, and the lips, the patient presents a pitia- ble spectacle. He is unable to talk ; his teeth are exposed, from the impossibility of closing his mouth ; the saliva either runs in streams over the lower lip, or he goes about with a handkerchief in his hand which he uses to absorb the perpetual flow ; every attempt at degluti- tion causes him the utmost distress, and puts him in danger of his life from strangulation. When he opens his mouth the glutinous saliva is GLOSSO-LABIO-LARYNGEAL PARALYSIS. 5Q5 seen hanging in viscid strings from the roof, and his tongue, which he cannot move, lies torpid like an inert mass of muscles as it is. The facial expression is well seen in the accompanying woodcut (Fig. 52), made from a very accurate sketch of one of my patients suf- Fig. 52. fering from the disease in question, and who entered my consulting- room with his handkerchief to his mouth to absorb the streams of saliva which were flowing. The condition of the patient becomes still more painful from the im- plication of the respiratory muscles. The walls of the chest become paralyzed, and he is unable not only to breathe deeply, but to cough so as to keep the bronchial tubes clear of accumulations of mucus. So feeble is the respiratory power, that with all the effort he can make he cannot blow out a candle. And, besides the impossibility of articulation, the larynx becomes paralyzed at a later period of the disease, and phonation becomes im- possible. The patient is then doomed to perpetual silence, even the power of whispering being lost. A remarkable fact is characteristic of many cases of glosso-labio- laryngeal paralysis, and that is the tendency of the morbid action to extend so as to implicate other nerve-cells lower down in the spinal 13 506 DISEASES OF THE SPINAL CORD. cord. But the cells thus affected are not motor, but trophic, and as a consequence the resulting condition is not paralysis but muscular atro- phy. In none of my cases was there muscular atrophy in any part of the body, but in one, to be presently referred to more at length, there was incipient paralysis of the right arm. The case was, therefore, simi- lar to the one reported by MM. Duchenne and Joffroy, and which will be more specifically referred to hereafter. Gradually, as the disease advances, the physical powers of the pa- tient yield. He becomes unable to walk, not from paralysis, but from general debility, due to insufficient nutrition and imperfect respiration. His appetite remains good, but he is afraid to take any more food than is barely sufficient to sustain life, for experience has taught him that suffering and danger are attendant on every attempt at deglutition. At last he ceases to make the effort, and is fed with liquid food through a stomach-tube. The saliva during sleep runs down his throat, and fits of suffocation are the result. Too weak to walk, he remains in bed, his head turned to one side so as to allow free egress for the saliva, and he dies either from asphyxia, from the cessation of the action of the heart through the continued extension of the lesion to the cells sup- plying the pneumogastric nerve, or from some intercurrent affection. Generally the mind remains clear to the last, but in a very interest- ing instance of the disease occurring in an officer of the army, sent to me by my friend Dr. Fleming, of Pittsburg, this was not the case, manifest dementia making its appearance toward the close. The emo- tions are, however, almost invariably easily excited. The first case of this disease coming under my observation was one referred to me, over eight years ago, by my friend Dr. Edward Bradley, of this city. The patient was a watchmaker, and very intelligent. Though unable to speak a word, I obtained a good deal of information from him relative to his disease by asking him questions, the answers to which he wrote. The accompanying facsimile of one of his writ- ten communications to me (Fig. 53) will, I doubt not, prove of interest. It was made partially in answer to questions, and partially at his own suggestion. The date (March, 1847) was given in answer to my ques- tion when the disease appeared, and the year mentioned is a mistake for 1867. As he states, there was a little trouble with his right arm. This was of the nature of paralysis, there being no muscular atrophy anywhere. The patient died about six months after I saw him, the disease lasting a little over a year. Another case—the eighth—was a patient in the New York State Hospital for Diseases of the Nervous System. In him the affection began in the orbicularis oris, and gradually involved the tongue and muscles of deglutition. The left side was first affected, and then, a few weeks afterward, the paralysis extended to the right. There was nystagmus of both eyes. The mind was perfectly clear. He formed GLOSSO-LABIO-LARYNGEAL PARALYSIS. Fig. 58. 507 508 DISEASES OF THE SPINAL CORD. the subject of a clinical lecture on glosso-labio-laryngeal paralysis which I delivered during the session of 1870-71, at the Bellevue Hos- pital Medical College. The case is further remarkable as occurring in an exceptionally young person, the patient being but thirty-two years of age. Duchenne 1 states that he has never observed it in persons under forty. I subjoin a representation of this patient (Fig. 54), taken Fig. 54 from a photograph. The paralysis of the orbicularis oris is evident, al- though it is partly concealed by the mustache. At the time it was taken the patient could swallow, but was conscious of a difficulty in beginning the act of deglutition. In this case the first symptom observed by the patient was a marked anaesthesia of the face and lining membrane of the cheek on the left side. Krishaber2 has since reported an instance of like character, and regards the loss of sensibility as a valuable precursory sign, and as ex- hibiting in a very striking manner the physiognomy of the disease. I subjoin the engraving (Fig. 55), from a photograph, representing a patient who came from the West to consult Dr. Sayre and myself. He 1 " De l'electrisation localisee," Paris, 1861, p. 648. 2 " Ansesthesie de la sensibility reflex des voies aSriennes et digestives, comme pre- curseur de la paralysie labio-glasso-laryng6e," Gazette hebdomadaire, November 29, 1872. GLOSSO-LABIO-LARYN GEAL PARALYSIS. 509 entered my consulting-room holding his handkerchief to his mouth, to catch the streams of saliva which were pouring from it, unable to speak a word and scarcely able to swallow. Fig. 55 Causes.—The etiology of glosso-labio-laryngeal paralysis is very obscure. Duchenne attributes one of his cases to mental anxiety ; two cases appeared to be due to syphilis and rheumatism. In no other in- stance could he assign a cause. Of my own cases, one was apparently due to business troubles re- sulting from petroleum speculations ; and, in one, excessive application to business appeared to be the cause. In one other case, that of a gentleman of this city, the disease was evidently associated with syphi- lis, and in one it was apparently caused by a blow on the back of the head, and in one by exposure to a strong draught of cold air, which blew directly on the nape of the neck and occiput. In none of the others could I assign any cause. All of my patients were between the ages of forty and sixty, except the one whose case and portrait (Fig. 54) have been given. Diagnosis.—Attention to the account of the symptoms given will prevent any mistake in diagnosis, as there is no affection which resembles in its entirety the one under consideration. In the very early stage however, it may be confounded with simple paralysis of the tongue ; or if the disease begins in the lips, as in the case cited, with facial pa- ralysis In glossoplegia there are other symptoms of cerebral disorder and in facial paralysis the loss of power is not confined to the lips. It may possibly, in some cases, not be distinguished from the general paralysis of the insane, which generally begins with paralysis ol the tongue and weakness of the lips. The facts that this disease is manifested also by mental symptoms, and that the paralysis gradually 510 DISEASES OF THE SPINAL CORD. involves the other muscles of the body, will suffice for making an exact diagnosis. In facial diplegia the expression of countenance is very much like that of a patient suffering from glosso-labio-laryngeal paraly- sis, but here the resemblance ends, and careful examination shows even here many points of difference. It is only necessary to state that the tongue is not paralyzed, and that there is no difficulty of swallowing in double facial paralysis. In progressive muscular atrophy, attacking the tongue, the veil of the palate, and the lips, a mistake might also be made. But, as Du- chenne remarks, progressive muscular atrophy rarely begins in that way, and, when it does, other muscles of the body, especially the the- nar and hypothenar eminences, will soon become involved. Charcot has, however, recently reported a case, to be presently more fully quoted, in which progressive muscular atrophy was clearly combined with glos- so-labio-laryngeal paralysis, and in which, on post-mortem examina- tion, though the volume of the tongue was not diminished, the muscu- lar fibre had undergone degradation. In such a case, of course, a complete diagnosis could only be made after death. In ordinary pro- gressive muscular atrophy, the fact that the atrophy comes on before the paralysis, is to be borne in mind. From diphtheritic paralysis attacking the muscles of the pharynx, glosso-labio-laryngeal paralysis is readily distinguished by inquiries relative to the history of the case, and by the fact that the tongue is not involved in the first-named disorder. Prognosis.—There is no instance on record of a cure. All my patients affected with the disease are dead, except one whom I occasionally see. A case of improvement and one of cure have been reported by Dr. Cheadle,1 but certainly neither was an instance of glosso-labio-laryngeal paralysis, although the face, the tongue, and muscles of deglutition, may have been paralyzed. In the first of these the disease began with sudden loss of speech, then retro- ceded, then returned. There was facial paralysis, incontinence of urine, and left hemiplegia. The woodcut, from a photograph, of this case does not exhibit a single feature of glosso-labio-laryngeal paralysis. The case was probably one of syphilitic basilar meningitis, and the pa- tient greatly improved " under iodide of potassium, rest, and nutritious food," and was discharged able to swallow with very little difficulty and to articulate imperfectly, indeed, but so as to be understood. In the second case a complete cure was effected, and, as indicative of the character of the disease, I subjoin the essential parts of Dr. Cheadle's report : A woman, aged forty-two, entered St. Mary's Hospital in Novem- ber, 1867. Her speech was so much affected that it was difficult to 1 " Glosso-Labio-Laryngeal Paralysis," " St. George's Hospital Reports," vol. v., 1871, p. 123. GLOSSO-LABIO-LARYNGEAL PARALYSIS. 5H make out a word of what she attempted to say*; but, from the state- ment of a fellow-servant who accompanied her, and her own subsequent statements, the following history was elicited : For some months she had suffered from frequent attacks of violent shooting pain in the head, accompanied by dimness of vision, and quite unlike any headache she ever felt before. With this exception, she had remained in good health till a few days before she applied for medical aid, when she was sud- denly seized, while sitting in a chair in the daytime, with total loss of speech and paralysis of the right side. Her face was drawn, the right arm and leg utterly useless, and she found herself only able to utter inarticulate sounds; there was no loss of consciousness, or it was so tran- sitory as to escape observation. The use of the leg was fully regained in about a week ; but the arm remained weak for a considerable time. For two days speech was so far abolished that she could only utter inarticulate sounds. When fully examined several weeks after the attack, it was found that she could walk perfectly well, but that the arm was weak and sen- sation slightly impaired. Her speech was thick, indistinct, and nasal, and she was not able to protrude the tongue fully. The condition of the lingual, palatal, and facial nerves was not accurately ascertained. She complained of severe shooting pains in the head, and of extreme drowsiness. She had had four still-born children ; and an eruption, which she said was very much like small-pox, made its appearance shortly after her first confinement. She took small doses of iodide of potassium, but there was no im- provement. Mercury was also given, without good result. She then came to the hospital. Articulation was still very indistinct; she spoke as one very drunk, and was quite unintelligible. In reply to questions addressed to her, she had uttered meaningless sounds. The treatment was continued, and she gradually improved, so that at last she spoke with perfect fluency and clear articulation. No one, who has ever seen and studied a single case of glosso-labio- laryngeal paralysis, could mistake this case of Dr. Cheadle's for one of the disease described by Duchenne. It was probably a case of syphi- litic cerebral disease like the first, and like it recovery took place under anti-syphilitic treatment. Ameliorations may certainly be produced, but probably no cure. The average duration of the disease is about two years. Morbid Anatomy and Pathology.—Previous to the very recent re- searches which have given us a clear insight into the morbid anatomy of glosso-labio-laryngeal paralysis, the lesions, detected by several ob- servers, were atrophy of the roots of the hypoglossal, facial, spinal accessory, and pneumogastric nerves. But late investigations have 512 DISEASES OF THE SPINAL CORD. shown that the lesions of the nerve-roots are secondary to others more central in their situation. It has already been shown, in this chapter, that the morbid process in certain diseases consists of atrophy and disappearance of nerve-cells forming the nuclei of origin of certain nerves. Very minute examina- tions, made in the cases of persons dying of the disease under notice, show very clearly that it also consists of atrophy and disappearance of nerve-cells. Thus, in the case cited from Charcot,1 the tongue had preserved its former thickness and normal dimensions, but the patient could not ar- ticulate, and was obliged to express herself by signs. Intelligence was perfect. There was some atrophy of the arms. The post-mortem examination showed that the extrinsic muscles of the tongue, and those of the supra- and sub-hyoidean regions, were of normal appearance and condition. The intrinsic muscles were pale and of diminished hardness. The laryngeal muscles were healthy, except the posterior crico- arytenoid and crico-thyroideus, and presented here and there a yellow coloration. The muscles of the pharynx had undergone no appreciable altera- tion. The muscular coat of the oesophagus appeared to be of normal consistence and color. In the spinal cord the alterations were confined to the anterior horns of gray matter, and to the proper nerve-elements, the neuroglia being healthy. The abnormal condition consisted in a disappearance of nerve-cells. In the bulbar region it was noticed that the nucleus of the hypo- glossal presented very pronounced alterations, which here, as below, related exclusively to the nerve-cells. The neuroglia was intact. Many of the cells were in a state of pigmentary degeneration. The group of cells, considered by Lockhart Clarke to be the inferior nucleus of the facial, were smaller, and less in number than in the normal state. The other cells constituting the nucleus of the facial were in like condi- tion. Similar changes were observed in the cells in relation with the filaments of origin of the spinal accessory and the pneumogastric nerves. In the case which Duchenne 9 has made the basis of some original views on the subject of atrophy of nerve-cells, and to which reference has already been made, it was found that the cells constituting the nuclei of origin of the hypoglossal, the facial, the spinal accessory, and the pneumogastric, had become—those that remained—affected with 1 " Note sur un cas de paralysie glosso-laryng6e suivi d'autopsie," Archives de physi- ologie, tome iii., 1870, p. 247. 8 " De l'atrophie aigue et chronique des cellules nerveuses de la moelle et du bulbe rachidienne, a propos d'un observation de paralysie glosso-labio-laryng6e," par Du- chenne (de Boulogne) et Joffroy, Archives de physiologie, No. 4, 1870. GLOSSO-LABIO-LARYNGEAL PARALYSIS. 513 pigmentary degeneration, and were atrophied, while many had disap- peared altogether. Among the earliest properly conducted examinations of the medulla oblongata is that made by Dr. E. R. Hun,1 of Albany, in a case which appears to have been a typical one of glosso-labio-laryngeal paralysis. Sections made from the medulla oblongata showed disappearance of the nerve-cells and hyperplasia of the neuroglia in that part where were situated the nuclei of origin of the facial and hypoglossal nerves. The cells that remained had, in many cases, lost their radiating processes, and were in a state of pigmentary degeneration. In this case there were in addition symptoms indicating the existence of secondary amyotrophic lateral spinal sclerosis, as described by Bou- chard and Charcot, and the lateral columns of the cord were found scle- rosed. It may, therefore, be considered as satisfactorily determined that the essential lesion in glosso-labio-laryngeal paralysis is found in the medulla oblongata and upper part of the spinal cord, and that it con- sists of atrophy and disappearance of certain nerve-cells constituting the nuclei of origin of the hypoglossal, the facial, the spinal accessory, and the pneumogastric nerves. But we are not on that account to disregard the fact that phenomena similar to those of glosso-labio-laryngeal paralysis may exist, and as the result of very different lesions of the medulla oblongata, or even of no discernible morbid condition of that organ. Thus in a case reported by Dumesnil2—in which there was paralysis of the tongue, the lips, and the veil of the palate, together with atrophy of the muscles of one of the upper extremities—the hypoglossal, facial, and spinal accessory nerves were found atrophied. No thorough microscopical examination was made of the medulla oblongata, and hence such lesions as those described by Charcot and Duchenne were not detected. But, whether they were present or not, it is undoubtedly true that eccentric lesions of these nerves would cause paralysis of the parts involved in glosso- labio-laryngeal paralysis. Trousseau 3 has described three cases in which post-mortem examina- tions were made. In one of these, the results were negative from in- completeness of the investigation ; in the second, the roots of the hypo- glossal nerve were atrophied, and the medulla oblongata was harder than was normal; and, in the third, the roots of the hypoglossal and spinal accessory were in like condition. In all of these cases no proper microscopical examination was made of the medulla oblongata, and consequently we are without information as to the exact condition of that organ. But we can remark of these Labio-Glosso-Laryngeal Paralysis," American Journal of Insanity, 1871, p. 194. a Gazette hebdomadaire, Juin, 1859, p. 390. s "Lectures on Clinical Medicine," Bazire's translation, 1866, p. 117, et seq. 514 DISEASES OF THE SPINAL CORD. cases, as of Dumesnil's, that they only show that paralysis may be produced by lesions of the nerves, a fact which required no further demonstration than it had already received many centuries ago. It scarcely, however, admits of a doubt that the atrophy of the nerves was the result of central disease, and that this disease was situated in the medulla oblongata. In Dr. Wilks's J case, the roots of the hypoglossal and spinal acces- sory nerves were found atrophied, and the medulla oblongata was evi- dently the seat of serious disease, but no examination as to the cell- lesions was made, nor indeed was it possible then, before the researches of Lockhart Clarke, to make such an examination. Voisin 2 reports the case of a patient aged seventy-seven, who en- tered the Salpetriere, and who soon after admission suddenly lost her speech. Gradually, however, she reacquired the power, though she had forgotten some words. After remaining three months in the hos- pital, she again, after a violent fit of excitement, was deprived of speech, and also lost the power to purse up the lips and to raise the tongue. The mastication and deglutition of solid substances were impossible, the saliva flowed from the mouth, the uvula was immova- ble, the inspiration rattling, and the respiration generally difficult. Taste and sight extinguished. The glottis was unfortunately not examined. The mind was unimpaired, and there was no paralysis of the limbs. The patient had to be nourished through an oesophageal tube. She died suddenly after the last attack. Now, although this is called by Voisin a case of glosso-pharyngo- labial paralysis, a title which he uses as synonymous with glosso-labio* laryngeal paralysis, it is very evidently not the affection originating in the nuclei of the bulbar nerves, and progressing slowly but without in- termission to a fatal termination. It is of the same character as the cases cited from Dr. Cheadle, and would not be referred to here but for the fact that a post-mortem examination was made. The results were as follows : There was a small yellow focus of softening at the external part of the left lenticular ganglion, which extended to the island of Reil. To this circumstance the reporter attributes the amnesic aphasia. At the upper and lower surfaces of the two lesser cerebral hemi- spheres, just beneath the connecting arm of each, were discovered two tumors which appeared to be epithelioma of the arachnoid. The left tumor, of the size of a walnut, reached to the medulla oblongata, in such a manner that the auditory, facial, hypoglossal, and spinal accessory and glosso-pharyngeal nerves were compressed. These nerves were by one-half slenderer than those of the right side. The facial was soft- ! " Guy's Hospital Reports," vol. xv., p. 1. 2 Annates medico-psychologiques, January, 1871, analyzed in the Journal of Psycho- logical Medicine, New York, vol. v., 1871, p. 816. GLOSSO-LABIO-LARYNGEAL PARALYSIS. 515 ened. The tumor on the right side was of smaller circumference, and did not extend to the medulla oblongata. Neither the medulla oblongata nor the pons was sclerotic. No microscopic examination of the medulla was made, and there- fore nothing can be inferred relative to the state of the nerve nuclei. In a case in which I had the opportunity of making a post-mortem examination, there was also paralysis of the tongue, the lips, and the pharynx, but the associated phenomena were not such as to warrant the disease being designated as an inflammation of the anterior tract of gray matter, causing glosso-labio-laryngeal paralysis. The patient was an elderly gentleman of this city, who had suffered from paralysis of the lower extremities, and to a less extent of the arms, for several years. This condition had been preceded by several seizures not involving loss of consciousness, but mainly characterized by deprivation of speech, irregular respiration and circulation, and vomiting. When I first saw him there was defective articulation, the tongue could only be slightly moved, and there was partial paralysis of both sides of the face. The function of deglutition was very much impaired. Solids could not be swallowed at all, and liquids escaped through the nostrils. The saliva ran in streams from the mouth. But the most marked disturbance was in the respiration and the action of the heart, both of which were exceedingly irregular, the latter intermitting frequently, and generally not skipping a single beat, but two or three at once. His mind was unimpaired. I predicted his death in a few days, for, from the history of the case as well as from the existing phenomena, I was convinced that the nu- cleus of the pneumogastric was involved with that of the hypoglossal, facial, and spinal accessory of both sides, and that the disease was ad- vancing. He died within a week, and a post-mortem examination was allowed. The brain was apparently healthy throughout, except that the pons Varolii and medulla oblongata were in a state of extreme softening. These were removed, together with the vertebral arteries as far down as the lower border of the anterior pyramids, and with the basilar and its transverse branches. The coats of the basilar were thickened, and the lumen of the vessels almost entirely obliterated. The two lower trans- verse branches on either side were entirely closed by dense fibrous clots, presenting all the appearance of thrombi. The left vertebral artery was also diseased and closed by an old clot extending about an inch and a quarter from its junction with the vertebral of the opposite side. The tissue of the pons Varolii and medulla oblongata was so much softened as not to admit of hardening in chromic acid. The parts were placed in absolute alcohol and examined in a few days, but. the degeneration was so thorough that nothing more could be ascertained than the fact of the almost complete destruction of the nerve-elements. 516 DISEASES OF THE SPINAL CORD. In this case, although the symptoms were in some respects similar to those of glosso-labio-laryngeal paralysis, yet it is very obvious that the affection was not this disease. The paralysis of the extremities and the paroxysms of speechlessness were indicative of a more extensive and different lesion, and the post-mortem examination showed that the original trouble was altogether extrinsic. The bulb was invaded from the exterior instead of from the interior. It would be just as proper to designate the case described on page 486, under the head of spinal paralysis of adults, one of glosso-labio- laryngeal paralysis on account of the bulbar symptoms, as to consider the one just described and others of its class as coming under this cate- gory. That ischasmia of the medulla oblongata, however, will give rise to the symptoms of glosso-labio-laryngeal paralysis is not only evident from pathological considerations, but also from recent anatomical re- searches. Thus Duret1 concludes, as the results of his investigations, that, when a clot is situated in one of the vertebral arteries, it interrupts the circulation in the anterior spinal artery, and consequently in the median arteries which arise from it ; that is to say in the arteries which supply the nuclei of the spinal accessory, the hypoglossal and the infe- rior root of the facial. It therefore causes the development of the symptoms of glosso-labio-laryngeal paralysis. When the clot occupies the inferior part of the basilar trunk, it cuts off the blood from the sub- protuberantial branches which supply the nucleus of the pneumogastric, and sudden or at least rapid death is the consequence. In regard to the character of the morbid process by which the de- generation, atrophy, and disappearance of the nerve-cells are effected, Leyden 2 considers it to be a myelitis, and this is probably the correct view. In this light, therefore, it does not differ essentially from the corresponding process which, situated lower down in the cord, produces infantile spinal paralysis and the spinal paralysis of adults. Wachsmuth,3 who was among the first to study the subject, argued, from a consideration of the symptoms, that the affection in question was characterized by destruction of the nerve-cells in the floor of the fourth ventricle, and that the degeneration of the nerve-roots was a secondary process. As we have seen, it was reserved for Charcot and Duchenne and Joffroy to establish the correctness of this opinion by post-mortem investigations. As to the acute glosso-labio-laryngeal paralysis, or acute bulbar pa- ralysis, as it has been called by Leyden4 and other German writers, 1 " Sur la distribution des arteres nouricieres du bulbe rachidien," Archives de physio- logie, 1873, p. 97. 2 "Ueber progressive Bulbarparalyse," Archiv fur Psychiatrie und Nervenkrankhei- ten, B. ii. und in., 1870-7.". 3 "Ueber progressive Bulbarparalyse und diplegia facialis," Dorpat, 1861. * " Klinik der Nervenkrankheiten," Berlin, 1875, B. ii., p. 157. GLOSSO-LABIO-LARYNGEAL PARALYSIS. 517 and the " glosso-labio-laryngeal paralysis of apoplectic form " of Jof- froy J and of Proust,2 cases such as those described by these authors, are to be considered in the light of the foregoing remarks, and not as instances of inflammation of the anterior tract of gray matter leading to destruction of the motor cells. In regard to the coexistence ef glosso-labio-laryngeal paralysis with certain affections of the cord, characterized by atrophy of the muscles, the point will be fully considered under the heads of progressive mus- cular atrophy and amyotrophic lateral spinal sclerosis. One other point: What is the essential physiological character of the cells which have become degenerated, atrophied, and many of which have disappeared ? In infantile spinal paralysis, and in the spinal paralysis of adults, we have seen reason to think that the cells which are the seat of disease are both motor and trophic, for these af- fections are evidenced by paralysis and atrophy. But in the disease under consideration there is no atrophy, for glosso-labio-laryngeal pa- ralysis is not a disease in which the muscles are defectively nourished, but one the essential feature of which is paralysis. It is reasonable, therefore, to suppose, with Duchenne, that the nerve-cells which have become diseased are motor cells. Onimus 3 asserts that there is no evidence to show that glosso-labio- laryngeal paralysis ever exists without atrophy of the tongue, but this is directly at variance with the experience of other observers and al- together inconsistent with my own investigations. That there is a form of progressive atrophy affecting the tongue is very certain, but it is not glosso-labio-laryngeal paralysis. As regards the relation of the symptoms observed to the known distribution and functions of the nerves concerned, there is no difficulty. The affection of the hypo- glossal causes the paralysis of the tongue, and the consequent impossi- bility of articulation, and of moving the food in the mouth ; the im- plication of the facial accounts for the paralysis of the lips and the muscles of the veil of the palate, and the resultant impossibility of sounding certain letters, and of swallowing; the extension to the spinal accessory explains the paralysis of the larynx, the loss of pho- nation, and the feebleness of respiration ; and death, when it takes place as it sometimes does from the sudden stoppage of the heart's ac- tion, is due to the implication of the pneumogastric, to which cause other paralyses of the muscles of animal life are to be ascribed. Treatment.—From what was said relative to the prognosis, it will have been perceived that there is not much to expect from treatment. I have, however, occasionally produced good results which have, for a 1 " Sur un cas de paralysie labio-glosso-laryngee a forme apoplectique d'origine bul- baire," Gazette Medicate, 1872, No. 41. ' " Sur la paralysie labio-glosso-laryngee," Gazette des Hopitaux, 1870. * " Paralysie labio-glosso-laryngee," Gazette des Hopitaux, September '30, 1872. 518 DISEASES OF THE SPINAL CORD. time at least, rendered the condition of the patient more tolerable. Thus the first patient who came under my care was much relieved by fara- dization of the paralyzed muscles. He improved very much in his ability to swallow, and in power over his tongue and lips. These ameliorations were not permanent. In the case of the gentleman from Pittsburg, as well as in all the other cases but one, similar treatment, together with the use of the primary galvanic current and phosphorus, was without the least effect. In this latter case some benefit was apparently produced for a time. The course of the disease was certainly less rapid than before treatment was begun, but it nevertheless slowly advanced to a fatal termination. 3. Inflammation of the Trophic Cells. In admitting the existence of trophic cells in the anterior tract of gray matter of the spinal cord, I have been influenced by what I con- sider to be the weight of evidence. The fact is one which, in the pres- ent state of our knowledge, is not capable of absolute demonstration; but the subject is of such a character as scarcely to require proof of that nature. The inference for their existence is as strong as that which we draw relative to the presence in the spinal cord of cells spe- cially in relation with the functions of motion and of sensation. As we have seen, there are affections of the cord in which there are both pa- ralysis and atrophy. In such cases, we have good reason for concluding that the cells which are in nervous connection with the paralyzed and atrophied muscles have both motor and nutrient properties. This de- duction is strengthened by the fact that there is another disease which is characterized by the existence of paralysis without atrophy, and which post-mortem examination shows to be due to the degeneration, under the influence of inflammation, of certain cells situated in the me- dulla oblongata and in direct anatomical relation with the nerves sup- plying the paralyzed parts. These cells, there is every reason to believe, are exclusively motor. We have now to consider the affections of the spinal cord, and still of the anterior tract of gray matter, which are manifested by atrophy without paralysis, except in so far as an atrophied muscle necessarily possesses less power than one which is of full size. Two such affections have been recognized, or, rather, one—progres- sive muscular atrophy—has been regarded as a disease of the anterior tract of gray matter of the spinal cord by the great weight of authority; while the other—facial atrophy—is now for the first time, so far as I am aware, placed in the same category. That this is warranted by the clinical histories of the cases I shall have to adduce, will, I think, be apparent to the reader. PROGRESSIVE MUSCULAR ATROPHY. 519 a. Progressive Muscular Atrophy. Although cases of progressive muscular atrophy were noticed by the older writers, the first systematic account of the disease was given by Duchenne,1 in 1849. In 1850 M. Aran9 published his memoir, in which he gives the histories of eleven cases; and three years subse- quently Cruveilhier3 read a paper on the same subject before the Academie de Medecine. About the same time other memoirs were published on the subject. But, although Cruveilhier was not the first to write upon the affec- tion in question, he was the first to describe it, and Duchenne and Aran were aware that he had done so in his lectures for several years. The disease is therefore sometimes called Cruveilhier's atrophy. Symptoms.—The first symptom observed in the majority of cases is loss of strength and dexterity in certain muscles of the body. If these are in the lower extremities, the patient finds that he tires in walking sooner than he used to do. If in the upper extremities, he experiences weakness in the shoulder, arm, or hand, according to the muscles af- fected. Soon afterward pains simulating those of neuralgia are felt in the paretic muscles. These are not probably due to the central lesion, but are the result of muscular fatigue which is itself due to the incipient atrophy which even at this stage exists. In the majority of cases—according to my experience in all—fibril- lary contractions are perceived. Thus, of fifty-two cases of progressive muscular atrophy which have been under my charge during the past ten years, these contractions formed a prominent feature in every one. They consist of slight twitchings of separate bundles of muscular fibres, and give the sensation of something alive being under the skin. They can often be seen, especially when superficial fibres are involved, and they are generally the avant courriers indicating the extension of the disorder. Even if for a time they are not noticed they can always be excited by a smart tap on the atrophied muscle, except in the latter stages of the disease. The loss of strength attracts the attention of the patient to his limbs, and then he finds that the weakness is accompanied by atrophy. If, as is usually the case, the disease begins in one of the upper ex- tremities, the thenar and hypothenar eminences very commonly give the first evidence of atrophy. The ball of the thumb. disappears, and the muscles filling the space between the first and second metacarpal bones 1 "Atropine musculaire avec transformationgraisseuse," "Memoires del'academie des sciences," 1849. 3 " Recherches sur une maladie non encore decrite du systeme musculaire," Archives Generate de Medecine, 1850. 3 " Sur la paralysie musculaire progressive atrophique," Archives Generate de Medecine, 1853. 520 DISEASES OF THE SPINAL CORD. —the adductor pollicis and the first interosseous — likewise shrink away. The whole outline of the metacarpal bone of the thumb can thus, very soon, easily be made out. The ball of the thumb is often the starting-point of the disease, and when this is not the case, it generally becomes involved at some time or other in the course of the affection. Of the fifty-two cases occurring in my experience, the disease appeared first in the ball of the thumb in nineteen, and eventually attacked this part in twenty-one others. The upper extremities were the original seat of the disease in forty-two cases, the trunk in four, and the lower extremities in six. Whether the affection begins in an upper or lower extremity, the tendency is for the opposite member to be next involved. The physiognomy of progressive muscular atrophy is very striking, particularly when the face or the hand is its seat. One very well- marked case of the former has come under my observation, and it can readily be understood that the change effected by the disappearance of the facial muscles must be very evident. In the case in question—rep- resented in Fig. 56—the right side of the face was strikingly involved, Fig. 56. and the muscles of the neck and shoulder on the same side were af- fected to a marked degree. In the hand, the atrophy of the muscles which give this member its plumpness, and enable it to perform the complex movements' of which the fingers are capable, causes appear- ances which are easily recognizable. By the disappearance of the thenar eminence, the skin over it hangs in loose folds, the thumb falls by its own weight, and cannot be brought into apposition with the index-finger—the palm of the hand is hollowed out, and the metacarpal bones can be distinctly seen and felt. In the forearm, the situation of the disease can be readily ascer- PROGRESSIVE MUSCULAR ATROPHY. 521 tained by the flattening produced by the disappearance of the affected muscles, and in the arm and shoulder the effects of the disease are still more evident. In three cases, the disease had begun in the right del- toid, and had not extended beyond this muscle when the patients came under my charge. In all, the shoulder was flattened, and the head of the humerus and the acromion process could be distinctly seen. In another case it was limited to the trapezius and scapular muscles of both sides. In the lower extremity, the changes in the foot are not so remark- able as the corresponding ones in the hand, but the effects produced by the atrophy of the peroneal muscles, the tibialis anticus, and those forming the calf of the leg, are very striking. In the one case, the foot drops, and the patient is obliged to bend the knee to a greater ex- tent than usual in order to make the toes clear the ground ; in the other, the heel cannot be raised, and the ankle gives way with the weight of the body. When the muscles on the anterior face of the leg are in process of destruction, the forms of the tibia and fibula can be distinguished, and the space between the two bones is unfilled. The disappearance of the calf makes the posterior aspect of the leg flat. In the thighs the atrophy is also readily perceived, and modifies very materially the gait of the patient. When the extensors on the anterior face of the thigh are involved, the leg cannot be thrown forward; when the flexors are the seat, the leg cannot be raised, and the whole mem- ber has to be lifted up by the action of the flexors of the thigh on the pelvis. A singular circumstance connected with the disease is the tendency exhibited for a single muscle or a group of muscles to escape atrophy, while all the surrounding ones are profoundly affected. Thus, as in a case reported by Duchenne,1 all the muscles of the hand and forearm were completely atrophied with the exception of the supinator longus, which remained in its normal condition. This is well shown in the cut (Fig. 57) from Duchenne's work. Sometimes the atrophy, after destroying a muscle or two, ceases to extend. Thus, in a case referred to me by Dr. D. H. Goodwillie, of this city, the atrophic process had been spontaneously arrested after com- pletely destroying the muscles of the right thenar eminence, and the patient had remained for eighteen years entirely free from any active manifestations of the disease. The temperature of the atrophied muscles is usually several degrees below the normal standard. In the case of a gentleman whom I recent- ly examined with reference to this point, and whose right hand, fore- arm, and arm, are in a state of advanced atrophy, I found, by means of 1" De 1'electrisation localisee," troisieme edition, Paris, 1872, p. 506. 522 DISEASES OF THE SPINAL CORD. Dr. Lombard's instrument, the temperature of that extremity to be 5° Fahr. below that of the other. The cutaneous capillaries are usually relaxed, and hence the skin over the affected parts is discolored by the passive engorgement. The electric contractility of the affected muscles is not diminished so long as there are any muscular fibres to be acted upon. As the morbid process generally pursues no regular course in its progress through a muscle, but takes bundles of fibres here and there without re- gard to their topographical relations, the contraction of the muscle to the electric stimulus is exceedingly irregular. Instead of the whole muscle responding, there are lacunae which correspond to the bundles of fibres which have disappeared. After a time no electrical excitation, however strong, pro- duces even a fibrillary contraction, for the whole parenchymatous tissue has been ab- sorbed, and nothing remains but the inter- stitial connective tissue. The reflex excitability in the early stages appears to be increased, but as the disease advances it becomes less and less, and is finally altogether lost. Thus when the fibril- lary contractions, which characterize the in- itial period, are temporarily absent, they can be readily reexcited, as previously men- tioned, by striking the skin over the affected muscle. Besides the paralysis, which it must be clearly understood results from the atrophy, and is directly proportional to its extent, there may be contractions. These, when present, are due to the fact that the atro- phy has not attacked all the muscles of an extremity simultaneously, or to a like degree, and consequently, the normal antagonism being destroyed, distortions take place. When these occur in the hand, they produce the main en griff'e of Duchenne. Of the twenty-mne cases occurring in my experience, seven only had any distortions. In infantile paralysis, which is similar in several respects to progressive muscular atrophy, contractions and distortions are much more common. The pupils are sometimes contracted from the implication of nerve- cells in the cilio-spinal region of the cord. This was the case in one or both eyes in four of my cases. PROGRESSIVE MUSCULAR ATROPHY. 523 The course of the affection is slow, but in the great majority of cases it advances to a fatal termination. Death takes place from the muscles of respiration becoming involved, from exhaustion, or from some inter- current affection. Several of my cases have lasted over ten years. It is worthy of notice that up to the present time there is no in- stance on record of the muscles of the eye-ball or the levator palpebrse superioris being affected. The accompanying woodcut (Fig. 58), fiom Friedreich, represents a Fig. 58. patient, Ludwig Bessing, forty-five years old, who certainly presents a remarkable example of the disease. Almost all the muscles of the body, trunk and extremities, were in a state of extreme atrophy, the 521 DISEASES OF THE SPINAL CORD. only exceptions being found in the left forearm. The disease had re- mained stationary for many years, during all of which period there were strong fibrillary contractions. No hereditary influence could be ascer- tained to exist. In a recently-published memoir, MM. Duchenne and Joffroy1 have shown that glosso-labio-laryngeal paralysis is sometimes complicated with progressive muscular atrophy, and that this latter affection, impli- cating the muscles of the tongue, the lips, and the veil of the palate, has hitherto been confounded with the first-named disease. It differs from it, however, in the essential fact, which is applicable to the dis- order appearing in other parts of the body, that the loss of power is not the initial symptom, but results directly from the diminution in the size of the muscles. This point will be further considered under the head of Diagnosis, when other cases similar to that here referred to will be brought forward. The progressive muscular atrophy of infants presents some features different from those met with in adults. Duchenne,2 who has elucidated this point of the subject, has ascertained that the initial atrophy, instead of beginning in the upper extremities, as it usually does, or in the trunk or lower extremities, as is occasionally the case, starts from certain muscles of the face, giving a very peculiar expression to the counte- nance. I have never witnessed, to recognize it, a case of progressive muscular atrophy in an individual under the age of eight years. Con- sequently, no instance of the infantile form of the disease has come under my notice. Duchenne has witnessed fifteen cases, and, in each, the beginning of the malady occurred between the ages of five and seven. The muscle first to be affected is the orbicularis oris, and, as he states, its failure to contract occasions a characteristic thickness of the lips. The expansion of the mouth, as in laughing, is then only effected by the buccinator and the risorius. Eventually, other muscles of the face become involved, and finally the atrophy extends to the superior extremities, the trunk, and the lower limbs. The accompanying cut (Fig. 59), after Duchenne, represents in profile the face of a boy thirteen years of age, whose lips had, in in- fancy, become thick and pendent, and whose orbicularis oris, levatores labii superioris, levatores labii superioris alaeque nasi, and the zygo- matici, had become atrophied, and, when stimulated by strong faradaic currents, gave no response. At the age of twelve the muscles of the chest had become affected. In this case, as in one other in Duchenne's experience, the disease 1 " De l'atrophie aigue et chronique des cellules nerveuses de la moelle et de bulbe racbidien," Archives de Physiologie, No. 4, 1870, p. 499. 2 Op. cit, p. 518. PROGRESSIVE MUSCULAR ATROPHY. 525 had been transmitted through the mother, who was herself the subject of progressive muscular atrophy. Fig. 59. Causes.—Progressive muscular atrophy is not a disease of old age. Only two of my cases were in persons over fifty; four were between forty and fifty, and forty-six were under forty. Of these latter, three were between fifteen and twenty, and two between eight and ten. The period of life at which it appears to be most common is that extending from twenty-five to thirty-five. Sex is a strong predisposing cause. All of my cases were in males, except one, a lady from Providence, Rhode Island, in whom the face and tongue were involved in the morbid process. Roberts 1 states that, of ninety-nine cases, eighty-four were males, and only fifteen females,! Other authors have noted the greater proclivity of males. The difference appears to be due to the greater severity of muscular exertion required in many of the occupations of men. Hereditary influence is a well-recognized predisposing cause. Two of my cases sent to me by Dr. Lincoln, of Washington City, were brothers, two others are sons of a prominent manufacturer of this city, and fourteen others had relatives affected with the disease. But by far the most remarkable history of the hereditary transmis- sion of the disease, which has come to my personal knowledge, is con- tained in the following account, which constitutes a pamphlet written 1 "An Essay on Wasting Palsy," London, 1858, p. 135. 526 DISEASES OF THE SPINAL CORD. by one of the unfortunate subjects, and sent to me by Dr. R. F. Andrews, of Gardner, Massachusetts. The interest attaching to the whole matter, as well as in consideration of the graphic, though homelv, manner in which the story is told, will, I am sure, be sufficient apology for my quoting the entire pamphlet : "muscular atrophy. "Among my ancestors and their neighbors this disease was known as the ' "Wetherbee Ail;' definitely, it is a wasting or consumption of the muscles. Until recently, it has been considered incurable ; the cause is unknown, but gen- erally the first intimation the patient has of it is a shock. My opinion is that its inception is some time previous, but not noticed. From and ever after the shock its progress and character are remarkable, the various symptoms and details of which will be seen in the individual cases I shall attempt to describe. "I have been unable to trace the history of this disease beyond my great- grandfather, Ephraim Wetherbee, and all I know of his history is that he had six sons and two daughters, and that he died of the ' Wetherbee Ail.' His son Asa experienced a sensation in the calf of both legs, as if struck smartly with a whip; I do not know how long he lived, but he failed from that time; Isaac, another son, had the same disease, but I have been unable to learn aDy partic- ulars in his case. Two others, Calvin and Joseph, the latter my grandfather, died in South America of diseases prevalent in that country; I can say nothing of the others. Hannah Wetherbee, one of the daughters, I can remember to have seen walk feebly and soon after confined to her room nearly helpless, and to have seen her coffin-lid screwed on. Sarah married a Mr. Paine; she had had seven children and was in good health ; she was walking on the street and felt as if hit in the calf of the leg by a stone, and turned expecting to see the boy who threw it, but concluded that was not the case; she lost the spring of her toes, as she expressed it, and never walked naturally afterward; she told her family, on her arrival home, that she had the ' Wetherbee Ail.' She lived seven years, had the best of care and medical treatment; she had two children during her sickness, the last a son, after she had become perfectly helpless and only nine months previous to her death. She had nine children; one died young, the others are living and in good health. I had these particulars from the eldest, Sarah Paine, who married Spaulding, and is nearly sixty years of age, has gen- erally been in good health, excepting during some three years she suffered from nervousness and lost all her strength; but she recovered and for some twenty years has been well. She had a son and daughter who both married; the daughter died of consumption of the blood, the son is in good health. Mrs. Spaulding names other cases but can give no particulars except that one felt the first shock in the foot under the shoe-buckle, such as were worn a hundred years ago; another was attacked in the brain and lived but twenty-four hours (I should not call that a case of muscular atrophy); another requested that an examination should be made after his death, which being done showed that all the muscles were consumed. "Joseph Wetherbee, my grandfather, had a son and daughter; the daughter, Lucy, married a Mr. Pitts; she had only a son and daughter. The daughter lived some twenty years and died of some sudden and severe sickness. The son, J. Henry Pitts, is still living and is about forty-three years of age; has suffered PROGRESSIVE MUSCULAR ATROPHY. 527 much from rlieumatic fever. Aunt Lucy herself, enjoyed good health till about fifty years old, when she died. She believed there was nothing peculiar in the so-called ' Wetherbee Ail.' Her last sickness was of an entirely different char- acter. "I now come to the case of my father. He was of a robust build, had a strong constitution and was temperate, drinking no spirits since my remem- brance, probably not much before; used some tobacco at times, and worked hard at different trades, as shoemakiug, farming, and chair-making. When about thirty-nine he remarked that he was growing old fast, and some of the neighbors discovered a slight limp in his walk. I was not living at home at that time, and do not know much of his condition in the early stages of his sickness. He first discovered a weakness in the right thumb, being unable to open his pocket-knife in the usual way. The right hand and arm lost strength faster than the left; and, contrarily, the left leg failed the fastest. He thought the direct cause of his lameness to be over-exertion in harvesting a crop of meadow-hay, in August or September, 1844. He continued to labor about a year. The progress of the disease was rapid; he suffered somewhat from painful muscular contractions or cramps, otherwise he had but little pain. The larger muscles of the arms and legs became soft and flabby, and diminished in size. In November, 1845, he cut his fingers in the shop, went home and never entered the shop again. He got about the house with crutches several months, comfortably. During the follow- ing winter he had rheumatic fever. In the summer of 1846 he became nearly helpless. Mother and myself lifted-him to his feet, and to and from his bed and chair. The kidneys were also affected, and the lungs were very weak. So he wasted in flesh and strength, and died on the 10th of October, 1846, a little more than two years after the hard work in the meadow. " I can say no more of the above cases, except that the persons were native- born Americans. Mrs. Spaulding thinks we descended from the English. I do not learn that there was dissipation in any branch of the family. There are branches of the family in which nothing of the kind appears; there is nothing of it in the Wetherbees in Scotland. Mrs. Spaulding thinks the disease was in the family previous to the time of my great-grandfather. "I was born on July 23, 1831, in Westminster, Massachusetts. At the age of five I was thrown from a wagon and got a scalp-mark from the horseshoe. At the age of six I remember an aching head and discharge at the ear; at seven or eight a bad cold, with soreness of chest, a cough and hot gin-sling, none of which were in the least agreeable. When eleven I was badly poisoned with ivy, although before that I had handled it with impunity; at fourteen another cold and affected chest and lungs, with ulcers, or something like, in the head. " From this time to the age of twenty-one I had some sick-headache; got sick three times from trying to paint outside work, got poisoned with ivy and dog-wood, but did not lose many meals or much sleep. I worked at chair- making and had no lack of out-door exercise. As I have spoken of shocks be- ing felt by some of the above-named persons, I am reminded that I felt one on a day in the summer that I was sixteen ; I felt as if struck with a piece of board on the left shoulder, head, and neck. I looked around for the cause but saw no one; I was not hit nor hurt; have felt something similar since, but as nothing came of I thought no more about it. At twenty-one I had a lame stomach, partly from work and from getting a blow in the breast. Oue plaster set that all right, and I have had nothing of it since. 528 DISEASES OF THE SPINAL CORD. " In January, 1855, I had lameness in the right wrist and hand, attributing it to a slight, and at the time unnoticed, sprain by rolling logs. I had much pain and trouble during three or four years; many times I could scarcely write, and came to use the hammer and saw with the left hand. It is useless to name the various modes of treatment, as time only seemed effectual in restoring the parts to nearly their natural condition. In December, 1855, I had a severe cold, affected lungs and head ; had discharges at the ear, but kept the house for a few days and recovered. Early in the summer of 1857 I had poor appetite and no ambition, headache, and slight night-sweats. I gave up work early in August, put myself under a doctor's care, improving much in two months, and before winter gained my usual health. Early in the spring of 1858 I had palpitation of the heart, caused by eating new maple-sugar; have been subject to it ever since, at intervals from a week to a year and a half, always brought on by drink- ing water or ale, or eating an apple. I felt somewhat weak during their con- tinuance, but usually kept at what I happened to be doing, though they lasted from six to thirty-six hours. Two or three years following I had two sharp stitches in the back, by lifting a slight weight, resulting in a lame back for a season. " In August, 1862, I enlisted in the army and soon went to Virginia; had but little difficulty in getting accustomed to camp-life and climate. I had no occasion to answer surgeon's call until the following winter, when I got cold, being on guard night and day during Burnside's so-called ' mud march,' resulting in pain in the bowels and diarrhoea, but that all wore away in a month or two. During May, 1863, while in camp at Washington, I* took a cold which troubled me till after the battle of Gettysburg, when I had my left thigh fractured by a spent grape-shot. The fracture, only a simple diagonal, was never set, the bone unit- ing in its own way and time, consequently the left leg is about two inches short- er than the other, and crooked. " In 1864 I received my discharge. I walked with a cane the following sum- mer, then gave it up ; experienced no difficulty excepting the limp resulting from the shortness of the leg. During the year 1865 I was engaged in work which kept me on my feet. I frequently walked two miles, out and back, but experir enced more fatigue than in previous years. In May, 1866, I went to Chicago, and engaged in sedentary occupation; had about seven-eighths of a mile to walk to and from work. I usually walked rapidly, many times beating the horse-cars. In July, 1867, I went to Pennsylvania and engaged in chair-making; on my feet all of the time, and some of the time standing still at a machine; also walked much over the rough hilly roads in that country. I was there upward of three years; during the time I had two or three attacks of lame back, also of piles. When taking an armful of stock from the floor I found it convenient to keep a stick in the right hand to assist in rising. In a letter to my brother I remarked I felt that I was getting old. As I was then about the same age my father was when he made the same remark, the coincidence is remarkable. " Late in 1869 or early in 1870, I noticed a fibrinous contraction just above the right knee, about half-way from the anterior to the inside. It is a tremu- lous twitching of the muscles, which is seen in the muscles of slaughtered ani- mals after the skin is taken off. It is painless but somewhat disagreeable, and more noticeable after retiring. In two or three days it was gone. I was at that time standing at a lathe during the day, and walking rapidly morning, noon, and night. In November, 1870, I came to Gardner, where my employment was such that I had to stand stiller than ever. I was advised to sit on a stool part PROGRESSIVE MUSCULAR ATROPHY. 529 of the time, but I was not inclined to do so. I walked rapidly to and from the shop, each trip requiring about twelve minutes, four trips a day up hill and down. In February, 1871, I felt a general lameness or muscular soreness from over-exertion, loss of sleep, and taking cold. I had had such experiences before, most persons have the same. About the 20th or 25th of March I noticed for the first time that I went up-stairs with much difficulty, the trouble seeming to be in the right thigh. On the 26th of March I walked to Westmiuster, a distance of five miles, and back. I felt generally fatigued, but noticed no par- ticular lameness. That was the last foot-journey of any distance I ever took. Twice in April I quickened my pace to pass some persons on the sidewalk, and felt a quick, painful sensation in the anterior portion of the right thigh. A few days subsequent to this there was an alarm of fire about twelve o'clock. I started to run, but gave it up after a few steps, and have not tried to run since. " I was a little anxious about all this, but did not suspect any permanent lameness existed. I cannot say when the thought of the ' Wetherbee Ail' came into my mind. On May 11th, as I was going of an errand in the morning, I stopped to throw a stone at a small hawk in an apple-tree, but fell myself, and the hawk flew away. Twice soon after I fell on throwing a stone. About this time I had severe cramps in the right thigh, and have the impression that there were cramps in the right thumb. I consulted a doctor about this time, and be- gun a regular course of treatment. The 1st of June I gave up going home for my dinner, and sat on a stool much of the time while at work. I still walked comfortably, but could not raise my weight up an ordinary step, and I had to be careful that the knee set at every step, or it would cripple and let me down. The reader will notice that the leg which was not broken failed; as it was some two inches longer than the other, it had to bear the greater burden, and, in go- ing up-hill or up-stairs, virtually had to raise my weight two inches higher at every step than the broken leg. The tremulous twitching was very marked during this time, and occasional painful cramps. I continued to lose strength all summer, and was obliged to give up some kinds of work. " September 1st, I found that the right thigh measured only sixteen inches, while the left measured nineteen. I used a cane at this time and found it of much service. At this time I rode to and from the shop. About the 1st of November I found the left leg began to fail. The 1st of January, 1872, I found much difficulty in walking only a short distance. I gave up work and went to the Massachusetts General Hospital for five weeks; but no effect of the treat- ment was apparent; think the right thigh had decreased to fourteen and one- half inches in one year. There was but very little strength in the right leg, the muscle of the thigh was very flabby, and the heat was lower than in the other leg. I resumed my occupation in February. The fibrinous contractions and painful cramps had by this time nearly ceased in the right leg, but were visible in the left; also noticed weakness in the right thumb, especially when cold, aud could not hold a carpenter's pencil in the usual way. I cannot state the number of times that I fell; I continued to ride to my work. Late in May I could bear no weight on my left toes. Meantime I had bandaged my right foot and leg to the knee, on account of swelling. On the 27th of July I was thrown from a car- nage, the immediate result of which was a general muscular soreness, particu- larly in the left foot and arms. " From this time the progress of the disease was marked and rapid, espe- cially in the ball of the right thumb and the left thigh. I now found it unsafe to 34 530 DISEASES OF THE SPINAL CORDi step without a cane, or out of the reach of something permanent. As the cold weather came on, I had to change my job for a lighter one in a warmer place. I gave up walking in the shop, used a wheel-chair, and was during the fall put into a buggy by a strong man. I continued to work through December, except- ing some of the coldest days, but on the last afternoon of the year 1872 I fell and severely sprained the left knee; was obliged to quit work, and have done nothing since. " At no time, since I first felt the lameness in the right thigh, have I been able to say with truth that I was a little better, or even about the same; but that I was not so strong as I was a month previous. This disease never stands still. I will close this sketch by saying, that at this writing I cannot stand alone, have no control of the right leg whatever, and cannot move the toes. The left is very weak; both feet, and the legs below the knee, are somewhat cold most of the time. I dress without assistance. My arms are not strong enough to raise my weight to my feet; have not strength to cough or sneeze with any force. Have a fair appetite and sleep well. It is probable that nearly every muscle in the system is affected, as I have felt the cramps and tremulous contractions in nearly every part. There is no loss of sensation in any part. The large muscles of the right thumb are much wasted, the whole hand has a bony appearance, and the third finger droops. Sometimes I cannot pick up a pin, and my writing is scarcely legible. I gave up all treatment six months ago, as I could never see any difference in the progress of the disease while under treatment and while not. " One theory is, that this disease is not inherited by the descendants of the females ; and the history of Mrs. Paine's family seems to confirm it. My object in writing this is, that those into whose hands it may fall, who are predisposed to this disease, may keep a watch upon themselves ; and I exhort them to mod- eration in labor and physical exertion, and in all things, and that they may have a history, though imperfect, of the cases which have appeared in our family; that they may immediately, on suspicion that they are attacked by any unusual thing, apply for the best help within their power. I waited some two months be- fore taking any measures for relief. This disease is also known as' wasting palsy.' It is known in other families. The so-called living skeletons,- who are exhibited as curiosities, are sufferers from muscular atrophy in its worst form. I am the oldest of five ; one sister and three brothers still enjoy fair health. None of us have used tobacco or spirituous liquors. "E. H. Wetheebee. Gardner, Massachusetts, March 81,1873." In relation to this case, Dr. Andrews, in sending me the pamphlet, writes, under date of March 30, 1874: "This man, Wetherbee, died December 23, 1873. " His sister has recently consulted me with symptoms of the same disease. The left arm and shoulder are affected. The twitching of the fibrillae is worse at night. I prescribed iron and quinine, and rest. I was present at your clinic at Bellevue two years ago when you exhibited a patient—a bridge-builder—from Ohio, with the disease.' Two members of this family, within the knowledge of the writer of the pamphlet, were affected with progressive muscular atrophy, and it PROGRESSIVE MUSCULAR ATROPHY. 531 is probable that other members, as he was informed, before his great- grandfather, were its subjects. An interesting circumstance is, that two of the cases were females, and it is likewise a notable fact that the children of one of these, nine in number, exhibited no symptoms of the disease. We have seen that in pseudo-hypertrophic spinal paralysis the affection is only transmitted through the females, while progressive muscular atrophy, so far as this history goes, appears to be only im- mediately hereditary through the males. Atavism was therefore mani- fested in a different way than it is in the former affection. Duchenne, however, as we have seen, has witnessed two cases occurring in children in which the disease was transmitted directly through the mothers who were themselves the subjects of the malady. But nothing on this point can surpass the instructive histories re- lated by Dr. Naunyn * relative to cases brought before his medical clin- ic in Konigsberg. Six generations were subject to the disease. Mem- bers of three generations were alive at the time Naunyn delivered his lecture, and the clinical histories of seven cases were personally known to him. The oldest of these, Dorothea Braun (nk,e Bessel), was seventy years old. Her father and grandfather had the affection, to her knowl- edge, and her father told her that her great-grandfather was also its sub- ject. Dorothea had eleven brothers and sisters, of whom only one. Minna, a sister, had the disease. Of her own seven children four wers affected. Of Minna's three, one dying in early infancy, two were dis eased. Of Dorothea's uncles, seven in number, two suffered from the malady. The accompanying table shows at a glance the relationship of the several members of this remarkable family, and the channels through which the disease was transmitted directly, and by atavism. From its examination we sec— 1. None of the sons of Daniel Bessel were affected, but two of the daughters, Dorothea and Minna, were, and the malady was propagated by them. 2. Of Minna's three children, all females, two had the disease. 3. Of Dorothea's seven children, two boys and two girls were af- fected, while two boys and one girl escaped. 4. One of the boys, Hermann, and one of the girls, Emilie, who es- caped, had each a boy who had the disease, thus affording two examples of atavism, one through the male and one through the female. This history is in marked contrast to that of Wetherbee so far as the line of descent is concerned, and the two together may be con- sidered as definitely settling affirmatively the question of the heredi- tary transmission of progressive muscular atrophy. j " Ueber Hereditat der progressiven Muskelatrophie," reported by Dr. Eichorst in Berliner kltnische Wochenschrift, Nos. 42 and 43, 1873. Carl Bessell. < ai\ BmspcI. Daniel Bessel. 1. Fritz. 2. Carl. 3. Dorothea. 4. Louis. 5. Rudolf. 6. Minna, 1. Fkriunan... 8. Henriette. 9. August. 10. Julius. 11. Heinrich. l. Marie. 2. Marie. 3. Johanna. 1. Julius. 2. Bertha. 3. Laura. 4. Hermann. 5. Theodor. 6. Robert. 1- Emilie. Five Miscarriages. I. Ernst. 2. Martha. 1. Otto. 2. Clara. 3. Carl. 1. Fritz. 2. Gustav. The individuals whose names are printed in heavy-faced type wore the subjects of the disease—the others escaped. 2 c o w PROGRESSIVE MUSCULAR ATROPHY. 533 From some facts which will be adduced under the head of treatment there is reason to believe that syphilis is occasionally a cause of pro- gressive muscular atrophy. The exciting cause is often impossible of detection. This was the case in twenty-nine of the instances that have come under my observa- tion. Of the remaining twenty-three, injuries of the spine were the cause in two, exposure to cold and dampness in thirteen, and excessive muscular exertion in eight. Of these latter cases, two occurred in the persons of ballet-dancers, the disease making its appearance first in both gastrocnemii muscles simultaneously ; one in a gentleman who had overtasked the muscles of the upper extremities by severe and long- continued exertion in rowing—the muscles about the shoulders being affected; in two, the muscles of the right hand were first attacked, as the result of excessive use of the pen in writing; in one, it was induced by the occupation, that of a bricklayer, requiring the patient to bear the weight of his body, during his work, mainly on one leg—the one attacked; in one, it was apparently induced by running a long distance; in one, it began in the thenar eminence of the right hand of a bridge- builder; in one, it attacked the muscles of the hand and forearm, begin- ning in the ball of the thumb in a man whose occupation—faro-dealer— required him to use his thumb and fore-finger in a peculiar way for many hours at a time. Venereal excesses have been alleged as a cause, but I have seen nothing to support the assertion. Diagnosis.—Progressive muscular atrophy may be confounded with infantile spinal paralysis, spinal paralysis of adults, pseudo-hypertro- phic spinal paralysis, amyotrophic lateral spinal sclerosis, and various secondary forms of atrophy. From all these diseases it is discriminated without difficulty, if at- tention be paid to its peculiar features, which in the main are as fol- lows: 1. The absence of fever and of pain in the back. 2. The gradual progress of the atrophy, the muscles being attacked one by one and not en masse, as in the other diseases named. 3. The fact that there is not paralysis in the proper sense of the word, the loss of power being simply the result of a diminished mass of muscle. i. The retention of the electric contractility so long as there are muscular fibres to contract. 5. The presence of fibrillary contractions, which are very rarely met with in other atrophic diseases, except amyotrophic lateral sclerosis, the diagnosis from which will be herewith pointed out. Progressive muscular atrophy, when manifested in the tongue, has often been mistaken for glosso-labio laryngeal paralysis. It is readily distinguished, however, from this latter disease by the fact that atrophy is not an accompaniment of the morbid process which characterizes 534 DISEASES OF THE SPINAL CORD. glosso-labio laryngeal paralysis. In progressive muscular atrophy at- tacking the tongue the organ is marked by knots and depressions, the latter corresponding to the situation of the atrophied muscular bundles and the former to the as yet untouched portions. In glosso-labio laryn- geal paralysis the tongue lies motionless in the mouth, undiminished in size. In locomotor ataxia there is sometimes a wasting of the muscles, but the fact that the atrophy is shown in masses of muscles at once, and the clinical history of the patient, will suffice to render the diagnosis exact. In rheumatic affections there is often atrophy, but this is consecu- tive on paralysis, and in the cases of tumors of the cord we have the phenomena of slow compression in addition to those of muscular atro- phy- In cases of injury of the cord or of the nerves supplying a part, pa- ralysis is the first symptom to make its appearance, though atrophy may very quickly follow. In such instances the electric contractility is soon lost. Attention to the clinical history of such cases will render a mis- take in their diagnosis almost out of the question. Prognosis.—From what has been said, it will readily be apprehended that progressive muscular atrophy is a very serious disease; indeed, it is one of the most progressive of all the affections to which the term has been applied. In only three cases have I succeeded in arresting the course of the disease, and in restoring the atrophied muscles. One of these was that of a highly-intelligent gentleman, formerly an officer in the navy, but now a resident of this city, whose case has already been referred to as having been induced by rowing; the other was that of the patient, also previously mentioned, in whom the affection was induced by cold, and which began in the right deltoid muscle. Both of these patients were entirely cured, regaining full muscular power. The other was a man who came to my clinic at the University Medical College during the win- ter of 1874-'75. In four other cases, which I saw before the disease had advanced to a great extent, its progress was arrested, but there has as yet been no restoration of the wasted muscles; in two of these there was no prob- able cause of the affection. The coexistence of a clinical history of syphilis probably makes the prognosis more favorable than would otherwise be the case. The existence of an hereditary tendency renders the prognosis much more grave; and the fact of the disease having lasted a long time is also of unfavorable import. Morbid Anatomy and Pathology.—Investigations in regard to the morbid anatomy of progressive muscular atrophy relate to the condi- tion of the spinal cord, the nerves, and the affected muscles. PROGRESSIVE MUSCULAR ATROPHY. 535 The spinal cord has been examined in cases of progressive muscular atrophy by Bergmann, Meryon, Gull, Luys, Lockhart Clarke, and others, with very different results; some of these observers finding no change whatever, and others detecting notable variations from the nor- mal structure. In three cases examined by Clarke,1 disorganization of the spinal cord, especially of the gray matter, was found, with, in one case, deposit of amyloid corpuscles. More recently Hayem,4 and Charcot and Joffroy,3 have studied the morbid anatomy of progressive muscular atrophy with great care. In Hayem's case, the disease affected the muscles of the upper extremi- ties to such an extent as to render them powerless from the shoulders down. The patient died from paralysis of the diaphragm, and of pneu- monia. On post-mortem examination, the spinal cord appeared healthy to the naked eye. The anterior roots of the cervical nerves were, how- ever, notably atrophied. The most attenuated were those of the second, third, fourth, and fifth pairs. The sympathetic was healthy. On mi- croscopic examination of the cord, the most marked characteristic was atrophy and disappearance of the nerve-cells. In some portions there were none to be seen, but there were large numbers of free nuclei, and of cells containing many nuclei. The atrophy of the nerve-cells, and of the anterior cornua of gray substance, was greatest at the level of the second and third cervical nerves, and extended as low as the fifth cervical. This region was that from which the nerves supplying the atrophied muscles were derived. In the dorsal and lumbar regions there was no atrophy of nerve-cells or of nerve-roots. A consideration of this case shows, as Hayem remarks, that it is one which, during life, exhibited the usual symptoms of progressive muscu- lar atrophy, and that, at the post-mortem examination, lesions were found in the muscles in the anterior roots of the nerve, and, above all, in the spinal cord. The alterations from the healthy structure of the cord consisted of— 1. Abnormal vascularization with dilatation, and sclerosis of the ar- terioles, and of the larger capillaries. 2. A more or less abundant exudation surrounding the blood-ves- sels. 3. Multiplication of the elements of the interstitial tissue (the neu- roglia), and finally atrophy, and disappearance of a very great num- ber of the nerve-cells. 1 Beale's " Archives of Medicine," vol. iii.r 1861; also, same, vol. iv.; also, British and Foreign Medico-Chtrurgica* Review, vol. xxx., 1862. 8 " Note sur un cas d'atrophie musculaire progressive, avec lesions de la moelle," Ar- chives de Physiologie, No. 2, 1869, p. 221, and No. 3, 1861, p. 391. ' Deux cas d'atrophie musculaire progressive, avec lesions de la substance grise et du faisceaux ant6ro-lat6raux de la moelle 6piniere," Archives de Physiologie, Nos. 3 and 5, 1869. 536 DISEASES OF THE SPINAL CORD. These facts point to the existence of chronic inflammation of the gray substance of the cord, beginning in the nerve or parenchymatous tissue, and subsequently involving the neuroglia or interstitial sub- stance. The two cases of MM. Charcot and Joffroy have also been very care- fully and thoroughly studied. The chief features of the first case were, progressive muscular atro- phy, especially marked in the superior extremities; atrophy of the muscles of the tongue and of the orbicularis oris, and paralysis with rigidity of the inferior extremities. The patient was a woman, and, be- coming suddenly very weak, died asphyxiated. At the autopsy, the anterior roots, especially those of the cervical region, were found greatly atrophied and discolored. The cord ap- peared healthy to the naked eye, except that at the dorso-lumbar en- largement it was softened. On microscopical examination, however, the nerve-tubes of the anterior columns were discovered to be atrophied, a great number being only represented by the axis cylinder, while the connective tissue was very much increased. The posterior columns were not involved in the least. In examining the gray substance of the cervical region, the authors were struck with the extreme degree of atrophy which the cells of the anterior cornua had undergone; a large proportion of them had entirely disappeared, leaving no trace behind them. The posterior cornua ap- peared to exhibit all the qualities of the normal condition. The alterations in the other regions of the cord were not directly connected with the muscular atrophy, except as regards the medulla ob- longata, where the cells of the nuclei of origin of the hypoglossal were found to be atrophied, and even completely destroyed. In the second case, similar structural changes were found.1 As Charcot states, when the alterations of the neuroglia are very pronounced, the anterior horn, which is the seat of the morbid process, may be considerably reduced in size. This condition is well shown in the accompanying woodcut (Fig. 60), which represents a section of the spinal cord taken from the cervical region of a patient who had been the subject of progressive muscular atrophy—a, the left anterior horn of gray matter; b, the right anterior horn, the cells of which are atro- phied with the exception of a small group at c. The whole right ante- rior horn is seen to be diminished in size. 1 These cases, which at the time were considered to be instances of progressive mus- cular atrophy with complications, are now to be classed under the head of amyotrophic lateral spinal sclerosis. I have described here the morbid anatomy exhibited by them in so far as it relates to the lesion of the cells in the anterior horns of gray matter, reserv- ing the consideration of the other lesions for a subsequent division of the subject. It may be said now, in anticipation of a fuller discussion, that the alterations of the gray matter of the anterior uorns appear to be the same in the two diseases. PROGRESSIVE MUSCULAR ATROPHY. 537 MM. PreVost and David' have recently reported a case of atrophy of the thenar eminence, similar to that related on page 521, as occur- ring in my own experience. They had the opportunity, however, of making a post-mortem examination, the patient dying of a wound of the head. The man, the subject of the disease, had had from his in- fancy complete atrophy of the muscles of the ball of the right thumb. Even the bone was atrophied. There had never been pain. Pig. 60. On post-mortem examination there were found: manifest atrophy of the anterior root of the right eighth cervical nerve; slight atrophy of the anterior root of the right seventh cervical nerve, and atrophy of the right anterior horn of gray matter in relation with these roots. The muscles of the thenar eminence were entirely destroyed ; but all the other muscles of the hand and arm were normal. In this case the relation between the spinal lesions and the affected muscles was sufficiently explicit. Still more lately MM. Pierret and Troisier * have examined the spinal cords of two patients who died of progressive muscular atrophy, and have confirmed in all essential respects the results obtained by the observers previously mentioned. The character of the lesions of the cord and nerves may therefore be considered as definitely ascertained; and it is equally an established fact, first noticed by Cruveilhier, that " Note sur un cas d'atrophie des muscles de l'eminence thenar droite avec lesions de la moelle Epiniere," Archives de Physiologie, 1874, p. 593. 'Note sur deux cas d'atrophie musculaire progressive," Archives de Physiologie, 1875, p. 237. 538 DISEASES OF THE SPINAL CORD. the anterior roots of the spinal nerves derived from the affected portion of the cord and supplying the diseased muscles are generally found atrophied from the disappearance of a certain number of nerve-tubes. This is a secondary lesion resulting from the spinal degeneration. The atrophy of the muscles is due to the degeneration and ultimate disappearance of the fibrillae. To the naked eye they appear pale and attenuated. By microscopical examination, it is seen that the trans- verse striae of the fibrillae are in course of disappearance, and as the dis- ease advances they are perceived to fade away altogether. Eventually, the longitudinal striae also disappear. At the same time, the muscular fibrillae break up into granules, and then undergo regressive metamor- phosis into fat. It is not uncommon to see a bundle of fibrillar, in one part of which the transverse striae only have vanished; in another, the longitudinal; in another, the process of disintegration complete ; and in another, oil-globules occupying their place. Fat-corpuscles are fre- quently found deposited between the bundles of fibrillae. After a time the fat disappears, and nothing is left of the muscle but a cord of con- nective tissue made up of the perimysium. Sometimes the interstitial fat is deposited in such large amount as to take away from the atrophied parts all appearance of emaciation, and, in fact, to mask the essential feature of the disease. Duchenne has particularly called attention to this circumstance, and has given en- gravings representing patients thus affected. This fact, it appears to me, furnishes an additional argument to those previously advanced rela- tive to the propriety of placing pseudo-hypertrophic spinal paralysis in the present group of diseases ; and Charcot, who considers progressive muscular atrophy an affection of the cells in the anterior horns of gray matter, but regards pseudo-hypertrophic spinal paralysis as a malady of the muscles, speaks of the excessive lipomatosis—lipomatose luxu- riante—of the former disease, without appearing to recognize the fact as indicating any relationship between the two. The essential points in the morbid anatomy of progressive muscular atrophy are no longer matters of doubt. The bearing of these points on the real nature of the disease is next to be investigated. At the outset of the inquiry relative to the pathology of progressive muscular atrophy, the question arises, Is it an affection of the muscles, the nerves, the sympathetic system, or the spinal cord ? As regards its being a disease primarily of the affected muscles, Friedreich' is the most strenuous contestant in support of the affirma- tion. His main argument is that lesions are found in the muscles while they are not found in the spinal cord or nervous system, except in a few instances. But he neglects to state these very important facts, that in every case he cites, in which lesions of the cord were not found, the examination was made before Lockhart Clarke had taught us how 1 " Ueber Muskelatrophie," u. s. w., Berlin, 1873. PROGRESSIVE MCSCULAR ATROPHY. 539 histological investigations of the nervous centres were to be carried on, and that in every case of progressive muscular atrophy, in which the spinal cord has been examined since that time, and according to that method, disease of the anterior tract of gray matter has been found. Thus the first examination which he cites was made in 1858 ; the last in 1867. In the intervening period the lesions of the cells in the ante- rior horns did not attract attention—were not, in fact, discovered. Lockhart Clarke, Charcot, Joffroy, Duchenne, Hayem, Pierret, Prevost, and others, had not made the examinations which have placed the existence of the central lesion beyond a doubt. Now, as to the relation of cause and effect which the spinal and muscular lesions bear to one another, opinions vary, and the question appears to be one which, in its very nature, is incapable of being posi- tively solved. We can only take the evidence on both sides, and de- termine the matter according to what strikes us as being the weight of testimony; and this appears to be in favor of the doctrine of primary spinal disease. We have in support of this view— 1. The fact that those cells of the cord are diseased which are in ana- tomical and physiological relation with the affected muscles. 2. The absolute certainty that similar lesions of the anterior horns of gray matter will cause atrophy of muscles —infantile spinal paraly- sis, spinal paralysis of adults, pseudo-hypertrophic paralysis, acute mye- litis, etc. In these diseases we know from the central as well as from the peripheral phenomena that the morbid process starts from the spinal cord. We have hence evidence that atrophy of nerve-cells will give rise to atrophy of muscles. 3. On the contrary, we have nothing to show that atrophy of a muscle will cause inflammation and degeneration of spinal nerve-cells. 4. If the disease were a primary affection of the muscular system, we ought to find the nerves diseased at their extreme peripheral termina- tions in the muscles; such, however, is not the case. The ascending neuritis, which Friedreich assumes to exist, is not shown to be a patho- logical entity. Neither the patho-anatomical facts nor the symptoms of progressive muscular atrophy give any color of truth to his theory. It is not to be doubted, however, that peripheral lesions of the ner- vous system will cause central disease. But we can readily concede that much, without going to extreme lengths with Friedreich. But no one can properly study the question without perceiving the manifest inconsistency of Charcot and others in contending for the cen- tral origin of progressive muscular atrophy while denying such a be- ginning to pseudo-hypertrophic spinal paralysis, an affection which pre- sents so many analogous features to the first-named disease both in its symptomatology and its peripheral and central lesions. Here Fried- reich is supported by the eminent French pathologist. As to the affection being a primary disease of the nerves, the only 540 DISEASES OF THE SPINAL CORD. evidence we have of that doctrine is the fact of the atrophy of the an- terior roots of the spinal nerves in direct relation with the atrophied muscles. Cruveilhier regarded this condition as the essential lesion, mainly, however, because he was unable with his imperfect means of research to discover the morbid process in the cord. This nerve-atro- phy is like that of the muscles—to be regarded as entirely secondary to the central disease, and as being directly dependent thereon. If it were primary or due to the muscular atrophy, we would find it not only manifested in the anterior nerve-roots but in the peripheral extremi- ties ; beginning in them and passing along the trunks of the nerves to the cord. When we come to consider the relation of progressive muscular at- rophy to the sympathetic nervous system we find little or nothing to warrant us in considering it as one of cause and effect. It is true that Jaccoudl and others have observed lesions of the sympathetic, asso- ciated with the disease in question; but Charcot, Vulpian, and Hayem, by the employment of the most approved methods of research, have failed to confirm these results; and quite recently M. Lebimoffa has most thoroughly and conclusively, in a case of undoubted progressive muscular atrophy, investigated the sympathetic nervous system, and has found neither fatty degeneration of the nervous element nor de- generation or proliferation of the neuroglia. All that he discovered was a deposit of pigmented granulations in the protoplasm of the con- nective-tissue cells—a condition which he very properly ascribes to the general exhaustion and the cachectic state of the patient. In this case the characteristic alterations of the cells of the anterior horns were very pronounced. Hence we are, I think, forced to conclude that progressive muscular atrophy is not primarily a disease of the muscles, the nerves, or the sympathetic system, but of the anterior tract of gray matter of the spinal cord. As to the nature of the process by which the cells are destroyed there is every reason to believe that it is a very slow, chronic inflam- mation. Relative to the physiological functions of the cells which are the seat of the disease, there is not much to say in addition to the remarks already made when infantile spinal paralysis and spinal paralysis of adults were under consideration. Progressive muscular atrophy, pure and uncomplicated, is unaccom- panied by paralysis, except such loss of power as is directly due to the diminution of the volume of the affected muscles. The inference is, 1 " Bulletin de la societ6 medicale des hopitaux," 1864; and, " Traite de pathologia interne," tome i., 1870, p. 357. 2 " Recherches sur l'etat du systeme nerveux sympathique dans un cas d'atrophie mu» culaire progressive spinale protopathique," etc., Archives de Physiologie, 1874, p. 889. PROGRESSIVE MUSCULAR ATROPHY. 541 therefore, that it is not the motor cells which have disappeared or be- come atrophied, and yet, on post-mortem examination, we find that nerve-cells of some kind have been diseased. The presumption is, and it is reasonable, that these are cells which are specially connected with the nutrition of muscles—trophic cells—and that progressive muscular atrophy is a symptom indicating the existence of disease of the trophic cells. The very existence of these cells is a matter of inference, but in my opinion the argument in favor of the affirmative is very much strengthened by the facts furnished by the morbid anatomy of progres- sive muscular atrophy. Dr. Handfield Jones l has recently written for- cibly against the existence of any special trophic nerves, and, by exten- sion of reasoning, trophic nerve-cells. But he was unaware of the more recent researches of Duchenne and Joffroy,2 upon which, in ac- cordance with these observers, I have based my views of the pathology of progressive muscular atrophy, and to which I have already alluded. We have only to take into consideration the phenomena which are ex- hibited in glosso-labio-laryngeal paralysis as it affects the tongue and progressive muscular atrophy attacking the same organ, ,to perceive how wide is the difference between the two affections. In the case of a lady from Rhode Island, now under my care, the thenar eminences of both hands, certain muscles of the arms, and others of the lower ex- tremities, are in a state of profound atrophy. One side of the face is also affected. She swallows with difficulty and speaks with great indis- tinctness. Here are some of the symptoms of glosso-labio-laryngeal paralysis to a superficial observer, but when the patient opens her mouth the tongue is seen not as a mass of reddened, flabby, inert muscles ly- ing torpid, but atrophied to a marked degree on the left side and capable of being moved as well as the diminished volume of muscular tissue will permit. Here we have atrophy of the muscular system beginning in the upper extremities and finally attacking—still preserving its charac- teristics—the muscles of the face and tongue. On the other hand, we may have the morbid process, which gives rise to glosso-labio-laryngeal paralysis, extend down the cord and attack the cells of the anterior horns. But it is then a paralysis which results, not an atrophy, and the lesions of the anterior horns are to be classed with the secondary degenerations of the cord. Are we not, from these two categories of cases, still further war- ranted in assuming the existence of motor and trophic cells both in the spinal cord proper and the medulla oblongata ? To answer this ques- tion in the negative it appears to me we are forced to disregard some of the most cogent teachings of morbid anatomy and pathology. "'Are there Special Trophic Nerves?" "St. George's Hospital Reports," vol. iii 1868, p. 89. 8 " De l'atrophie aigue et chronique des cellules nerveuses," etc., Archives de Physi- ologic, No. 4, 1870, p. 499. 542 DISEASES OF THE SPINAL CORD. Treatment.—The most approved means of treatment consist in the use of the primary or galvanic current to the spine, and the faradaic to the atrophied muscles. The former is best applied by placing one pole on the nape of the neck and stroking the skin on each side of the ver- tebral column with the other. The current should be as strong as the patient can endure. A seance should be given every alternate day, and should last about ten minutes. The faradaic current should be carefully and thoroughly applied to every atrophied muscle within reach which responds, and should be powerful and slowly interrupted. In those muscles which do not con- tract to the induced current the primary may be employed, but such a course will rarely be necessary, the muscle being, in the vast majority of cases, beyond the reach of remedial means. It is probably entirely atrophied. By the use of these measures I have succeeded in curing three cases. These have already been referred to. The last, a man whose thenar and hypothenar eminences were markedly atrophied, and in whom the flexores carpi ulnaris and radialis were already affected, came with his physician to my clinic at the University Medical College. I advised the treatment mentioned; it was carried out, and in the course of two months the muscles were almost completely restored. The atrophy showed no further disposition to extend. I have since heard that this patient entirely recovered. If there is the least suspicion of syphilis, iodide of potassium in large doses should be administered. In the case of a gentleman affected with progressive muscular atrophy, with an undoubted clinical history of syphilis, and who, residing out of New York, I see only about once a month, a very positive arrest of the disease appears to have resulted from this treatment. When he first consulted me the right thenar and hypothenar eminences were entirely destroyed; the interossei and lumbricales were nearly so. All the muscles of the forearm were more or less affected, and the disease was manifesting itself in the left thenar eminence, which was already decidedly wasted. He was at first treated by electricity, but there was no improvement, and while this agent was being used the left triceps showed signs of atrophy, and fibrillary contractions occurred in the muscles of both arms, which were not yet wasted, and in those of the trunk. The electricity was now discontinued after having been employed over six weeks, and the iodide of potassium was administered in gradually-increasing doses, beginning with ten grains three times a day. At about the time thirty-grain doses were reached, the fibrillary contractions ceased. He continued to increase the doses till he took half an ounce a day. There were then no contractions, and no further extension of the atrophy had taken place. The medicine was now discontinued for ten days, when it was resumed and continued as before. He still takes the iodide in gradu- PROGRESSIVE FACIAL ATROPHY. 543 ally-increasing doses every alternate month, up to forty grains three times a day. A year and more has now elapsed since I first saw this patient, and there has been no advance of the disease since the treat- ment with the iodide was begun, and no fibrillary contractions in any part of the body since their disappearance nearly a year since. A few cases of improvement have been reported as occurring from hydro-therapeutics. It is very probable that the majority of the instances in which amel- iorations or cures are asserted to have been produced by one thing and another were not in reality cases of progressive muscular atrophy. Every physician, whose practice is extensive in the class of nervous diseases, has doubtless had many patients consult him in whom the diagnosis of progressive muscular atrophy has been made, but who were affected with very different affections from that very intractable malady. b. Progressive Facial Atrophy. The remarkable affection now to be described under the name of progressive facial atrophy has been known since 1825, when Parry1 de- scribed the case to which all subsequently noticed have a more or less close resemblance. Although cases were subsequently reported it seems to have attracted little attention till Lande,2 in 1869, and Fremy,3 in 1872, published their monographs. No account of the disease has yet appeared in this country, and only one case has been repor-ted in Great Britain since Parry's above cited. This case, described by Dr. Moore,4 of Dublin, appears to have been a typical one, which is certainly not the fact with several of those quoted by Fremy. The disease, which was called by Romberg—who was the first to give it an independent existence—trophoneurosis facialis, by Moore uni- lateral atrophy of the face, and by Lande laminar aplasia, does not seem to be very common. Eleven cases have been collected by Lande, and Fremy adduces twenty-four additional ones, several of which, how- ever, are as I have said not cases of the disease in question. One in- stance only has come under my observation. Various theories relative to its essential character have been ad- vanced. These, with the reasons which have induced me to consider it as having affinities with progressive muscular atrophy, will be fully brought forward under the head of morbid anatomy and pathology. Symptoms.—The case which occurred in my own experience was that of a lady forty-one years of age, who consulted me first in January, Cited by Romberg, " Lehrbuch der Nervenkrankheiten des Menschen," Berlin, 1854. * " Essai sui l'aplasie lamineuse progressive," Paris, 1868. 8 "Etude critique de la trophonevrose faciale," Paris, 1872. 4 " Case of Unilateral Atrophy of the Face," Dublin Quarterly Journal of Medical Sci- ence, 1852, p. 245. 544 DISEASES OF THE SPINAL CORD. 1874. Twenty years previously she had noticed as the first symptom a very slight degree of weakness in those muscles of the left side of the face concerned in the movements of the lips, so that, when she at- tempted to smile or laugh, the mouth did not expand to the same extent on that side as on the right. This condition lasted several months without giving her much an- noyance, till on waking one morning she noticed a pale, almost white spot on the skin immediately over the left malar bone. This was of a sub-rotund form, and gradually enlarged to the size of a dollar, becom- ing paler in hue and more irregular in outline. Then she began to notice that there was a lack of the fullness which characterized the right side of the face, and this was especially evident at the situation of the spot. Here a depression was plainly to be seen. Then a second depression, but this time without being preceded by paleness of the skin, began to appear. This was situated at about the middle of the chin, half an inch to the left of the median line. This extended most toward the right side, and in the course of two years had reached the median line and had a length of about two inches toward the angle of the mouth. During the time that these depressions were extending she had been subject to fibrillary contractions all over the left side of the face. There were no other symptoms, beyond the exceedingly gradual ex- tension of the first depression, for fifteen years. Then a third spot, sit- uated on the skin immediately over the angle of the jaw, on the left side, appeared and gradually extended as had the first. A depression likewise occurred in the soft parts at this spot, and, extending, finally reached the first depression. When she consulted me there was a marked difference in the size of the two sides of the face, especially the lower part. The skin over the forehead on the left side was glossy and the belly of the occipito-fron- talis muscle was decidedly thinner than that of the opposite side. The left eye appeared to be less prominent than the right, the temporal muscle was thinner, and the masseter was certainly not so thick as its fellow. All the muscles of the angle of the mouth, as well as the left half of the orbicularis oris, were atrophied. The depression on the chin involved the depressors of the lower lip and angle of the mouth. The elevator of the upper lip and of the ala nasi was not affected. The skin over the left side of the face was apparently attached firm- ly to the parts below, and did not admit of being moved or pinched be- tween the fingers. It was decidedly thinner than that of the other side. I could.not ascertain that there was any atrophy of the bones. The pulsations of the carotid, temporal and facial arteries were as strong on the left side as on the right. There was no discoloration or falling off of the hair, no aberration PROGRESSIVE FACIAL ATROPHY. 545 of sensibility, no unilateral sweating, and no difference in the amount of sebaceous secretions on the two sides. The motor power of the left side of the face was weaker than that of the right. When the mouth was expanded, the action was markedly less on the left than on the right side. The left buccinator was thinner and weaker than the right, the left half of the orbicularis oris did not contract to the same extent as the right when the mouth was pursed up, and the jaws were less strongly brought together on the left than on the right side. Yet there was no paralysis in any muscle, and each, on very thorough exploration with the faradaic current of moderate power, con- tracted well. Examined with the aesthesiometer the sensibility was found to be intact. At no time had there been numbness, pain, or any abnormal sensation. The tears, saliva, and buccal and nasal mucus, did not appear to be altered, either in quality or quantity. The tongue was not involved, and, when protruded, came out straight. -Deglutition was unimpaired. The temperature of the two sides of the face was examined by a delicate thermometer, but no difference could be found to exist; but in October, 1875, I again had the opportunity of examining this patient, and then, by means of Dr. Lombard's thermo-electric apparatus, I as- certained that the left was .7° centigrade lower in temperature than the right side. The general health was excellent. Although not allowed to have a photograph taken, I obtained the permission of this lady to examine the muscular tissue, and punct- uring the buccinator with Duchenne's trocar I succeeded, with some little difficulty, in extracting a fragment for microscopical investiga- tion. For purposes of comparison, I operated in the same manner on the corresponding part of the opposite muscle. The results of the ex- amination will be given when we come to the consideration of the mor- bid anatomy and pathology. Taking this case as a more or less perfect type of the disease which I have designated progressive facial atrophy, we have in the next place to consider the symptoms as they have generally been manifested, and as they have sometimes been exhibited with a greater or less de- gree of variation. The first symptom which ordinarily makes its appearance is the white spot, which shows an evident tendency to extend. The centre of greatest atrophy is in intimate topographical relation with this spot, and it is here, therefore, that the depression is most marked. The skin becomes thinner, as is well perceived when a f old of it is pinched between the. fingers, as can be done in the early stage of the disease. The cellular tissue also diminishes in volume. The hair, eyebrows, eyelashes, and beard, generally either fall out 35 546 DISEASES OF THE SPINAL CORD. or lose their color, changing to a gray or even perfectly white hue. The sebaceous secretion is usually less on the affected than on the sound side. Sometimes the larger arteries are apparently diminished in cali- bre, but the capillary circulation, as evidenced in blushing, is as active on the affected side as on the other. The muscles have generally been atrophied both in thickness and length. Fibrillary contractions have sometimes been observed. It is probable they would be generally noticed if attention were directed to them. It is rarely the case that sensibility is disturbed ; but occasionally neuralgic pains have been experienced. The cartilages and even the bones have been sometimes the seat of atrophy. The special senses remain intact, and the secretions of the tears, the saliva, and the buccal mucus, are not diminished. Of the eleven cases collected by Lande, the tongue was atrophied on the side corresponding to the facial disease in five cases, and, when protruded, pointed toward the affected side. In several cases the atrophy extended to the veil of the palate and the uvula; but the function of deglutition has never been impaired. In three of the cases cited by Lande, the atrophy affected the larynx. Phonation was impaired in one of these instances. In none of Lande's cases in which the point was inquired into was there any difference in the temperature of the two sides. In five of Fr&ny's cases the affected side was of a temperature lower from a few tenths to one and a half degree. In no case has there been complete paralysis of any muscle, and the portion which remains, always contracts to the excitation of the elec- trical stimulus. Fremy's statistics are very much to the same effect as those of Lande, though they are, I think, open to the objection that some of his cases were not true instances of the disease. Of twenty-seven cases cited by him, of which details are given, the tongue was affected eight times, the lips nine, and the veil of the palate five times. In seven other cases no statement is made in regard to these points, and in one it is vaguely stated that there was buccal atrophy. In four of these cases the affection involved at the same time both lips, the tongue, the veil of the palate, and its pillars on one side. The progress of the disease is exceedingly slow, the condition exist- ing in many cases for several years. It appears, however, to be dis- tinctly progressive in character. No death has occurred from it, nor has any post-mortem examination been made with the view of inquiring into the nature of the affection in any patient dying of an intercurrent disease. The accompanying figures from Lande represent the face of a woman affected with progressive facial atrophy. In Fig. 61 a front PROGRESSIVE FACIAL ATROPHY. 547 view of the countenance is given, and the atrophy of the left side is clearly shown. Fig. 62 represents the left side of the face; and, for purposes of comparison the right, unaffected side, is given in Fig. 63. Fig G'-\ F:o. 61. Fig. 63. Causes.—Little is known relative to the etiology of this singular disease. It appears, however, generally to originate during early or adult life, and females are more subject to it than males. In one case it ensued after a fall on the head, and in one it followed an attack of scarlet fever. No evidence of hereditary transmission has been ad- duced. Diagnosis.—Lande gives a long list of diseases from which facial atrophy is to be diagnosticated. I do not see that the affection is likely to be confounded with any other than progressive muscular atrophy, and, perhaps, in some cases, in its early stages with facial paralysis. As regards the first of these—progressive muscular atrophy—it rarely if ever begins in the face, and is not confined to that part of the body in any case. Moreover, there is discoloration of the skin, and no cutaneous atrophy. Instead of being tightly stretched over the soft parts below, the skin is loose and can be easily taken up in a fold be- tween the fingers. When the face is its seat, as it sometimes is, second- arily, its manifestations are not confined, as are those of facial atrophy heretofore observed, to one side. The lesions as regards the face, the tongue, and deglutition and phonation, are much more profound in pro- gressive muscular atrophy than in facial atrophy. Relative to facial paralysis (Bell's) there can ordinarily be no diffi- culty in making a diagnosis. As in my case, there may be a marked weakness of the facial muscles in the first stage of the disease under notice. But the mode of origin—Bell's paralysis coming on suddenly ^—and the fact that in it the electric contractility of the muscles is al- ways diminished, while in facial atrophy it is unimpaired, will suffice for the distinction. Prognosis.—No case of a cure is on record. The affection is not 548 DISEASES OF THE SPINAL CORD. one which, as heretofore observed, terminates in death, but it is evident that there are cases in which it shows a tendency to involve organs of which the perfect integrity is essential to life. Morbid Anatomy and Pathology.—Bergson,1 who appears to have been the first to study the disease under consideration, regarded it as not due to either disorder of the motor or sensory nerves or of those which preside over the glandular secretions. Without indicating the precise primary seat of the affection, he looked upon it as essentially consisting in a morbid state of the layer of cellular tissue situated be- tween the skin and the muscles. Other cases were reported, and in 1851 Romberga described it as a " tropho-neurosis of the face," a disease characterized by atrophy but of which the primary seat was unknown. Lasegue * reported a case in 1852 under the title of " partial atrophy of the face," and Moore,4 in the same year, called it " unilateral atrophy of the face." None of these writers made any decided effort to locate the disease or to interpret its real nature till, in 1860, Samuel,5 citing a well-marked case, first reported in 1848 by Hueter, advanced the opinion that pro- gressive facial atrophy was an affection of the trophic system of nerves, and, following Moore, he designated it unilateral atrophy of the face. Then, as we have seen, Lande," in 1869, wrote a very complete monograph on the disease, which he called " laminar aphasia " (aphasie lamineuse), by which term he intended to convey the idea which he entertained of its nature, that it was an affection of the cellular tissue primarily. Subsequently, Eulenburg7 very fully described the malady under the name of " hemiatrophia facialis progressiva," and, taking into con- sideration the fact that the manifestations of the disease are exhibited in those parts which are supplied by the fifth pair of nerves, he regarded it as the result of a lesion of this system, or at least of a derangement of its function. Finally, Fremy,8 in a monograph of great excellence, enters at length into a consideration of the pathology of the disease, and con- cludes that it is to be classed with those trophic neurotic disorders which 1 " De Prosopodysmorphia sive nova Atrophia facialis," Berlin, 1873, cited by Lande. 9 " Klinische Wahrnehmungen und Beobachtungen," Berlin, 1851. 8 " Atrophie partielle de la face," Archives Generates, tome xxix, 1852. 4 " Case of Unilateral Atrophy of the Face," Dublin Quarterly Journal of Medical Sci- ence, 1852. 6 " Die tropischen Nerven," Leipzig, 1860. 8 " Essai sur l'aphasie lamineuse progressive (atrophie du tissue connectif) celle de la face en particulier," Paris, 1869. T " Lehrbuch der functionellen Nervenkrankheiten," Berlin, 1871. 8 " IStude critique de la trophon6vrose faciale (Physiologie pathologique)," Paris, 1872. PROGRESSIVE FACIAL ATROPHY. 549 nave been studied by Romberg, Samuel, Charcot, and Vulpian, and that it essentially depends upon derangement of the trifacial nerve. All these opinions have been thoroughly considered by Vulpian.1 He shows very conclusively that progressive facial atrophy is not a disease of the sympathetic system, and then, in further illustration of his views, says: " Certain peculiarities of this affection seem to indicate that the tro- phic disorder of the face is produced by an intracranial lesion. But the difficulties are so great in the way of imagining that a limited lesion could give rise to all the alterations which occur in the face, the hair, the buccal cavity, and even in the neck, as in some cases, that we can see how M. Lande was led to reject the idea of a primitive lesion of the nervous system, and to admit only a protopathic lesion of the cellular tissue of the face. At the same time I do not think that his doctrine will obtain many partisans. Indeed, it is very difficult to abandon the idea of an intracranial lesion as the cause of the trophoneurosis. This affection is produced in a certain number of cases as a consequence of traumatic violence inflicted on the head or face. Its development is accompanied, in the great majority of cases for several years, with pains of greater or less violence seated in the head, ordinarily toward the fronto-temporal region. Sometimes there are spasmodic movements of the muscles of the face or of the jaws. In some rare cases there has been numbness in the superior extremity of the opposite side. These are the circumstances which seem to point to a cerebral lesion. But we cannot affirm that such lesions exist, while we have no post-mor- tem examination to enlighten us on this point, and while we are em- barrassed to designate a seat for the lesion, which can reasonably ex- plain all the phenomena of the disease. It has been proposed to at- tribute the trophoneurosis to a lesion of the ganglion of Gasser, but can we cite a single case in which lesions of this organ have existed in con- junction with an ensemble of symptoms such as that presented by the disease under notice ? If it be true that the greater part of the altera- tions produced in the malady are in the region supplied by the trigem- inus, and even in the course of certain of its branches (cicatricial de- pression of the forehead in the course of the frontal branch), we are com- pelled to admit that it is not so with all the changes (for example, those of the neck, rare, it is true). The special atrophy which is shown in the affected regions is not easily explained in the present state of our knowledge by the modifications of nutrition resulting from lesions of the trigeminus. We see nothing similar to the lesions of facial tropho- neurosis produced as a consequence of experiments made on this nerve or on the ganglion of Gasser. We ought not to forget, however, the nutritive troubles of the cornea, so common in lesions of the ganglion of Gasser and rare in facial trophoneurosis. Then in some cases there 1 "Lecons sur l'appareil vaso-moteur," tome ii., 1875, p. 432. 550 DISEASES OF THE SPINAL CORD. is atrophy of certain facial muscles, whatever M. Lande may say to the contrary ; and we do not know, either clinically or by experimentation, that muscular atrophy is ever directly produced by alterations of the trigeminus or its ganglion. For to speak only of the tongue, the lat- eral half of which is so often atrophied in facial trophoneurosis, I have demonstrated that section of the lingual nerve is not followed by appre- ciable atrophy of the lingual muscles. " The difficulties which we encounter, when we attempt to connect the trophoneurosis with a lesion of the trigeminus, are increased, when we seek to explain the production of this disease by an encephalic lesion seated, for example, in the vicinity of the nucleus of origin of the fifth pair. " To conceive an hypothesis so little plausible, we would be forced to suppose the existence of multiple lesions seated in one of the halves of the isthmus of the encephalon. But all tentative explanation appears to me to be perfectly vain, since we are ignorant whether there is or is not a primary lesion of the nerves or the nerve-centres. We can, however, positively affirm that, taking into consideration all the char- acteristics of facial trophoneurosis, it is not due to vaso-motor pertur- bation acting on the parts which are the seat of the disease." As we have seen, there has been thus far no examination of the nerve-centres, the nerves, or the muscles. But, in the case which was under my observation, I obtained, as stated, portions of the sound and atrophied buccinator muscles, and submitted them to careful micro- scopical examination. The result was that I ascertained that the fibril- lae of the atrophied muscle exhibited no evidence whatever of degen- erative changes—the transverse and longitudinal striae were distinct, and there were no traces of fatty degradation. But the transverse diameter was reduced to about one-third the normal size, as is seen in the cuts herewith given, which are drawn from the camera lucida to an exact and uniform scale when magnified four hundred diameters. In Fig. 64 is shown a single fibre from the right buccinator muscle, and in Fig. 65 three fibres from the corresponding part of the left bucci- nator. Fig. 66 represents a transverse section of the right, and Fig. 67 one of the left buccinator muscles. Examination also shows that not only is the diameter of the fibrillae markedly diminished, but the length is also lessened, as is evidenced by the fact that the transverse stria? are very much closer together in the atrophied than in the sound fibrillae. It will likewise be perceived that there is in the affected muscle a notable diminution of the thickness of the layers of the internal perimy- sium, or connective tissue, which separates the fibres from each other. This tissue appears to be somewhat hypertrophied on the right side. This, therefore, constitutes the first positive contribution to the morbid anatomy of progressive facial atrophy, but, small as it is, it PROGRESSIVE FACIAL ATROPHY. 551 affords very important indications in regard to the nature and seat of the affection. It shows that progressive facial atrophy is not one of those diseases manifested by degenerative changes of the muscles such as we have Fig. 64. Fig. 65. Fig. 66. Fig. 07 seen take place in infantile paralysis, spinal paralysis of adults, pseudo- hypertrophic paralysis, and progressive muscular atrophy. It is an at- rophy pure and simple without the slightest tendency to degeneration. As regards its primary seat, nothing definite can be stated at pres- ent, in the absence of investigations into the condition of the nervous system; but I have felt warranted in placing it provisionally, at least, in the class of diseases which consist in inflammation of the nuclei of certain nerves. So far as analogy is concerned there is a marked affinity not to say resemblance between the symptoms of progressive muscular atrophy af- fecting the muscles of the face, the tongue, and the pharynx, and those of some cases of progressive facial atrophy, in which not only the face is involved, but also the tongue, and in one case at least the larynx. We have seen that in glosso-labio-laryngeal paralysis the muscles of the same regions are involved, but instead of atrophy we have paralysis. Now, when we come to seek out the primary seat of progressive muscu- lar atrophy affecting the face, tongue, and throat, and that of glosso- labio-laryngeal paralysis, we find both in the bulb and especially in the nuclei of origin of the facial, the hypoglossal, the spinal accessory, and pneumogastric nerves. If two such different but cognate diseases may occupy the same anatomical situation, why may not progressive facial atrophy, different but cognate, be also an affection of the same region ? The fact that the atrophy involves other parts than the muscles is no valid objection against this hypothesis. We have seen that in infantile 552 DISEASES OF THE SPINAL CORD. spinal paralysis there is sometimes an atrophy of the bones. And yet we all agree to consider this disease as a primary affection of certain cells in the anterior tract of gray matter. I am, therefore, of the opinion that progressive facial atrophy is an affection of the trophic cells of the bulb which are the nuclei of the fa- cial, the hypoglossal, and the spinal accessory nerves. That ordinarily the lesion does not extend farther than the facial, but that sometimes when the tongue is involved it reaches the nucleus of the hypoglossal and occasionally that of the spinal accessory. In these cases in which there are aberrations of sensibility the nucleus of the sensory root of the fifth pair may be affected, and in those in which the temporal and masseter muscles are involved the motor root may also be implicated. Or the pain which is sometimes an accompaniment of the disease may be due to the contracting process going on in the muscles and con- nective tissue by which the terminal branches of the trigeminus are compressed. Why the atrophy should so generally affect the left side of the face in preference to the right I do not pretend to explain; but, since the recognition of aphasia and its association in the vast majority of cases with lesions of a circumscribed region of the left hemisphere, we need not be surprised at the additional instance of hemitopology, incom- plete as it is, afforded by progressive facial atrophy. Finally, the question may be asked, Why should the manifestations be restricted to one side ? I should answer that I do not know any more than I am aware why ptosis or external strabismus should affect the eyelid and eyeball of one side; or why hemi-chorea should exist; or why, when a person has an attack of cerebral hasmorrhage, he should not straightway have another on the opposite side of his brain. It would, it appears to me, be just as pertinent to ask, Why should a patient who has atrophy of one side of his face have it on the other also ? We must remember that only about thirty-five cases, real and supposed, of the disease have been observed. Perhaps the next will cross the Rubi- con—the mesial line. The first two cases reported occurred on the left side, then there was one on the right, and then eight on the left. If the third case had escaped observation, we should have had to appearance a uniform im- plication of the left side, to the exclusion of the right. Now about a dozen cases are reported as involving the right side. It appears to me, however, that the indisposition manifested to pass the mesial line is a strong argument against the affection being a local lesion only. Treatment.—Slight success was obtained by Hueter and Moore by the use of faradaic currents to the atrophied region. I employed both these and the primary current, the latter to the nucha as well, in the case under my care, but without perceptible effect. I also administered INFLAMMATION OF THE POSTERIOR TRACT OF GRAY MATTER. 553 strychnia and other tonics without benefit. This treatment, however, seems to be indicated and is in general urged by those who have writ- ten on the subject. No cure has, however, yet been reported. It must be borne in mind that diseases which are slow to advance are also slow to recede. III. INFLAMMATION limited to the posterior tract of gray matter of THE SPINAL CORD. The functions of the posterior tract of gray matter being, so far as we know, exclusively sensory, we should expect to find inflammation of this region manifested exclusively by aberrations of sensibility. So far, however, nothing has been done toward the recognition of the symp- toms of such a lesion, and the localization of their immediate cause in the posterior horns of gray matter. According to Charcot, we only know that when they are the seat of a profound alteration there is more or less pronounced cutaneous anaesthesia of the corresponding side of the body. The posterior tract of gray matter is eertainly an important part of the channel by which sensory impressions reach the brain from the parts below. It is quite certain, not only from the teachings of experi- mental physiology, but also from the instruction we derive from disease and injury of this region, that when it is profoundly altered there is a corresponding degree of anaesthesia in the parts below; not, however, ac- cording to my experience and that of others, on the same side as the lesion, but on the opposite side. To Brown-Sequard we are mainly in- debted for a knowledge of the fact that the gray matter of the cord is the conducting medium for sensory impressions; that there is a decussa- tion of the conductors is also a fact which he established. If, therefore, a lateral half of the spinal cord be divided so as to , include the whole of the gray matter, the animal upon which the experi- ment is performed loses sensibility in the parts below, on the opposite side of the body, and—which is not, however, a matter of present in- quiry—motion on the same side. Cases in which these phenomena—loss of motion on one side and of sensibility on the other—are coexistent from spinal disease, are by no means very infrequent. Several such have been under my care in hospital and private practice, and I have always attributed them to a lesion of one lateral half of the cord disturbing the power of motion on the same side and of sensation on the other. But experiment shows that, while one part of the posterior nerve- roots passes over to the opposite side immediately on its entrance into the cord, another part passes upward and another downward. The effect, therefore, of a limited lesion involving one lateral half of the 554 DISEASES OF THE SPINAL CORD. cord would be profound anaesthesia of the opposite side of the body and a slight degree on the same side. Accordingly in such cases as those I have referred to, there is always a trace of numbness on the side the motion of which is paralyzed. The action of a lesion of one lateral half of the cord in only slightly diminishing sensibility on the side of the alteration while greatly lessening it on the opposite side will be readily understood from an examination of the accompanying diagram, Fig. 68; a, the left half of the spinal cord, b the right half ; c, a right posterior root, with its ascending fibres d, its descending e, and its decussating fibres f; g decussating fibres from the opposite side. A lesion of the right side of the cord at h will produce great loss of sensibility on the Fig. 68. r I j / 1 opposite side, and slight loss on the same side. That the decussation takes place in the gray substance has not been absolutely settled by anatomical demonstration, but it remains extremely probable, mainly by the fact that the commissure is composed chiefly of gray tissue. Dalton * says in relation to this matter: " The transmission of sensitive impressions, therefore, takes place through the gray matter. This sub- stance, which is itself insensible to direct irritation, forms the medium of communication between the peripheral fibres of the sensitive nerves and the brain above." And again: " It is certain, however, that after section of one lateral half of the cord the phenomena which indicate a crossing of the sensitive tracts are distinctly marked. We have repeated this experiment, and have found that after such a section in the dog, in the dorso-lumbar region, the difference in the effects produced upon sensation and motion on the two sides is very striking: sensibility is either lost or very much dimin- 1 "A Treatise on Human Physiology," sixth edition, Philadelphia, 1875, pp. 353-356. TETANUS. 555 ished upon the opposite side, while upon the same side with the section, where there is complete muscular paralysis, the sensibility remains and is increased in intensity. With this brief statement of the physiology and pathology of the subject as at present known, I leave the further discussion of the dis- eases of the posterior tract of gray matter till science has given us more definite information than we now possess relative to its functions and derangements. IV. INFLAMMATION OF THE ANTERIOR AND POSTERIOR TRACTS OF GRAY MATTER OF THE SPINAL CORD. The gray matter of the spinal cord as a whole, is subject to at least one disease—tetanus—which, according to recent investigations, is in reality a central myelitis. Since Lockhart Clarke in 1864 gave the re- sults of his examinations on this subject, other data to a like effect have been published, and, though differences in the lesions have been observed these are of secondary importance to the main fact that in tetanus the central gray matter is the chief seat of the alterations. The circum- stance that the white matter has also been found diseased no more in- validates the correctness of the statement than the fact that a patient dying with the symptoms of pneumonia, still has that disease, even though there be a patch or two of inflamed pleura as a secondary lesion. a. Tetanus. Two varieties of tetanus are generally described by systematic writers—the idiopathic and the traumatic; but, as they are character- ized by similar phenomena, differing mainly as to their modes of origi- nation and severity of their symptoms, there would be no advantage in considering them separately. Symptoms.—The first symptom to make its appearance in cases of tetanus is a feeling of pain or oppression in the epigastric region. In the beginning it does not attract much attention, but, as the disease advances, it becomes exceedingly severe, and adds greatly to the dis- comfort of the patient. Soon after the occurrence of this pain, uneasiness is generally ob- served about the throat. This is, perhaps, no more than a sense of stiffness of the muscles concerned in deglutition, but it is not long be- fore swallowing is impeded to a considerable extent. With these symptoms there are ordinarily mental and physical depression, sensa- tions of chilliness, and a general f eeling of malaise. The foregoing constitute a prodromatic or formative stage, which may last a few hours or several days, and which is occasionally over- looked when the disease is intense and rapid in character. In the next stage the epigastric pain is still a prominent symptom. 556 DISEASES OF THE SPINAL CORD. It is seated just below the sternum, and generally extends backward to the spinal column. It appears to be due to spasm of the diaphragm, so that this muscle is among the first, if not the very first, to be affected in the vast majority of cases. The difficulty of swallowing increases, and then the muscles of the jaws become contracted, constituting the condition known as trismus or lockjaw. At first there is only stiffness of these muscles with those of the neck, but gradually they become rigid, and the patient experiences difficulty, if not "impossibility, in opening the mouth. The facial muscles do not escape, and an expres- sion like the risus sardonicus is produced from the retraction of the angles of the mouth, the elevation of the alas nasi, and the expansion of the nostrils. At the same time the eyes are staring, the brows cor- rugated, and the countenance anxious or wearied in appearance. Sometimes gradually, at others suddenly, the morbid action, extends to other muscles. Generally it passes to those of the neck, the back, and the loins, causing violent contraction, and bending the body back- ward. This state is called opisthotonos. The contraction of the power- ful muscles referred to is so great as to cause the body to assume the form of an arch, the head being thrown far back, the abdomen pro- truded, and thus, if the patient were placed on his back, only the occiput and heels would touch the bed. Opisthotonos is the usual va- riety of spasm. Two other forms are occasionally met with. In one of these—em- prosthotonos—the body is bent forward from the contraction of the thoracic, abdominal, and pelvic muscles. In the other—pleurosthotonos— it is bent laterally. This latter may be met with in opisthotonos, owing to the muscles on one side being more strongly affected than on the other. Both emprosthotonos and pleurosthotonos are rare. Of very many cases of tetanus that have been under my observation, I have only seen the former four and the latter three times. The spasms char- acteristic of the disease are tonic; but, though they do not entirely re- lax, they are marked by more or less exacerbation, according to the severity of the attack, and the care taken of the patient. Any cause calculated to excite reflex action will induce an accession. Thus the contact of the bedclothes with the body—the legs especially—the touch of the hand, the forcible shutting of a door, the rumbling of carriages in the street, even the blowing of a breath of air on the skin, may pro- duce an aggravation of the spasm. Even without any apparent excita- tion these fits occur. They are marked by great pain, and may be so violent as to break the teeth, and the bones of the legs, and tear the large muscles of the thighs. During their continuance, and often when they are not present, the pain at the pit of the stomach becomes un- endurable, and the patient may lose consciousness through its intensity. I have several times seen this event occur. The tonic rigidity of the muscles of respiration induces difficulty of TETANUS. 557 .breathing, and the same result may ensue from spasmodic closure oi the glottis. Death has frequently taken place suddenly from one or other of these causes. With all this muscular excitement and mental disturbance there is rarely any fever. The skin is hot, and the thermometer often ranges from 105° to 110° Fahr., but the pulse is frequently small and weak. Owing to the difficulty of swallowing, the patient suffers from hun- ger and thirst, and thus the powers of the system are still further re- duced. The bowels are always obstinately constipated. Wakefulness is generally present from the first. When the patient does sleep, it usually happens that the muscles are relaxed, to be again suddenly affected with spasm as soon as he awakes. The mind is clear throughout, even in the most severe cases. When loss of consciousness occurs from extreme pain, it is from syncope, and not from any implication of the brain in the essential nature of the disease. Death usually takes place by apncea. It may, however re- sult from exhaustion, and, according to some authorities, from the spasmodic action attacking the heart. The duration of the disease is very variable. The shortest case on record is one observed by Prof. Robinson, of Edinburgh. The patient, a negro waiter, cut his finger with a piece of broken china. He was immediately seized with tetanus, and died within fifteen minutes. Mr. Poland quotes a case in which death took place in five hours ; in a case cited by Lepelletier in a few hours ; in one by Dr. Jackson in twelve ; in one by Dr. Leith in eighteen; and in one observed by Mr. Curlino- in nineteen.1 The shortest duration in any case I have witnessed was twenty-six hours, though I believe there were several much shorter, which oc- curred during the recent war in this country. The average period of duration in fatal cases is from the third to the fifth day. Instances in which it has been prolonged far beyond this limit are not uncommon. Hennen" reports a case in which it lasted six weeks, and then the patient died of another disease. He re- ports another case in which it lasted seven weeks,' and ended in recov- ery. I have seen three cases in which it extended to the fifth week. The period which elapses between the reception of the cause and the beginning of the symptoms is also subject to great variation. In a case already cited it was only fifteen minutes ; in another, quoted from Dr. Randolph by Reeves,3 the spasms ensued immediately after the pa- tient was stung by a bee ; and in another, which occurred in his own 1 All the above .instances are quoted from Reeves's " Diseases of the Spinal Cord and its Membranes," London, 1858, p. 387, et seq. ' " Observations on some Important Points in the Practice of Military Surgery " etc Edinburgh, 1818, p. 263. '' 3 Op. cit, p. 3T7. 558 DISEASES OF THE SPINAL CORD. experience, they came on in a sensitive female immediately after run- ning a needle into her finger. There is doubt, however, as to such cases really being tetanus. In the last one cited it is stated that " the body and extremities were rigid, mouth closed, and the jaws fixed, the eyes the same. At short intervals the whole body was affected with convulsive shocks ; the administration of a dose of chloroform removed them, but the back and neck remained rigid for three days." This at- tack was probably a manifestation of hysteria. In eighty-one cases collected by Mr. Curling, the disease began between the fourth and fourteenth days, both inclusive, and in nineteen on the tenth day. The following table from Reeves shows the period of the occurrence of the disease in three hundred and forty-three cases : Within six, twelve, eighteen, or twenty-four hours............. 12 From 1 to 2 days........................................ 12 " 3" 5 " ........................................37 « 6 " 8 " ........................................94 " 9 " 12 " ........................................77 " 12 " 14 " ......................................52 " 15 " 17 " ................................... ---26 " 18 " 20 " ....................................... 9 " 21 " 23 " ........................................ 9 " 24 " 26 " ........................................ 6 " 27 " 29 " ........................................ 9 " 30 " 32 " ........................................ 1 343 Causes.—The most common cause of tetanus is bodily injury of any kind, from the slightest to the most severe, and of any part of the body, although wounds of some parts, as of the thumb and great-toe, are more apt to be followed by the disease than those of other regions. It has been known to result from the bite of a tame sparrow, from the sticking of a small fish-bone in the pharynx, from a seton in the thorax, from the stroke of a cane across the back of the neck, from the blow of a whip-lash, from fractured bones, and from every other imaginable wound or injury. In a case under my charge in this city, it was caused by a splinter of wood slightly scratching the palm of the hand ; in an- other a slight punctured wound of the foot produced it. Next in frequency to wounds, tetanus is induced by exposure to cold and damp. This is the exciting cause in the great majority of cases of idiopathic tetanus, and it increases liability in those who have suffered from wounds. It was not uncommon, during the recent war, for the number of cases of tetanus to be very much increased immedi- ately after a sudden change of the weather from dry and mild to wet and cold. It has also apparently been caused by worms, by a-bortion and labor, and by diseases of the womb. Terror has the reputation of having in- TETANUS. 559 duced tetanus in one case reported by Dr. Willan, and in others ob- served by Hennen. In the form occurring in very young children, and known as tris- mus nascentium, it appears to be induced by inattention to the cut um- bilical cord. The tendency to tetanus, especially among soldiers and others who have been wounded, is increased by poor diet, confinement in ill-venti- lated hospitals, inattention to cleanliness, and neglect to give proper care to the wounds they may have received. Diagnosis.—The only affections with which tetanus is liable to be confounded, by any but the most ignorant, are the hysterical simulated affection, and the condition induced by poisoning with strychnia and other substances of its class. That hysteria can simulate tetanus, as well as almost all other dis- eases, we have abundant evidence. A case has already been referred to in this chapter which was evidently hysterical, and several others have come under my observation. A lady now under my charge has repeated attacks of hysterical spasms, during which her jaws are tight- ly closed, she is unable to swallow, and her body is bent backward so as to assume the position of opisthotonos. Such seizures are readily distinguished from tetanus by the facts that they are unaccompanied by pain or real distress, are of very tran- sient duration, and are accompanied by other manifestations of hys- teria. From the artificial tetanus caused by strychnia, the diagnosis is more difficult; for, so far as the more obvious symptoms go, there is such a great similarity that even the most skillful diagnosticians might be, for a time, undecided. It is well known that strychnia is not unfre- quently used for the purpose of committing murder or suicide, and it is possible so to employ it for either of these purposes as to cause its effects to extend over a long period of time, and thus to add to the difficulties attending the discrimination. Even in such a case, however, the diagnosis can be made if due care and a thorough inquiry into the history of the case be made. In the first place, the tetanus of strychnia always shows itself in the lower extremities before trismus ensues. The legs are stretched widely apart, and the hands are generally involved. In natural tetanus, trismus precedes spasm in the extremities; indeed, the lower extremi- ties are rarely affected to any great extent. The arms generally escape altogether. The epigastric pain, which constitutes so prominent a feature of true tetanus, is not present in the toxic variety. I have witnessed three cases of poisoning by strychnia, and this pain was not complained of in either of them. In the tetanus of strychnia, the symptoms are developed with great 560 DISEASES OF THE SPLNAL CORD. rapidity, and death takes place generally within a half an hour, al- though life may be prolonged, in exceptional cases, somewhat beyond this period. In true tetanus it is very rarely the case that death takes place within twelve hours, and ordinarily not till several days have elapsed. In those cases of poisoning by strychnia in which the doses have been small, and administered at comparatively long intervals, the symp- toms are mitigated in violence, and consequently one of the distinguish- ing features of the two affections is lost. Still, the general character and sequence of the phenomenon are the same, and it is not improbable that careful observation and inquiry will fail to elicit the true nature of the case. Prognosis.—The longer the time that has elapsed between the recep- tion of the injury or subjection to other cause, the greater is the prob- ability of a favorable termination. When the paroxysms are slight, and the intervals between them long, the prognosis is also more favorable. A low bodily temperature is a favorable indication. On the contrary, an elevated temperature is of fatal augury. The duration of the dis- ease is likewise an important element in the prognosis; and, when it has lasted over a week, death does not often take place. Cases are, however, on record in which a fatal result has supervened after the affection has existed for several weeks. Tetanus is, nevertheless, one of the most fatal of maladies. Dr. O'Beirnel witnessed two hundred cases without a single recovery. Hennen3 never saw a case of acute symptomatic tetanus recover. McLeod3 has collected and analyzed twenty-three cases which occurred in the British army in the Crimea, of which but two recovered. Demme4 refers to eighty-six cases in the hospitals in Italy during the campaign of 1859, of which six were cured ; and Hamilton6 has observed eight cases, of which three recovered. Nine cases have been under my immediate care, of which there were three recoveries. Of the many cases which I observed in the course of my inspections of camps and hospitals in the army during the recent war, I do not know how many terminated favorably. I am disposed, however, to believe that the number was not great. Hamilton states that his information leads him to think that, of one hundred and fifty cases which occurred during the war, the recoveries were few. Morbid Anatomy and Pathology.—As regards the cord, the results of post-mortem examination of patients who have died of tetanus have 1 " Dublin Hospital Reports," vol. iii., pp. 343, 378. 2 Op. cit, p. 262. 8 "Notes on the Surgery of the War in the Crimea," London, 1858, p. 153, etaeq. Also table, p. 439. 4 " Militar-chirurgische Studien," Wiirzburg, 1861. 6 " A Treatise on Military Surgery and Hygiene," New York, 1866, p. 695. TETANUS. 561 up to a comparatively late period been very unsatisfactory. Roki- tansky,1 in chronic cases, found a proliferation of connective tissue. Wedl," in one case, discovered increased redness of a portion of the spinal cord. Curling3 declared that serous effusion with increased vas- cularity was generally observed in the membranes investing the medulla spinalis, and also a turgid state of the blood-vessels above the origin of the nerves ; and Wunderlich * regarded the lesions as consisting in a proliferation of the connective tissue of the cord, the medulla oblongata, and the cornua cerebri and cerebelli. But, in 1864, Dr. Lockhart Clarke,8 after a careful examination of the spinal cords of six persons who had died of tetanus, found as the uniform results an abnormally enlarged condition of the blood-vessels throughout the gray matter, especially in the posterior horns, and granular disintegration of the nerve tissue. He expresses the opinion that tetanus depends (first) upon an excessively excitable state of the gray nerve tissue of the cord induced by the hyperaemia, and morbid condition of the blood-vessels, and the exudation and disintegration resulting therefrom, and (second) that the spasms are the result of the persistent irritation of the peripheral nerves by which the exalted excitability of the cord is aroused, and thus the cause which at first induced in the cord its morbid susceptibility to reflex action is subse- quently the source of that irritation by which the reflex action is excited. Subsequently, Dickinson" found enlargement of the blood-vessels throughout the gray substance of the cord, with perivascular exuda- tion, rupture of the blood-vessels in many places, and granular disin- tegration. Dr. Clifford AllbuttT has reported the results of his examination of the spinal cords in four cases of tetanus. He found diminution of the consistence of the cord of various degrees and situation ; haemorrhage in two cases visible to the naked eye ; enlargement of the blood-vessels; exudation of a granular plasma surrounding the vessels ; enlargement of the cells of the gray matter, and the granular degeneration of Clarke. Outside of this cord he found the nerve thickened and con- 1 "Beitrage zur Pathologie des Tetanus," Virchow's Archiv, tome xxvi., 1862. 8 " Rudiments of Pathological Histology," " Sydenham Society Translation," London, 1855, p. 276. 8 "A Treatise on Tetanus," etc., London, 1836. 4 Archiv der Heilkunde, 1862. 6 Lancet, 1864; Medical Times and Gazette, 1865; also, more fully, "On the Pathology of Tetanus," Medico-Chirurgical Transactions, vol. xlviii., 1865, p. 255. • "Description of the Spinal Cord in a Case of Tetanus," Medico-Chirurgical Trans. actions, vol. Ii., 1868, p. 267. '"On the Changes of the Spinal Cord in Tetanus," "Transactions of the Patho logical Society of London," vol. xxii., 1871, p. 27. 36 562 DISEASES OF THE SPINAL CORD. gested, and bathed in inflammatory products. These results were con- firmed by the subsequent examination of Drs. Clark and Dickinson. Dr. Fox' made post-mortem examinations of four cases. In one the only abnormality remarked was dilatation and distention of the vessels of the spinal pia mater. In the others there were softening, haemorrhage, amyloid bodies, in the gray substance, and thickening of the vessels. Michaud2 examined the cord in four cases. He found that the gray matter presented a general red appearance. The vessels were enor- mously enlarged. There were numerous free nuclei and foci of perivas- cular exudation. The gray substance, and especially the posterior commissure, was the seat of these alterations which, according to him, consist essentially in a proliferation of the nuclear elements of the con. nective tissue. The appearance which Lockhart Clarke considers to be a granular degeneration, Michaud regards as being due to these nuclei existing in the exudation around the blood-vessels. He considers teta- nus to be an acute inflammation of the gray tissue of the cord. When either of the upper extremities is the seat of the wound, which is the primary cause of the disease, the lesions of the cord are found in the cervical enlargement, and, when either of the lower limbs is injured so as to induce the affection in question, the spinal lesions are found in the lumbar enlargement. The nerves coming from the wounded part have been found the seat of inflammation by Airlong and Tripier,3 and by Michaud. In other cases they have not exhibited any change. The muscles of the body suffer secondarily. The violent spasmodic contractions to which they are subjected often produce ruptures of their tissue and extravasations of blood. On the other hand, it has often happened, especially in very rapid cases, that nothing has been found which could fairly be regarded as constituting the essential feature of the disease. Billroth 6 affirms that his examinations of the spine and nerves, in cases of tetanus, have thus far given only negative results, and this is in accordance with the ob- servations of the great majority of pathologists. But these discrepan- cies are, I think, to be ascribed to defective methods of examination, and in no event can they disprove the positive data obtained by others. It is contended by some authors that tetanus, like hydrophobia, is due to blood-poisoning. The fact, that a condition, so nearly resem- bling it as to be with difficulty diagnosticated from it, may be caused 1 " Recherches anatomo-pathologiques sur l'6tat dea systemes nerveux central et p6n- phdrique dans le tetanus traumatique," Archives de Physiologie, 1871, p. 59. 2 " The Pathological Anatomy of the Nervous Centres," London, 1874, p. 355. 8 Archives de Physiologie, 187^, p. 244. 4 Op. cit. 5 " General Surgical Pathology and Therapeutics, in Fifty Lectures," Hackley's translation, New York, D. Appleion & Co., 1871, p. 353. TETANUS. 563 by the injection of strychnia into the blood, appears to favor this view. However this may be, the character of the symptoms, as well as the anatomical lesions, indicates the spinal cord to be the seat of the disease. The spinal cord is both an organ for the generation of nerve-force, and for conducting impressions to and from the brain. In tetanus it is this first-named function which is deranged, and this is shown by the great exaltation of reflex excitability which exists. Every thing capa- ble of causing a reflex movement of the slightest kind, and even excita- tions which in health would be altogether unperceived by the cord, augments its intrinsic action to a great extent where tetanus exists. Now, we are able to produce a similar increase of reflex action by strychnia; and, in those cases of disease in which the amount of blood in the cord is increased, very small quantities of strychnia produce the characteristic phenomena of stiffness in certain muscles, and of aug- mented reflex excitability. The condition is aggravated by the medi- cine; and, if we had no other facts to support the theory, we should be warranted in concluding that, in cases of strychnia-poisoning, the amount of blood in the cord and the excitability of the organ are both increased. From a consideration of all the points bearing on the sub- ject, we are warranted in concluding that tetanus essentially consists in a morbid exaltation of the functions of the spinal cord as a nerve- centre. Bernard1 has investigated this matter with his usual exactness. He says : " Strychnia produces convulsions by exaggerating the sensibility of certain parts; it also causes reflex movements. We have seen that the point of departure is in the sensitive system; for, where the posterior roots of the nerves are cut, the animal dies without convulsions." An experiment performed by myself and my friend and collaborator, Dr. S. Weir Mitchell,* shows that the action of strychnia is to destroy the nervous excitability from the centre to the periphery. Its influ- ence, therefore, must first be exerted on the spinal cord. " Under the skin of a large frog, whose left sciatic nerve was pre- viously divided, a few drops of a strong solution of strychnia were in- troduced. Tetanic spasms ensued in two minutes. After forty-five minutes the nerves were irritated by galvanism. That of the left side, which had been cut, responded energetically, while no motions could be produced through the uncut nerve. The former remained excitable for two hours later." '"Lecons sur les eflfets des substances toxiques et medicamenteuses," Paris, 1857, p. 386. ' " Experimental Researches relative to Corroval and Vao; Two New Varieties of Woorara, the South American Arrow-Poison," American Journal of the Medical Sciences, July, 1859; also "Physiological Memoirs," Philadelphia, 1863, p. 181, et seq. 564 DISEASES OF THE SPINAL CORD. Bernard1 asserts that the action of strychnia extends no farther than the spinal cord ; and any one who has seen a frog under the influ- ence of this substance cannot have failed to notice that all the symp- toms indicate exalted spinal action. We are therefore led by observation and experiment to the conclu- sion that the lesion of tetanus is seated in the gray matter of the spinal cord, and that, although we cannot at present affirm an absolute identity of the lesions, in each case we have enough data to enable us to say in general terms that tetanus is essentially an inflammatory affection of the gray matter of the spinal cord. Vulpians has shown that strychnia does not produce organic lesions of the cord. He kept a frog for a month under its influence, and on kill- ing the animal found the cord in all its parts in a perfect state of integ- rity. But on this point there is a difference of opinion, Jacubowitsch and Roudanowsky asserting that the processes of the nerve-cells are torn, and that the cells themselves are often ruptured. It is not, how- ever, probable that the condition of the cord, in poisoning by strychnia, ever goes beyond the point of hyperaemia, which, being of recent oc- currence, would disappear on death supervening. It is also extremely probable that, in the cases of tetanus in which recovery takes place, the organic derangements discovered by Lockhart Clarke do not occur. This is his opinion : Hyperaemia is the first stage of all inflammations, and it is of course entirely possible that the morbid process should be aborted at this stage. Indeed, it is a matter almost of certainty that in some fatal cases of tetanus the pathological action has not gone beyond the hyperaemic stage, and hence the absence of lesions in the cases ex- amined by Billroth and others. But an hyperaemia of this kind is of course as much of the nature of inflammation as though the process had reached its full development. How does a wound of the extremity or trunk of a nerve cause te- tanus ? It has been supposed by some authors that there was a neuri- tis in each case which advanced centripetally till it reached the spinal cord. In regard to this point, Mitchell3 says : " There is a prevalent belief that tetanus is more apt to arise when large nerves are slightly hurt than on other occasions ; but, although there are on record many cases where this terrible malady has followed the inclusion of nerves in ligatures, in the mass of tetanic histories the causal irritation has arisen in the extreme distribution of nerves, and where there has been no proof of precedent injury to large trunks. Were it otherwise, I must more often have seen tetanus, whereas, in two hundred recorded instances of wounds of great nerves which passed 1 Op. cit, p. 359. * " Convulsions pendant un mois chez une grenouille empoisoned par la strychnia; iff tGgrite complete de la moelle epiniere," Archives de Physiologie, 1868, p. 306. 3 " Injuries of Nerves and their Consequ:: -.'es," Philadelphia, 1872, p. 147. TETANUS. 565 under my eye during the war, not a single case of lock-jaw was seen, although in perhaps one-half, the injuries were recent, and we actually witnessed a part of the process of healing. In fact, the tendency tow- ard irritation resulting in spasm seems to increase as the nerves divide and approach the skin. Brown-Sequard succeeded once in causing te- tanus by leaving a rusty tack in the foot of an animal. I have never been able to get this result by any method, nor, in some seventy sec- tions or wounds of nerves in animals, have I ever encountered it." The experience of Dr. Mitchell on this point is sufficient to deter- mine it against the existence of a neuritis extending to the cord. Were there any such cause it would undoubtedly be more apt to arise from a wound of the trunk of a nerve and to extend to the cord, than from an injury of the terminal extremities. Moreover, the facts that tetanus has been known to follow in a few minutes after the reception of a wound, and that there is no pain along the course of the nerve, are directly at variance with the idea of a peripheral and ascending neuritis as the cause of the spinal lesions. Treatment.—There is scarcely a sedative or stimulant remedy in the pharmacopoeia which has not been employed and recommended in teta- nus. Aconite, ether, belladonna, chloroform, cannabis Indica, conium, opium, tobacco, Calabar bean, ice, counter-irritants, alcohol, and many other substances, have been used, and cases reported which have appar- ently recovered under their administration. Then, of surgical means, excision of the injured nerve and amputation of the wounded member have also been recommended, but are not, I believe, practised now. Latterly the bromide of potassium and hydrate of chloral have been employed with favorable results. A case in which the latter agent was successfully used in tetanus is reported by Dr. Wirth,1 of Columbus, Ohio. In about a month the pa- tient took nine ounces and two drachms, in doses of from thirty to forty grains, at times as often as every one and a half hour. In this case opium in large doses had been administered without effect. A number of other cases, in which chloral was administered, are cited in the same number of the New York Medical Journal in which Dr. Wirth's case appears, in several of which it was successful. A very thorough analysis by my friend Dr. D. W. Yandell,2 of Louis- ville, of an unpublished report on tetanus, by Dr. R. O. Cowling, em- braces so much valuable information on the subject that I quote the summary entire. The term acute is applied to tetanus occurring within nine days of the injury, and chronic to cases ensuing after nine days : " Calabar bean was given in thirty-nine cases, with thirty-nine per cent, of recoveries. Of these reported cures, but one was of acute te- 1 New York Medical Journal, November, 1870, p. 419. 2 American Practitioner, September, 1870, p. 152. 566 DISEASES OF THE SPINAL CORD. tanus ; five others were in cases which recovered before the expiration of fourteen days. Per contra, there were ten deaths from chronic te- tanus. " Indian hemp used in twenty-five cases, with sixty-four per cent. of recoveries, of which three cases were acute, and six recovered before the symptoms lasted fourteen days. " Chloroform relieved seventy per cent, of thirty-five cases, nine of which were acute, and eight recovered before fourteen days. Three chronic cases died, and two after symptoms lasted fourteen days. " Ether.—Sixty per cent, of fifteen cases recovered ; five acute ; seven inside of fourteen days. One chronic case died. " Opium.—Fifty-seven per cent, of one hundred and sixty-five cases recovered ; twenty-two acute ; twenty-nine before the fourteenth day. Twenty-six chronic cases were lost, and four after the disease had con- tinued fourteen days. " Tobacco relieved fifty per cent, of forty-one cases ; six acute ; six before fourteen days of the disease. Four chronic cases died, and one after fourteen days. " Quinine.—Seventy-three per cent, of fifteen cases recovered; one acute ; three before fourteen days. Three chronic cases ended fatally, and one after fourteen days' duration. " Aconite.—Eight per cent, of fourteen cases recovered; none acute; none recovered before fourteen days. Death in one chronic case. " Stimulants.—Eighty per cent, of thirty-three cases recovered ; four acute ; six within fourteen days. Six chronic cases died, and three after fourteen days. " Mercury.—Fifty-seven per cent, of seventy-five cases got well; twelve before fourteen days. Seventeen chronic cases were lost, and two after fourteen days. " Bleeding.—Fifty-five per cent, of fifty-eight cases recovered ; nine acute ; ten before the fourteenth day. Seven chronic cases were lost, and two after fourteen days. " Cold Affusion.—Seventy-three per cent, of eleven cases recov- ered ; three acute ; three before fourteen days. Two chronic cases died. " Ice-bags.—Seventy-seven per cent, of nine cases recovered; one acute ; two in less than fourteen days. " Amputation.—Sixty per cent, of seventeen cases recovered ; four acute ; four in less than fourteen days. Three chronic cases died, and one after fourteen days. " Division of nerve relieved seventy-five per cent, of three cases ; one acute ; one before the fourteenth day. One chronic case died. " Purgatives.—Sixty-six per cent, of seventy-four cases recovered ; thirteen acute.; twelve before fourteen days. Ten chronic cases died, and three after fourteen days. TETANUS. 567 " Turpentine relieved seventy per cent, of sixteen cases ; six acute; four before fourteen days. Five chronic cases died, and two after fourteen days." Among the conclusions arrived at by Dr. Yandell from these data are, that " recoveries from traumatic tetanus have been usually in cases in which the disease occurs subsequent to nine days after the injury ; that when the symptoms last fourteen days recovery is the rule, and death the exception, apparently independent of the treatment ; that chloroform, up to this time, has yielded the largest percentage of cures in acute tetanus ; that the true test of a remedy for tetanus is its influ- ence on the history of the disease : does it cure cases in which the dis- ease has set in previous to the ninth day ? does it fail in cases whose duration exceeds fourteen days ? and that no agent, tried by these tests, has yet established its claims as a true remedy for tetanus." It is, perhaps, scarcely necessary to say that I fully accord with these opinions. Judging from its effects upon the spinal cord, it was supposed by Mr. Morgan that woorara injected into the blood might prove efficacious in tetanus. Experience, however, has not confirmed this view ; and the researches of Dr. Cowling show that it is one of the most inefficient of remedies. In a case which was under my charge fifteen years ago, when I was one of the surgeons of the Baltimore Infirmary, I injected corroval—a remedy which the investigations of Dr. Mitchell and myself had proved to be antagonistic to strychnia—into the blood. The patient, a colored boy, became affected with tetanus two days after his arm had been am- putated by my friend and colleague Prof. Nathan R. Smith. Cannabis Indica, morphia, and chloroform, had been used without effect, when at my request Prof. Smith turned the case over to me, in order that cor- roval might be administered. Two drops of a strong solution of the substance in water were injected into the cellular tissue of the forearm. At the time the pulse was 160, and the respirations about 75. There was very decided opisthotonos. In three minutes the pulse had fallen to 152. Two more drops were then injected, and the pulse fell to 144. As it soon rose again, two more drops were injected,-when it fell to 132, and the respirations to 64. The spasms still continuing, two more drops were injected. In five minutes the pulse began to decline rap- idly, and in ten minutes had fallen to 90. At this time the patient had a violent tetanic spasm, and during its continuance the pulse became intermittent. It then rapidly went down to 40, then to 30, and during a violent spasm the patient died. From this record it will be seen that at no time did the corroval exercise the least effect over the disease.1 1 " Traumatic Tetanus; Inoculation with Corroval; Death," by Edward Milholland, M. D., Resident Physician at the Baltimore Infirmary. In Maryland and Virginia MedU cal Journal, January, 1861, p. 13. 568 DISEASES OF THE SPINAL CORD. As I have stated, three successful cases have occurred in my prac- tice. One of these I saw in consultation with Dr. J. Lewis Smith, of this city. It was traumatic, and had ensued two weeks after a wound of the foot by a nail. The patient was treated by cannabis Indica, and the persistent application of ice to the spine. The spasms were greatly lessened in force and frequency, and recovery took place within two weeks. Another, which was also traumatic and acute—that is, making its appearance within nine days after the injury—was treated accord- ing to the same plan, and recovered in sixteen days, though the jaws remained stiff for several weeks afterward. The wound was caused by an ice-pick being accidentally thrust through the hand. The third case was that of an eminent musician of this city, who, while drilling with the regiment to which he belonged, injured his thumb with a splinter from the stock of his rifle. The first evidence of tetanus appeared on the twelfth day. The attack was not very severe. I administered the extract of cannabis Indica (Squires's) in doses of half a grain every two hours, and kept up the application of ice to the spine continuously for six days. There were several violent spasms during this period, and the opisthotonos was well marked. At the end of a week the cannabis Indica was omitted for a day, but, the spasms becoming more frequent and severe, it was resumed as before, and continued with tolerable regu- larity for ten days longer. During this period there were but two spasms, and the opisthotonos became less. It was then gradually di- minished, and on the twenty-fifth day was left off altogether, the patient being convalescent. I am disposed to think that, whatever internal medication be adopt- ed, the application of ice to the spine is a measure which should always form a feature of the treatment. IV. INFLAMMATION OF THE ANTERIOR COLUMNS OF THE SPINAL CORD (SCLEROSIS OF THE COLUMNS OF turck). Tiirck' has shown that the anterior columns of the spinal cord are subject to a chronic inflammation such as is now known under the name of sclerosis. In the cases which he described the morbid process in- volved symmetrically a small region on each side of the anterior median fissure—that part which is designated the column of Tiirck. Micro- scopical examination showed proliferation of the neuroglia, with degen- eration of the true nerve-elements. 1 " Ueber Degeneration einzelner Ruckenmarksstrange, welche sich ohne primare Krankheit des Gehirnes oder Riickenmarks entwickelt," " Sitzungsberichte der Kaiser- lichen Academie der Wissenschaften," Mat. nat. CI., 1856, p. 112. INFLAMMATION OF THE LATERAL COLUMNS. 569 The course of the disease, the symptoms, causes, etc., together with the morbid anatomy and pathology, do not differ essentially from the cor- responding affection of the lateral columns which is more frequent and is more thoroughly understood. Our present knowledge leads us to the inference that the columns of Turck are in function similar to the lateral columns. The number of cases in which they have been found altered is as yet small, and they have not been very thoroughly worked up. In some cases they have been sclerosed in conjunction with a like con- dition of the lateral columns. I shall, therefore, pass at once to the consideration of the next divis- ion of the subject. V. INFLAMMATION OF THE LATERAL COLUMNS OF THE SPINAL CORD (PRIMARY SYMMETRICAL LATERAL SCLEROSIS). Tiirck,1 who, as we have seen, demonstrated the fact that the ante- rior columns of the cord could be the primary seat of sclerosis without any other region participating in the lesion, also showed that the lateral columns could be similarly affected. Tiirck's investigations were al- lowed to remain scarcely noticed for ten years, when Charcota made like observations and since then has aided in establishing it as a dis- tinct pathological condition. Symptoms.—The chief phenomena of the disease under considera- tion are paralysis and contraction of the affected limbs. The lower ex- tremities are, more than the upper, liable to be the seat of these symp- toms. The loss of power is very gradual, and there is no atrophy be- yond the general emaciation consequent upon diminished use of the muscles. Sensibility is not in general affected, but in some cases there is more or less pain in the paretic limbs and in the back near the seat of the disease. The paralysis is rarely complete. At first the patient merely tires more readily, slight exertion fatigues him, and this is especially noticed in the muscles which flex the leg upon the thighs, and the consequent sensation of weariness is experienced in the popliteal space. Some- times it is shown in the sudden relaxation of the extensor muscles of the leg and the fall of the patient thereby; at others, in the fact that the extensors of the foot become weak, allowing the toes to drop, and hence causing stumbling. The gait then becomes characteristic. Owing to the fact that the patient's extensor muscles are weak, he is unable to lift the feet high enough to cause them to clear the ground, and hence he throws them out by means of the abductor muscles of the thigh, and thus causes them to describe an arc of a circle. Then in putting them 1 Op. cit, p. 112. 1 V Union Medicate, 1855. 570 DISEASES OF THE SPINAL CORD. down the heel strikes the ground a longer time before the sole than it does in the natural gait, and hence the foot comes down with a jerking motion. This is the ordinary manner of walking practised by a person affected with the disease under notice. In another form of locomotion, the body is moved laterally on the thighs, first to one side and then to the other, in such a way as to cause the feet to be raised high enough without the complete action of the extensor muscles. The gait is there- fore similar to that of a duck, or of a woman with a very wide pelvis. The motion of the body is almost serpentine, and the feet glide over the ground barely lifted high enough to avoid contact. In both the methods of walking the patient requires support. At first a cane answers, then he comes to crutches, and eventually the as- sistance of an attendant becomes necessary. As a consequence of the paralysis, and the contractions which event- ually ensue, the movements are often complicated and sometimes ren- dered impossible by the legs becoming interlocked at every attempt to walk. In a patient from Connecticut under my care, not long since, this difficulty was a very prominent feature, and though the muscles of flexion and extension were sufficiently strong to allow of his walking, those which abduct the thighs were so materially paralyzed, and the adductors were so greatly contracted, as to produce the condition mentioned. Reflex movements, so far from being lessened, are generally exalted, and this for the reason that the gray matter of the cord is not involved The electric contractility of the muscles remains unimpaired. The contractions to which the limbs are subject are usually mani- fested in the adductor and flexor muscles. The affected limb is thus drawn across the other, or when both are involved they are strongly in- terlocked, while at the same time, or subsequently, the leg is bent upon the thigh and the thigh on the pelvis. Sometimes the contractions re- lax, but they again supervene, and generally persist with more or less intensity till the closing stages of the disease, when the power of the cord becoming exhausted entirely, and all the muscles being paralyzed, the spasmodic action ceases. A very remarkable case is one reported by Charcot,1 of a woman who, after several hysterical attacks, was seized, after having been great- ly frightened, with a violent paroxysm of hysteria, which was soon fol- lowed by a general trembling, accompanied by a weakness of the limbs. At the end of a month the feebleness was such that she could not leave her bed. About the same time the trembling ceased, but was succeeded by a contraction which affected at first the extremities of the left side, but in the course of three weeks involved those of the right side also. The neck also became rigid. 1 Cited by Bourneville, "De la contraction hyste'rique permanente," Paris, 1872, p. 77. INFLAMMATION OF THE LATERAL COLUMNS. 571 All these phenomena persisted, they even increased so that in the early part of 1850 she was admitted into the Charite. At that time she was confined to her bed in the dorsal decubitus, not being able to move her limbs. Her general health was good, and her cerebral functions were normal. The muscles of the neck were painful and stiff. The skin on the left anterior part of the thorax was hypera?sthetic, the condition being exactly bounded by the median line. The tactile sensibility was a little obtuse in the left superior extremity, but the sensibility to pain was exaggerated. The muscular sensibility was also more marked than in the normal state. The superior extremities were strongly contracted; the forearm was flexed on the arm, and the fingers were also strongly flexed. Attempts made to extend the limbs were only partially successful and caused pain. The contracted muscles were the seat of continuous spontaneous pains, and from time to time sudden movements took place in these members, either spontaneously or as a consequence of reflex action. Neither of these limbs could be moved by voluntary power. The trunk was rigid and its muscles were painful to pressure. Pressure on the cervical region of the skin also caused pain. Both inferior extremities were also strongly flexed. Pressure on the muscles caused pain, and there were also darting pains through these limbs. The case was regarded as one of hysteria. The patient remained in the hospital two years, and left in about the same state as when she entered. Subsequently the symptoms almost entirely disappeared, nothing remaining but a weakness of the lower extremities and a slight degree of contraction of the upper. But in 1855 she had another hys- terical- attack, and this was followed by a return of the former condi- tion. In 1856 she entered the Salpetriere, and in 1862 her case was studied by M. Charcot. The symptoms were similar to those which have been described, though even more pronounced. In 1864 she died during an attack of erysipelas. The post-mortem examination showed the essential lesion to consist of sclerosis of the lateral column from the medulla oblongata to the lower boundary of the lumbar enlargement. The gray matter was healthy' throughout. A study of this case shows that the principal symptoms of primary symmetrical lateral sclerosis are as Tiirck described them in his memoir —paralysis, contractions, and pain in the back and limbs. Causes.—The causes of the disease are probably similar to those pro. ducing so many other spinal affections—cold, dampness, over-exertion, syphilis. Nothing very definite is known on the subject. Diagnosis.—The elements of the diagnosis of primary symmetrical lateral sclerosis of the spinal cord are the presence of contractions with 572 DISEASES OF THE SPINAL CORD. paralysis but without atrophy, and the absence of any organic disease of the brain or superior part of the cord (bulb) which could give rise to the condition as a secondary disorder. It must, however, be borne in mind that contractions are the expression of degeneration of the lateral columns. It is only by attention to the clinical history of the case that we can ascertain whether the lesion is primary or secondary. The distinction between the disease in question and progressive muscular atrophy is so clear as scarcely to require comment, and from amyotrophic lateral spinal sclerosis, the absence of atrophy and its ac- companiments, and of a tendency to attack the nuclei of the bulbar nerves, will serve to make the discrimination. It has more affinities, so far as its symptoms are concerned, with chronic spinal meningitis, multiple spinal sclerosis, and with tumors which, by their pressure on the cord, may give rise to very similar phe- nomena to those exhibited in lateral sclerosis. I am afraid the difficul- ties of making a diagnosis between it and these affections are, in the present state of our knowledge, almost insurmountable. I know of no sure signs by which the discrimination can be made. Prognosis.—Although remissions may take place, the prospect of an entire cure is not very great. The progress of the disease is, however, slow in the majority of cases, and its course may, I am satisfied, be ma- terially retarded if not altogether arrested in some cases. Morbid Anatomy and Pathology.—Ttirck was the first to associate sclerosis of the lateral columns with a definite set of symptoms. In three of the cases of the twelve on which his memoir is based he found these regions of the cord the seat of symmetrical sclerosis. It has been very definitely settled that the lateral columns are, in embryonic hfe, anatomically distinct from the rest of the cord; and, though in the pro- cess of development this anatomical separation is apparently lost, pathol- ogy shows us that it in reality exists. Charcot,1 in considering this subject, calls attention to the fact that transverse sections of the cord in cases of primary symmetrical lateral sclerosis made through the cervical enlargement show that the altera- tion embraces a greater extent of the cord than when any other part is affected. Thus, when the region in question is the seat of the lesion the sclerosis extends anteriorly as far as, and even beyond, the external angle of the anterior horn, while posteriorly it almost encroaches on the posterior tract of gray matter. On the outside it is always sepa- rated from the cortical layer by a tract of white tissue which remains intact. In Fig. 69 is represented a transverse section of the cord made through the cervical enlargement, a denotes the sclerosed portion ex- tending beyond the external angle of the anterior tract of gray mattel 1 Op. cit, p. 220. INFLAMMATION OF THE LATERAL COLUMNS. 573 reaching to the posterior tract behind, and separated from the cortex by a layer of unaltered white substance. Fig. 00. Fig 70. In the dorsal region the lesion is more circumscribed, as is readily seen from an examination of Fig. 70, which represents a section of the cord through the middle of that part. In front it scarcely reaches the posterior boundary of the anterior tract of gray matter. As in the section just described, the sclerosed portion does not extend to the cor- tical layer of the cord. In the lumbar region the lesion is still less extensive, occupying only about a quarter of the area of the lateral columns. Unlike the lesion in the cervical and dorsal regions, it touches the cortical layer of the cord (Fig. 71). Finally, in those cases in which the morbid process extends to the medulla oblongata, we find it seated in the anterior pyramids, not in the nuclei of the bulbar nerves, as in cases of amyotrophic lateral spinal sclerosis to be presently considered. Fig. 72 represents a transverse Fig. 72. section of the medulla oblongata through the middle part of the olivary bodies ; a a, the anterior pyramids in a state of sclerosis. In primary symmetrical lateral sclerosis, the initial stage, as in other inflammatory affections of the spinal cord, whether acute or chronic, is probably congestion. Treatment.—In the early period of the disease large doses of ergot will rarely fail to be of service. I have several times succeeded in relieving the paralysis and arresting the spasms of the limbs in cases presenting all the initial phenomena of lateral sclerosis, by the persistent and free use of this remedy. But to be efficacious it must be given in Fig. 71. 574 DISEASES OF THE SPINAL CORD. the very first stage, before the paralysis becomes extreme, or permanent contractions are present. A drachm of the fluid-extract three times a day is the smallest dose likely to prove efficacious. If there is reason to suspect the influence of syphilis in producing the disease, the iodide of potassium in large and gradually-increasing doses should be administered. Charcot and Gombault' have proved the existence of disseminated sclerosis of the cord in a woman affected with syphilis, and there is of course reason to believe that the diffused form such as that now under consideration may have a like origin. In such cases mercury may also be given, preferably in the form of the bichloride, with the iodide of potassium. Later, no treatment is, so far as we know, calculated to materially arrest the progress of the disease. I have employed the chloride of barium, with apparently some temporary advantage. Nitrate of silver and cod-liver oil have also occasionally improved the strength of the patient and lessened the rigidity of the contractions, but only for a short time; and the primary uninterrupted galvanic current to the spinal col- umn and the contracted muscles has also proved serviceable in the same way and to a like extent. Up to quite a recent period I had never derived any benefit in cases of lateral sclerosis from counter-irritation, but I am disposed to think from some late experience that the actual cautery, applied on each side of the spinous processes throughout the entire length of the vertebral column and frequently repeated, is useful. For the relief of pain, morphia may be administered, or what is I think preferable, as it does not appear to be an excitant of the cord, co- deine. Half a grain or more may be given as required. Hypodermic injections of atropia, beginning with the one hundred and twentieth of a grain and increasing gradually, are beneficial in mitigating the spasms of the muscles. VI. INFLAMMATION OF THE LATERAL COLUMNS OF THE SPINAL COED AND OF THE ANTERIOR TRACT OF GRAY MATTER (AMYOTROPHIC LAT- ERAL SPINAL SCLEROSIS). For the recognition of this affection and the patho-anatomical data relative to its identity, we are indebted to Charcot, who, with his cus- tomary ability, has presented a mass of facts abundantly sustaining his views in regard to -its autonomy. Cases exhibiting the phenomena of amyotrophic lateral spinal sclerosis were noticed, and their details published before he enunciated his doctrines on the subject; but the re- 1 " Note sur une cas des ldsions diss6min6es des centres nerveux observers chez une femme syphilitique," Archives de physiologie, 1873, p. 143. , AMYOTROPHIC LATERAL SPINAL SCLEROSIS. 575 lations of the lesions to the symptoms were not known previous to his observations. Symptoms.—The first symptom to make its appearance in the affec- tion under notice is paralysis, which occurs ordinarily gradually, ad- vances steadily, and may involve at the same time one or more of the limbs. Generally atrophy ensues soon after the appearance of the pa- ralysis, and, as in infantile spinal paralysis, and the spinal paralysis of adults, involves whole groups of muscles at once—not the individual muscles in succession, as in progressive muscular atrophy. After a time the morbid process in its ascending course reaches the medulla oblongata, and, thus implicating the nuclei of the facial, spinal accessory hypoglossal, and pneumogastric nerves, especially the two latter, causes atrophy of the tongue, and many of the other symp- toms met with in progressive muscular atrophy affecting these centres. Finally, death takes place from interruption to the processes of respira- tion and circulation. The muscles which are the seat of atrophy are subject, as in pro- gressive muscular atrophy, to fibrillary contractions, which, however, as in the last-named affection, precede the atrophy, and advance and attain their greatest development pari passu with the wasting. The electro-muscular contractility remains unaffected in these mus- cles, which are the seat of the atrophy so long as any muscle remains to contract. But the feature which is most characteristic of amyotrophic lateral spinal sclerosis is the permanent contractions of which the affected limbs are the seat. These, though in part due, as Charcot' says, to the paralysis of certain antagonistic muscles, are mainly caused by spas- modic contractions of the non-paralyzed or partially paralyzed muscles, so that the joints are rigidly flexed. The position assumed when the forearm and hand are the seat of this deformation, is shown in Fig. 73. The fingers are flexed upon the palm, the thumb adducted, and the hand strongly bent upon the arm. In the case of a gentleman who came under my observation in Sep- tember, 1874, the position of the left hand was very similar to that shown in the figure. The arm was semiflexed, and the whole member held firmly against the walls of the chest, by the action of the pectoral and latissimus dorsi muscles. Any attempt to overcome the contrac- tions was strongly resisted by the muscles, and caused very consider- able pain. The atrophy of the paralyzed muscles was well marked, and fibrillary contractions were easily excited, even if not present when the inspection was made. In this case the disease had appeared suddenly six months previous- ly, after exposure subsequent to a debauch. The upper extremities 1 " Lecons sur les maladies du systeme nerveux," 3me. fascicule, Paris, 1874, p. 284. 576 DISEASES OF THE SPINAL CORD. only were affected, but there was, even when I saw the patient, a little restraint in the movements of the tongue. I did not see him again, but I heard that death had ensued from dysentery three months after Fig. 73. his visit to me. I also learned that his tongue had become atrophied, * and that there was difficulty of swallowing. In another case the contracted muscles were the pectorals, and the left arm was, in consequence, drawn strongly across the front of the chest. This patient, a man forty years of age, was paralyzed in both upper extremities, but the contraction, when I first saw him, was limited, as stated, to the pectoral muscles. He visited me again about six months afterward, and then the right upper extremity was also contracted throughout its extent. The fingers were bent on the palm to such a degree that they could not be opened by any force which it was safe to apply, and pressed so strongly on the palm as to cause pain. If the nails were allowed to project beyond the ends of the fingers—and it was very difficult to keep them short—they entered into the skin and caused painful sores. The hand was flexed on the wrist, the elbow half bent, and the arm was held firmly against the side of the chest. At the time of the first visit of this patient there was no evidence of any alteration of the medulla oblongata, but at the second visit there were several indications of incipient bulbar paralysis. Deglutition was effect- ed with difficulty, the tongue could not be carried to the roof of the mouth, was protruded only slightly upon great effort being made, and was the seat of constant fibrillary contractions. The atrophy of the paralyzed muscles was well marked, and fibril- lations were so strong as to be a source of great discomfort. The lower extremities were not then involved, and the bladder and sphinc- ters were intact. I have not seen the patient since—now about seven months—and am ignorant of the subsequent course of the disease. AMYOTROPHIC LATERAL SPINAL SCLEROSIS. 577 The contractions are not always similar, either in extent or strength, in the corresponding limbs, and they may for a time, especially in the early stages of the disease, disappear. But they reappear later, and tend to become more and more rigid as the affection advances ; still, in the most extreme period of the malady, as the atrophy becomes pro- nounced, they disappear wholly or in part, there being little if any muscle left to maintain the contraction. Another feature is a spasmodic extension of the paralyzed limbs, especially the lower, which is most strongly marked as the patient lies in bed ; or the members may be involuntarily flexed and remain in that condition for several minutes or longer. These movements are not ordi- narily accompanied with pain, as are those of spinal meningitis, which in many respects they resemble. The patient very generally experiences severe pains in the affected limbs, which are aggravated or excited by pressure or traction in the muscles. Numbness is also usually present to a greater or less degree, but there is never complete anaesthesia. A peculiar kind of tremor is sometimes seen in the limbs, the mus- cles of which are partially paralyzed and atrophied. This is in reality not so much a tremor as it is a more extensive movement, resembling that which is present in some old cases of hemiplegia from cerebral haemorrhage. It is only, like that, manifested when voluntary move- ments are attempted. As previously stated, the disease, unless death ensues from some in- tercurrent affection, eventually extends to the medulla oblongata. In none of my cases has this circumstance been present to any marked degree while the patients were under my observation ; but in two, as we have seen, there were indications of such extension when they passed from under my notice. Charcot states it to be an invariable se- quence, so far as his observations extend, and he sums up the subject as follows : The paralysis of the tongue, inducing a difficulty of swal- lowing and of articulation, may cause a complete loss of the power of speech. The paralyzed tongue presents very soon, in general, a cer- tain degree of atrophy ; it is shrunken, wrinkled, and agitated with vermicular movements. The paralysis of the veil of the palate makes the voice nasal, and, with the laryngeal paralysis, renders the act of deglutition difficult. The orbicularis oris being paralyzed, an alteration in the form of the countenance takes place. The mouth is considerably enlarged transversely, through the predominance of the action of the muscles which are not involved. The naso-labial furrows are depressed. The symptoms give to the physiognomy a sad expression. The mouth, es- pecially after laughing or weeping, remains for a long time half open, and allows the viscid saliva to flow continually. Finally, by reason of the implication of the pneumogastrics, grave 37 578 DISEASES OF THE SPINAL CORD. troubles of the respiration and circulation supervene, and cause the death of the patient, already weakened by insufficient nourishment. In some cases there are variations from the ordinary course of the disease. It has begun in the lower extremities instead of the upper, and again has been restricted in its domain for a long time to a single limb or to one side of the body. In two cases, according to Charcot, it has begun with the bulbar symptoms, wdiich in general appear only at the end. In regard to such instances as these last, there is doubt of their being examples of amyotrophic lateral sclerosis. Causes.—Exposure to cold and dampness appears to be the most efficient exciting cause of the disease. In one of Charcot'sl cases, the patient, an itinerant showman, was exposed during a journey to cold and rain. The following morning he was taken with a chill, which was repeated thirty-six hours afterward, and then he was seized with pains along the course of the nerves, and in the joints mainly of the upper extremities. Fibrillations accompanied them, and paralysis and atrophy soon followed. In the case occurring in my own experience, the patient became intoxicated, and wandering into the Central Park, lay all night on wet grass, exposed to a cold, drizzling rain. In the morning he was arrested and taken to the police court, and sent to Blackwell's Island for ten days. On his way up, he was subjected to the influence of a cold wind, which, blowing on his wet clothes, chilled him more and more. The following morning he was discharged, his friends having ascertained his situation and paid his fine. But he already felt a degree of weak- ness in his arms, and in the course of a week they were to a great extent deprived of motor power. Fibrillary contractions were present from the first, but there was no pain anywhere. In the majority of cases no cause can reasonably be assigned. There appears to be no hereditary influence to the disease. Diagnosis.—The diagnosis of amyotrophic lateral spinal sclerosis presents many features of interest. A consideration of the essential phenomena shows that they are as follows : 1. Paralysis occurring in symmetrical parts of the body, unaccom- panied by anaesthesia. 2. Atrophy following the paralysis, and attacking masses of mus- cles. 3. Spasmodic rigidity, eventually leading to permanent contrac- tions, lasting up to the last stage of the disease. 4. Extension of the affection to the lower extremities, and the su- pervention of intermittent and tonic contractions or rigidity. 5. The implication of the medulla oblongata, and death in the course of two or three years. Thus, we see that the affinities of amyotrophic lateral spinal sclero- sis are with spinal paralysis of adults and progressive musoular atrophy 1 " Deux cas d'atrophie musculaire progressive," Archives de physiologie, 1869, p. 637 AMYOTROPHIC LATERAL SPINAL SCLEROSIS. 579 with which latter disease it was confounded by Dumesnil,1 Charcot,5 and others, up to quite a late period. But the differences between it and both these diseases are suf- ficiently striking to prevent much danger of confounding them. Thus from spinal paralysis of adults it is discriminated by the facts that reflex excitability is not impaired, nor the electric excitability of the muscle diminished, as in the former affection ; that the atrophy is more profound and constant; that fibrillations are present, and especially by the existence of the spasmodic contractions of the limbs which form so prominent a feature of amyotrophic lateral spinal sclerosis. From progressive muscular atrophy the distinction can be readily made out. In the facts that paralysis precedes the atrophy, that the wasting takes place in groups of muscles, and that spasmodic contrac- tions occur in amyotrophic lateral spinal sclerosis ; while in progres- sive muscular atrophy the paralysis is consequent on the wasting, the muscles shrink singly and irregularly, fibre by fibre, and spasmodic con- tractions do not occur, we have sufficiently precise diagnostic marks of differences between the two affections. Prognosis—There is no case of cure on record. The course of the disease is progressively onward. In the majority of cases the fatal ter- mination occurs within two years; occasionally, it is deferred for a few months longer. Morbid Anatomy and Pathology'.—As I have said, amyotrophic lateral spinal sclerosis has, until quite lately, been regarded as, at most, an eccentric form of progressive muscular atrophy. It is among the reports of cases of this affection, therefore, that we must search for early data relative to the morbid anatomy of the disease under consid- eration. Dumesnil,8 in 1867, reported the details of five cases of spinal disease under the name of progressive muscular atrophy, two of which were, undoubtedly, instances of amyotrophic lateral spinal sclerosis. In both of these, symptoms such as have been described were present, and, on post-mortem examination, lesions of the lateral columns and anterior horns of gray matter were found to exist. Charcot and Joffroy4 have given with fullness of detail the particu- lars of two cases of amyotrophic lateral spinal paralysis, in which the post-mortem examination was very thorough. " Nouveaux faits relatifs a la pathogenie de l'atrophie musculaire progressive'' Gazette hebdomadaire, Nos. 27, 29, 30, 1867. Deux cas d'atrophie musculaire progressive avec lesions de la substance grise et des faiseaux ant6ro-lateraux de la moelle 6piniere," Archives de physiologie, No. 4, 1869. "Nouveaux faits relatifs a la pathogenie de l'atrophie musculaire progressive," Gazette hebdomadaire, Nos. 27, 29, 30, 1867. Deux cas d'atrophie musculaire progressive avec lesions de la substance grise et des faiseaux ant6ro-lat6raux de la moelle epiniere," Archives de physiologie, 1867. 580 DISEASES OF THE SPINAL CORD. The first of these is reported as a case of progressive muscular atrophy, especially marked in the upper extremities, with atrophy of the muscles of the tongue and of the orbicularis oris and paralysis with rigidity of the inferior limbs. On post-mortem examination the nerve- cells of the anterior horns in the cervical and dorsal regions were found atrophied, while many had disappeared. In the bulb there were atrophy and disappearance of the nerve-cells, constituting the nucleus of the hypoglossal. The anterior roots of the spinal nerves and the roots of the hypoglossal and the facial were also atrophied. In addition, there was symmetrical diffused sclerosis of the lateral columns. In this case the bulb was affected after the lower parts of the cord, and the lesion of the nuclei of the hypoglossal and facial was of such a nature as to cause atrophy of the tongue and orbicularis-oris muscle. The instance was, therefore, of a typical character. The second case has already been cited under another head of this chapter. It is entitled—Progressive muscular atrophy especially mani- fested in the upper extremities; acute pains in the limbs coming on in paroxysms ; anaesthesia in certain parts of the body ; paralysis with rigidity of the inferior extremities; lesions of the nerve-cells of the anterior horns of gray matter; centres of gray degeneration in the posterior horns; symmetrical diffused sclerosis of the lateral columns ; considerable thickening of the spinal dura mater and pia mater of the cervical enlargement. This case was not an uncomplicated one, but still the essential lesions of the anterior horns of gray matter and of the lateral columns are perceived to have been present. Gombault1 reports the case of a woman in whom the symptoms were not developed with any suddenness, but in whom there gradually supervened loss of power with atrophy and contractions in the upper extremities, then paralysis with atrophy in the lower limbs, and finally atrophy of the muscles of the tongue and lips, with difficulty of swal- lowing, and the other symptoms of glosso-labio-laryngeal paralysis. Post-mortem examination showed the lateral columns to be symmetri- cally sclerosed, and in the anterior horns of gray matter symmetrical lesions, exactly limited to this region, and consisting of atrophy, pig- mentary degeneration, and disappearance of the nerve-cells. In the bulb, the nuclei of origin of the bulbar nerves were similarly altered. It is perceived, therefore, that in amyotrophic lateral spinal sclero- sis the essential lesions are seated symmetrically in the lateral columns and in the anterior horns of gray matter, and that when the morbid process extends—as it always does, if the patient does not die in the mean time of some intercurrent affection—to the medulla oblongata, it 1 " Sclerose symetrique des cordons lateraux de la moelle et des pyramides anterieurs dans la bulbe; atrophie des cellules des cornes anterieures de la moelle ; atrophie mus- culaire progressive; paralysie glosso-laryngGe," Archives de physiologie, 1872, p. 589. AMYOTROPHIC LATERAL SPINAL SCLEROSIS. 581 invades the nuclei of origin of the nerves which are affected in glosso- labio-laryngeal paralysis. The accompanying woodcut from Charcot Fig. 74. represents a section of the bulb made at the level of the middle part of the nucleus of the hypoglossal ; a b to the right of the imaginary line R R' represents the normal condition ; a, the nucleus of the hypo- glossal composed of about thirty multipolar ganglion-cells; e, a vessel circumscribing the nucleus; c, the floor of the fourth ventricle; d, the fasciculus teres ; b, nucleus of the pneumogastric. On the left the letters a' b', etc., represent the corresponding parts in a case of amyo- trophic lateral spinal sclerosis. It is perceived that only five or six cells exist in the nucleus of the hypoglossal. The nucleus of the pneu- mogastric is, on the contrary, normal. Now, it appears to me that M. Charcot is wrong in considering, as he apparently does, every case of glosso-labio-laryngeal paralysis ac- companied by progressive muscular atrophy of the muscles lower down, as one of primary amyotrophic lateral spinal sclerosis. Those cases of glosso-labio-laryngeal paralysis which, at a later period, exhibit the phenomena of progressive muscular atrophy in the muscles of the upper extremities and of other parts of the body are,- in my opinion, not cases in which there is primitive lesion of the lateral columns, but examples of secondary degeneration of the cord, being produced as a consequence of the superior lesion. The case reported by Dr. Hun,1 of Albany, is quoted by Charcot2 as an instance of amyotrophic lateral spinal sclerosis, but, according to the 1 " Labi o-Glosso-Lann goal Paralysis," American Journal of Insanity, 1871, p. 194. 2 "Lecons sur les maladies du systeme nerveux," Paris, 1874, p. 229- 582 DISEASES OF THE SPINAL CORD. view above expressed, it was in reality a case of glosso-labio-laryngeal paralysis with secondary degeneration of the spinal cord. The patient, a man aged fifty-eight, first noticed that the saliva dribbled from his mouth when speaking or writing. Shortly afterward he was conscious of a difficulty in the pronunciation of words, and then there were evi- dent hesitation and defect in the articulation of certain words, and his voice became nasal. A year afterward there were complete loss of speech, difficulty of deglutition—any effort at swallowing being attended with paroxysms of coughing and suffocation—and paralysis of the tongue, which could only be protruded a quarter of an inch beyond the edge of the teeth. There was partial loss of motion in both arms, but no atrophy. A month subsequently it was noticed that he dragged his feet a little, but he could still walk alone for a considerable distance. The pa- ralysis advanced until he was unable to walk, and the difficulty of deglu- tition increased. When seen by Dr. Hun, January 4, 1871, " he was sitting in a chair propped up by pillows, being unable to lie down on account of dyspnoea; complete loss of motion except a little nodding of the head and a little movement of the right hand; sight and hearing unimpaired; speech entirely lost; mouth partly open; and lips immovable, except a slight twitching of the left angle of the mouth; cheeks flaccid; tongue completely paralyzed and lying on the floor of the mouth; respiration feeble, and occasional coughing ; pulse 90 per minute and regular ; both arms paralyzed and slightly flexed, and attempts to straighten the fingers caused pain; lower extremities completely paralyzed, and feet and ankles cedematous ; defecation natural; micturition slow and fre- quent; attempts to swallow occasioned distressing cough and suffoca- tion, and the aliments were often rejected through the nose. " He remained in this condition until the afternoon of the same day, when an attempt to swallow some porridge brought on severe coughing and strangling. At seven o'clock that evening he died without a strug- gle. " Autopsy twenty hours after death. " External Appearances.—Rigor mortis well marked. Body spare but not emaciated, no very evident signs of muscular atrophy. " Head.—Scalp very dry. Skull-cap removed with great difficulty, owing to adhesions of the dura mater, which was torn in trying to sepa- rate it from the bone. Dura mater very much thickened. Arachnoid normal with considerable serous infiltration of the sub-arachnoidean connective tissue. Pia mater much injected. The cerebral substance, both cortical and medullary, appeared to be of normal color and consist- ency but exceedingly hyperaemic. The following conditions of the cranial nerves were found : 1. Olfactory normal; 2. Optic normal; 3. Motor oculi normal; 4. Patheticus small; 5. Trigeminus, on the left AMYOTROPHIC LATERAL SPINAL SCLEROSIS. 5S3 side flattened, gray, and softened; on the right side larger and very hy- peraemic; 6. Abducens atrophied especially on the left side; 7. Facial atrophied and gray on both sides ; 8. Auditory normal; 9. Glossopha- ryngeal normal; 10. Pneumogastric atrophied on both sides; 11. Spinal accessory much atrophied; 12. Hypoglossal so much atrophied on both sides as to resemble mere threads or filaments of connective tissue. The corpora striata and optic thalami were normal. The cerebellum was very hyperaemic, but otherwise presented nothing unusual. The pons Varolii and medulla oblongata appeared to be of firmer consistency than usual. " Spinal Cord.—Spinal meninges much injected. The anterior spinal roots were atrophied, especially on the left side. Transverse sec- tions of the cord showed the anterior cornua of gray matter, as well as the left anterior and right lateral column, to be of a dark rose-color, as if very hyperaemic. " Portions of the brain, cerebellum, and spinal cord were immersed in absolute alcohol, preparatory to making sections for microscopic exami- nation. When sufficiently hardened, thin sections were made, stained with carmine, rendered transparent with benzole, and mounted in bal- sam. " The sections of the brain revealed nothing abnormal. The sec- tions of the cerebellum showed a very hyperaemic condition of the part, and a granular degeneration of the large ganglionic cells forming the middle layer of the cortical portion. , " Thirty sections were made at various levels of the medulla oblon- gata, involving the roots and nuclei of implantation of the cranial nerves, especially those of the facial and hypoglossal. Careful micro- scopic examination of these specimens, with objectives varying from fifteen to nine hundred diameters, demonstrated that the portion of medulla forming the floor of the fourth ventricle was the seat of several pathological lesions. " There was a decided hypertrophy or overgrowth of the connective tissue, which appeared to have encroached upon and to some extent replaced the several groups of ganglionic cells which form the nuclei of implantation for the facial and hypoglossal nerves. The individual cells comprising these groups were separated from one another, and in many instances had lost their stellate appearance ; their radiating pro- cesses having been destroyed, so that each cell remained isolated and disconnected from its neighbors. These cells had also undergone a de- generative process, which in many cases rendered them simply a collec- tion of fine granules, and a deposit of brownish-yellow pigment had taken place to such an extent as to give the cells an appearance almost precisely similar to those which are normally found in the locus niger of Soemmering ; they were fewer in number than usual and diminutive in size. 584 DISEASES OF THE SPINAL CORD. " Sections of the cord made in the cervical, dorsal, and lumbar re- gions, showed a sclerosis with increase of the connective tissue in the anterior and lateral columns, which was most marked in the left ante- rior and lateral columns. The multipolar ganglion cells, situated in the anterior cornua of gray matter, were fewer in number than usual, and many of them appeared granular and very much pigmented." As Dr. Hun subsequently remarks, there was here " a descending degeneration of the motor tracts of the cord consecutive to a primary lesion situated in the medulla. This is fully in accordance with the views presented by Bouchard in his work on secondary degenerations of the spinal cord, and accounts for the progressive paralysis of the trunk and extremities which follows the original loss of motion in the lips, tongue, and palate." The cases cited by M. Charcot from Leydenx are similar in general characteristics. To repeat, glosso-labio-laryngeal paralysis is a paralysis without atrophy. Paralysis and atrophy consequent to it of other parts lower down, are due to secondary degenerations of the cord. Amyotrophic lateral spinal sclerosis is a paralysis with atrophy. It has a tendency to ascend and to involve the nuclei of the bulbar nerves, causing the atrophy of the muscles of the lips, tongue, and palate, and accompanied with fibrillary contractions, which latter are not phenomena of glosso- labio-laryngeal paralysis. Such cases as those of Hun, Leyden, and others, as well as several which have come under my own experience, are, so far as their lower spinal phenomena are concerned, to be classed not with the protopathic, but the deuteropathic spinal amyotrophies of Charcot, the secondary spinal degenerations of Bouchard, to which attention will be given hereafter. Even if we adopt M. Charcot's view that in such cases there is a real atrophy of the tongue, which is concealed by the hyperplasia of the perimysium, and the deposit of fat between the muscular fibres, we could not avoid perceiving the difference between such instances and those of true progressive muscular atrophy attacking the tongue, and in which there are fibrillations, and no interstitial fat to mask the ver- itable condition. The lesions of the muscles in amyotrophic lateral spinal sclerosis are similar to those met with in progressive muscular atrophy. The peri- mysium is increased in quantity and the muscular fibrillae undergo fatty degeneration and atrophy. In considering the relation of the phenomena to the lesion, the ques- tions to engage attention are mainly those which have already been suffi- ciently dwelt upon, when the other affections characterized by paralysis and atrophy were under notice. One symptom, spasmodic contraction, 1 "Ueber progressive bulbare Paralysie," Archiv fiir Psychiatrie, Band ii., S. iii. PROGRESSIVE LOCOMOTOR ATAXIA. 585 a concomitant of primary symmetrical spinal sclerosis, is, as has been pointed out when that disease was under consideration, the direct con- sequence of the lesion of the lateral columns. Treatment.—In regard to a malady of so hopeless a character as amyotrophic lateral spinal sclerosis, there is little or nothing to say un- der this head. We have no means at our command capable of arrest- ing the onward tendency of the disease. VII. INFLAMMATION (SCLEROSIS) OF THE POSTERIOR ROOT-ZONES OF THE SPINAL CORD (PROGRESSIVE LOCOMOTOR ATAXIA). In the former editions of this work I described locomotor ataxia under the designation—based upon its patho-anatomy as then under- stood—of posterior spinal sclerosis. The recent investigations of Charcot and his pupils have, however, shown that the morbid process which gives rise to the remarkable group of symptoms known as loco- motor ataxia, is in reality situated in the subdivisions of the posterior columns, lying between the columns of Goll and the posterior horns of gray matter, and called the posterior root-zones. In accordance, there- fore, with its exact morbid anatomy, locomotor ataxia should be designated by the term placed at the head of this section. But, for convenience, I shall generally use the name locomotor ataxia, and no confusion can arise from this course, so long as we bear in mind the relation which it bears to the more exact pathological designation. Although other writers, and especially Romberg,1 had described a disease answering to that now generally known as locomotor ataxia, we are mainly indebted to Duchenne a for giving a full and distinct ac- count of an affection which, before his studies, had scarcely attracted attention. Since then, the morbid anatomy, the pathology, and the symptomatology, have been so thoroughly studied by Charcot, Pierret, Westphal, and others, whose labors will be presently more specifically referred to, that the disease in question may be said, with truth, to be one of the most thoroughly understood in the whole range of medical science. Symptoms.—Locomotor ataxia has no uniform set of initial symp- toms. Sometimes it begins with dull, heavy pains in the small of the back or other part of the spinal column, which are very soon followed by sharp, electric-like pains, which shoot down the limbs along the course of the nerves, and which are very generally taken by the patient for twinges of neuralgia or rheumatism ; or it may be first manifested "'Lehrbuch der Nervenkrankheiten," Berlin, 1840; also, "Sydenham Society's Translation," London, 1853. 8 " De l'ataxie locomotrice progressive," Archives Generates de Medecine, 1858; also, " De l'61ectrisation localis6e," Paris, 1861. 586 DISEASES OF THE SPINAL CORD. by a feeling of constriction around the body like that which is so com- mon in acute myelitis. Again, the first symptoms are cerebral, and may consist of attacks of vertigo, pains either in the front or back of the head, epileptic fits, disturbances of vision, such as diplopia, ptosis, and defective accom- modation. In this form the pupils are contracted often to mere points, or occasionally they will be found to be, one contracted, and the other dilated. At other times the stomach and bowels are disordered ; vomiting is frequent, and there may be diarrhoea or obstinate constipation. Or, finally, the initial phenomena may be connected with the sensibility, giving rise to anaesthesia, and the various abnormal sensations con- nected therewith. In whatever way it may begin, locomotor ataxia is soon chiefly manifested by disorders of motility, but inquiry reveals the -fact that these are in reality secondary, being dependent upon the diminished sensibility which always exists. As this is the essential feature of the disease, I propose to inquire into its characteristics at some length. ( If the lesion, as it usually does, exists in the dorso-lumbar region of v o-'*\ <■ _ the cord, the first evidences of anaesthesia or of perverted sensibility < .,,'/. are noticed in the feet. A common feeling is as if the toes are too large for the shoe, or as if pieces of some plastic material are between them. Sometimes there are burning pains in the soles of the feet, and very generally " pins and needles " and other forms of numbness. A curious symptom is that, not only is the sensibility lessened, but the transmission of sensitive impressions to the brain does not take place with the normal degree of activity. I have noticed this phenomenon in rather more than half the cases that have come under my observation. In a lady, now a patient, a pin stuck into the calf of the leg is not felt for fourteen seconds on the right side and sixteen on the left. In a patient with posterior spinal sclerosis, under treatment in the New York State Hospital for Diseases of the Nervous System, if the feet were put into hot water the sensation was not felt for almost three minutes. As he said, " My feet might be scalded till the flesh dropped off and I would not know it till the mischief was done. Then I should feel it sharply." The explanation of this symptom is to be found in the fact that the conducting power of the posterior columns is lessened by the lesion, and hence the brain does not receive in the usual time the im- pressions made upon the nerves. The ability to feel pain is therefore diminished, but there is, besides, a marked abatement of the tactile sensibility. The extent of this can only be accurately measured by the aesthesiometer. When this instru- ment is used, we find that the two points can be widely separated and a single impression only be felt on parts of the body which in the nor- mal condition would give the sensation of two points at a much less PROGRESSIVE LOCOMOTOR ATAXIA. 587 distance apart. A gentleman from Virginia consulted me recently, in whom I diagnosticated locomotor ataxia, and who, instead of being able to perceive the two points with the end of the index-finger, when the twelfth of an inch apart, could feel but one point, though the two were separated to the extent of an inch and a half. Sometimes, even in the early stages of the disease, the loss of sensibility is so great that the patient hardly feels the points at all. This loss of sensibility gives rise to some curious sensations, espe- cially in the soles of the feet. These are usually such as might be pro- duced by the interposition of some substance between the foot and the shoe, or between the shoe and the ground. One patient feels as if he has cushions on the soles of his feet, another as if bladders of air are interposed, another as if he is constantly treading on sticks, or, if riding in an omnibus, as if the hem of a lady's dress had got under his feet, and one a short time since described the sensation to me as being like that which he thought he would feel if his feet had been dipped into tar, and then into sand. In some-cases the ability to distinguish differences of temperature, or to appreciate the sensations produced by the application of hot or cold bodies to the skin of the affected parts, remains, but this is not, as some authors assert, a constant phenomenon, for in the majority of cases the sensations produced by heat or cold are just as unappreci- able as those caused by any means capable of giving rise to sensitive impressions. But the symptoms by which locomotor ataxia is recognized most readily are those which relate to motility, and the phenomena often make their appearance at a very early stage of the affection. At that time there is no loss of motor power, but there is an inability to coordinate the muscles—to bring them to harmonious action, and thus to execute with precision the various voluntary movements. Thus, in the act of standing, a great many muscles are simultaneously made to contract, and each one to just that necessary degree which is essential to maintain the body in the erect posture. Very often the first evidence of any motor trouble is experienced in regard to this faculty of standing. This impediment is, however, not one of paralysis, for, if the patient looks at his feet, he has no more trouble in standing alone than a perfectly sound man. A gentleman connected with the city government of Brooklyn con- sulted me a short time since for an affection which was very evidently locomotor ataxia. The first indication of disease, as he informed me, was that it had been his habit, while at his morning ablutions, to shut his eyes, and he had noticed, about two months previously, that when he did so he could not maintain his equilibrium. When he visited me he was unable to stand with his eyes shut, and his gait was perfectly characteristic of locomotor ataxia. 588 DISEASES OF THE SPINAL CORD. Before the locomotion of the patient becomes obviously affected, he experiences inconvenience in placing his feet upon small surfaces. Thus, when he attempts to enter a carriage, he finds it difficult to guide his foot to the step, and in mounting a horse he cannot readily hit the stirrup. A gentleman from Maryland, who is now a patient of mine, and who is affected with the disease in question, tells me that among the first symptoms which he noticed was the difficulty he experienced in putting his foot into the stirrup. He was obliged to use his hand as a guide. A like trouble is frequently experienced in ascending a stair- case. The gait of a person suffering from locomotor ataxia is very much changed from that which is natural. Instead of the foot being placed upon the ground with an easy motion, the heel a little in advance of the sole, and the latter gliding down gently, the leg is, as it were, jerked forward, the heel comes down suddenly, and the sole follows, at a con- siderable interval, with an abrupt flapping motion. In ordinary walking the placing of the foot on the ground consists of one movement—there being no stoppage between the touching of the ground by the heel and the planting of the sole of the foot; but, in the gait of a person affected with posterior spinal sclerosis, the foot is placed on the ground by two distinct movements, one for the heel and another for the sole of the foot. But, besides these irregularities of the progressive movements, there are others which are likewise notable. The leg is not carried directly forward, but is thrown out a little from the median Hne, and this gives the patient a motion like that of one walking on a tight-rope, and bal- ancing himself with a pole. The object of this movement is doubtless to widen the base, and thus to enable the patient to preserve more readily his centre of gravity within it. In standing, he, for the same reason, always separates the feet to a greater than normal distance. In walking or standing, it will be observed that the patient affected with sclerosis of the posterior root-zones of the spinal cord keeps his eyes fixed on his feet, or on the ground a little distance in advance. He is obliged to do this for the reasons—which with others will be more fully considered under the head of pathology—that the sensibility of the soles of the feet being diminished, and the muscular sensibility being also lessened, he is deprived, to a great extent, of the chief means by which he was formerly enabled to recognize the position of his feet, and of the dynamic condition of his muscles. He hence is obliged to make use of another sense—his vision—in order to obtain the necessary information. Therefore, when he shuts his eyes, or is obliged to walk in the dark, he is deprived of the assistance of his eyesight, and, having only his diminished tactile and muscular sensibility to guide him, moves in an exceedingly timid and disorderly manner, or else is unable to walk at all. PROGRESSIVE LOCOMOTOR ATAXIA. 589 Under some circumstances he is unable to go forward, even with the assistance of his eyesight. Experience has taught him that he can- not rely on very important senses, which formerly he implicitly trusted. He loses confidence in them, and is not reassured, even with vision to assist him. He therefore uses extraordinary caution in walking over a tiled floor, on the ice or snow, in descending a staircase, or in crossing a street crowded with vehicles. In a recent clinical lecture,1 delivered to the class of the Bellevue Hospital Medical College, I called special attention to this phenomenon of loss of confidence, and adduced several cases in illustration of this point. That there is little paralysis of motion to account for these abnor- malities, can be readily shown by a few inquiries and experiments. Thus it will ordinarily be found that the patient who is unable to stand with his eyes shut, or take a step in the dark, can push strongly with his legs, or walk a short distance with a good deal of vigor. He is still good for a " spurt," but long-continued muscular effort fatigues him. When the lesion is above the origin of the nerves which go to form the brachial plexus, the upper extremities are the seat of symptoms which are similar to those described as manifesting themselves in the legs. There are numbness and other indications of anaesthesia, together with more or less difficulty in coordinating the muscles into harmonious action. The patient finds that the ends of his fingers have lost, to some extent, their acute tactile sensibility, and that there is restraint in the management of the fingers. He experiences these difficulties in button- ing his clothes, in picking up a pin, in writing, and in other actions requiring nice manipulation. If he attempts, for instance, to carry a glass of wine to his lips, he spills a portion of the contents ; and, if told to place his finger on any particular part of his face, the movement is accomplished with a wabbling motion, and the finger is darted suddenly to the part as it approaches it. All persons possess a knowledge of where the different parts of their bodies are situated, which does not depend upon the sense of sight, although probably acquired by that sense and experience. There is such an intimate and exact relation be- tween the ends of the fingers and the cutaneous surface of the body that, if a spot no bigger than the head of a pin be made with a pencil on the forehead, a person can close his eyes and touch it with the end of his finger without difficulty every time he makes the attempt. He can also, with the eyes shut, carry the end of his fingers straight to the tip of his ear, the middle of his eyebrow, or any other part of his body within reach. A person, however, laboring under sclerosis of the pos- terior root-zones of the spinal cord, cannot do any of these things. He loses, at a very early period of the disease, that intimate topographical relation which exists between the ends of the fingers and the rest of the 1 " Clinical Lectures on Diseases of the Nervous System," Journal of Psychological Medicine, January, 1871. 590 DISEASES OF THE SPINAL CORD. body ; and hence, when he closes his eyes, and attempts to put the tip of his index-finger on the end of his nose, he misses his aim, sometimes by as much as two or more inches. M. Onimus ' has called attention to the fact that important indica- tions are afforded by an examination of the handwriting of ataxics, the defective power of coordination being well shown even when the eyes are open, but being still more strongly manifested when they are shut. The difficulty which they experience is in making the round letters, such as a, c, and o. Besides the incoordination there is a jerking movement of the pen, and a kind of impulse to continue writing after the word is finished. Finally, when the ataxia of the arm is at its height, there is an impossibility of writing a single word, and we obtain only a set of traces confused and without order. I am able, after many ex- periments, to confirm the foregoing observations. In Fig. 75, a, is seen the attempt of a patient with his eyes open, and looking at his pen, to write the word " Civilization." At b is a like attempt made when the eyes were shut. Fig. 75. a As in the legs, when the lesion is so low down in the cord as only to affect them, there is no well-marked paralysis. The grip of the pa- tient is strong, and the dynamometer shows the existence of considera- ble strength. He is, however, not capable of continued muscular effort; and, though he may be able to lift several hundred pounds, or to carry another person around the room, his muscles are exhausted with the gradual and regular expenditure of a much less amount of force. A phenomenon is often noticed as regards the upper extremities, which also exists with the lower, but which cannot be so readily mani- fested—and that is, that the patient loses the ability to distinguish even considerable differences between weights. In the normal condition, if two weights, differing in the ratio of thirty-nine to forty, are put one in one hand and one in the other, the difference is perceived without diffi- culty. The lower extremities, according to Jaccoud, are not so sensi- tive, and cannot distinguish a less difference than from about fifty to seventy grammes. ' Gazette Medicate, February 21, 1874; also, Chicago Journal of Nervous and Menial Diseases, April, 1874, p. 254. PROGRESSIVE LOCOMOTOR ATAXIA. 591 A person affected with locomotor ataxia, due to sclerosis of the posterior root-zones above the origins of the nerves which form the brachial plexus, may have an ounce-weight put into his hand, and if in a few seconds it be removed, and one of half an ounce be substi- tuted, he will not be able to tell correctly which is the heavier. Or both hands may be extended, and the two weights placed simul- taneously in them. The eyes should, of course, be closed. Some- times less differences can be perceived, but ordinarily greater ones are not distinguished. In the case of a gentleman now under my charge, there is an impossibility of telling which of two pieces of lead, the one weighing one ounce and the other a pound, is the heavier. Spath * states that, in a case under his charge, the patient could not distinguish between two weights, which differed as one to one hundred No means for measuring the extent to which the patient is able to determine the state of muscular contraction is at all comparable to the dynamograph. The range of its usefulness is, however, limited—owing to the fact that posterior spinal sclerosis is not very frequently seated high enough in the cord to affect the muscles of the upper extremities. When the lesion is not above the origin of the nerves which go to form the brachial plexus, the line is straight, as in the accompanying figure, Fig. 76. which represents the tracing made by a patient suffering from sclerosis of the posterior root-zones in the lower dorsal region of the cord. But, when the seat of the disease in the cord is anywhere between the fifth cervical and first dorsal vertebrae, the ability to maintain a uniform degree of pressure is impaired, and lines resembling the following are produced: Fig. 77. Both the above were made by the same patient, the upper with the » " Beitrage zur Lehre von der Tabes dorsalis," Tubingen, 1864. 592 DISEASES OF THE SPINAL CORD. right and the lower with the left hand. He was perfectly confident, till I showed him the tracings, that he had exerted a uniform pressure while the paper was traversing the pencil. Under the name of baraesthesiometer, Eulenberg * has recently de- scribed an instrument for estimating the sense of pressure, by means of which very accurate determinations can be made for different parts of the body. He succeeded in demonstrating a considerable impair- ment of the sense of weight in the great majority of cases of locomotor ataxia examined, even when sensibility to pain, tickling, or electric irritation, was but slightly affected, and the sense of temperature was normal. The reflex power is generally notably increased. The touch of the bedclothes, or even the rubbing of one leg against the other, is suffi- cient to cause powerful contractions. Involuntary movements of the limbs, independent of those due to reflex excitations, are rarely met with. The electro-muscular contractility is always increased. It has already been mentioned that there are frequently ocular troubles. These generally occur among the early symptoms, and relate either to vision, to the movements of the eyeball, or to both. Indeed, the very first symptoms may be connected with the eye or the nerves supplying its muscles. Thus there may be amaurosis due to gray atrophy of the optic nerve, or of the disk, a condition readily detected by the ophthalmoscope. Or the third pair of nerves may be involved, causing ptosis, divergent strabismus, and dilatation of the pupil; or the sixth pair of nerves alone may be affected, causing convergent strabismus; or there may be only contraction of the pupil and promi- nence of the eyeball from the irritation propagated from the cilio-spinal centre through the sympathetic nerves. These ocular troubles never take place in sclerosis of the posterior root-zones existing below the cilio-spinal centre—the upper dorsal region of the cord. Galezowskia has called attention to a very important fact in con- nection with the ocular disturbances of ataxics, and that is the loss of the ability to distinguish certain tints and colors. Thus patients affect- ed with locomotor ataxia, and who are at the same time amaurotic from gray atrophy of the optic nerves, are unable to distinguish the secondary tints of the scale (1 to 5, Plate F), and lose the perception of red and of green. The perception of yellow and blue is not lessened. On the contrary, it appears in some cases to be rendered abnormally delicate. I have frequently verified the extreme value of these tests, 1 Allg. Med. Cent-Zeitung, No. 93, 1869; also, Journal of Psychological Medicine, October, 1870, p. 622. i "Du diagnostic des maladies des yeux par la chromatoscopie rdtinienne," etc., Paris, 1868; also, "E^chelles typographiques et chromatiques pour l'examen de l'acuite visuelle," Paris, 1874. PROGRESSIVE LOCOMOTOR ATAXIA. 593 and have often observed the phenomena referred to when there was no other disturbance of normal vision, so far as all type-tests were con- cerned. The disturbances in the healthy action of the stomach and intes- tines, which have already been alluded to as common initial symptoms, are sometimes very distressing. As the pains in the limbs are often taken for evidences of neuralgia or rheumatism, so these gastric and intestinal troubles are frequently regarded as indicating the existence of dyspepsia. I have had a number of patients under my charge who, with double vision, ptosis, contracted or unequal pupils, incoordination, and the other symptoms of locomotor ataxia, had been told that "it was all dyspepsia," because vomiting and gastric pain were prominent features of the disease. These symptoms are also due to the relations of the sympathetic nerves with the spinal cord, and are not present in cases where the lesion is low down in the lumbar region. When, however, this part of the cord is involved, there are very remarkable disorders of the genital system. These consist of frequent nocturnal emissions with or without erections, or of an inordinate desire for sexual intercourse. A gentleman who consulted me a few weeks ago, and who was affected with the disease in question, informed me that he had several times had as many as eight seminal emissions in one night, and that his sexual desire was almost inextinguishable. Paralysis of the bladder is a common circumstance, and the sphinc- ter is not infrequently likewise affected. The bowels are usually obsti- nately constipated. The feeling of constriction around the body which is so common a symptom in acute myelitis, and which is met with in other organic affections of the cord, is rarely absent in cases of sclerosis of the poste- rior columns. Although the course of the disease in the great majority of cases is onward to a fatal termination, there are often periods of remission as in other spinal affections, and it rarely happens that the duration is not several years. A gentleman from Westchester County, in this State, has been affected for over twenty years, and still walks tolerably well. Another, from Boston had been subject to the disease for over twelve years. When I first saw him he could not stand with his eyes shut, had the characteristic ataxic gait, was subject to genital and urinary troubles, but yet was no worse than he had been six years previously. He visited me again in October, 1875, walking as well as when I saw him originally, but still subject to the electric-like pains in as great degree as ever. Another, from Pittsburg, has been in a stationary condition for several years; and another, from Binghamton, in this State, remains about as he was three years ago. I could easily cite twenty others whom I occasionally see professionally, who hold their own, and who have been affected for from five to ten years. Romberg gives the aver- 594 DISEASES OF THE SPINAL CORD. age duration at from ten to fifteen, Jaccoud at from six to eight, and all authors agree that the course is slow. Of the many patients affected with sclerosis of the posterior columns of the spinal cord who have been under my charge during the last ten years, five only have as yet died, so far as I am aware. Of these, one had been affected seven years, one eight years, and two about ten years, one eight and a half years. There are several cases now under my charge in which the affection has existed longer than either of these terms. The advance of the disease in the cord causes an aggravation of all the symptoms, and the appearance of others not previously no- ticed. The loss of motor power is now a prominent feature, the mus- cles become atrophied, bed-sores make their appearance, there is ana- sarca, and the patient, if not carried off by some intercurrent affection, dies of the extreme exhaustion induced by his disease. Among the anomalies of sclerosis of the posterior root-zones of the spinal cord, the joint affections are especially worthy of attention. Their connection with posterior spinal sclerosis was first indicated by Char- cot.1 Previous to his observations, they had been noticed, but they were ascribed to an intercurrent rheumatism, and, many years before locomotor ataxia was recognized as an independent disease, the associa- tion of spinal disease with inflammation of the joints was pointed out by Prof. J. K. Mitchell,9 of Philadelphia ; and his son, Dr. S. Weir Mitchell, with Drs. Morehouse and Keen,3 had also related cases in which wounds of the spine had been followed by arthritis. Since Char- cot's paper was published, Dr. Benjamin Ball * has cited cases of like affections coexisting with locomotor ataxia. In the cases in question there is no fever, redness, or pain. The swelling is due to the accumulation of liquids in the synovial cavity, and the affection is the result of defective nutrition of the bony, car- tilaginous, and soft parts connected with the joint. These accidents make their appearance usually in the interval be- tween the occurrence of the shooting-pains so characteristic of the first stage and the motor difficulties which mark the beginning of the sec- ond stage. Generally they disappear without leaving permanent or- ganic changes behind them, but in some cases the head of the bone may be absorbed, and spontaneous dislocation be the result. Of the cases of locomotor ataxia which have come under my obser- vation, in seven only were there any troubles of the joints. Death may take place either as the direct consequence of the lesion 1 " Sur quelques arthropathies qui paraissent ddpendre d'une lesion du cerveau ou de la moelle epiniere," Archives de physiologie, No. 1, January, 1868, p. 161. 2 American Journal of the Medical Sciences, vol. viii., 1831, p. 55. 3 " Gunshot-wounds and other Injuries of Nerves," Philadelphia, 1864. 4 " On Diseases of the Joints connected with Locomotor Ataxy," Medical Times and Gazette, October 31, 1868. PROGRESSIVE LOCOMOTOR ATAXIA. 595 of the spine, or as the result of some intercurrent affection, such as pneumonia, dysentery, phthisis, or cystitis. Causes.—I have been very unsuccessful in my efforts to ascertain the cause in the greater number of persons affected with progressive locomotor ataxia who have been under my observation. The opinion is very prevalent that it is generally the result of excessive venereal in- dulgence ; and, although this is undoubtedly sometimes a cause, it cer- tainly is not so common a one as is generally supposed. I have care- fully inquired into the etiology of all the cases I have seen, and have only been able to assign inordinate sexual indulgence as the cause in a very small proportion. The impression has probably arisen from the fact that there are frequently aberrations of the sexual function as phe- nomena of the disease. Injuries and exposure to cold and dampness were apparently the causes in some cases, standing in a constrained po- sition—three cases in railway conductors—in others, the excessive use of alcoholic liquors in a larger proportion, and syphilis in probably one- twentieth of the cases. In the majority, however, no cause can reason- ably be assigned. As regards the predisposing causes, it is certainly more common in men than in women—four cases only in my experience pertaining to the female sex. The age from twenty-five to forty is that in which it most frequently appears. There seems to be no direct hereditary influence to the disease. Diagnosis.—A consideration of the symptoms detailed in the fore- going pages will prevent posterior spinal sclerosis from being confound- ed with any other affection of the spinal cord. It may, however, be difficult at times to discriminate between it and the lesions of the cere- bellum, and the distinction has frequently not been made by very skill- ful diagnosticians. At one time Duchenne held the view that locomo- tor ataxia was really the result of a lesion of the cerebellum, but he subsequently x retracted this opinion, and accepted the doctrine that the spinal cord is the seat of the disorder. In a recent memoir2 I have endeavored to point out the differences between cerebellar disease and the affection now called posterior spinal sclerosis. In that essay I have said : " Derangement of locomotion certainly does result from injury or disease of the cerebellum. Experi- mental physiology, as well as pathology, proves this. Beyond a doubt the disorder is, however, clearly due to vertigo. There are, moreover, headache, vomiting, and eventually in some cases hemiplegia, generally of the opposite side to that of the cerebellar lesion, a fact at variance with Larrey's assertion. The gait of a person thus affected is exactly 1 " Diagnostic differential des affections c6r6belleuses et de l'ataxie locomotrice pro- gressive," Gazette hebdomadaire, 1866. 1 " The Physiology and Pathology of the Cerebellum," Journal of Psychological Medi- cine, April, 1869. 596 DISEASES OF THE SPINAL CORD. similar to that of a drunken man. As Carre says, the movements are not abrupt, jerking, and exaggerated, as they are in locomotor ataxia. They are more uncertain, and do not depend upon any defect of co- ordination, but upon weakness of the voluntary power. " When either of the peduncles of the cerebellum is affected there is an irresistible impulse to go sideways, and sometimes gyratory move- ments are produced." The characteristic symptom of cerebellar lesion is vertigo; and, although this is sometimes met with in sclerosis of the posterior root- zones, it is not a prominent feature, and is rarely present at all except in the very earliest stage. In the cerebellar lesions the cutaneous sensibility is unimpaired, whereas in posterior spinal sclerosis it is always diminished. A patient with disease of the cerebellum can stand and walk better with his eyes shut than with them open, for the vertigo is not in the former condition felt to the same extent. The reverse is true of loco- motor ataxia. The history of the case will also serve as a good guide to the diagnosis. In the latter or even in the developed stage of loco- motor ataxia it would be difficult to mistake it for any other affec- tion. Prognosis.—The prognosis is no more favorable than that of ante- rior or lateral spinal sclerosis. A few cases are cured, more are relieved, but the great majority go on unchecked. Of the cases which have come under my observation, seven were cured, and they were subjected to treatment from a very early stage. Of these, four were probably of syphilitic origin, but in the other three no such cause was at all probable. One of them was a woman. The cases in which amelioration has been produced are more numer- ous. In fact, it is not at all uncommon to succeed in retarding the on- ward progress of the disease, and of thus prolonging the life of the patient. Morbid Anatomy.—Within the last few years many very important contributions have been made to the morbid anatomy of locomotor ataxia mainly by the pathologists of that great French school of the Salpetriere with Charcot at its head. For the complete understanding of these a few words relative to the normal anatomy of the parts con- cerned are necessary. In embryonic and early infantile life the posterior columns are di- vided into two unequal parts by a fissure extending from the angle formed by the posterior median fissure and the posterior commissure of gray matter. The internal or median part is wedge-shaped, is of greater extent in the cervical region than in the dorsal, and greater in this than in the lumbar. It is called the slender column of Brudach, cuneiform column or column of Goll. The external part of the posterior column is all that region bounded PROGRESSIVE LOCOMOTOR ATAXIA. 597 externally by the posterior horn of gray substance and interiorly by the column of Goll. It is called the external band of the posterior column, or the posterior root-zone. In adult life the fissure separating these two regions no longer ex- ists, but its situation is generally marked by a furrow on the periphery of the cord, and a histological difference exists between them, in that the columns of Goll contain a greater amount of connective tissue than do the posterior root-zones. Now, although it often happens that both these subdivisions of the posterior columns are the seat of the alteration giving rise to locomotor ataxia, it has been very positively shown that the essential lesion is that of the posterior root-zones, and that it is to the disease of these re- gions that the peculiar symptoms of locomotor ataxia are due. In fact sclerosis of the posterior columns may exist and there be no ataxic symptoms whatever, as is shown by the secondary phenomena of Pott's disease. Here a degeneration or sclerosis of a part of the posterior col- umns throughout their whole extent exists, and there are none of the characteristic symptoms of locomotor ataxia present. But the appar- ent discrepancy is explained when we come to find that in these cases the lesions are confined entirely to the columns of Goll. As we shall see hereafter, this is not the only evidence, for the col- umns of Goll are subject to primary sclerosis without the production of ataxic symptoms. On the other hand, when the posterior root-zones are sclerosed, the phenomena of locomotor ataxia are always present, whether the col- umns of Goll be involved or not. This point has been determined by a case very thoroughly investigated by Pierret,1 in which a woman named Moli suffered from the electric-like pains, and incoordination of locomotor ataxia, which were mainly experienced in the upper extremi- ties. On post-mortem examination that part of the cord—the cervico- dorsal—in relation with the upper extremities was found to be scle- rosed in a thin lamina existing only in the posterior root-zones. The columns of Goll were perfectly healthy. In another case the same observer had the opportunity of confirming the results previously obtained. A woman (Cutta) had suffered for many years with electric-like pains in the lower extremities, plantar anaes- thesia, and incoordination. Standing and walking were impossible. In late years she had experienced constricting pains around the body. The superior extremities were not in the least involved. On post-mor- tem examination the posterior columns in the lumbar region were scle- rosed throughout their whole extent, except that on each side a little islet of healthy tissue remained. At the sixth dorsal vertebra the scle- rosed tissue was less extensive and almost entirely confined to the col- 1 " Sur les alterations de la substance grise de la moelle Epiniere dans l'ataxie locomo- trice," etc., Archives de physiologie, 1870, p. 597. 598 DISEASES OF THE SPINAL CORD. umns of Goll, the posterior root-zones only exhibiting on each side a little islet of sclerosed tissue. A little higher these islets disappeared and the lesion was entirely limited to the columns of Goll.1 Now, if the lesion of the columns of Goll had been at all connected with the symptoms observed during life in the lower extremities, we should not be able to account for the entire exemption of the superior extremities from all ataxic phenomena, for the columns of Goll in that part of the cord in relation with them were the seat of marked lesion. In another case reported in the same memoir, both upper and both lower extremities were affected, and on post-mortem examination the whole of the posterior columns in the lumbar, dorsal, and cervical re- gion were altered. Hence, comparing this case with the other, the conclusion is irresist- ibly arrived at that the ataxic phenomena exhibited in the upper ex- tremities of this second case were due to the lesion of the posterior root-zones, and not to that of the columns of Goll. Even when the columns of Goll are the seat of marked disease, it is more than probable that the lesion originates in the posterior root-zones and therefore affects the columns of Goll secondarily. Pierret expresses the opinion, in which Charcot concurs, that the implication of the col- umns of Goll is a phenomenon analogous to that which produces an as- cending median sclerosis as a result of partial myelitis, and that the lesion is only produced in those cases in which the morbid process is very strongly pronounced in the lumbo-dorsal region of the cord. In a subsequent memoir, M. Pierret2 discusses with great ability the anatomical disposition of the fibres entering into the composition of the posterior columns of the cord, and shows that the external fasciculi are in reality the posterior root-zones, and that it is in them the essential lesion of locomotor ataxia resides. But it is not always the case that the morbid process stops with the posterior root-zones and the columns of Goll; the posterior horns of gray matter, the lateral columns, and even the anterior horns, may be reached. As to the spinal nerves, it will almost invariably be found that the posterior roots are atrophied. The intra-cranial lesions are important. Indeed, there is reason to think that they are often the starting-point of the disease. They have been very carefully studied by many observers, and the fact that one of the most striking of them—that of the optic nerve—can be observed with the ophthalmoscope, gives additional interest to the subject. The alteration which the optic nerves undergo is a slow progressive 1 "Note sur la sclerose des cordons posteYieurs dans l'ataxie locomotriceprogressive,' Archives de physiologie, tome iv., 1871-72, p. 364. 8 " Considerations anatomiques et pathologiques sur le faisceau post^rieur de la moelle Epiniere," Archives de physiologie, 1873, p. 334. PROGRESSIVE LOCOMOTOR ATAXIA. 599 sclerosis, causing atrophy of the disks and of the nerves themselves. From the color which the nerves assume, the condition is known by ophthalmologists as gray degeneration. According to Leber, and Weck- er and Jaeger, the essential changes met with in gray degeneration of the optic nerve are a marked increase in the quantity of connective tissue, especially of the cell-elements, and the appearance of numerous grumous cells. The lesion is therefore of the same character as sclero- sis affecting the other parts of the nervous system. The ophthalmoscopic appearances have been so clearly stated by Wecker and Jaeger,1 that I quote from them the following details : " The clinical characters are especially revealed by the particular appearance of the papilla and by the narrowing of the visual field. " An essential sign which we have claimed for the ophthalmoscopic image of gray degeneration, is the more or less complete absence of an atrophic excavation. It is of course easy to understand that such ex- cavation is much less apt to be formed when there is a substitution of cellular tissue than when, as in simple atrophy, the entire nervous struct- ure disappears. " In gray degeneration of the nerve the initial signs of the disease consist in a simple change in the color of the papilla without any exca- vation. It becomes pale, as is perceived by the examination of the erect image with Helmholtz's plates, and it assumes a more or less pro- nounced bluish tint. "With this change of color there is a coincident change in the transparency of the tissue of the disk. It becomes impossible to fol- low the central vessels in their ramifications ; they seem to be applied to the bluish-white tissue of the papilla, and the whitish sclerotic ring offers a marked contrast to the opaque tissue of the nerve." According to these authors, the ophthalmoscopic appearances in cases of gray degeneration are sufficiently characteristic to enable the diagnosis of locomotor ataxia to be made with certainty from them alone. This is, however, I am inclined to think, too positive a state- ment. We may, however, safely conclude that when they are coexist- ent with the disturbance of chromatic perception previously referred to ; when the pupils are contracted—they are dilated in ordinary optic neuritis and atrophy of the optic nerve—and especially when electric- like pains are present, we have as positive indications of the existence of locomotor ataxia as are desirable. Besides this atrophy of the optic nerve, there is another condition to which it is subject, as a consequence of a preexisting sclerosis of the posterior root-zones, and that is a chronic neuritis. This state is in- duced when the spinal lesion is seated in that part of the cord known as the cilio-spinal centre. The ophthalmoscope in these cases reveals 1 " TraitS des maladies du fond de l'ceil," Paris, 1870, p. 73. 600 DISEASES OF THE SPINAL CORD. in the early stages the existence of choked disk, and subsequently sim- ple atrophic changes. This condition is not peculiar to locomotor ataxia, but may be caused by other chronic affections of the spinal cord. It is referred to by Dr. Clifford Allbuttl in his excellent mono- graph as " simple or primary atrophy of the optic nerve, sometimes ac- companied at first by that slight hyperaemia and inactive proliferation which make up the state I have called chronic neuritis. This sort of change I have never found as a result of spinal injuries, but I have often met with it in chronic degeneration of the cord, and in locomotor ataxy." Besides the optic, others of the cerebral nerves may be affected. Those most commonly involved are the third, the sixth, and the audi- tory; the lesion of this latter causing deafness and other disturbances of hearing. The lesions found in the brain never affect primarily the hemi- spheres. To be sure, it is sometimes the case that there are mental troubles, but they come on toward the close, and are probably the result of defective nutrition and sympathetic action. The other cerebral lesions, like that of the optic nerve, are in very intimate anatomical relation with the posterior columns of the cord. They are, therefore, met with in the lower cerebellar peduncles, in the restiform bodies, and in the optic thalami, and consist of degeneration and atrophy. The situations of the spinal lesions and their general character were well known to Romberg a before the researches of Duchenne, Charcot, and others. Thus, he states that he was present at the post-mortem examination of the cord of a former patient. The organ was reduced one-third in diameter, and the atrophy was confined to the lower part of the posterior columns. The posterior nerve-roots were also atro- phied, but the anterior columns were healthy. He was also acquainted with the fact that the cerebral nerves were similarly affected. Although it is probable that the sympathetic is atrophied in some part of its extent, in many cases of locomotor ataxia, the fact has not been demonstrated, except as regards one instance reported by Donnezan, in which a filament from the superior cervical ganglion was found atrophied. The ganglion itself was healthy. In the later stages of the affection the muscles may exhibit a con- dition of atrophy. In such cases their tissue will be found on micro- scopical examination to have undergone fatty degeneration and substi- tution to a greater or less extent. 1 " On the Use of the Ophthalmoscope in Diseases of the Nervous System," etc., Lou- don and New York, 1871, p. 198. 3 " Lehrbuch der Nervenkrankheiten des Menschen," " Sydenham Society Transla- tion," London, 1853, vol ii,, p. 399, PROGRESSIVE LOCOMOTOR ATAXIA. 601 The morbid anatomy of the joint-affections which sometimes result from the spinal lesion consists in an accumulation of water in the syno- vial cavity, and a general oedema of the soft parts. The most common seat of this alteration is the knee, and next after that the shoulder. The hip, the elbow, the wrist, and the smaller joints, may also be in- volved. Occasionally, the trouble does not stop here, but the articulat- ing surfaces may become rough from atrophy of the proper bone- tissue, and eventually a considerable part of the osseous substance dis- appears, giving rise to spontaneous laxation. The accompanying fig- ures, from Charcot, illustrate the nature of the change. In Fig. 78 is represented the superior extremity of the healthy humerus, and in Fig. 79 the corresponding part of a humerus exhibiting the lesions produced by locomotor ataxia. Fig. 78. Fia. 79. Pathology.—The theory of posterior spinal sclerosis which is gen- erally held is, that the lesion impairs a faculty by which the muscles are brought into harmonious action—a faculty of coordination. According to this view, the first thing to be done was to locate this faculty in an organ, and Duchenne, with whom it originated, adopting the ideas of Flourens and others, placed it in the cerebellum, and therefore regarded what he designated progressive locomotor ataxia as a disease of the cerebellum.1 Thus he said: " In conclusion, regarding the order of appearance, and the habitual progress of the symptoms which mark the three periods of progressive locomotor ataxia, we find that the central morbid action which pro- duces the phenomena symptomatic of this disease begins in general in the motor nerves of the eye, and in the tubercular quadrigemina, ex- tending thence to the superior and inferior cerebellar peduncles and finally to the cerebellum." As already stated, Duchenne has since abandoned this view of the 1 "De 1'electrisation localisee," deuxieme Edition, Paris, 1861, p. 611. 602 DISEASES OF THE SPINAL CORD. location, and now assigns its seat to the posterior columns of the cord, but, in order to make the morbid anatomy agree with the theory of the disease which he holds, he places his faculty of coordination in the cord. But, although it has been established by numerous post-mortem examinations that the cerebellum is not the seat of lesion in cases of locomotor ataxia, and although the differential diagnosis between dis- eases of the cerebellum and posterior spinal sclerosis has been very clearly made out, there are some who still hold the view that, although the cerebellum shows no traces of disease, and that, although the poste- rior columns of the spinal cord may be in a state of sclerosis, the symp- toms are the result of an interruption to the passage, from the cere- bellum through the posterior columns to the spinal nerves, of that force which coordinates the muscles into harmonious action. In the memoir to which reference has already been made, I have entered at length into the consideration of the question of the location of a coordinating faculty in the cerebellum, and have, I think, adduced sufficient facts and arguments to show that coordination is not one of its functions. Without going into a full account of the subject, a synopsis of the con- clusions arrived at will probably not be deemed out of place : 1. The consequences of removal of the cerebellum, if the animal survives the immediate effects of the injury, are not enduring. This conclusion is supported by experiments by Flourens,1 Hailing,1 Wag- ner,3 Dalton,4 myself," and others. The physiological inference, of course, is, that, if the faculty of coordination resided in the cerebellum, it ought to be permanently removed with the ablation of the organ. 2. The entire removal of the cerebellum from some animals does not apparently interfere in the slightest degree even for a moment with the regularity and order of their movements. I have performed a num- ber of experiments with reference to this point, on different classes of animals. They prove very clearly that the cerebellum is not the gen- erator of coordinating power in all animals that have it: a fact in com- parative physiology which is fatal to the hypothesis that this is its function in man. 3. The disorder of movements which results in birds and mammals immediately after injury of the cerebellum is not due to any loss of coordinating power, but is the result of vertigo. If the cerebellum be removed from a pigeon it exhibits disorder in its movements, but a careful examination of the phenomena exhibited, 1 "Recherches expdrimentales sur les propri6t6s et les fonctions du systeme ner- veux," Paris, 1842. 2 "Experimenta quaedam de affectibus laesionum in partibus encephale," 1826. 8 " Nachrichten von der Universitat und der Konigl. Gesellschaft der Wissenschaften zu Gottingen; " also, Journal de la physiologie de Vhomme et des animaux, Avril, 1861., 4 American Journal of the Medical Sciences, January, 1861, p. 83; also, " Treatise on Human Physiology," fourth edition, 1867, p. 416. 6 Op. cit, p. 24. PROGRESSIVE LOCOMOTOR ATAXIA. 603 shows that it is suffering from a vertiginous sensation. Even when placed upon its breast and allowed to remain at rest, there is a trem- bling and swaying of the body, such as is produced by alcoholic intoxi- cation. Exactly such symptoms can be caused by giving pigeons bread soaked in alcohol. 4. The phenomena of cerebellar disease or injury, as exhibited in man, are not such as show any derangement of the coordinating power. Many cases are on record which support this proposition. Andrals states that, of ninety-three cases of cerebellar disease which he has studied, only one appeared to support the theory which locates the co- ordinating power in the cerebellum. Many special instances might be brought forward, and several have occurred in my own practice. The case of Alexandrine Labrosse, re- ported by Combette,3 is, however, worth referring to more specifically. His paper is entitled " Case of a young girl who died in her eleventh year, in whom there was complete absence of the cerebellum, of the posterior peduncles, and of the annular protuberance." Magendie ex- amined the brain after her death, and satisfied himself that the defect was congenital. As M. Combette remarks in regard to this case, Ale- xandrine Labrosse had been able to walk for several years, but always in an uncertain manner. Gradually her legs lost their strength, and she became paraplegic. She preserved the use of her upper extremities to the last. It is very evident, therefore, that the weakness of her legs was due to paralysis, for, had it been the result of incoordination, the arms must necessarily have participated. For these reasons, I think, it cannot be considered, with any degree of probability, that the cerebellum has any thing whatever to do with the symptoms manifested in sclerosis of the posterior root-zones of the cord. Neither is it, in my opinion, necessary to assume the existence of an organ whose office it is to exercise a coordinating power. Other authors have ascribed the incoordination which is so promi- nent a phenomenon of sclerosis of the posterior root-zones to the loss of what they call the muscular sense. Sir Charles Bells has argued strongly in support of the existence of such a sense. He enunciates his theory in the following sentence : " Between the brain and the muscles there is a circle of nerves ; one nerve conveys the influence from the brain to the muscle, another gives the sense of the condition of the muscle to the brain." It is by this connection that we are enabled, according to Sir Charles 1 " Clinique mSdicale," seconde Edition, tome v., p. 735. Journal de physiologie experimental et pathologique, par F. Magendie, tome xi., Paris, 1831, p. 27. 8 " On the Nervous Circle which connects the Voluntary Muscles with the Brain," 14 Philosophical Transactions." Also, " The Nervous System of the Human Body," Lon- don, 1830, p. 225. 60-i DISEASES OF THE SPINAL CORD. Bell and other physiologists, to form an idea of the state of contraction of a muscle, and to lessen or increase the contraction as may be neces- sary. According to some writers, in locomotor ataxia the patient loses this muscular sense, or is unable to exert it, for the reason that the spinal columns through which the perception reaches the brain are, by disease, rendered incapable of transmitting it. In my opinion—and I shall endeavor to support it presently—there is no such perception as that referred to, and its existence is certainly not established by the case reported by Dr. Ley to Sir Charles Bell, and which is incorrectly quoted by Trousseau ; for it proves nothing more than that defective sensibility existed, and that the sense of sight had to be used in order to obtain a correct idea of what the insensible muscles were doing. A lady having been recently delivered, and having suffered severe haemorrhage, was seized soon afterward with headache and numbness. Dr. Ley was called to see her. " I found her," he says, " laboring under severe headache, not con- fined to, but infinitely more violent upon one side than the other, and occupying the region of the temporal and occipital bones above the mastoid process, and attended with considerable pulsation. "Upon one side of the body there was such defective sensibility, without, however, corresponding diminution of power in the muscles of volition, that she could hold her child in the arm of that side so long as her attention was directed to it ; but, if surrounding objects withdrew her from the notice of the state of her arm, the flexors gradually re- laxed, and the child was in hazard of falling. The breast, too, upon that side, partook of the insensibility, although the secretion of milk was as copious as in the other. She could see the child sucking and swallowing, but she had no consciousness from feeling that the child was so occupied. Turgescence of that breast produced no suffering, and she was unconscious of what is termed the draught on that side, although that sensation was strongly marked in the other breast. " Upon the opposite side of the body there was defective power of motion, without, however, any diminution of sensibility. The arm was incapable of supporting the child, the hand was powerless in its grip, and the leg was moved with difficulty and with the ordinary rotary movement of a paralytic patient, but the power of sensation was so far from being impaired that she constantly complained of an uncomfortable sense of heat, a painful tingling, and more than the usual degree of un- easiness from pressure or other modes of slight mechanical violence." After a few months she died ; having, in the mean time, received no improvement from the active treatment employed, and having also be- come pregnant again. On post-mortem examination there were found evidences of chronic inflammation of the membranes of the brain. The cord was not examined. Certainly this case presents nothing which PROGRESSIVE LOCOMOTOR ATAXIA. 605 may not be met with in any patient who has anaesthesia on one side and paralysis of motion on the other. I have observed a number of similar cases, and they neither prove the existence of a muscular sense, nor do they have any special bearing on posterior spinal sclerosis be- yond the fact that they exhibit deficient sensibility. But, before proceeding to the further discussion of this subject, clear ideas should be entertained relative to.the anatomy and physiology of the spinal cord. The researches of Dr. J. Lockhart Clarke have given us very exact information on these points, and I shall therefore quote from him in full.1 As Dr. Clarke states, before he began his researches on the struct- ure of the spinal cord, it was universally taught, both in England and abroad, that the posterior roots of the spinal nerves were attached ex- clusively to the lateral columns of the cord; whereas he showed, what is now universally admitted, that they are attached immediately to the posterior columns, and not at all to the lateral. The importance of this fact in both a physiological and 'pathological point of view, and espe- cially in its relation to sclerosis of the posterior root-zones, will pres- ently appear. In Fig. 80, which represents a transverse section of the right lateral 1 See Dr. Clarke's paper on " Locomotor Ataxy," in British Medical Journal, Septem- 25, 1869, p. 344, from which I take this account and the accompanying woodcuts. 606 DISEASES OF THE SPINAL CORD. half of the lumbar enlargement of the cord, the posterior nerve-roots (I) are seen to enter through nearly the entire breadth of the posterior col- umn, excepting that strip nearest the posterior median fissure called the column of Goll (a); and in Fig. 81, which represents a longitudinal sec- Fig. 81. tion of the cervical enlargement of the cord, we see the course of the roots of four consecutive nerves (P, P, P, P) within the cord. These roots are of three kinds : The first kind (a, a, a, a) enter the cord trans- versely, and pursue a very remarkable course. Each bundle, after traversing the longitudinal fibres of the posterior column (PC) in a compact form, and at a right angle, continues in the same direction to a considerable but variable depth within the gray substance (G), dilat- ing and again contracting, so as to assume a fusiform appearance. It there bends round upon itself, at a right or more obtuse angle, and, running for a considerable distance in a longitudinal direction down the middle of the cord, sends forward, at short intervals, into the anterior gray substance, a series of fibres, some of which mingle with those of the anterior roots (A), while others enter the anterior white column, as at AC, AC, in which they run longitudinally, both upward and downward. The second kind of posterior roots (b, b, b) also traverse the poste- rior column transversely, but sometimes a little obliquely from without inward. Their component fibres are finer than those of the other bun- dles, measuring about the ^ ^ 0th of an inch in diameter. Some of these fibres cross over transversely to the gray substance of the op- posite side through the posterior commissure behind the canal. Others extend into the posterior and lateral white columns of the same side, while the rest may be traced deeply into the anterior gray substance (G, Fig. 81), where they diverge in different directions, and are ulti- mately lost to view. The bundles forming the third kind of posterior roots (c, c, c, Fig. ' 81) enter the end obliquely. A few of their fibres proceed near the sur- face of the posterior column both upward and downward, and pass out again with roots above and below them. The rest cross the postenor PROGRESSIVE LOCOMOTOR ATAXIA. 607 column obliquely and chiefly upward, a small number only running downward. Interlacing at the same time with each other and with the roots already described, these fibres diverge, and for the most part reach the gray substance at points successively more distant from their en- trance into the cord in proportion to the obliquity of their course, the most divergent and superficial taking a longitudinal course at least for some distance, with the fibres of the posterior column, among which they are lost. From these investigations (" Philosophical Transactions," 1853), Dr. Clarke inferred that the posterior white columns of the cord cannot be the only channels for the transmission of sensory impressions, an inference which was verified two years later by the experiments of Brown-Sequard (Gazette medicate, 1855). Such being the anatomical connection of the posterior nerve-roots with the posterior columns of the cord, it is evident that no part of the length of those columns except the fasciculi bordering on the posterior median fissure—the columns of Goll—can be damaged either by injury or disease without involving destruction of a corresponding number of nerve-roots; and, since reflex action of the cord requires that impres- sions be conveyed by nerve-roots to the gray substance, the diminution of reflex action in cases of injury to the posterior columns is thus readily explained. We have also in these facts an explanation of the pains which are felt in the parts supplied by nerves coming from the diseased parts of the cord. The sclerotic process causes pressure to be exerted on the roots, and, in accordance with the law that irritation applied to a nerve- centre or trunk is felt most acutely in the peripheral branches, we have the pain experienced not in the cord but in distant regions. Subsequently, as the integrity of the nerve-roots and of the paren- chymatous substance of the posterior root-zones becomes destroyed, the hyperaesthesia is succeeded by anaesthesia, and indeed in many case.s coexists with it from the very earliest development of the symptoms. Dr. Clarke, in the anatomy and physiology of the posterior nerve- roots and their relations to the cord, which he has thus so satisfactorily elucidated, presents a theory of the phenomena of incoordination met with in posterior spinal sclerosis, t■■•" -"k-:«h I will allude more specifi- cally directly. In the mean time a few words in reference to the " muscular sense " are necessary to the understanding of the whole subject. Landry l declares that, whenever a muscle is caused to contract, the brain perceives the seat and the extent of the contraction. I am very sure that no sensation starts from the muscle which can give the brain any idea on the subject. As Trousseaua remarks: 1 "Memoire sur la paralysie du sentiment d'activitS musculaire," Paris, 1855 8 Op. cit, p. 159. 608 DISEASES OF THE SPINAL CORD. " An important distinction must be drawn between the conscious- ness of a movement which has been executed, and the consciousness of the muscular contraction which performs the movement. When after shutting our eyes we execute without effort a pretty extensive move- ment, we are unable, even on paying the strictest attention, to feel the contraction of our muscles, although we may feel the movement com- municated to the lever by the contracted muscles. This fact is so true, that, when we ask an intelligent person, who knows nothing of anat- omy and physiology, which is the seat of the movements through which the fingers are flexed or extended, he immediately points to the hand, and never to the forearm. It is only when the muscular effect is con- siderable and kept up for a long time, that it is perceived where the contraction really occurs. Normally, then, we have no consciousness of muscular activity, but merely the consciousness of the movement itself, which is a perfectly different thing." In a very thorough essay on the subject, Dr. Bastian2 has discussed the whole subject of the " muscular sense." He denies—and I think with good reason—the existence of any such special sense. In his opinion, there is no consciousness of the state of muscular contraction, and that the estimations by which we regulate the extent to which it is necessary, for instance, to contract the muscles of the upper extremity to sustain a certain weight in the hand, are "inferences based upon previous sensory impressions of the passive kind, upon impressions emanating from the skin, from the joints, and from the muscles them- selves, so that m my opinion there are no conscious impressions deriv- able through the ' muscular sense.'" This, as I think, is not to be considered as an appanage of the intellect, but rather as an unconscious organic guide in the performance of voluntary movements. Why, it may be asked, do. I not, as Trousseau has already done, deny its exist- ence altogether ? And to this I should reply by saying : " Although there is no evidence to lead us to believe that we derive any conscious impressions through the intervention of this so-called ' muscular sense,' there is evidence to show that the brain is assisted in the execution of voluntary movements by guiding impressions of some kind, which, while they differ from the impressions producible by means of the ordi- nary cutaneous and deep sensibility, may differ still further from these, owing to the fact of their not being revealed in consciousness at all." This impresses me as being a very philosophical view of this rather difficult question, and it is in part sufficient to explain the incoordina- tion existing in cases of sclerosis of the posterior root-zones; but, for the full understanding of the subject, it appears to me we must bring forward another fact in the physiology of the spinal cord which has not 1 Remarks on the " Muscular Sense " and on the " Physiology of Thinking," British Medical Journal, May 1, 1869, and subsequent numbers. PROGRESSIVE LOCOMOTOR ATAXIA. 609 hitherto, so far as I know, been made applicable. The spinal cord serves two distinct purposes in the economy. It transmits nervous force to and from the brain, and it is a centre which generates nervous force. Referring now to the anatomical details given by Dr. Lockhart Clarke, we find that the posterior nerve-roots not only reach the white substance of the posterior root-zones and antero-lateral columns, but that they are in intimate relation with the gray matter. Now, the white substance simply serves for the transmission of nervous force, the gray elaborates it. Hence a great many of the muscular actions which we perform are done through the agency of this gray matter of the cord, and are without the intervention of the brain, and the brain can only be brought to bear upon them through the agency of the white substance. The states of muscular contraction are, therefore, in all probability, perceived by the gray substance of the cord, and, as the brain has no consciousness of the perceptions of the cord, we are not made aware of the states of muscular contraction. The muscular sense, therefore, does not exist, at least in the same manner as do the other senses. In sclerosis of the posterior root-zones of the spinal cord the lesion generally involves the posterior nerve-roots, the posterior white sub- stance, and the posterior cornua of gray substance. Hence the cord loses both in the ability to transmit and to generate nervous force. Those unconscious acts of muscular coordination which are regulated by the gray substance of the spinal cord can no longer be perfectly accom- plished, and the brain is brought to assist in the determination through the sense of sight. The patient cannot stand well with his eyes shut, or walk in the dark, or determine differences of weight, because he is rely- ing altogether on the perceptive faculty of the spinal cord, and this organ is not in a condition to perform its work with precision ; and his movements and muscular contractions are rendered still more uncertain from the fact that the cutaneous sensibility is diminished. In the normal condition we frequently—in determining weights, for instance—are greatly assisted by the sense of sight, and there is noth- ing surprising in the fact that, in a disease like locomotor ataxia, the spinal cord should be unable to perceive states of muscular contraction without the assistance of the brain. And, as the conducting power of the cord is also lessened, the brain cannot act with its full power; and, therefore, even with all the assistance to be derived from the chief gen- erator of nervous force in the body, the patient's muscles are not so well coordinated as in health. Dr. Lockhart Clarke, in the memoir already cited, explains the inco- ordination upon another principle, which, although, as I think, not sufficient to account for the phenomenon, may, and probably does,, exer- cise some influence. His view is, that there is a physiological state of the muscles dependent on reflex action, that is absolutely essential to 010 DISEASES OF THE SPINAL CORD. the proper coordination of voluntary movements, and that is, their toni- city, or that moderate but constant state of contraction which keeps the antagonist muscles, or those that are variously opposed to each other, in equilibrium or static tension. In the performance of voluntary movements a constantly-varying number of muscles, each of which differs more or less in force and in the particular direction which it gives to the limb or part, are associated together in action in an endless variety of ways. Each of the muscles that compose these varying groups must contract either simultaneously or successively to a certain particular extent, with a certain degree of force, and with a certain degree of rapidity, in relation to the actions of the others, according to the resultant direction desired in the voluntary effort; and this end- less variety of ways, in which a constantly-varying number of muscles are balanced against each other in contraction for the performance of constantly-varying and complicated voluntary movements, affords the most exquisite and beautiful example of what, in physical science, is termed the composition of forces. In this balancing of muscular force we have to learn by experience, and to remember the exact voluntary effort required to contract each muscle to its proper extent, with'its proper force, and with its proper degree of rapidity, in relation to the action of the others that complete the group employed. Now, it is evident that if some of the muscles of the group employed have lost their normal tension or tone, they will not properly respond to the excitation of the voluntary stimulus, and will fail to perform their proper part in balancing the effects of the other muscles of the group that retain their tension, in the execution of any given movement. In proportion, therefore, to the exact amount of tension lost by any mus- cle or muscles of the group, and the number of muscles that have lost that tension, there must necessarily be a proportionate amount of dis- orderly movement of incoordination. But it appears to be satisfactorily proved, by the experiments of Brondigeest, Rosenthal, and others, that this constant tension or tone of the voluntary muscles is due to a con- stant reflex action of the cerebro-spinal centres, and is immediately dependent on impressions conveyed from the muscles to those centres by the posterior roots of the nerves. Now, Dr. Clarke has shown how these posterior spinal roots are spread out through the posterior col- umns of the cord; how impossible it is for these columns to be de- stroyed to any great extent without involving destruction of the nerve- roots ; and how, consequently, the columns are so destroyed in loco- motor ataxia. But, except in the very last stage of this malady, all the posterior roots are not injured by disintegration, and some of them are still competent to carry impressions to the gray substance of the cord; so that some of the muscles retain their tone, while others lose it to a greater or less extent. This is Dr. Clarke's explanation of the peculiar feature of posterior PROGRESSIVE LOCOMOTOR ATAXIA. 611 spinal sclerosis, in almost his own words. That it is ingenious and plausible, all physiologists and pathologists will admit. An interesting point connected with the pathology of locomotor ataxia is the fact that the spinal lesions sometimes exist in conjunc- tion with the cerebral lesions which are the anatomical basis of general paralysis of the insane. This subject was alluded to when the last- named disease was under consideration. Westphal,1 who was the first to give special attention to this matter, does not believe that there is any direct relation between the morbid process in the cord and that in the brain. Neither of them is, in his opinion, secondary to the other. They simply coexist as the expression of an excessive proclivity to dis- ease of the nervous system, just as any other two diseases may be pres- ent, one in the brain and the other in the cord, without there being any direct interdependence between them. This is undoubtedly correct. Locomotor ataxia is by no means uncommon in patients affected with the other forms of insanity. Several such cases have come under my own observation, and Dr. Patrick Nicol,2 in an excellent memoir, has adduced several instances which have occurred in his experience. As we have seen, the lesions in sclerosis of the posterior root-zones are not always confined to the original seat. Among other parts of the cord liable to be involved is the anterior tract of gray matter. Hence we have the more complete development of paralysis and the superven- tion of atrophy in the affected muscles. A remarkable instance of loco- motor ataxia combined with muscular atrophy formed the subject of a clinical lecture,8 which I delivered at the Bellevue Hospital Medical College, in the winter of 1871-'72. In this case there were electric-like pains, incoordination, ocular troubles, ptosis, double vision, plantar an- aesthesia, etc. After about two years muscular atrophy set in, begin- ning in the left leg, then involving the right corresponding member, then the left arm, and finally the right upper extremity. In this case the lesion of the posterior root-zones was the primary lesion, the anterior tract of gray matter subsequently becoming sym- metrically implicated. There were no contractions like those present when the lateral columns of the cord are the seat of disease. In the case of the woman Moli, reported by Pierret,4 to which refer- 1" Ueber den gegenwartigen Standpunct der Kentnisse von der allgemeinen progfessiven Paralyse der Irren," Griesinger's Archiv fur Psychiatrie und Nervenkrankheiten, Heft i., Band i., 186*7. 2 " On Progressive Locomotor Ataxy and some other Forms of Locomotor Deficiency, as found in the Insane," "West Riding Lunatic Asylum Medical Reports," vol. i., 18*71, p. 178. 3 " Clinical Lectures on Diseases of the Nervous System," New York, 1874, p. 156. * " Sur les alterations de la substance grise de la moelle 6piniere dans l'ataxie locomo- trice conside>6es dans leurs rapports avec l'atrophie musculaire," Archives de physiologie, 1870, p. 690. 612 DISEASES OF THE SPINAL CORD. ence has already been made, there were also the combination of the symptoms due to the lesion of the posterior root-zones, and those re- sulting from the extension of the morbid process to the anterior horns of gray matter-i—the right side being the seat of profound musculai atrophy. On post-mortem examination it was found that the right an- terior horn of gray matter in the dorsal and cervical regions was the seat of degenerative changes in the nerve-cells, many of which had dis- appeared. The horn was markedly diminished in size. These changes are shown in the accompanying figure (Fig. 82) from Pierret—a, the posterior roots ; b, the internal radicles, the sclerosis being limited to their area ; c, the right anterior horn of gray matter atrophied. This association of muscular atrophy with sclerosis of the posterior root- zones is to be explained by the fact, first pointed out by Kolliker,1 that some of the internal fibres of the posterior roots pass toward the ante- rior horns of gray matter, and can be traced as far as the large cells forming the external group. The connection of the fibres of the pos- terior roots with the anterior horns of gray matter is also referred to by Lockhart Clarkea and Gerlach." Fig. 62 TreatBlGnt.—It must be remembered that locomotor ataxia often spontaneously remits in the violence of its symptoms. Indeed, the re- mission may at times amount to almost a complete intermission. But taking this fact into full consideration, I am quite sure that the disease is not in every case uninfluenced by medical treatment. A great many medicines have been recommended, and numbers of cures have been re- ported. Careful inquiry, however, suffices to show either that the al- 1 " A Manual of Human Histology," " Sydenham Society Translations," vol. i., 1853, p. 415. 2 " Philosophical Transactions," 1853. 3 Strieker's " Manual of Histology," American edition, New York, 1872, p. 645. PROGRESSIVE LOCOMOTOR ATAXIA. 613 leged cures were merely instances of more or less complete remission, or that the cases were really not examples of the disease in question. To even mention the assumed remedies would be profitless labor. In the very earliest period of the disease ergot is calculated in some cases to be of decided benefit. It should be administered in doses of at least a drachm three or four times a day, and continued for several months. The bromide of potassium, sodium, or calcium, is an effica- cious adjuvant. Under the combined use of these remedies I have repeatedly seen the electric-like pains diminish in violence or even alto- gether disappear. The gastric disturbances may often be alleviated by bismuth, or, what is usually still more efficacious, by the saccharated pepsin in doses of fifteen or twenty grains with each meal. With these measures the primary galvanic current applied to the spine, on each side of the spinous processes, is an agent which ought to be used. Cases have been reported by Meyer, Benedict, and others, in which it alone has apparently effected cures—or arrest of the morbid process—and Rosenthal * speaks highly of its beneficial influence. I have used it with success in several cases in conjunction with the means previously mentioned. Ordinarily, it has not appeared to me to be of any material service. The pains in the back and around the abdominal and thoracic regions may be combated with codeine in doses of from half a grain to one or even two grains, or with hypodermic injections of morphia. If the case comes under observation when the motorial troubles are well marked, or if, after having used it for a month, no decidedly beneficial effect follows the treatment just specified, I omit the ergot, and frequently use instead, the nitrate of silver in doses of the quarter of a grain three times a day. According to Rosenthal,1 Wunderlich, Charcot and Vulpian, Herschell, Klinger, Duguet and Vidal, have ex- tolled its merits. This remedy has in my hands apparently proved ser- viceable in several cases which were well advanced, but I am not able to speak definitely on the subject, for the reason that with it bromide of potassium, and especially galvanism, were used. Two cases were cured by the combined remedies—one of them was that of a distin- guished journalist, who, in the first place, was treated with ergot, and subsequently, when this medicine appeared to be of no further effect, with the nitrate of silver. At the present time, seven years having elapsed, this gentleman is well, free from pains, able to coordinate, and with no symptom of the affection remaining. The disease was first manifested by an epileptic paroxysm, and soon afterward ocular trou- bles made their appearance. The electric-like pains, abdominal con- striction, and incoordination in the upper and lower extremities, were 1 "Klinik der Nervenkrankheiten," Stuttgart, 1875, p. 394. 8 Op. cit, p. 390. 614 DISEASES OF TnE SPINAL CORD. well marked. He was under treatment for about four months. The other case was that of a lady of this city. The disease in her began with pain in the back, and electric pains in the lower extremities. Ptosis, dilatation of the right pupil, and diplopia followed, and then gradual loss of sensibility in the soles of the feet, and difficulty in coor- dinating the muscles of the legs. The disease had lasted two years and a half when the patient came under my charge. She was treated with the nitrate of silver and the other remedies mentioned, for nearly a year, and throughout the whole period gradually improved till her recovery was complete. The nitrate of silver was suspended for a week after each month of its administration. In a third case ergot and nitrate of silver were given together with- out the bromide of potassium. This case was that of a gentleman, a merchant of this city, residing in Bridgeport, Connecticut. He had had ocular troubles, and was suffering from pains, incoordination, plantar anaesthesia, paralysis of the bladder, and swelling of the right knee, when he came under my charge, being sent to me by my friend Dr. Hubbard, of Bridgeport. The disease had then lasted only a few months. With the medicines, the constant galvanic current to the spine and spinal nerves was employed. He was entirely cured in less than three months. In all cases inquiry should be made with reference to the existence of a syphilitic taint. If affirmative results follow the investigation, the iodide of potassium should be administered in gradually-increasing doses as recommended for acute spinal meningitis, or in combination with corrosive sublimate, according to the formula given on page 308, recol- lecting that galvanism is likewise to be used, and such other treatment as the special symptoms may seem to require. Two cases were cured by this treatment; one of them was that of a gentleman from the West —a fully-developed case—who had been treated by my friend Dr. Bumstead, for other syphilitic troubles, and who sent him to me for his spinal disease. The incoordination, plantar anaesthesia, pain in the lumbar region, and the electric pains, were all present, together with slight diplopia. He was under treatment for about ten months. I met him a few weeks since in a railway-car, the picture of health, and, as he told me, perfectly well. The other case occurred in the person of a gentleman of this city, and was similar in general features to the preceding. A cure was ob- tained, after like medication, in six months. In another case, after ergot had been used for several months with- out apparent benefit, the nitrate of silver was administered with the effect, to all appearance, of checking the further progress of the disease, and producing decided amelioration of the existing symptoms. The patient, a distinguished member of the dramatic profession, by my ad- vice, withdrew from the stage, and being in Philadelphia, he consulted PROGRESSIVE LOCOMOTOR ATAXIA. 615 at my suggestion Dr. Weir Mitchell, who unhesitatingly confirmed my diagnosis. He took the nitrate persistently for about six months, and was so greatly improved that I gave my consent to his resuming his profession. There are now no pains; his coordination is good, and his general health leaves nothing to be desired. In several cases I have obtained ameliorations by the use of phos- phoric acid, phosphorus, and chloride of barium, but after extensive experience with these agents, I am unable to report any permanently good results. If the vesical sphincter be paralyzed, belladonna may be used with advantage, preferably in the form of hypodermic injections of atropia gradually increased daily, from the one hundred and twentieth of a grain to the thirtieth. Hydro-therapeutics in all forms, and faradization, have never, ac- cording to my experience, been of the slightest benefit, except as re- gards the use of the latter to the affected muscles. The ether-spray recommended by Jaccoud has been entirely inefficacious in my hands, and the same may be said of all plasters and embrocations. One auxiliary means of treatment I have lately employed with ad- vantage, and that is, keeping the patient as much as possible from using the groups of muscles which have lost their coordinating power, and requiring him, when he walks, to employ crutches to assist him. By systematically carrying out this plan the nervous force of the pa- tient is not wasted, and a diseased organ, such as is his spinal cord, is not overtasked. Lately I have employed, and thus far with apparently good results, the actual cautery to the spinal column. I have used it in eleven cases. The effect has been to lessen, and in three cases entirely to abolish, the electric pains and the feeling of constriction around the body. In one fully-developed case which I had before the medical class of the Uni- versity of New York, the pains, which were of great intensity, ceased within a few hours after the first cauterization. Ten days subsequent- ly I repeated the operation, the pains in the legs having returned, and again the relief was complete. Again, in the case of a gentleman from the interior of this State, who had suffered for several months with plantar anaesthesia, abdomi- nal constriction, and incoordination, complete immunity was ob- tained by the actual cautery several times applied, in conjunction with ergot and bromide of sodium, continued for two months. While, therefore, I am not able to report definitely the cure of a single case in which the actual cautery has been used, there is certainly reason to hope that it may be found of permanent service. In using it, I have first rendered the skin anaesthetic with the ether- sPrav> and have then, with the platinum disk, heated to a white heat, made three or four applications on each side of the spinous processes, 616 DISEASES OF THE SPINAL CORD. at the upper level of the lesion in the cord, as nearly as could be as- certained. A week afterward, the operation should be repeated a little lower down, and so on, according to the situation and progress of the lesion. VIII. INFLAMMATION--SCLEROSIS--OF THE COLUMNS OF GOLL. We have seen that the columns of Goll or posterior median fasciculi are generally the seat of a lesion simultaneously with, or more probably secondarily to, that which, existing in the posterior root-zones, causes the group of symptoms we call locomotor ataxia. There is, however, no doubt that they may be the seat of primary disease, and, though the data are not yet sufficient to enable us to give the clinical history of the affection as fully as is desirable, we are not altogether without information on the subject. Our definite knowledge rests upon one case reported in full by Pierret,1 and which I quote, greatly condensed as follows : Catherine Magnaigat, when thirty years of age (1855), experienced numbness, " pins and needles," sensations of heat, and deep-seated pains in the extremities, especially the upper. There were also pains in the loins, obstinate headache, and a sense of tightness around the chest. In 1860, vertigo and weakness of the lower extremities super- vened. She did not distinctly feel the ground with her feet, and she was obliged to walk with a cane. In 1863 she entered the Salpetriere, and came under M. Charcot's care. Her condition was then as follows : Tactile sensibility was diminished in the soles of the feet, the left especially. She could not walk without a crutch, which she used under her right arm. When she wished to go forward she experienced an impulse to spring or leap, and finally she advanced by a series of short steps, and felt as if impelled by a force she could not resist. When she closed her eyes while standing alone she maintained the erect position for a while, but would eventually have fallen unless supported. She was easily fatigued, and walking caused pains which compelled her soon to stop. Her feet seemed to stick to the ground when she made volun- tary efforts to lift them. Sometimes, when she attempted to advance, she felt herself irresistibly drawn toward the left side. When after having taken a few steps she wished to go back, she turned round sud- denly as if moved by a spring. In 1866 she, for the first time, experienced constricting pains around the body low down, and electric-like in character. Soon after- ward she felt similar pains in the anterior part of the thighs. Cu- taneous sensibility was then diminished in the lower extremities. 1 " Notes sur un cas de sclerose primitive du faisceau median des cordons post& rieurs," Archives de physiologie, 1873, p. 74. INFLAMMATION OF THE COLUMNS OF GOLL. 617 The idea of the exact position of the limbs was not in the least im- paired, and there was no incoordination. Such was her condition when in 1871 she died of pneumonia. The post-mortem examination showed that the columns of Goll were throughout their whole extent in a state of sclerosis. It was most manifest in the dorsal region, where it, to a slight extent, invaded the posterior root-zones, to which circumstance, doubtless, the electric-like pains experienced by the patient were due. The case would appear to show that sclerosis of the columns of Goll gives rise to certain symptoms in the lower extremities, however much the superior may retain their normal condition. In some cases of loco- motor ataxia there has been noticed an unusual feeling of heaviness in the lower extremities, or a marked tendency to go backward, or a great feeling of fatigue after slight exertion, a marked incertitude in standing erect, or even an irresistible feeling of propulsion. In such instances, therefore, the columns of Goll were affected at the same time with the posterior root-zones. M. Pierret holds the opinion that these columns, to some extent, preside over motion. The accompanying woodcuts (Figs. 83, 84, 85, 86) represent scle- rosis limited to the columns of Goll, and are taken from M. Pierret's memoir Fig. 83 refers to the cervical region, Fig. 84 to the dorsal, Fig. 85 shows the appearance of a section made at the level of the second dorsal vertebra, and Fig. 86 one taken from the upper part of the lumbar enlargement. The sclerosed portion is represented at a in each figure. Fig. S3. Fig. 84. a Fig. 85. Fig. 86. a a a 618 DISEASES OF THE SPINAL CORD. In the present state of our knowledge, all that we can do is to await further developments relative to the interesting points raised by the case which M. Pierret has so well studied. IX. DISSEMINATED INFLAMMATION OF THE SPINAL COED—MULTIPLE SPINAL SCLEROSIS—SCLEROSIS IN PLATES—INSULAR SCLEROSIS. Thus far we have considered the inflammatory affections of the spinal cord as they appear in one or another of the anatomical divisions which make up that nerve-centre. But we have now to engage our- selves with a lesion which has no fixed habitation, which is met with in the gray and white matter indiscriminately, and which occurs in distinct foci, patches, plates, or islets, in various parts at the same time or con- secutively. This is what is known as multiple spinal sclerosis or sclerosis in disseminated plates—the sclerose en plaques diss'emin'ees of Charcot. Symptoms.—Multiple spinal sclerosis generally first manifests its presence by more or less weakness in one or the other lower extremity. Before long the corresponding limb becomes involved; and, eventually, if the disorder continues to form additional centres of morbid action, the upper extremities are successively attacked. At other times the first symptoms are connected with sensibility, and consist of the various sensations of numbness, tingling, "pins and needles," formication, and the like. Or these phenomena may make their appearance simultaneously with the paresis. The gait of a person affected with multiple spinal sclerosis is uncertain and titubating—like that of an individual slightly intoxicated. Although there is defective coordination, the patient stands as well with the eyes shut as open, and has no additional difficulty in walking in the dark or with the eyes closed. The paralysis advances, but there are no marked disturbances of sensibility, and the numbness which may have been present to some extent in the early stage usually disappears. The patient is, therefore, sensitive to changes of temperature, to pain, and to pressure. Pains are very uncommon. Occasionally, there are slight painful sensations in the paralyzed parts, but they are temporary. The general health usually remains good, and the mind is unaf- fected. Later, in the course of the disease, rigidity or contraction makes its appearance in the paralyzed limbs, or both these conditions may co- exist in the same extremity, some of the joints being contracted, and others rigidly extended. The tendency is for these conditions to be- come permanent. Again, there are violent tonic convulsions in the paralyzed limbs which may be spontaneous, but which are readily ex- DISSEMINATED INFLAMMATION OF THE SPINAL CORD. 619 cited by impressions made upon the skin of the affected extremities, or even sometimes by mental emotions. They may precede, or coexist with, or follow the permanent contractions. In some instances these phenomena are not met with. They were absent in the case of Dr. Pennock, reported by Drs. Morris and Mitchell; in a case under my own charge, and in which I made an examination of the cord soon after death ; and in a case reported by Friedreich,1 in which multiple spinal sclerosis existed in conjunction with the lesions of locomotor ataxia. When present, as they generally are, these permanant contractions of the muscles exhibit different phases in the upper and lower extremi- ties. In the former the flexors predominate over the extensors, while in the latter the extensors prevail. The spasmodic tonic convulsive move- ments of the limbs are especially met with in the lower extremities, the upper being rarely their seat. After a time, which may vary from three or four to fifteen or twenty or even more years, the limbs become almost entirely paralyzed, and the contraction and rigidity are still more strongly marked. Whatever voluntary movements the patient is capable of executing now cause pains in the parts. The sensibility usually, however, even at this period remains but little affected. Reflex excitability generally exists though perhaps slightly impaired; sometimes it is altogether lost. The bladder and the sphincter ani retain their power to the last. Bed-sores form on the parts subjected to pressure as the patient lies in bed, and death eventually ensues, either from exhaustion or from some intercurrent affection. Such is a description of multiple spinal sclerosis as it is ordinarily en- countered—and it must be confessed that the clinical features are not very striking or peculiar. But even this type, imperfect as it is, is sub- ject to great diversities. Sometimes there are violent pains of an elec- tric-like character simulating those which are so prominent a feature of locomotor ataxia and like them resulting from the implication of the posterior root-zones in the lesion. Sometimes the superior extremities are attacked first. Again, anaesthesia constitutes a prominent feature, and the phenomena ordinarily present may be more or less modified in extent and intensity in different cases. In their very excellent monograph on the subject, MM. Bourneville and Guerard,8 in detailing the symptomatology of the spinal form of disseminated sclerosis, say: " After a variable time the superior and inferior extremities^ become the seat of rhythmical agitations, which are only present, however, 1 "Ueber degenerative Atrophie der spinalen Hinterstrange," Archiv fur pathologist Anatomie und Physiologie, 1863, p. 433. 8 "De la sclerose en plaques dissSmine'es," Paris, 1869, p. 61. 620 DISEASES OF THE SPINAL CORD. when spontaneous or voluntary movements are made. In the state of repose the members are not affected with any tremor." In this connection I desire to repeat what I wrote five years ago,1 that " tremor is never observed in spinal sclerosis of any form, diffused, multiple, or cortical, unless the pons Varolii or superior ganglia of the brain are implicated. In the only case of this latter form published— that of Vulpian 2—the sclerosis extended throughout the whole length of the cord, and likewise involved the pons Varolii, cerebellar peduncles, and other intra-cranial organs, besides being accompanied with well- marked spinal meningitis. The tremor observed at a late period of the disease cannot, therefore, be ascribed to the lesion of the cord below the medulla oblongata." Of the cases cited by Bourneville and Gu^rard in which post-mortem examinations were made, one from Vulpian and one from Morris and Mitchell, in which the lesions were restricted to the cord, there was no tremor at any time in the course of the disease; and in a case of my own already cited, and which will be still more specifically referred to here- after, in which the cord was the seat of several islets of sclerosed tissue, tremor had never been a feature of the symptomatology. As we shall see hereafter, wrhen we come to the consideration of the cerebro-spinal form of the disease—multiple cerebro-spinal sclerosis— tremor constitutes one of the most prominent phenomena of the affec- tion. We have already seen that it is a marked symptom of the purely cerebral type of the affection. I am quite sure, however, that in the disease we are now considering, restricted as its lesions are to the spinal cord, rhythmical tremor is not encountered. Causes.—The causes of multiple spinal sclerosis are not well under- stood. In a case fully reported by Vulpian,8 the affection appeared to have been induced by a sprain of the left ankle. The extremity re- mained weak, and three years afterward the patient had a fall, and then the right lower extremity became weak and subsequently the right upper extremity. The left upper extremity was not affected for several years. In the case of Dr. Pennock, reported by Drs. Morris and Mitchell, the disease began while the patient was busily engaged in professional studies. In the case in which I verified the existence of the disease by post- mortem examination, it was apparently caused by exposure to cold and dampness. It is probable that blows on the spine, concussions—such as are pro- duced by railway accidents—and the gouty and syphilitic diatheses— 1 First and subsequent editions of this work, p. 473. * Op. cit, p. 64, et seq. * " Note sur la sclerose en plaques de la moelle epini&re," Union medicate, 1866, Juin 1, 9, 14, et 19, obs. L DISSEMINATED INFLAMMATION OF THE SPINAL CORD. 621 may induce multiple spinal sclerosis. There is in reality no reason, to my mind, why all the influences which are capable of causing the dif- fused forms of sclerosis which have been considered, may not also-cause the disseminated variety. But it is difficult to arrive at any definite information relative to this matter, so long as the clinical features of the disease are so little characteristic. Diagnosis.—There is very little in multiple spinal sclerosis sufficiently pathognomonic to aid us in our diagnosis of the affection. The symp- toms in some cases are identical with those of symmetrical lateral scle- rosis, in others they resemble those of locomotor ataxia, as in the two cases reported by Friedreich, to one of which allusion has already been made. In the present state of our knowledge, therefore, I am afraid we must wait for the scalpel and the microscope to determine with any degree of accuracy the diagnosis of multiple spinal sclerosis. Prognosis.—The disease is not one which is directly calculated to cause death. All the patients known to have died while subject to it, succumbed to some intercurrent affection, such as bronchitis, dysentery, typhoid fever, and pneumonia. It undoubtedly tends to weaken the vital powers, and hence is indirectly the cause of a fatal result. So far as any prospect of arresting, by therapeutic means, the tendency to the formation of other islets of inflammation and sclerosis, or of restoring the integrity of the cord is concerned, there does not appear to be much hope. For, though its progress is in many cases slow, and in others seems, at times, to be self-limited, it pursues its course unamenable, so far as we know, to medical treatment. In the diffused forms of spinal sclerosis there is but one centre of morbid action ; in the disseminated there are several, which, if not coexistent, tend, through an inherent proclivity, to be produced indefinitely. To this circumstance is due the fact that the prognosis of the disease under consideration is more un- favorable than that of sclerosis of the posterior root-zones or even sym- metrical lateral sclerosis. Morbid Anatomy and Pathology.—Multiple spinal sclerosis consists in the dissemination through the cord of masses of sclerosed tissue, which have resulted from the proliferation of the neuroglia and the consequent atrophy and disappearance of the proper nerve-elements. They are of a gray color, of increased consistence, of irregular size and form, and may exist in any part of either the gray or white tissue of the cord ; often, however, manifesting a tendency to involve the two lateral halves of the cord symmetrically. In the case reported by Vulpian, the volume of the cord was evi- dently diminished, and on different points of its surface exhibited an ashy-gray coloration. The antero-posterior diameter of the cord was markedly lessened at those places where the islets of sclerosed tissue existed. In this case there had been progressive paresis, rigidity, and con- 622 DISEASES OF THE SPINAL CORD. traction, with extension of all four limbs, without tremor of any kind. The alterations were found in the anterior, lateral, and posterior col- umns, -and in the anterior and posterior horns of gray matter. In the case of Dr. Pennock, reported by Drs. Morris and S. Weir Mitchell,1 the sclerosed tissue was confined mainly to the lateral col- umns. The posterior were involved to a very small extent. In this case there were partial anaesthesia, gradually-advancing paralysis im- plicating all four extremities, and paralysis of the bladder. The intel- lectual faculties were never affected in the least. The course of the disease was progressively onward, and, though there was toward the last a total loss of voluntary power below the neck, reflex action re- mained unaffected. There were no tremors with or without voluntary movements. In regard to this case, Dr. Mitchell, who made the micro- scopical examination, remarks that there were : " 1. Integrity of mental and moral manifestations. " 2. Absolute loss of voluntary motive power below the head, or rather below the neck. " 3. Sensation nearly perfect. " 4. Respiration good ; reflex motion preserved and exhibited in the form of spasm or irritation of certain parts of the skin." All of which are what we should expect to find in sclerosis almost entirely confined to the lateral columns. In the case which I have mentioned as coming under my own obser- vation, the patient, J. H., consulted me in the winter of 1869-70. He was then unable to walk without a cane and the assistance of an attend- ant. He had previously been treated at a water-cure establishment, and more recently by the Swedish movement-cure, and of course with- out benefit. The symptoms were mainly connected with motility. Both lower extremities were paralyzed ; the bladder was inactive, but not the sphincter, and there was obstinate constipation. There were occasional fibrillary contractions of the paralyzed muscles, and at times pain in the back and limbs—never, however, of any great degree of severity. There were no tremors, either with or without voluntary motions. The patient obtained very little benefit from the treatment to which I subjected him, and I advised him to return to his home in Ohio. A few months afterward, he died. The dorsal, lumbar, and sacral regions of the cord were sent to me for examination by his physicians, Drs. Ramsey and Bishop, of Delhi, Ohio. In a letter, the latter informed me that the vessels of the pia mater were injected. The cord arrived in good condition, having been carefully preserved in strong alcohol. Upon inspection, the antero-lateral columns in the 1 American Journal of the Medical Sciences, July, 1868. DISSEMINATED INFLAMMATION OF THE SPINAL CORD. 623 middle and lower dorsal regions to the extent of three and a half inches were seen to be of a grayish tint, which became deeper in shade from above downward. Below this, at the junction of the dorsal with the lumbar portion, was another patch two and a half inches in length, and also involving the whole superficies of the antero-lateral columns ; and, separated from this by a portion of apparently healthy tissue, was another discolored, irregular patch, an inch and a half in length, along the left antero-lateral column ; and, below this, a similar tract, two inches and an eighth long, involving the right antero-lateral column. The difference in consistence between these patches and the other parts of the cord was very decided, and the white striae were well marked. The sacral portion of the cord presented no abnormal appearance to the naked eye. Sections of the cord were then made through the sclerosed portions; and it was seen that the gray matter was only involved where the horns approached the surface ; and that, wherever a lesion existed, the normal contour of the sections was altered so as to make them sub- ovoidal, and thus to lessen the circumference. The greatest depth of any part of a sclerosed region was two-twelfths of an inch, and this was in the superior patch. The average thickness was about the one- twelfth of an inch. The whole cord in my possession was then immersed in a solution of chromic acid in water, and left there for a month to harden. Immedi- ately previous to examining with the microscope, the sections were col- ored by an ammoniacal solution of carmine. Under a twelfth-inch ob- jective, it was seen that, throughout the whole extent of the sclerosed portion of any section, the nerve-tubes had entirely disappeared ; and, wherever the gray substance was affected, the nerve-cells were dimin- ished in number. In the place of these elements were connective tis- sue, a large quantity of molecules, and connective-tissue cells in great abundance. In several sections taken from the dorsal, lumbar, and sacral re- gions, and which were apparently normal when viewed with the naked eye, the neuroglia was found to be in excess, and the nerve-tubes in a state of disintegration. The gray matter, except in those sections made through the part where the sclerosed portion extended from the white matter to it, was uniformly healthy, and in no part were the posterior columns in- volved. In this case there was no tremor, although it was clearly one of multiple sclerosis, probably entirely confined to the spinal cord. At no time had there been head-symptoms of any kind. Histologically, therefore, we see that the sclerosed tissue consists mainly of an exces- sive amount of connective tissue—the neuroglia of Virchow. The cells are increased in size, and the nuclei are larger and much more numerous 624 DISEASES OF THE SPINAL CORD. than in the normal condition. The capillaries are thickened, from the deposition on their walls of several layers of rounded cells. The effect of this morbid process is to compress the nervous fila- ments and to cause their atrophy. The fluid portion undergoes fatty degeneration, and the axis cylinders become disintegrated. Still, how- ever, they present somewhat of their characteristic color and consist- ency, and appear as white striae traversing the morbid tissue. The membranes often exhibit evidences of inflammation, and are thickened, opaque in spots, or red in some cases, while in others they are adherent to each other and to the cord. Treatment.—Something can be done to mitigate the violence of the symptoms. Hypodermic injections of atropia have often a happy effect in diminishing the force and frequency of the tonic contractions. The nitrate of silver has been used by M. Piorry with temporary good re- sults. The primary or galvanic current has, in my hands, been of like effi- cacy in lessening the contractions or spasmodic rigidity, but with this agent, as well as'with the others mentioned, there can be no great cer- tainty that we are dealing with a case of multiple spinal sclerosis. We are, therefore, forced to treat symptoms instead of lesions. Still, for the cure of the disease we may attempt the measures recom- mended for symmetrical lateral sclerosis, but with even less prospect of success. I should be disposed to use, with thoroughness and persisten- cy, the actual cautery in the manner recommended when discussing the treatment of locomotor ataxia. X. SECONDARY INFLAMMATION AND DEGENERATION OF THE SPINAL COED. It is a well-recognized fact that disuse of an organ promotes its atrophy and degeneration. A muscle, which from any cause is rendered incapable of contracting, becomes smaller, and its fibrillae undergo con- version into fat. The same law applies to other organs, and among them the spinal cord. Whatever interrupts the passage of the normal excitations through its columns causes degeneration. Thus, if there be a cerebral haemorrhage, preventing the action of the brain on the mus- cles, the anterior columns of the cord, not being stimulated by their ac- customed excitation, undergo the change mentioned. If the cord itself be the seat of a lesion, or the posterior nerve-roots, and perhaps even the nerves or muscles, the posterior columns above, no longer being re- quired to convey impressions to the brain, suffer atrophy and degenera- tion. To this alteration, which is not itself a primary disease, but which is always, in its very nature, consecutive to lesions in superior or inferior parts of the nervous system, the term secondary degeneration has been applied. SECONDARY INFLAMMATION AND DEGENERATION. 625 The fact that the spinal cord is affected by lesions of the brain was observed by Cruveilhier,1 who, however, failed to notice any consecu- tive change in the cord below the decussation of the pyramids. L. Tiirck a was the first specially to inquire into this important sub- ject, and, in a series of memoirs extending through the years from 1851 to 1855, he showed that the cord underwent secondary degeneration, both from lesions of the brain and of its own substance. Since these memoirs, other pathologists, among whom MM. Charcot, Turner, Roki- tansky, Vulpian, Cornil, and Lancereaux, may be mentioned, reported cases, but no one has investigated the subject with so much thorough- ness as M. Bouchard.3 Symptoms.—The most important symptoms referable to secondary degeneration of the cord from cerebral lesions are muscular contractions. These are not the contractions which sometimes exist from the very in- ception of a hasmorrhage, for instance, but those which come on at a later period of the disease, and which, like the first, have generally been thought the consequence of irritation existing about the cicatrix. Bou- chard, however, shows very clearly that they are the result of secondary changes taking place in the spinal cord, and the clinical history of which has not hitherto been carefully studied. They are very frequent. Of thirty-two cases of old hemiplegia analyzed by Bouchard, they were present in all but one. From my own experience I think it is safe to say that it is very rare to meet with a case of hemiplegia of over a year's duration in which they do not exist. In examining a patient suffering from an old hemiplegia, it is com- mon to find the forearm of the paralyzed side flexed on the arm. Fre- quently, also, the fingers are bent into the palm of the hand, the hand flexed on the forearm, and the whole member carried across the front of the body, and held firmly against it by the contraction of the pecto- ralis major muscle. In such a case we find the muscles atrophied, hard, and stretched to an extreme degree of tension. Rectification of the position is, to a great extent, impossible by the voluntary efforts of the patient. He may be able to accomplish a little motion, and to do still more by using the sound hand to extend the affected arm ; but, if the hemiplegia has been of considerable duration, the range of his motility, with or without assistance, is very small, and is sometimes nothing.. I have found that the electric contractility of such muscles is diminished in some of their fibres, unaffected in others, and exalted in others, so that, when the electrical stimulus is applied, a hard, irregular, and knotty contraction is obtained. 1 "Anatomie Pathologique," liv. xxxii., p. 15. 8 " Ueber secondare Erkrankung einzelner Riickenmarks3trange und ihrer Forsetzun- gen zum Gehirne," " Sitzungsberichte der Kaiserlichen Wiener Academie," 1851. "Des degenerations secondaires de la moelle 6piniere," Archives generates de med., 1866. 40 626 DISEASES OF THE SPINAL CORD. This condition is much more common in the muscles of the upper extremity than in those of any other part of the body. The muscles of the trunk are never involved, and, unless, as Bouchard appears to think, the muscles of the face are occasionally affected, the alteration is entirely confined to the extremities. Of these, the upper are much more frequently its seat. Thus, of the thirty-one cases of rigidity with contraction, studied by Bouchard, the upper extremity was implicated in all, and the lower but in fourteen. In none of his cases was the lower extremity affected without the upper also participating, and he lays this down as an invariable occurrence. I, however, had a patient under my charge, a gentleman from the West, who five years previous- ly had had an attack of cerebral hemorrhage which rendered him hemi- plegic on the left side. There was not the slightest contraction of the muscles of the left upper extremity, but the toes of the left foot were strongly flexed, and the sole of the foot turned inward by the contrac- tion of the flexor longus digitorum, and the tibialis posticus. In another case, the only contraction was in the flexors of the toes of the left foot. So great a degree of inconvenience did this condition induce, rendering as it did walking or standing extremely painful, that, after ineffectual efforts at extension, I amputated the second toe, to the great relief of the patient. In another instance under my charge, the upper extremity was not carried across the front of the body, but was drawn backward by the contraction of the latissimus dorsi. The period at which these secondary contractions begin in cases of hemiplegia has been carefully studied by Charcot, and he has ascer- tained that they habitually make their appearance during the seeond month. The fingers are usually the first to be affected from the con- traction of the flexor muscles in the forearm. A symptom mentioned by Bouchard, as sometimes occurring, a trembling in the arm when it is raised, I have witnessed many times. Sometimes, especially, in the lower extremity, it is only necessary for the patient, while the foot rests on the ground, to give the leg a few voluntary movements, when the agitation is kept up for a long time involuntarily. Atrophy of the paralyzed muscles may be one of the secondary re- sults of brain-disease ; as we have seen, it is of a primary spinal affec- tion. When the cord itself is the seat of primary disease, the lateral col- umns below undergo degeneration, and the muscles become permanently contracted. Many cases of distortion which ensue on sclerosis, tumors, and other lesions, are the result of this secondary degeneration. M. Charcot is of the opinion that the epileptiform attacks sometimes met with in hemiplegics may result from these secondary descending degen- erations affecting the peduncles, the pons, and the medulla oblon- gata. SECONDARY INFLAMMATION AND DEGENERATION. 627 No symptoms referable to ascending secondary degenerations— those of the posterior columns—have been recognized. Causes.—Secondary degeneration of the spinal cord may result from primary lesions of the cerebral hemispheres, of the cerebral pedun- cles, of the pons Varolii, of the medulla oblongata, of the spinal cord itself, and of the posterior roots of the spinal nerves. The immediate causes are the loss of the due supply of arterial blood, and the arrest of nutritive action from deficient nervous influence. The Diagnosis calls for no special consideration. Prognosis.—This is not so unfavorable as might at first sight be supposed. Bouchard concludes that a cure is possible even in severe cases. In five cases which came under his observation, and in which there was complete paraplegia due to the compression of the cord in Pott's disease, complete cures were obtained in four, and a partial cure in the other. In the four entirely successful cases as regards the res- toration of sensibility, and the power of motion to the paralyzed limbs, there were contractions. He therefore concludes that the nerve-fibres of the cord, like those of the peripheral nerves, may be regenerated. My own experience is to the same effect. In cases of muscular con- tractions resulting from cerebral hemorrhage, and secondary degenera- tion of the cord, and in like troubles due to primary lesion of the cord itself, followed by secondary degenerations, I have several times suc- ceeded in effecting the complete relaxation of the contracted muscles, and the entire restoration of sensibility and the power of motion to the paralyzed limbs. Morbid Anatomy and Pathology.—Secondary degeneration is gen- erally found in the white substance, the gray being seldom affected. This might certainly have been expected, owing to the fact that it is the conducting power of the cord only that is lessened, and, as this power resides almost entirely in the fasciculi of the white substance in the antero-lateral and posterior columns, it is here that we ordinarily find the lesions. When a fibre belonging to the white substance is injured, either in the cord or in its intra-cranial prolongations, the secondary degeneration ensues either above or below the seat of the primary lesion, but it extends through the entire length of this portion to its central or peripheral extremity, according as it involves sensory or motor filaments. To these two varieties, the terms ascending and descending degeneration are applied. The affected fibres alone are changed, and the alteration extends throughout their whole length. But, as the white fibres are constantly receiving other fibres which have had no initial injury, the secondary degeneration becomes rela- tively less the greater the distance is from the seat of the primary lesion. The morbid condition depends upon three processes : atheroma of the capillaries and the formation of granular corpuscles in the degener- L 628 DISEASES OF THE SPINAL CORD. ated tissue ; the degeneration and atrophy of a greater or less number of nervous filaments; the proliferation of connective tissue which takes the place of the nerve-tubes. These changes are similar to those which occur in the several forms of sclerosis, to which attention has already been directed, and are essentially inflammatory in character. When there is atrophy of the paralyzed and contracted muscles as a result of secondary degeneration of the cord we may be very sure that the anterior horns of gray matter are involved. Charcot' cites a case which he reported to the Socikte de Biologie, in which a woman aged seventy was suddenly struck with left hemiplegia, occasioned, as the post-mortem examination showed, by a cerebral haemorrhage seated in the centrum ovale of the right hemisphere. Contraction of the para- lysed muscles supervened very soon, and, two months after the attack, the muscles of the inferior as well as of the superior extremity began to atrophy at the same time that their electric contractility was notably diminished. The muscular atrophy advanced with great rapidity, and simultaneously the skin on the paralyzed parts, when submitted to press- ure, was the seat of numerous bullae and even erosions. The examination of the spinal cord revealed the existence of a de- scending sclerosis, occupying the left side, and presenting its ordinary features. But in addition, at several points of the cervical and lumbar enlargements, the anterior horn of gray matter of the same side exhib- ited evidences of an inflammatory process, and at these points the large nerve-cells had undergone a marked degree of atrophy. Similar cases have been reported by Hallopeau. Treatment.—The best results in my experience have been obtained from the use of the primary galvanic current to the cord, the same or the induced current to the muscles, forcible extension and flexion of the contracted limbs, and the internal administration of nitrate of silver, chloride of barium, and cod-liver oil. It will generally be found that the opposing muscles are more or less paralyzed, and that great good may be effected by stimulating them with the primary or induced cur- rents. The division of tendons is never necessary, unless for the recti- fication of distortions of the toes or fingers. Sometimes the toes are strongly flexed against the sole of the foot, rendering it almost impos- sible to walk, from the pain produced by the dorsal surface being brought in contact with the ground, and hence obliged to bear the weight of the body. In such cases the tendons may with propriety be divided, unless the toes can be kept extended by some convenient pro- thetic apparatus, or as in the case under my care, to which reference has been made, the toe may, if necessary, be amputated. Passive exercise of the affected muscles will do much to restore them. Indeed, I am disposed to think that in some cases the tendency to con- tractions, which is so evident in most cases of cerebral haemorrhage, 1 " Lecons sur les maladies du systeme nerveux," 1874, p. 245. NON-INFLAMMATORY SOFTENING OF THE SPINAL CORD. 629 may be obviated by passive movements of the paralyzed limbs being begun at an early period, and continued for a long time. CHAPTER VI. NON-INFLAMMATORY SOFTENING OF THE SPINAL CORD. Softening of the spinal cord is, as we have seen, the common ter- mination of acute myelitis, in which connection it has been sufficiently considered ; but it may originate primarily, and in that event possesses a clinical history very distinct from that of acute inflammatory softening. Symptoms.—The first symptom usually noticed in softening of the spinal cord is numbness in those parts of the body below the seat of the lesion. Soon after the occurrence of this symptom there is weakness of the same parts, and then the deficiency of sensation and the feebleness of motor power advance together, both gradually becoming more and more strongly marked. There are no muscular twitchings, no contrac- tions of the limbs, no pains either at the seat of the disease or in the paralyzed limbs. The bladder very soon becomes involved, and the patient finds that, when he attempts to urinate, the stream is not so strong as it once was, and that he is obliged at times to use the expulsive force of the abdomi- nal muscles in order to complete the evacuation of the bladder. Gradu- ally the contractile power of this viscus becomes less, and finally is altogether lost. The sphincter generally participates. The desire to urinate becomes more frequent, and when the inclination is felt the patient must at once yield to it. Eventually the bladder likewise becomes entirely paralyzed, and then there is neither the ability to expel the urine nor to retain it, and consequently it dribbles away constantly. Sometimes the first evidence of softening of the cord is perceived either in the bladder or its sphincter, and it may be restricted to these parts for a considerable period. I have a patient at the present time under treatment for what I have no doubt is softening of the cord, and in whom the bladder-troubles were the only notable symptoms for over two years. The intestines are similarly affected, and the bowels are either ob- stinately constipated or the sphincter ani is relaxed, leading to fecal evacuations as soon as the contents reach the rectum. Reflex excitability is weakened from the first, and gradually disap- pears, unless, as is rarely the case, the gray matter be unaffected. The progressive advance of the disease reduces the patient to a con- dition of utter helplessness. He is unable to walk, sensation is abol- 630 DISEASES OF THE SPINAL CORD. ished in the paralyzed limbs, his urine and faeces are passed involun- tarily, bed-sores occur, the venereal appetite is extinct, or, if it should remain, erections are impossible, and the parts of the body below the seat of the disease are to all intents and purposes cut off from commu- nication with the parts above. This condition may last for years with- out a fatal termination ensuing, but intercurrent affections, especially resulting from the bladder-troubles, may eventually cause death. Such is the course of spinal softening when the lesion is low down and involves both antero-lateral and posterior columns. When it is higher up, the symptoms are also referable to the thoracic extremities, and to the muscles concerned in deglutition and respiration. There are likewise visceral disturbances. When the lesion mainly affects or is confined to the antero-lateral columns, the symptoms manifested are in intimate relation with the known physiological functions of the region in question. Thus the power of motion in the limbs below the softened portion of the cord gradually becomes less, the gait is from the first staggering, and, though even at a late stage the patient may be able to move his limbs while lying down or sitting, he cannot support the weight of his body upon them. When he tries to stand without extraneous aid, it is seen that he is especially weak in the knees and ankles. There is no more diffi- culty in standing or walking with the eyes shut than when they are open. This paralysis of motion, in which the bladder generally participates, may be of the most profound degree, and yet sensibility be perfect. A gentleman was under my care in whom I diagnosticated softening of the cord in that part extending on the right side from the second dorsal vertebra downward probably as far as the fourth sacral, while on the left side it began at about the fourth lumbar and extended downward probably as low as the fourth sacral. I gave the lesion these topo- graphical limits for the reason that on the right side the muscles sup- plied by the crural and sciatic nerves had lost their electro-muscular contractility, while it certainly did not extend above the origin of the iliohypogastric nerve, as the lower part of the rectus abdominis, which receives its motor power through this nerve, retained its contractile power. On the left side the muscles supplied by the crural nerve were possessed of their normal motor power, while those supplied by the sciatic had lost their contractility. It was, therefore, very certain that on this side the lesion did not extend above the fourth lumbar, the lowest spinal nerve contributing to the formation of the crural. I was able also to restrict the morbid process entirely to the antero- lateral columns, for in no part of the skin below the upper supposed limit of the lesion was there any loss of sensibility. The least impres- sion made upon the skin was felt. Tickling the sole of the foot excited laughter, but no reflex movements. I was therefore able to determine NON-INFLAMMATORY SOFTENING OF THE SPINAL CORD. 631 that the gray matter was involved. The bladder was paralyzed, and its sphincter likewise. The sphincter ani was also deprived of its con- tractile power to a great extent. The patient died at Cape May, and I had no opportunity of making a post-mortem examination. Probably, however, the lesion was essen- tially that which I have described. In all cases of spinal softening in- volving the antero-lateral columns, the electro-muscular contractility is soon lost, so that even the strongest induced or primary currents fail to cause contractions. As regards the implication of the posterior columns, there is an equal facility for determining the fact from a consideration of the symp- toms. The functions of these columns are intimately connected with sensation, and when such a morbid process as softening is set up in them the symptoms are those which indicate impairment of the cutane- ous and muscular sensibility. Thus, in a gentleman formerly under my charge, there had been going on for several months a morbid action in the spinal cord unattended by any prominent symptoms except anaes- thesia. There had never been pain or any derangement of motility, but simply a gradually-increasing loss of sensibility in both lower ex- tremities and in all the other parts of the body below the upper limit of the seat of the lesion. He was unable to walk in the dark or with his eyes shut, or to stand alone with his eyes closed and his feet close together, for he obtained no idea of his position unless he could have the aid of his eyes or hands. He had full power over the bladder and voluntary control over its sphincter and that of the rectum, but he never experienced the desire to urinate, did not feel the flow of urine through the urethra, nor the passage of the faeces through the anus, and evacuated his bladder and bowels at stated periods merely from the knowledge acquired by ex- perience that it was time to do so. Examination with the aesthesiometer showed that the upper limit of the lesion on both sides was in that part of the cord from which the second lumbar nerves are derived, for the loss of sensibility was appar- ent in all those parts supplied by the crural and sciatic nerves, both as regarded the skin and the muscles. Very weak faradaic currents caused muscular contractions, but the strongest which it was possible to ob- tain from a powerful machine produced no pain. There was no muscular incoordination, neither had there ever been electric-like pains in any part of the body. The patient died in 1873. For a year previously he had exhibited indications of insanity, and finally committed suicide by hanging himself to his bedpost. A post- mortem examination was made of his brain, but the physician who then had charge of the case thought it too great a trouble to examine the cord, and thus an opportunity for studying what must necessarily have been important lesions was lost. 632 DISEASES OF THE SPINAL CORD. In this case there was, I think, ample reason to diagnosticate a lesion of the posterior columns without any implication of the antero- lateral. The reasons for believing this lesion to have been softening will be indicated under the head of diagnosis. Causes.—The causes of spinal softening are not very clearly under- stood. Doubtless it arises as a consequence of acute myelitis, but it is often an independent and apparently a primary affection, being unpre- ceded by any obvious symptoms indicative of spinal derangement. Such influences as give rise to cerebral softening will, in all probability, cause spinal softening, and among them must be placed obliteration of blood-vessels from embolism and thrombosis. The actual occurrence of occlusion of spinal vessels from either of these causes has not, however, so far as I am aware, been demonstrated. The further etiology of spi- nal softening is not as yet a matter of any certainty, though I think several cases that have been under my observation could reasonably have their cause laid to excessive sexual indulgence. Diagnosis.—The diagnostic marks of most value in cases of sup- posed spinal softening are the absence of sensory and motor excite- ment. Thus there are no pains referable to the back or other parts of the body, no hyperassthesia, no twitchings, no spasms, no contractions, no exalted reflex actions. And this is the case in that form of the dis- ease involving the whole thickness of the cord, or in either of those limited to the anterior or posterior columns. There is no other affec- tion of the spinal cord which is not characterized, at some time or other of its progress, by irritation either of the sensory or motor nerves, or of both, excepting some cases of spinal anaemia giving rise to the cate- gories of symptoms previously considered. The clinical history of such cases, and the comparatively light character of the phenomena, will serve to distinguish them from those in which the lesion is softening. Prognosis.—The prognosis is always unfavorable as regards recov- ery and complete restoration, but spinal softening is not necessarily a fatal disease. At least, I have seen cases which had existed for many years, and which apparently had no elements of a fatal termination about them. But they were instances in which the seat of the disease was in the lower dorsal, or lumbar or sacral region of the cord. When it is higher up, the prospect of death ensuing is more probable. The restoration of the cord to its normal structure is impossible, and the patient lies paralyzed either in sensation or motion, or both, according to the situation and extent of the lesion, in a condition similar to that of a person who has received a wound inflicting irreparable injury on the cord. Such persons, as is well known, frequently live for many years afterward—then die of some entirely different disease. There is nothing about spinal softening calculated to produce exhaustion, un- less it be the tendency which exists to cystitis from paralysis of the bladder, and the consequent inflammation liable to be set up from the NON-INFLAMMATORY SOFTENING OF THE SPINAL CORD. 633 action of the retained urine. Care, however, will very greatly diminish the danger from this source. I have had a number of patients under my charge who had not, for many years, had a passage of urine from the bladder which was not effected with the catheter, and they had, in all that time, suffered no marked inconvenience. Morbid Anatomy and Pathology.—The appearance of a softened portion of the spinal cord to the naked eye has nothing very peculiar about it. When examined as to its consistence, it is seen to be some- times as soft as cream, at others scarcely altered in the resistance which it offers to the touch. In the first instance, when the lesion involves the gray and white matter together, section does not show the peculiar double crescentic arrangement of the former tissue, but it appears to be blended homogeneously with the white substance which surrounds it. Microscopically it is seen that the nervous tubules constituting the essential anatomical elements of the white substance are broken up, and no vestige of them remains in extreme cases—oil-globules and bodies called granule-masses, the constituent of which' is fat, having taken their place. In the gray substance the nervous cells are de- stroyed, and oil and fat have made their appearance in large amount. Even the neuroglia or connective tissue of the cord exhibits a similar disintegration and regressive metamorphosis. These changes impair the functions of the cord, both as a nervous centre and as a structure serving for the transmission of sensory impressions to the brain, and of nervous force from it. When the disintegration is complete, the effect is the same as if the cord had been entirely divided by a cutting in- strument. Treatment.—There is nothing to be done which can by any possi- bility restore the integrity of the spinal cord after the process of soft- ening has fairly entered upon its course. In the very early stages, if patients apply for treatment at these times, something may perhaps be accomplished by the use of phosphorus and strychnia, but the symp- toms come on so insidiously and gradually that the subject of them rarely has his apprehensions excited till it is too late to do any thing toward arresting the disease. And even when we do see cases which in appearance exhibit the symptoms met with in spinal softening in its initial stage, and which recover under treatment, there must always be a doubt in regard to the accuracy of the diagnosis—for many cases of temporary anaesthesia and impairment of motility are due to anaemia of the cord, the result of the causes set forth in a previous chapter. The patient, however, may be made comfortable to such an extent as to materially prolong his life. Care should to this end be taken that he does not sustain a fall or suffer an injury whereby the diffluent portion of the cord would be disturbed in its anatomical relations, and the danger of an attack of acute meningitis or of myelitis incurred. Bed-sores should be prevented, or, if they occur, treated according to 634 DISEASES OF THE SPINAL CORD. the methods previously mentioned, and full instructions should be given in regard to emptying the bladder with the catheter at regular times, and of going to stool at the same hour every day. Locomotion may be provided for by some one of the chairs devised for the use of paraplegics. As there is little, in softening of the cord situated below the origin of the phrenic nerves, which is directly calculated to de- stroy life, there is no reason why, with the adoption of proper meas- ures, the patient should not enjoy a measurable degree of comfort for many years. Probably the event most apt to occur is acute or chronic cystitis from paralysis of the bladder, but attention to the injunction above given will do much toward lessening the liability to this affec- tion. CHAPTER VII. TUMORS OF TEE SPINAL CORD. Following the example of Jaccoud, I shall consider under one head, tumors of the cord, of the membranes, and those which, growing from the interior surfaces of the vertebrae, may compress the cord, and thus interfere with its functions by deranging its structure. In the present state of our knowledge, we have not many exact data by which to dis- criminate between these several growths. Symptoms.—The phenomena which result from intra-spinal tumors, like those due to congestion, are of two categories, resulting as they do either from irritation or compression. Under the first head are em- braced pain in the back, in the limbs, and in the viscera, if the poste- rior columns are mainly the seat of the lesion or subjected to the press- ure of a vertebral tumor, and twitchings of the muscles, and contrac- tions of the limbs, if the antero-lateral columns are principally involved. When both sets of columns—as is generally the case—are affected, the troubles of sensibility and of motility are both present. If the tumor is situated in the cervical or upper dorsal region, there is generally tonic contraction of the muscles of the neck by which the head is thrown backward, causing the patient to present the appear- ance of a person affected with the opisthotonos of tetanus. There are in such a case usually ocular troubles, such as those previously men- tioned, and more or less gastric derangement. The symptoms, so far as the limbs and viscera are concerned, vary in their extent according to the situation of the morbid growth. The symptoms of strong compression are anaesthesia and motor pa- ralysis. These may or may not be accompanied with muscular atrophy. Reflex excitability and electro-muscular contractility are generally at first increased,.or at least not lessened, but, as the pressure augments TUMORS OF THE SPINAL CORD. 635 and the structure of the cord becomes more disorganized, they are less- ened. The bladder generally retains its power, but if the tumor be situated so as to compress the middle of the dorsal region there will be more or less difficulty in passing the urine which is retained through spasm of the sphincter. If the lesion exists at the upper part of the lumbar re- gion, or at about that part, the bladder and sphincter will be paralyzed, and the urine will dribble continuously.1 Many cases, of what may with Drs. Charcot and Brown-Sequard be called hemi-paraplegia, are due to spinal tumors. It often happens that these are small and compress a lateral half of the cord, leaving the other affected only by the transmitted pressure. A very remarkable case has been reported by Charcot,11 in which the left inferior extremity was completely paralyzed, while the right was simply weak without having lost the power of contraction in any of its muscles. On the other hand, sensibility was greatly lessened in the right limb, while it was exalted in the left. There was paralysis of the bladder, but no at- rophy of either limb. Finally, anasarca and bed-sores appeared, and the patient gradually sank. On post-mortem examination, a tumor was found growing from the dura mater on the anterior face of the cord and compressing its left lateral half. The accompanying wood- cuts (Figs. 87 and 88), reduced from Charcot's lithographic representa- tions, show the situation and relations of this tumor. Fig. 87 shows the growth in situ, and Fig. 88 the parts as they appeared when the tumor was pushed aside so as to allow the cavity to be seen in which it was lodged.9 Recollecting the facts that the fibres of the anterior or motor col- umns of the cord decussate at the medulla oblongata, while those of the posterior or sensory columns cross over soon after they enter the cord from the posterior roots of the spinal nerves, we can understand why, when the paralysis of motion is confined to one side, or is greater on that side, the lesion is on the corresponding side of the cord, and this loss of motility should be accompanied with anaesthesia of the opposite side of the body. Under the name of painful paraplegia (paraplkgie douloureuse), Cruveilhier referred to a form of spinal disease which has been subse- quently described more fully by Charcot. This latter author has ob- served six cases, in all of which there was cancer of the mammary gland. In three of these he had the opportunity of making post-mortem ex- 1 Charcot, "Lecons sur les maladies du systeme nerveux; seconde fascicule. De la com- pression lente de la moelle epiniere," Paris, 1873, p. 114. * Archives de physiologie, No. 2, p. 291. 8 This case is quoted at length by Dr. Brown-Sequard in the Lancet of September 25, 1889, p. 429. In previous and subsequent numbers of this journal Brown-Sequard haa contributed much valuable information on the subject of hemi-paraplegia. g36 DISEASES OF THE SPINAL CORD. aminations, and discovered carcinoma of a lumbar vertebra in each, to which the irritation and compression of the cord were due. According to him, " the skin, especially during the paroxysms of pain, is often Fig. 87. Fig. 88. very sensitive to the touch. At the same time walking becomes trouble- some, and later the patient cannot walk without help; finally, muscular atrophy ensues, and the patient loses the power to stand." Simon, from whom I quote these details, under the head of " para- plegia dolorosa," describes a case which came under his own observa- tion, in which, during life, symptoms similar to those mentioned by Charcot were noticed, and in which, after death, a cancerous tumor was found growing from the first lumbar vertebra and compressing the posterior columns of the cord. Other lesions were present in the pos- terior columns both above and below the tumor ; they were appar- ently of the nature of sclerosis. Similar cases have been described by other authors. Although it is rendered certain that cancerous tumors of the verte- bras may give rise to paraplegia characterized by great pain, it must be borne in mind that these symptoms are not a necessary accompaniment of the lesion, arid that they are met with in other affections of the cord. TUMORS OF THE SPINAL CORD. Qtf A tumor situated in the cervical or upper dorsal region of the cord sometimes gives rise to characteristic symptoms. Thus there may be dilatation or contraction of the pupil on one or both sides, or one may be contracted and the other dilated. Cough and dyspnoea, vomiting, difficulty of swallowing, epileptiform convulsions, and a remarkable slowness of the pulse, are sometimes among the phenomena. But such symptoms are by no means invariable. Many years ago Velpeau' re- ported a case of tumor of the cervical region of the cord in which none of these symptoms were present. The patient, a woman at thirty-four years of age, after having experienced mental troubles and been ex- posed to bad hygienic influences, suffered from convulsive movements of the limbs which were not of long continuance. Shortly afterward the left arm became the seat of a severe pain, and she had pains in the head. The pain in the arm increased, and little by little she lost the use of the limb. Renewed convulsive movements occurred in the in- ferior extremities, and were followed by complete paralysis. When she presented herself at the hospital she had no pain in the left arm, which was, however, entirely paralyzed, but which, nevertheless, retained its sensibility almost unaltered. Motion of the right arm, though difficult was still possible, but it was the seat of very severe pain. Respiration was normal but a little weak; the pulse was frequent, sometimes strong, but generally small and regular. There was a large and deep ulcera- tion on the sacrum; the lower extremities were anasarcous and were de- prived of all sensation and power of motion. The fecal matters and the urine were passed involuntarily and unconsciously. Gradually she lost the ability to move the right upper extremity. She sank almost im- perceptibly without apparent cause, and died after having been two months and a half in the hospital. On post-mortem examination numerous whitish opaline plates were found scattered over the arachnoid, but the principal lesion consisted of a tumor, which was situated between the arachnoid and the cord, and covered the entire anterior surface of the latter from the sixth cervical pair of nerves to the third dorsal. This growth appeared to have its origin in the left antero-lateral furrow. The anterior roots of the left spinal nerves within its area were so compressed that they were shrunk to mere threads, and the posterior roots of the same side were also sub- jected to pressure. The right posterior roots were in a normal condi- tion. The whole body of the cord was flattened by this tumor, but the left side was especially in this condition. The growth was cerebriform in appearance, and was thought to be cancerous. As an example of the symptoms resulting from a tumor occupying the dorsal region of the cord, the following, from Ollivier,8 is cited: 1 " Observation sur une maladie de la moelle 6piniere tendant a d^montrer l'isolement des fonctions des racines sensitives et motrices des nerfs," Journal de physiologie de Ma- gendie, tome vi., 1826, p. 138. = "Traite des maladies de la moelle epiniere," Paris, 1837, tome ii., p. 477. 638 DISEASES OF THE SPINAL CORD. A woman, aged fifty-two, had enjoyed good health till in 1819 she began to experience lancinating pains in the abdomen and breast. Af- ter several months these pains shifted their situation to the pelvis and the lower extremities, especially the left. These limbs then became the seat of varied phenomena, sometimes being cold, at others hot, and again numb ; they were also subject to the most intolerable itching. Then tbey became by turns immovable, and were agitated by convulsive movements. Although she could stand, walking was impossible. Fi- nally, in February, 1821, they began to atrophy, and at once lost all sensibility and power of motion. Then these symptoms disappeared, and there only remained numbness and pains apparently starting from the pelvis and traversing the nerves. In May, 1821, she entered the hospital. At this time the inferior extremities were rigid, and could not be flexed without causing pain of a very atrocious character. They were insensible to all external excitations, but were constantly the seat of severe and lancinating pains. There was, however, no pain along the vertebral column, and the general health of the patient was excel- lent. All these symptoms persisted till in January, 1823, the legs began to be flexed on the thighs, and these latter on the pelvis, to such an ex- tent that the heels pressed against the buttocks, and the knees touched the chest. Forced extension of the limbs was exceedingly painful, and when they were by main strength extended they at once returned to their former position as soon as the traction was discontinued. Two months before her death the left wrist and right knee became inflamed; the former suppurated, and the patient died six weeks afterward. Strychnia had been administered, but always aggravated the symp- toms. Morphia gave no relief. Examination after death showed the brain to be healthy. There was a band of sclerosed tissue on each side of the cerebellum. The spinal cord was healthy as far down as the tenth dorsal verte- bra. Here a tumor existed between the two layers of the arachnoid. The growth was oblong, and about two inches in length. It was simi- lar in appearance to brain-tissue, but firmer. It was not adherent to the cord, but throughout its whole extent pressed on the organ, which was softened throughout to the consistence of a thin jelly. At the most voluminous part of the tumor the cord was so much compressed that it was almost cut in two, so that there was the appearance of two cones with their apices together. A careful examination showed that in the softened part no trace of nerve-structure remained. Leyden,1 among other interesting cases, gives the following, of tu- mor occupying the lower dorsal region of the cord : The patient, a woman twenty-nine years old, after being delivered 1 " Klinik der Riickenmarkskrankheiten," erster Band, Berlin, 1874, p. 454. TUMORS OF THE SPINAL CORD. 639 Fro. 89. of a dead child, became affected with a pain in the right leg, which, starting from the foot, reached the knee, and finally settled in the calf. She noticed at the same time a weakness of this leg, which prevented her walking well, and eventually confined her to bed. These symptoms disappeared, and she remained well for over three years, when the right leg again became weak, and was the seat of constant lancinating pains, which were aggravated by muscular exercise. In April, 1872, the left leg was also affected with- similar pains. It soon became impossible for her to bend the knee or to move the limb. All these symptoms in- creased until, in February, 1872, she was unable to walk, and there was complete anaesthesia in both extremities as high as the hips. A painful sensation of constriction was felt around the body at the umbilicus. The electric excitability of the right lower extremity was lessened, of the left was normal. The reflex excitability of both lower extremities was increased ; the nutrition was good. At times they were the seat of strong contractions. By August, 1873, the patient was entirely confined to bed on her back, and deprived of all voluntary move- ment of her lower extremities. There were, however, often paroxysms of tremor in both feet so strong as to shake the whole body, and at times powerful contrac- tions of the muscles, drawing the thighs against the ab- domen, while the knees were flexed to their utmost ex- tent. The constricting pain around the body was still present. In the beginning of October the patient was seized with typhus fever and died. On examining the spinal cord it was found that a tumor existed on the right side, reaching from the seventh to the tenth dorsal ver- tebra, and firmly attached to the dura mater. The en- tire length of this growth was eighty millimetres (a lit- tle over three inches). (Fig. 89.) Causes.—Nothing is known relative to the etiology of intra-spinal tumors beyond the fact that they may result from the syphilitic, scrofulous, and cancerous dia- theses, and from wounds and injuries. Diagnosis.—There are no certain marks by which we can determine with any great degree of certainty that a tumor is compressing the spinal cord. We may suspect such to be the case when the motor paralysis is more marked on one side of the body than the other, and the anaesthesia exists to a greater extent on the opposite side. The existence of either syphilis, scrofula, or cancer, in connection with spinal troubles not clearly referable to some other dis- ease, may likewise excite the suspicion that a tumor exists. But the 640 DISEASES OF THE SPINAL CORD. symptoms—paralysis, hyperaesthesia, anaesthesia, contractions, rigidity, and spinal convulsions—are met with in other spinal disorders, notably in symmetrical lateral sclerosis. The unilateral predominance of the phenomena is probably, on the whole, most to be relied upon as a diag- nostic mark. Prognosis.—This is always unfavorable. It is less so when a syphi- litic origin can be made out. No others recover. Morbid Anatomy and Pathology.—The most common intra-spinal morbid growths are those which are developed from the vertebrae, and they include many syphilitic, scrofulous, and cancerous tumors. They originate either from the bones or from the periosteum. Formations resulting from either of these diatheses may also grow from the menin- ges or the substance of the cord. Parasitic tumors due" to either the echinococcus or the cysticercus, may also be developed within the spinal canal. Their usual seat is in the membranes ; and, according to Ollivier,1 the echinococcus is found in the spinal cavity of women only. Aneurismal tumors occasionally form in the intra-spinal arteries, and may compress the cord. Aneurisms of the thoracic or abdominal aorta may, by pressure, cause absorption of the vertebrae, and may thus eventually subject the cord to their influence. Among the other intra-spinal tumors are the glioma—a growth, the seat of which is especially in the brain and spinal cord, and whose struct- ure is very similar to that of sclerosed nerve-tissue—the sarcoma, the psammoma, the neuroma, fibroma, and myxoma, and tumors, generally syphilitic, developed from the vertebrae. Treatment.—The attempt should always be made, whenever the ex- istence of a tumor of the spinal cord is suspected, to effect its removal by anti-syphilitic treatment, with iodide of potassium and mercury. The following case will show the advantages of following this course: In the summer of 1869 I was requested to visit a gentleman who, I was informed, was paraplegic and subject to paroxysms of great suffer- ing. On making my examination, I found his limbs contracted, his re- flex excitability augmented, and motor paralysis and anaesthesia of both lower extremities. There were intense pain in the lower dorsal region, and violent spasms of the sphincter vesicae, alternating with paralysis of it and the bladder. There were also paroxysms of severe pain in the head, and occasional attacks of delirium. He denied any syphilitic infec- tion, but, on examining his head with my hands, I found a gummy tumor of the scalp over the right occipital region. Further inquiry and ex- amination revealed the existence of a similar tumor over the left radius. I inferred that there might be one or more like growths within the spinal canal, and I administered the iodide of potassium in gradually- 1 " Traite des maladies de la moelle epiniere," Paris, 1837, tome ii., p. 549. TRANSVERSE SECTION OF THE SPINAL CORD, SHOWING ITS ANATOMICAL DIVISIONS. (The Patho-Anatomy of the whole region colored pink is unknown.) A'. Columns of Tiirck. A. Lateral Columns. B. Posterior Eoot-Zonos. C. Posterior Horns of Gray Matter. D. Anterior Horns of Gray Matter. E. Columns of Goll. F. Anterior Root-Zones 999999999904 TUMORS OF THE SPINAL CORD. 641 increasing doses, with the bichloride of mercury in doses of the six- teenth of a grain three times a day. In less than two months every symptom of disease, except a general weakness, had disappeared. The tumor of the scalp went during the first month ; that of the arm a week later. The iodide of potassium was carried up to fifty grains three times a day. This patient continues in good health up to the present time. Even if there was not sufficient reason to diagnosticate the ex- istence of an intra-spinal syphilitic tumor, the success of the treatment can scarcely leave a doubt on the subject. If this treatment fail, there is nothing else left. As Leyden says, the only means of removal consists in extirpation by trephining the vertebral column. Who will be the first to attempt the operation ? As means of mitigating the pain and spinal convulsions, hypoder- mic injections of morphia or atropia, or of both combined, may be employed. This concludes what I have to say relative' to the diseases of the spinal cord. I have endeavored to make the subject as plain as possi- ble, but, in the study of a class of diseases still to a great extent ob- scure in their medical relations, there must necessarily be defects in the description. In order to a better understanding of the normal and morbid anat- omy of the cord as established by the most recent investigations, I have enlarged and modified from Charcot a diagram of a transverse section which will be found to give on examination very exact information. In it are clearly indicated the several divisions of the cord with the study of which we have been engaged. 11 SECTION III. CEKEBKO-SPIiYAL DISEASES CHAPTER I. HYDROPHOBIA. Although there are objections to the name employed to designate the terrible disease I now propose to consider, the same is true of all other terms which have been applied to it, and the present has the ad- vantage of being well known. So long as we are obliged, through ig- norance of pathology and morbid anatomy, to use a nomenclature based on symptoms, we must expect to be inexact. The name hydrophobia is as old as Galen, and still retains its preeminence, notwithstanding the fact that the symptom on which it is based is sometimes absent. Symptoms.—Beginning with the reception of the injury by which the body has been inoculated, we find that it heals in the ordinary way, and that there are no immediate signs of infection. At a period which varies greatly in different cases, pain or a sensation of uneasiness is usually experienced at the seat of the wound. This, however, is rarely of such intensity as to cause suffering, and probably would generally be overlooked or disregarded but for the apprehension which the pa- tient has, and which directs his attention to every sensation which can be attributed to the wound. But there may be absolutely no pain or uneasiness other than such as are met with in all wounds till the phe- nomena of the affection are manifested. The period between the re- ception of the injury and the beginning of the symptoms of hydropho- bia is known as the stage of incubation. The duration of this stage is variable. It is rarely shorter than a month, and probably never longer than two years. Instances are on record, however, in which the disease has been developed within ten days, and others, about which, however, there is much doubt, in which the latent period has reached to ten years and longer. The vast ma- HYDROPHOBIA. 643 jority of cases occur within seven months after the reception of the wound. In six cases which have been under my observation, the period of incubation varied from about twenty-five days to four months and a half. Dr. John Johnston,1 however, refers to an opinion that in hot coun- tries the disease has appeared in four or five days after the bite, and, on the margin of the page on which this statement is made, Dr. Hosack, to whom the book formerly belonged, has written a note, in which he states that it ensued in a child in New York five days after the bite was inflicted. During this period of incubation there are not often any indications of what is going to take place except in those cases in which there are abnormal sensations in the cicatrix or its neighborhood. Sometimes there are depression of spirits, anxiety, and derangement of the diges- tive functions, but these symptoms may fairly be attributed to the pe- culiar circumstances of the case, aside from any toxic influence due to infection. The first symptoms which appear are often directly connected with the cicatrix, which, if it has previously been free from abnormal appear- ances and sensations, now becomes subject to both. But there is no constancy even in these phenomena. They were altogether absent in one of my cases, and very slightly manifested in one other, if they were present at all. In this case, which I saw in consultation with Dr. S. Gr. Cook,a of this city, the patient, after other symptoms had appeared, oc- casionally clutched the place where he had been bitten, but denied, on being asked, that there was any pain at the spot. But, though there may be no symptoms of swelling, redness, or pain about the cicatrix, there are abnormal sensations in the nerves which radiate from it. Thus, if the injury has been in the leg, pains are felt along the courses of the sciatic and crural nerves ; if in the hand, simi- lar sensations are experienced in the radial, ulnar, median, and other nerves of the upper extremity. Occasionally the pain is felt in the epi- gastric region, and in any situation is ordinarily accompanied by head- ache. At about the same time the respiration becomes sighing and irregular, there is a feeling of oppression or constriction in the chest, the pulse loses its force and uniformity, and there is an indefinable sense of anxiety. The sleep is scarcely ever natural. Either there is insomnia or drowsiness, and sleep, when obtained, is disturbed by fright- ful dreams, and is unrefreshing. The bowels are constipated, the skin is dry, and there are alternate chills and flushes of heat. The duration of this stage is from two to four days. And then the period of full development begins ; characterized, at first, by an increase in the symptoms just mentioned, and subsequently 1 "Cases of Lyssa, with Remarks," p. 5, in "Medical Essays," printed 1795 to 1805. 8 " A Case of Hydrophobia," Journal of Psychological Medicine, January, 1870, p. 80. 644 CEREBRO-SPINAL DISEASES. by the appearance of others not previously present. A peculiar sense of uneasiness is felt at the epigastrium, and a pain and constriction of the throat, which add greatly to the distress. The tongue becomes stiff and painful, and articulation is thereby rendered indistinct; the respiration increases in irregularity, and becomes noisy and oppressed; the rigidity of the muscles of the throat prevents or impedes degluti- tion, and the patient dreads attempting to swallow, from the experience he soon acquires that his efforts in this direction are attended with pain and spasm, which greatly increase his sufferings. Sometimes the con- vulsion of the pharyngeal muscles is so great that substances are thrown with great force out of the mouth. This was the case in three of the instances I witnessed. At the same time the spasm extends to othei parts of the body, and occasionally becomes general. It is accompanied by pain in the epigastrium, and sometimes in the spine. Solids are swallowed with much more ease than liquids. Indeed, so great is the difference that the patient cannot even entertain the idea of swallow- ing any fluid, without being thrown into spasms. The sound of water splashing or trickling, the sight of it, the thought of it, and even an impression remotely connected with water, such as that produced by the reflection of rays of sunlight on the face by a mirror, will bring on a paroxysm of convulsions. "With the spasm there are sobbings, trem- bling, and then a condition of exhaustion, during which the patient is bathed in perspiration. The following day the phenomena are still more strongly marked. The mouth is dry and parched, and yet the patient dare not attempt to quench his thirst; vomiting ensues, the pulse becomes rapid and small, the pain in the pit of the stomach still increases, the headache is intense, and the countenance expresses terror, anxiety, and suffering. The pain in the spine augments and extends to the muscles of the neck and abdomen. The secretions of the mouth are altered, and the saliva is mixed with a frothy, tenacious mucus, which the patient is constant- ly attempting to eject, but which collects as fast as he can spit it out. The mouth and fauces are dry and painful, articulation is almost im- possible, and every attempt to relieve the distress by a few drops of water induces a return of the spasms and convulsions. Finally, every reflex excitation reaches the muscles of the throat; the contact of the bedclothes, the jarring of the bed by persons walking in the room, the rustling of window-curtains—any thing capable of acting on the hear- ing, the eyesight, or the touch, may cause the spasms. As the disease advances, all the symptoms increase in violence, and still others make their appearance. The urine and fasces are often passed involuntarily, the skin becomes exquisitely sensitive, the body is in a constant state of agitation and tremor, alternating with spasms} and the tough, stringy, tenacious mucus collects in the throat and im- pedes respiration. HYDROPHOBIA. 645 Thus far the mental symptoms have scarcely been considered, but they are present almost from the first. Indeed, they may be among the very first indications of disorder. They consist of emotional disturb- ances of various kinds, and sometimes radical changes of character and disposition. It has been alleged by some authors that the dreams, at a very early period after inoculation, are connected with the animal giving the the wound. I have never met with this symptom, but in the case pre- viously cited, and which I saw twice in consultation, a circumstance still more remarkable is related by Dr. Cook. The patient, a child three years old, was bitten by a bitch in heat on or about August 20, 1870. On November 15th the mother noticed that he slept badly ; on the 16th, among other manifestations, he " was cranky all day." On the 17th he was seen by Dr. Cook.1 " On entering the room," says the doctor, in his report of the case, " and seeing several children, and not noticing any thing wrong with any of them, I very naturally inquired which was the patient. I was pointed to a little boy sitting at a table in a high chair. On approach- ing him, he turned his face toward me, revealing the most peculiar-look- ing eyes I have ever seen. They were not like those seen in persons suffering from delirium in prolonged fevers, nor yet like those we see in the second stage of cerebral meningitis, although somewhat resem- bling both of these conditions, but more like the eyes of a person in a fit of violent anger, slightly combined with a feeling of fear. " When I reached out my hand to touch his, he shrank from me as from a blow, at the same time making a desperate effort to catch his breath, precisely as a naked person might if a pail of cold water was unexpectedly poured over him. This I understood to be a laryngeal spasm. It was very brief, lasting but the fraction of a minute, prob- ably not more than ten seconds. I took a seat a little distance from him, where I could see his every motion, and regarded him attentively for a long time. " He seemed an unusually intelligent child, for one of his age, speak- ing very-distinctly with a clear, ringing voice, which his parents in- formed me was a little unnatural, as it ' seemed strained.' He had at times a disposition to stammer, which was also unnatural. For one hour after my observation commenced, he talked almost incessantly of dogs, and repeated very few sentences a second time. He seemed familiar with all the most common breeds, relating some anecdote of the bull-dog, the mastiff, the bird-dog, the spaniel, the coach-dog, and the poodle. " Connected with all his naratives was a tragic or gloomy termina- tion. The mastiff, after carrying him an incredible distance about the city, finally disappeared through a bottomless hole in the street, he only 1 Op. cit., p. 81. 646 CEREBRO-SPINAL DISEASES. escaping a similar fate by suddenly dismounting. The bull-dog, after bringing for his admiration and pleasure a great variety of puppies, sud- denly turned cannibal, and swallowed the whole lot. The spaniel, after having been his playmate for a very long time, finally took it into his head one day to get on to a coffin that was being carried through the streets, and ride away to reappear no more." There were no other evidences of disordered mental action in this child, and he died, perfectly conscious to the last. Usually, however, this is not the case, and various morbid desires are entertained by the patient. Thus, in a case which I saw in this city in 1865, there was an impulse to strike those near, and an intense dislike of certain persons who had always been intimate friends of the patient. In both the other cases there were paroxysms of previous delirium, during which the sufferers bit and struck at all within their reach, and of which hallucinations and delusions constituted marked features. In the case of the boy just cited, the stories of dogs which he related were evidently delusions which he accepted as realities. The temperature is always elevated from the very beginning of the disease. It is rarely below 105° Fahr., and may rise as high as 110° during the height of a paroxysm or immediately after its cessation. Death usually takes place on the third day after the accession of the symptoms indicating the full development of the disease. The chief of these is laryngeal spasm. A fatal termination is rarely delayed till after the third day, though cases are not uncommon in which it has en- sued on the first or second day. In all the cases, except two, which have been under my observation, the third was the fatal day. In Dr. Cook's the disease may be considered as having been fairly developed on the 17th of November, the first day in which any spasm of the throat was witnessed. Death resulted on the evening of the 18th. In June, 1874, I attended, in consultation with Dr. Alexander Hadden, my sixth case of hydrophobia. The patient, a man about twenty-five years of age, had been bitten about three weeks before by a dog not clearly identified. When Dr. Hadden first saw him on the 24th of June, at 8.30 p. m., the man was in bed, complaining of nervousness, soreness in his neck and throat, and a strange feeling of tightness around the chest. His countenance was anxious, his pupils were di- lated, and his general appearance was that of a person facing some im- pending danger, and not in extreme pain. He said his throat was sore, and that he could not swallow any thing, not even water. Examination showed that there was no congestion or inflammation of his throat. His pulse, respiration, and temperature, were normal, excepting that he occasionally sighed. There was also a little disposition to hack and spit. He complained of thirst, but said he knew he could not drink, for the very sight of water made him shudder. He was told to try, and some water was brought, but the sight of it caused a violent spasm. He HYDROPHOBIA. 647 threw himseK around in the bed backward and forward, and ordered the water to be taken away. He immediately afterward called for the goblet, said he was thirsty and must drink, seized it, and with a violent effort succeeded in taking a single swallow, which was followed by a severe convulsive shudder and contraction of the muscles of the neck and chest. Dr. Hadden, recognizing the symptoms of hydrophobia, asked if he had been recently injured by any animal. At first he replied in the negative, but on the doctor's saying, " Not by a dog ? " he answered, " Only slightly on the knuckle of the right hand by a little black dog belonging to a baker around the corner on the avenue." He further stated that there was nothing the matter with the dog, for he had seen it afterward, and only about a week since it had been taken to the pound and the bite was inflicted three or four weeks before. For two days previously he had felt badly, was thirst}', and had drunk a good deal of water; and the evening before had gone out, but soon returned, saying he felt chilly. While taking a cup of tea at 6 P. M. that day (the 23d), he had experienced the first difficulty in swallowing. Shortly afterward, while going to the kitchen, a cool draught of air blew on him and caused him to stagger so that he nearly fell. The next morning Dr. Hadden saw him with Dr. Leavitt. "We found him in a frightful state of excitement; had broken down the bed, and was struggling with his attendants to get at liberty. He was shouting and crying out to them to let him go, and called for water, which, when brought, he could not drink. His mind was clear, and he knew all those around him; was spitting a viscid saliva, and was careful not to spit on any one, not even on his clothes. It was so abundant that his attendants were obliged to wipe it from his lips. Dr. Leavitt and myself, after viewing the case in all its aspects, concluded to inject in the tissue of the leg one-half a grain of morphine and one sixty-fourth of a grain of atropine in solution, which was done at 3 a. m. by Dr. Leavitt. We carefully watched the effect till 3.30 A. m., when his violence having in*no way abated, another injection was given in the same part, of three-eighths of a grain of morphine and one-eighth of a grain of atropine, which in some degree produced the character- istic effect of morphine, and very clearly the appearances of the atro- pine; for, notwithstanding he was struggling violently, the saliva, which had been very troublesome, was completely dried up, so much so that the patient himself remarked that he was very thirsty, and his mouth felt as if he had been chewing a brick. Fifteen drops of chloroform were then injected, with no effects whatever, unless to weaken his al- ready weak and frequent pulse. At 4.15 A. M., three-eighths of a grain of morphine were again introduced under the skin, without atropine. This quieted the patient so that he was easily restrained, and he re- mained in this condition from 4.30 A. m. till 10 a. m., when the effects 648 CEREBRO-SPINAL DISEASES. had so far passed off that the attendants were alarmed at his violence, and the abundance of saliva he was spitting from his mouth. Dr. Wil- liam A. Hammond saw him with me at this time. He supported the diagnosis and thought well of the treatment; he saw that it subdued vio- lence and suppressed the flow of saliva—the two most important feat- ures of this hopeless disease. At 10.15 A. m., by his order, three- eighths of a grain of morphia in solution were injected into the tissue of the thigh, which served to temper down the increasing violence of the spasms, but did not stop the flow of saliva. I accordingly, at 10.45 a. m., injected three-eighths of a grain of morphia and one-fortieth of a grain of atropia, which had the desired effect of producing the quieting effect of the morphia as well as the specific effect of the atropia on the salivary glands. The poisonous effects of the morphia and atropia were at no time apparent. He died at 4.15 p. m., June 26,1874, about twenty- four hours after the first spasm." ' As stated by Dr. Hadden, I was called to see the patient at about ten o'clock on the morning of June 26th. When I went into the room he was lying upon the floor pinioned, to a certain extent, and surround- ed with pillows to prevent him injuring himself. He was then spitting continually ; in fact, every expiration was accompanied by an effort to spit out the thick, tenacious mucus so characteristic of hydrophobia. His pupils were largely dilated, but, as Dr. Hadden stated, not more so than before the atropia was given. He was able to converse with tolerable fluency, and, when I put two or three questions to him, he an- swered, but not very directly. So far as I could make out, both from his answers and appearance, he was not suffering from acute pain. There was a good deal of movement of his limbs, not apparently spas- modic, for there seemed to be the element of volition in the actions he made with his arms and legs. He could not swallow fluids, and even a piece of ice given to him was ejected with force from his throat. His pulse was too rapid to be counted, and his respiration was hurried and irregular. I fully concurred in the suggestion to give him morphia for the pur- pose of moderating the intensity of his symptoms. A hypodermic in- jection was administered, and a sedative effect was produced. After I left, his paroxysms returned with great violence, and he died that after- noon. Generally death occurs during a spasm. This was the result in four of the six cases I have witnessed. In the others the patients died quietly, a consequence probably of the sedative medicines administered. When death takes place during the former condition it is probably due to apnoea ; in the latter, to exhaustion. In all cases the powers of life, 1 " Report of a Case of Hydrophobia," by Alexander Hadden, M. D., " Proceedings of the New York Neurological Society," Psychological and Medico-Legal Journal, Sep- tember, 1874, p. 166. HYDROPHOBIA. 649 from the violent convulsions, the loss of sleep, and the deprivation of food, are drained away to their utmost. Causes.—It has generally been supposed that hydrophobia has but one source in the human subject, and that is, inoculation by the saliva of an animal affected with rabies. It cannot be communicated to one individual by the saliva of another affected with hydrophobia, although there is no doubt that, under certain circumstances, the saliva of man, as well as the milk and other secretions, may become poisonous. Nei- ther can dogs or other animals be infected by inoculation with the saliva of a hydrophobic man. Magendie's' experiment, the only one of the kind which has ever succeeded, is of exceedingly doubtful import, as hydrophobia was prevailing among dogs at the time, and the animal may have been previously bitten. But it is very probable that the saliva of healthy animals, the dog especially, is, under certain circumstances, capable of producing hydro- phobia in man and other animals. A case of the kind is recorded in HuJ-eland's Journal of December, 1839, and similar ones are frequently met with. In none of the cases I have witnessed was the dog which had inflicted the wound supposed to have been rabid. In one case which I saw in this city, with a physician whose name I cannot recall, the patient, a stableman, was bitten by a dog that was to all appear- ance in perfect health. In the case reported by Dr. Cook, the animal, a bitch, was being led quietly through the passage-way of the house, when the child became entangled in the chain, fell against the dog, and was bitten apparently in anger. The animal was well known, and was not even suspected of being hydrophobic. She was in heat ; and Dr. Cook raises, for the first time to my knowledge, the question whether this circumstance renders the saliva of the animal capable of inducing hydrophobia in the human subject. With a view of throwing as much light as possible on the subject, he consulted the records of Bellevue Hospital, in order to ascertain the facts in relation to a man who died of what was supposed to be hydrophobia from the bite of a bitch in heat. The result of his inquiries was to show very certainly that the man did die of hydrophobia ; that the animal was not rabid, and that she was in heat. In the case, the details of which have just been given, there was a good deal of doubt in regard to the identification of the dog which in- flicted the bite. The patient said he had been bitten " by a little black dog belonging to a baker around the corner on the avenue." But no such dog was known, and there was no baker " around the corner," on either Second or Third Avenue. The only dog that was known to have bitten the man was alive and well on the 7th of July, two weeks after- ward. 1 " Dictionnaire des. sciences medicales," article " Rage," tome xlvii., p. 46. Alsr Journal de physiologie, tome i., p. 47. 650 CEREBROSPINAL DISEASES. In the present state of our knowledge, it is useless to pursue this point of the inquiry further. It is one in regard to which certainty ap- pears to be impossible of attainment. Fleming,1 however, seems to ad- mit the possibility of an animal under strong sexual excitement being able to communicate hydrophobia to a healthy animal when he says : " The hypothesis that certain ferments—an improper term—mav be de- veloped in great abundance in the saliva under the influence of psychi- cal disturbance, would account for those instances in which rabies .shows itself in dogs bitten by others which are excited or furious by sexual desire, though themselves healthy." It would appear that the saliva is the only means of communication. Dupuytren, Breschet, and Magendie, endeavored to convey the disease by injecting the blood of dogs, suffering from rabies, into the veins of healthy dogs, but always unsuccessfully. The flesh, milk, semen, and abdominal secretions, were likewise found not to be media for trans- mission. On the other hand, Eckel, of Vienna, after several failures, inocu- lated a dog with the blood of a man who was affected with hydropho- bia. On the sixty-second day thereafter the animal was seized with unmistakable rabies and died. Fleming, however, from whom I quote this statement, says that it must not be forgotten that, at the time of these experiments, rabies was raging as an epizootic. But Bouley,* who has investigated the whole subject of hydrophobia with great abil- ity, declares that it can be transmitted only by inoculation, and the only agent which has the power of communicating it is the saliva, in which alone the virus exists. Any other liquid taken from a rabid ani- mal is ineffective. Inoculation by blood, even its transfusion, has failed to produce any results. He also says that all living beings affected with hydrophobia are capable of transmitting it ; that is, the saliva of all rabid animals is virulent, it matters not to what species they belong. Whether or not it originates spontaneously in the lower animals, it is very certain that it has no other origin in man than inoculation. Although there is no sure evidence on the point, there appears to be no room to doubt that hydrophobia may be communicated by inocu- lation from a person affected with the disease to an unaffected indi- vidual. Aurelianus, Enaux, and Chaussier, and others cited by Flem- ing, mention instances in which it has been induced in persons who have accidentally had the saliva of hydrophobic patients applied to their lips. Fleming' states that in IS71 a girl named Bence died in Liverpool from hydrophobia. It was believed she had not been bitten, but the death of her little brother, from the disease, occurred about 1 " Rabies and Hydrophobia," London, 1872, p. 124. 2 "Hydrophobia," by H. Bouley, translated from the French by A. Liautaud, if. D., V. S., New York, 1874, p. 6. 3 Op. cit, p. 141. HYDROPHOBIA. 651 three weeks previously, and the supposition was that the virus had been communicated in some way to the girl through a wound in her foot. The fact that hydrophobia can be communicated from man to the lower animals is sufficiently well established by the experiments of Magendie, Breschet, Earle, and Renault. The wolf is said to be the most dangerous of all animals when rabid, for the reason probably that it seizes the neck or face, parts not fully protected by clothing, and thus the saliva is not so apt to be rubbed off as when the leg, for instance, is the part attacked. The slightest abrasion of the skin coming in contact with the saliva may be sufficient for inoculation. Cases are recorded in which the dis- ease has resulted from dogs licking the hand or face on which there were pimples or sores. Diagnosis.—That protean disease, hysteria, occasionally puts on the semblance of hydrophobia. Several cases of the kind have occurred to me, and, in all, the symptoms were in general character very much like those which are exhibited by genuine hydrophobia, though in some re- spects, perhaps, a little exaggerated. It will in these and similar cases —the result of fright and imagination—often be found that the patient has been bitten by a dog not long before. There is a want of consist- ency about the symptoms which of itself is sufficient to excite suspicion as to the real character of the phenomena. Thus, although at times the attempt to swallow will excite laryngeal and other spasms, these do not always occur under similar circumstances, and are not induced by those secondary and more refined influences, such as the sound of fall- ing water, bright lights in the face, excitations applied to the skin, see- ing others drink, etc., which so generally cause them in the real dis- ease. There are not the same anxiety and depression in the simulated disease as in the real, though the apparent emotional disturbance is much greater. The hysterical patient is loud in the expression of ap- prehensions, while the real hydrophobic one, though intensely anxious and terrified, endeavors to prevent others perceiving the state of his mind. The history of the case, the existence of the hysterical diathesis, and the fact that the symptoms come on soon after the bite without any period of incubation, will further aid in establishing the diagnosis be- tween the false and the real disease. The last case of the simulated disease which has come under my ob- servation was that of a policeman whom I saw in consultation with Dr. S. G. Cook in the summer of 1874. The man was then in the Park Hospital, held down on a bed, and snapping like a dog at every person who came in his way. At the sight of water he became intensely ex- cited, foamed at the mouth, and went through a series of fearful con- tortions of his limbs. But, when I took a glass of water in my hand and told him in a commanding voice to drink immediately, he swallowed the liquid without the slightest difficulty. 652 CERERRO-SPINAL DISEASES. The bromide of potassium in large doses was prescribed, and the next day all his symptoms had disappeared. On inquiry it was ascer- tained that he had been bitten by a dog several days before, and that his comrades had frightened him by their inquiries and suggestions. The fact that a disease resembling hydrophobia may be induced by physical derangement and by mental disturbance especially of the im- agination, and that death may be the consequence, is very well estab- lished, and may account for the apparently spontaneous instances, and for those cases of long incubation which are cited by authors. Thus M. Labadie Lagrave1 quotes from Raymond (de Marseille) the case of a child twelve years old who became hydrophobic without known cause and died at the end of ten days. Also a case from Rouppe of a sailor who had convulsions and died hydrophobic without known cause, and another from Pouteau of a man who died in fifteen hours with symptoms of hydrophobia which had ensued on a violent paroxysm of anger. Berthier 2 refers to several similar cases occurring as the result of menstrual derangement. Fleming * cites the instance of a woman who had been bitten in the face and who was admitted to the H6tel-Dieu in Paris. After a few days she was cured of her wounds and discharged. Going about her usual avocations one day she heard a man exclaim, " She has not gone mad, then ! " From that time she could not swallow liquids, and on the same day was readmitted to the H6tel-Dieu, and this time to die of hydrophobia. The following case is also given by Fleming: "A woman in the clinic of Dr. Maisonneuve had been bitten by a dog, which was supposed not to be rabid, and the injury had healed; when two months after the accident she was met by two students, who had been with the doctor at the time, and who asked her if she was not yet mad. Immediately she was seized with nervous symptoms, became intensely anxious and un- easy, and went into the hospital in the belief that she was hydrophobic. She was put under the care of M. Laugier and the following day was evidently affected with the disease; hemiplegia appeared, with a vio. lent delirium, accompanied by an irrepressible amount of fear, and she died asphyxiated in forty-eight hours." The temperature in all cases of pseudo-hydrophobia that I have wit- nessed was not above the normal standard. Hydrophobia has been confounded with tetanus, and some writers have regarded it as a modified form of this affection. The distinction is, however, so well marked that it scarcely seems necessary to dwell 1 Article " Hydrophobic," in " Nouveau dictionnaire de medecine et de chirurgie pra- tiques," tome xviii., Paris, 1874, p. 17. 2 " Des nevroses menstruelles," Paris, 1874, p. 169. 3 Op. cit, p. 176. HYDROPHOBIA. 653 upon it. The facts that in tetanus the spasms are tonic, while in hy- drophobia they are clonic ; that in the first-named they are mainly shown as regards the jaws and back, while in the latter they radiate from the throat; that in tetanus the mind is clear throughout, while in hydrophobia more or less mental implication is always present, will suffice to render any mistake in the diagnosis of the two diseases impossible. From epilepsy the distinction is so obvious as not to require further mention. Prognosis.—There is no authentic instance on record of a cure of hydrophobia. Several such have been reported, but inquiry has always shown misstatement or error somewhere. The fact that the hysterical counterpart has several times been regarded as the real disease, is the main support for the opinion of some authors that the affection is curable. Several years ago Dr. Ligget,1 of Maryland, reported a case of hy- drophobia cured by calomel. A careful examination of the details of this case excites very grave doubts in my mind in regard to its really being an instance of the disease in question. The subject was a negro-woman who had been bitten about two weeks before any symptoms were manifested. The dog was lying quietly in the yard, and bit her in the great-toe as she was teasing him with her foot. The animal was at once chained up, and died in two or three days with " all the symptoms of rabies canina in its most virulent form." It does not appear that the doctor saw the dog, and it is very probable that the rigid confinement would have caused the animal to exhibit symptoms which would easily be mistaken by laymen for those of hydrophobia. Again, the period of incubation was unusually short, and the symp- toms, as detailed by Dr. Ligget, are clearly not those of hydrophobia. Thus, although he repeatedly states that there was inability to swallow liquids, there is no distinct mention made of the pathognomonic laryn- geal and pharyngeal spasms which occur in hydrophobia, and which are so frightful in character. The convulsions all appear to have been gen- eral, and there was a " horror " of water, which is not a phenomenon of the true disease. For these reasons I am constrained to believe that the disease treated by drachm-doses of calomel was in reality one of hys- teria which assumed the form of hydrophobia. In this opinion I am sustained by an eminent medical gentleman residing in Dr. Ligget's neighborhood, who, as the latter admits, declared the affection to be "a case of4 that protean disease, hysteria, simulating hydrophobia." Calomel has been repeatedly tried before and since Dr. Ligget's case, Dut without effect. 1 " Case of Hydrophobia successfully treated with Drachm-Doses of Calomel," Ameri- can Journal of Medical Science, January, 1860, p. 96. 654 CEREBROSPINAL DISEASES. But, although the prognosis is so hopeless in the developed disease, it is much more favorable as regards the probability of the superven- tion of hydrophobia from the bites of rabid animals, for, of those bitten by dogs unmistakably affected with the disease, not more than one in fifteen becomes successfully inoculated. This liability differs greatly according to the circumstance of the part being covered or not. The wounds of the face, neck, or hands, are much more likely to be followed by hydrophobia than those inflicted on the legs or feet, where the virus is rubbed off by the clothing before the teeth reach the flesh. The bite of a rabid wolf is more apt to be followed by the disease than the bite of a dog, for the reason that the first-named generally seizes the throat or face. Thus, Trolliet states that at Brives, in France, seventeen per- sons were bitten by a rabid wolf, of whom ten died of hydrophobia ; and, of twenty-three bitten by another, thirteen died. On the other hand, Hunter states that on one occasion a dog bit twenty persons, of whom only one was inoculated. Those first bitten by a rabid animal are more liable to have hydrophobia than those bitten subsequently, when the poison is in a measure exhausted. Probably the most dan- gerous wounds are those which barely penetrate the epidermis, and in which, therefore, the venom is not washed away by any flow of blood. Morbid Anatomy.—Within the last few years the study of the mor- bid anatomy of hydrophobia has led to results which may be considered, at least for the present, as determining, with some degree of exactness, the situation and character of the essential lesions of this terrible dis- ease. In 1869 Meynert examined microscopically the spinal cords of a boy and girl, patients at Oppolzer's clinic, who died of hydrophobia. In the first case, he found thickening of the walls of the spinal ves- sels, amyloid degeneration and nuclear proliferation of the cells of the neuroglia. In the second case, the neuroglia of the posterior columns of the cord was hypertrophied, through swelling of the stellate bodies. In the antero-lateral columns there were granular and amyloid degenera- tion, and numerous distended blood-vessels. The cortical substance of the brain exhibited the presence of a large number of lacunae with colloid masses. The nerve-cells of this part were the seat partly of molecular disintegration, and partly of sclerotic enlargement. Next are the observations of Dr. Clifford Allbutt,1 who examined the nerve-centres in two patients, who died of hydrophobia while in- mates of the Leeds General Infirmary. Throughout the brain and spinal cord there were evidences of great vascular congestion with transudation into the surrounding tissue. In several places the walls of the vessels 1 "Specimens illustrating the Pathological Anatomy of Hydrophobia," "Transactions of the Pathological Society of London," vol. xxiii., p. 16, 1872. HYDROPHOBIA. 655 were thickened and there were here and there patches of incipient nuclear proliferation. There were also haemorrhages into the medulla oblongata. In many places there was a refracting material to be seen outside of the vessels, which probably was of the nature of a coagulated fibrinous exudation. Finally, Dr. Allbutt found in the encephalon occa- sionally, and in both spinal cords, and especially in both medullas, little gaps caused by the disappearance of nerve-strands which had passed through the granular degeneration of Clarke. These phenomena, adds Dr. Allbutt, point to the action of an animal poison acting primarily on the cerebro-spinal nervous system. Then in July, 1874, were my own researches,1 made at Dr. Hadden's request, in the case, the details of which, as observed during life, have just been given. As preliminary to the description of the microscopical appearances, it may be stated that, on removing the calvarium, the membranes of the brain were found to be congested, but there was no appearance of serous effusion to an abnormal extent either in the sub-arachnoidal space or in the ventricles. The substance of the brain was only slight- ly congested, but the consistence, especially of the cortical tissue, was somewhat less than normal. The cerebellum appeared to be healthy, as did also the pons Varolii, the corpus striatum, the optic thalamus, and other ganglia, with the exception of the medulla oblongata, which seemed to be slightly softened. The membranes covering it and the upper part of the spinal cord were congested. I took for examination (1) portions of the cortical substance of the brain ; (2) sections of the corpus striatum ; (3) sections of the optic thalamus ; (4) sections of the cerebellum ; (5) the pons Varolii ; (6) the medulla oblongata ; (7) a section of the spinal cord at the level of the second pair of cervical nerves ; (8) a portion of the pneumogastric nerve from the neck: 1. Cortical substance of the brain. My examinations of this tissue were made upon specimens which had been kept in absolute alcohol eighteen hours, in glass tubes sur- rounded with ice. I experienced no difficulty in cutting sufficiently thin sections. In all the sections the following conditions existed (ob- ject-glass one-fourth inch): a. The blood-vessels were increased in size and number, and their walls appeared to be thickened. b. There were minute extravasations of blood throughout, in some of which the blood-disks could still be distinguished, but in most of them they were broken down. c. The external layer of nerve-cells had almost entirely been re- placed by fatty matter in the form of oil-globules. The cells that re- 1 " Proceedings of the New York Neurological Society," July 7, 1874, in Psychological and Medico-Legal Journal, September, 1874, p. 169. 656 CEREBRO SPINAL DISEASES. mained were filled with a highly-refracting granular material, which was also oil in very minute particles. None of these cells were bi-nu- clear. Amyloid corpuscles were discovered generally at the junction of this with the next stratum. d. The second layer of cells had also to a great degree been re- placed by fat, but not to the same extent as the outer layer. It is well known that this layer is composed of more numerous and larger cells than the outer ; but there was no doubt of their atrophy or dis- appearance. e. The third layer, composed of large cells, was scarcely affected. A few oil-globules were seen, and occasionally an amyloid corpuscle. The remaining strata were not involved, so far as I could see, to the slighest extent. In Fig. 90 a vertical section of the cortical substance is seen: 1, the Pro. 90. outer or peripheral stratum ; 2, the second layer ; 3, the third layer or large cells. 2. The corpus striatum, the optic thalamus, and the cerebellum were in an apparently normal condition, though there was some evidence of arterial injection. 3. The pons Varolii was not examined in the fresh state, but was placed entire in a solution of bichromate of potash to harden. Subse- quently examined, it was found to be the seat of extravasation of blood, and the vessels were enlarged and their walls thickened. 4. The greater portion of the medulla oblongata was also placed in HYDROPHOBIA. 657 the bichromate of potash solution, but several sections were made after the part had been in absolute alcohol surrounded by ice for twenty- four hours. a. The first of these was made through the olivary bodies, at the level of the floor of the fourth ventricle, so as to include the nuclei of the pneumogastric and hypoglossal nerves. Numerous extravasations of blood could be seen with the naked eye, but with an inch objective they were more clearly made out. The ves- sels were then seen to be enlarged and more numerous than in the nor- mal condition. The gray matter forming the nuclei of the pneumogas- tric and hypoglossal nerves was observed to be of a distinctly granular appearance, and the roots of the nerves presented a like characteristic. In other respects the section exhibited nothing abnormal. b. Examined with a fourth-inch objective, this granular matter of the nuclei was seen to consist of oil-globules and amyloid corpuscles. The cells were ascertained to be atrophied both in size and numbers. Indeed, they had almost entirely disappeared. Of course it was not pos- sible, in a fresh and unprepared preparation, to form any definite idea of the relative proportion of nerve to neuroglia cells, but the deficiency of all cell-structure was very remarkable. (Fig. 91, a, oil-globules; b, amyloid bodies; c, nerve-cells; d, blood- vessels.) c. The nerve-roots, when examined in like manner, were seen to have undergone a similar change, the granular matter consisting en- tirely of fat, mainly in the form of oil-globules (Fig. 92). Sections made immediately below the level of the point of the cala- mus scriptorius, so as to include the main root of the spinal accessory 42 658 CEREBRO-SPINAL DISEASES. nerve and its nucleus, exhibited almost exactly the same appear- ances. Fig. 92. 5. The Spinal Cord.—The section of the cord was made at a point about midway between the first and second cervical nerves. The gray Fig. 93. matter of the anterior and posterior horns was found in a state of granu- lar and fatty degeneration, the cells atrophied, and the nerve-roots in a HYDROPHOBIA. 659 similar condition. In the white matter, both of the anterior and pos- terior columns, there was nuclear proliferation of the neuroglia-cells (Fig. 93). 6. The peripheral portion of the pneumogastric nerve, carefully re- moved by my assistant and placed in strong alcohol, exhibited a red ap- pearance, but this may have been due to imbibition. Benedict,1 about the time of my own observations, made a series of researches into the morbid anatomy of hydrophobia as met with in dogs. His results were— 1. The vessels situated between the cerebral convolutions were dis- tended with blood, and their external walls were coated with an exuda- tion of a highly-refractive material consisting of granules. 2. Numerous cavities were found to exist in the gray matter of the brain, and these were filled with a like granular, highly-refracting ma- terial similar to that found in the walls of the vessels. 3. Masses of myeline, indicative of softening, and chemical changes of the nerve-tissue, were also discovered. Benedict regards the appearances as identical with those which Lockhart Clarke has considered as indicating granular degeneration. From the foregoing data it will be perceived that at last something definite has been ascertained relative to the morbid anatomy of hydro- phobia. Wliether we regard the condition, according to Benedict, as an acute exudative inflammation, or as a granular degeneration, is of no con- sequence so far as the facts are concerned. Whether on the one hand the granular matter is an exudation, or whether it results from degenera- tion of the nerve-tissue, are points which will probably ere long be cleared up. My own view is in accordance with that of Lockhart Clarke, who, detecting a like change in other affections of the nerve-centres, views it not as an exudation but as a degeneration. As to the gross lesions, congestion of the brain and spinal cord has been found by many observers. Sometimes the nerves at the wound are inflamed, but this is not a uniform occurrence. The eighth pair has been found to present a pink- ish appearance in some cases. In four cases in which the blood was examined by Schivardi,8 infusoria of the genera bacterium, monas, vibrio, and torula, existed. The fauces, pharynx, larynx, trachea, and lungs, are generally found reddened and congested, as much from the asphyxia as from any spe- cific influence of the disease. Pathology.—Even if we had no information relative to the morbid anatomy of hydrophobia, no one who has ever witnessed a case could fail to perceive the implication of the hemispheres, the medulla oblon- 1 " Die anatomischen Veranderungen bei der Lyssa des Hundes," Wiener Medizinische Presse, July 5,1874. 8 " Observations nouvelles sur la rage," Besancon, 1868, p. 22. 660 CEREBRO-SPINAL DISEASES. gata, and the spinal cord. The hallucinations and other mental phe- nomena point to the hemispheres, the irregular action of the respira- tory muscles, and the heart, together with the gastric derangement and pharyngeal convulsions, indicates the implication of the pneumogastric nerves, and the spasms of the larynx point to the origins of the spinal accessory nerves in the spinal cord. Since we have arrived at some degree of exactness relative to the lesions in the disease, we cannot fail to have our conviction on these points strengthened. The nature of the virus is unknown. It is probably of the nature of a ferment, but this cannot be regarded as satisfactorily proved. In 1820, Dr. Marochetti observed, in the Ukraine, that during the formative period of hydrophobia small vesicles or pustules formed un- der the tongue, and that, if these were opened and cauterized, the fur- ther development of the disease was prevented. I have never been able to find these formations, but they were recognized, two years after Marochetti published his account, by Magistral, in France. This latter opened and cauterized them in the manner recommended by Marochetti in ten cases, in five of which, nevertheless, the affection went on to full development, and the patients died. I am not aware that any one else has discovered these pustules. For full details relative to hydrophobia as it appears in dogs, I must refer the reader to the late Mr. Youatt's excellent book on canine mad- ness, and to the more recent and thorough treatise of Fleming. I may, however, state that it is very clearly established that canine rabies is not so frequent in very hot as it is in temperate or cold weather ; that it is not induced by thirst or improper food, or by preventing copula- tion. Is hydrophobia primarily a disease of the nerve-centres or a blood- disease ? I suppose it is utterly impossible, in the present state of our knowledge, to answer such a question. It may start as a blood-disease and end as a nerve-disease. Blood-diseases lead to structural changes of various organs of the body, and the nerve-centres are likewise in- volved to a considerable extent. Is it not worth while to call attention to the numerous instances of blood-diseases which produce structural changes ? Hydrophobia may be a blood-disease, and yet afterward be succeeded by changes in the nerve-centres. It is not necessary to suppose that hydrophobia is a nerve-disease from the beginning. It is perfectly possible, however, that it may be, and there are a great many instances which can readily be adduced in proof of this assertion. Take tetanus for example. Very few pathologists pretend to say that tetanus is a blood-disease. It is a disease propagated through the nerve-tissue starting from injury of a peripheral nerve, and inducing structural changes in the spinal cord. Dr. Lockhart Clarke, as we have seen, has ascertained in a number of cases that the essential condition of tetanus is a granular degeneration of the cord, and that is, probably, HYDROPHOBIA. 661 only the beginning of the fatty degeneration I find in hydrophobia, and yet there is no suspicion of blood-poisoning in tetanus. Hydro- phobia presents many analogies to tetanus, not only in its morbid anat- omy but in its natural history. Epilepsy can be caused by injuries to peripheral nerves. I had a case some years ago of a lady who wounded her thumb, and six months afterward she had epileptic paroxysms, which were preceded by an aura originating in the cicatrix. And if epilepsy—which is another one of the spasmodic diseases—can be induced by a simple wound, why not hydrophobia ? So that we have examples of analogous diseases caused by wounds of nerves, without the necessity of supposing the blood to be primarily affected. Still, there cannot be much doubt that the poison in the saliva, and not the wound made by the animal's teeth, is the essential influence producing hydrophobia. It is not at all certain, however, that the lat- ter may not in some cases produce a modification of the characteristics of the disease, perhaps causing those tetanoid phenomena which are oc- casionally present. Treatment.—The measures of treatment relate to those proper im- mediately after the infliction of the wound, with the view of preventing the development of the disease, and those advisable after the affection is unmistakably manifested. Under the first category comes excision, which should be performed as soon as possible, and which is probably the best of all prophylactics. The operation should not be done with a niggardly hand, but every part with which the teeth of the animal have come in contact should be re- moved, as well as the tissue into which the poison may have become infiltrated. Previous to the operation, in fact as soon as the wound has been received, a tight ligature should be bound around the limb immediately above the injury, and, after the knife has done its work, cupping-glasses should be applied over the spot, till the tissues in the vicinity are thoroughly drained of blood. I have performed excision, for the wounds received from dogs certainly rabid, eleven times, and always with the effect of preventing hydrophobia. Cauterization may be performed instead of excision, and is preferred by some practitioners. Mr. Youatt used it with over four hundred per- sons bitten by rabid animals, and never unsuccessfully. Four times he employed it on himself, but there is a strong probability that the prac- tice at last failed with Mr. Youatt himself, for he committed suicide while supposed to be suffering from the initial symptoms of hydropho- bia. He preferred the nitrate of silver as an escharotic. Others have made use of the actual cautery, caustic alkalies, the mineral acids, arsenic, chloride of zinc, and carbolic acid. I have employed cauteriza- tion seven times—four with the nitrate of silver and three with the 662 CEREBRO-SPINAL DISEASES. actual cautery—upon persons bitten by rabid dogs, and always with success. Mr. Youatt at one time had faith that the Scutellaria lateriflora, or scullcap, was a preventive. lie moistened three pieces of tape with the saliva of a rabid dog, and inserted them as rowels into the skin of three dogs. To two of these he gave Scutellaria combined with belladonna, while the third was left to itself. On the twenty-ninth day after the inoculation this latter became rabid, while the others, several months afterward, were alive and well. Notwithstanding this experience, it would not be justifiable in the physician to neglect performing either excision or cauterization as soon as possible after the reception of the bite. Even if several weeks or months have elapsed, one or the other—preferably excision—should be performed. As to the treatment of the fully-developed disease, there is nothing, in my opinion, which has hitherto succeeded in arresting its onward course. Cases of cure have been reported, but, as already stated, they are open to the suspicion of not being true instances of the disease. Excessive bloodletting has been reported as a successful remedy ; in- jection of warm water into the veins dissipated the paroxysms in a case reported by Magendie, the patient, however, dying ; and nearly every stimulant, narcotic and sedative, in the materia medica, has been used. In the case which I saw with Dr. Cook, and which has already been cited, the hydrate of chloral was administered. The effect certainly was to mitigate the severity and frequency of the spasms, but it was, as Dr. Cook states, given too late in the course of the disease to produce any permanently curative result. In the present state of our knowledge I should be more disposed to rely on the hot-air bath at a temperature of about 200° Fahr., and the administration of hydrate of chloral in large doses frequently repeated, than on any other plan of treatment. In Dr. Cook's case the Turkish bath was proposed, but the parents of the child would not consent to its use. Hypodermic injections of mor- phia and atropia may be used with some advantage to mitigate the force of the paroxysms. Before concluding my remarks on hydrophobia, it is proper to allude to the attempts of Dr. Schivardi,1 of Milan, to cure the disease by the primary galvanic current. In one case the current was feeble, and was continued for nineteen hours. Great improvement ensued; the oppression disappeared, and the dysphagia was entirely relieved. Through some misunderstanding, advantage was not taken of these ameliorations, and the patient was allowed to die. In the other case, which was one of undoubted hydrophobia, occur- ring in a girl nine years old, the current from twenty-two Daniell's cells was employed. The current was passed from the soles of the feet to 1 " Observations nouveiles sur la rage." EPILEPSY. 663 the forehead for fifty-eight hours almost continuously, and the dura- tion of the disease prolonged to seven days and seven hours, when the patient died. During the last two days there were no hydrophobic symptoms. Further trials are necessary before the therapeutical value of gal- vanism in hydrophobia can be ascertained. CHAPTER II. EPILEPSY. Epilepsy, although only a symptom of a morbid condition, must for the present be considered as a disease, for the reason that we are not able to designate with certainty its exact seat, or the nature of the lesion which exists. It is characterized by paroxysms of more or less frequency and severity, during which consciousness is lost, and which may or may not be marked by slight spasm, or partial or general con- vulsions, or mental aberration, or by all of these circumstances collec- tively. The essential element of the epileptic paroxysm is loss of con- sciousness. Without that there is no true, fully-formed epileptic par- oxysm. Symptoms.—Although in many cases there are no precursory phe- nomena, it often happens that there are indications of an approaching attack. These are exceedingly variable in character and situation. They may consist of pain in the head, a sensation of constriction or fullness, vertigo, noises in the ears, a feeling as if the ears are stopped with cotton or water, flashes of light, or sudden blindness, illusions or hallucinations of any of the senses—irritability of temper, extraordinary cheerfulness, difficulties of speech, pains in various parts of the body, especially in the stomach, bowels, or ovaries, sensations of numbness or of tingling, or of an indescribable character, which begin in an ex- tremity or in some other region, and appear to pass rapidly to the head —a feeling of constriction in the throat, vomiting, sudden evacuation of the bladder or rectum, erections of the penis, with or without the sexual orgasm, and discharge of semen, with many others of almost every pos- sible description. The prodromata may precede the attack by a considerable period, but usually are only a few moments in advance of it. Indeed, often the interval is so short that they may be regarded as a part of the paroxysm. The sensations of numbness or tingling, or of an electric shock, as a sharp stab, or blow, or pain, which precede the attack and which origi- nate in different parts of the body, and in some cases seem to run rap- idly toward the head, are called aura?. Sometimes this aura is fixed, and may consist of various derangements of sensation besides those above 664 CEREBROSPINAL DISEASES. mentioned. In a number of my patients it has been a sensation at the pit of the stomach, such as that produced by a slight feeling of hunger or of anxiety. Again, it has consisted of a sharp impression on the tongue; at others of a subjective sense of smell, and again colored visions, or hallucinations of sight. In regard to these auras of colors, Dr. Hughlings Jackson * has made some interesting observations. He finds that red is the color which is usually seen first, though the others may follow in such rapid succession as to present an image of all the primary colors. Loss of the power to see colors (color-blindness) is generally first shown as regards red; and if this affection advances, the insensibility is progressively shown tow- ard the violet end of the spectrum. So in the epileptic chromatic hyperaesthesia, the formation of colors is in the same direction, and hence red is first perceived and violet last—theoretically, at least, for there are not yet sufficient data collected to enable us to speak with any degree of certainty on the subject. There are exceptions, how- ever, for Dr. Jackson cites the case of one of his patients who always saw blue just before an attack. In my own experience, red has been invariably the predominating color, and in most cases the only one. The case of the gentleman who, just before his paroxysm of epilepsy, saw an old woman clothed in red approach him, with a stick raised in a threatening manner, and the fit coming on as soon as the blow fell on his head, is well known. Two similar instances have come under my own notice. Other derangements of sight may coexist with the chromatism as epileptic aurae. Thus, Sauvagesa mentions the fact that a woman sub- ject to epilepsy saw during the paroxysm dreadful spectres, and that real objects appeared magnified to an extraordinary degree ; a fly seemed as large as a fowl, and a fowl appeared equal in size to an ox. In colored objects, green predominated with her, a fact which Ferrier states he has met with in other convulsive diseases. He also states that a very intelligent boy, who was under his care for convulsions of the voluntary muscles, when he looked at some large caricatures, glar- ingly colored with red and yellow, insisted on it that they were covered with green, till his paroxysm abated, "during which his intellects had not been at all affected." A young lady, who had overtasked her mind at school, was thrown thereby into what I regarded as a more or less hysterical condition, but which some authorities would probably consider epileptic. She saw spectres of various kinds all day, but every real object at which she looked appeared to be of an enormous size: a head, for instance, seemed to be several feet in diameter, and little children looked like giants. 1 British Medical Journal, February 7, 1874. 3 Reported by Ferrier, in "An Essay toward a Theory of Apparitions," London, 1813; p. 86. EPILEPSY. 665 When I took out my watch, while examining her pulse, she remarked that it was as large as the wheel of- a carriage. In the case of a young gentleman, now under my care for epilepsy, the attacks are invariably preceded by a period which lasts several hours and sometimes a whole day, during which he "sees small." Every thing appears to be of infinitesimal size. This phenomenon I have never seen noted by any other writer on epilepsy. Aurae connected with the sense of hearing are uncommon, except such as merely consist of tinnitus—roaring, buzzing, singing, etc.— these are often met with. But in one case there were distinct hallu- cinations of hearing preceding the attack, the patient always fancying that he heard his name repeatedly called. An aura may be entirely manifested by dreams or delusions. As an instance of the first I quote the following remarkable case from my trea- tise on " Sleep and its Derangements." The patient occasionally visits me for medical advice, but has had no epileptic paroxysm for over four years. " A lady of decided good sense had an epileptic seizure, which was preceded by a singular dream. She had gone to bed feeling somewhat fatigued with the labors of the day, which had consisted in attending three or four morning receptions, winding up with a dinner-party. She had scarcely fallen asleep when she dreamed that an old man clothed in black approached her, holding an iron crown of great weight in his hands. As he came nearer she perceived that it was her father, who had been dead several years, but whose features she distinctly recollected. Holding the crown at arm's length, he said: ' My daughter, during my life- time I was forced to wear this crown; death relieved me of the burden, but it now descends to you.' Saying which, he placed the crown on her head and disappeared gradually from her sight. Immediately she felt a great weight and an intense feeling of constriction in her head. To add to her distress she imagined that the rim of the crown was stud- ded on the inside with sharp points which wounded her forehead so that the blood streamed down her face. She awoke with agitation, excited, but felt nothing uncomfortable. Looking at the clock on the mantel- piece, she found that she had been in bed exactly thirty-five minutes. She returned to bed and soon fell asleep, but was again awakened by a similar dream. This time the apparition reproached her for not being willing to wear the crown. She had been in bed this last time over three hours before awakening. Again she fell asleep, and again, at broad daylight, was awakened by a like dream. " She now got up, took a bath, and proceeded to dress herself, with her maid's assistance. Recalling the particulars of her dream, she rec- ollected that she had heard her father say one day that in his youth, while in England, his native country, he had been subject to epileptic convulsions, consequent on a fall from a tree, and that he had been 666 CEREBROSPINAL DISEASES. cured by having the operation of trephining performed by a distin- guished London surgeon. " Though by no means superstitious, the dreams made a deep im- pression upon her, and, her sister entering the room at the time, she proceeded to detail them to her. "While thus engaged she suddenly gave a loud scream, became unconscious, and fell upon the floor, in a true epileptic convulsion. This paroxysm was not a very severe one. It was followed in about a week by another, and, strange to say, this was preceded as the first by a dream of her father placing an iron crown on her head, and of pain being thereby produced." Subsequently this lady had two other attacks, at intervals of several months, and both were preceded by the dream of the iron crown. In the case of a gentleman formerly under my treatment for epi- lepsy, the fits were invariably preceded by dreams of troubles of the head, such as decapitation, hanging, perforation with an auger, etc. It is probable that in such cases as the foregoing, the dream is ex- cited, as dreams often are, by derangements of sensibility, which are themselves the aurag. Delusions are probably not common as aurae. I have, however, had one case in a lady, thirty years of age, who had an epileptic seizure im- mediately after hearing of the sudden death of a gentleman to whom she was engaged to be married, and whose subsequent paroxysms were almost always preceded by the delusion that she was going to be killed. There was no delirium with this idea, and no exaggeration of motility, but the delusion was firmly held and acted upon to the extent that she would give away her effects, and make other preparations for her death. The following day the fit usually occurred, although sometimes it was delayed for two days, and then her reason regained its power. Delasiauve,1 of two hundred and sixty-four cases, found the parox- ysms unannounced in one hundred and one, and with precursory phe- nomena in one hundred and eighty-three. The prodromata were im- mediate in one hundred and fifty cases. These he divides into seven categories, as follows. It is to be recollected that cases may appear un- der one or more categories, according as the prodromata, as is often the case, are met with simultaneously in different parts of the body : First Series.—Precursory Signs in the Head.—Seventy-five cases. Vertigo, flashes of light.......................................... 33 Headache, weight in the head.................................... 15 Heat of face................................................... 3 Various localized sensations..................................... 13 Indefinite sensations............................................ 1 Illusions, hallucinations, and other sensorial aberrations............. 9 Rotation of the head or of the eyes............................... 5 Grinding of the teeth, derangement of the motility of the tongue...... 2 Tendency to sleep.............................................. 1 Constriction of the throat........................................ 3 1 " TraitS de l'epilepsie—histoire—traitement—medecine legale," Paris, 1854, p. 47. EPILEPSY. 667 Second Series.—Precursory Signs in the Throat.—Twenty-two cases. Oppression of the chest and sense of suffocation............,....... 9 Sensation of a ball or of motion in the' pectoral region............... 2 Shivering sensation of cold or of an aura.......................... 5 Pain or heat................................................... 4 Palpitations, spasms............................................ 2 Third Series.—Precursory Signs in the Abdomen.—Thirty-two cases. Pain with or without oppression, eructations, vomiting............... 13 Intestinal or uterine colic........................................ 3 Sensation of a ball............................................. 3 Sensation of cold, of a vapor, etc................................. 6 Stomachal heat................................................ 1 Undefinable sensations.......................................... 6 Fourth Series.—Precursory Signs in the Extremities.—Ninety- four cases. Numbness, contractions, jerkings, retractions, cramps, formications, etc.. 36 Pain with or without spasms..................................... 13 Tremblings.................................................... 10 Aura or phenomena approaching thereto.......................... 20 Undefinable sensations.......................................... 15 Fifth Series.—Precursory Signs, consisting of General and Un- definable Sensations.—Twenty-two cases. General agitation or rotation of the body.......................... 8 Condition of discomfort, fainting, etc.............................. 6 Vague sensations............................................... 7 Moroseness.................................................... 1 Sixth Series.—Precursory Signs situated in the Genital Orga?is. —Five cases, such as retraction of the testicles, aura starting from the testicles and spermatic cords, sensations located in the uterus, etc. Seventh Series.—Exceptional Cases.—Desire to defecate, to uri- nate, profuse perspiration, etc. The Paroxysm.—Great differences are observed in the character and severity of the paroxysm. Ordinarily two varieties are recognized, the petit mat or slight attack, and the grand mal or severe seizure. The first is unattended by marked spasm or agitation ; the latter is characterized by more or less violent tonic and clonic convulsions. These divisions are, however, not regarded as sufficiently precise by those who have studied the disease in question with care and precision, and more minute classifications of the phenomena of the epileptic par- oxysm have accordingly been made. The one which I have used in my lectures at the University Medical College for several years past is less 668 CEREBRO-SPINAL DISEASES. complex than some others, and embraces all the known varieties. It is as follows : 1. Momentary unconsciousness without marked spasm. 2. Unconsciousness with evident though local spasm. 3. Unconsciousness with general tonic and clonic convulsions. 4. Irregular or aborted paroxysms. Besides these several varieties, there are certain accompaniments, such as hysteria, mania, and paralysis, which will require consideration. 1. Momentary Unconsciousness without Evident Spasm.—The pa- tient is perhaps standing, engaged in conversation, when a momentary blank in his mental processes occurs. It probably does not attract at- tention ; it is instantaneous, disappears, leaving no feeling of discom- fort after it, and there is an almost immediate continuance of his thoughts and speech. Or he may be walking in the street when the accession occurs. He loses himself for an instant, but he continues to walk, and does not even stagger. In somewhat more severe seizures, if conversing, he stops suddenly, stares vacantly but fixedly for a moment, and may drop any thing which he has in his hand. If walking, his steps are arrested for an instant, he staggers and would fall but for the quick return of consciousness. Such is the general character of these absences, faints, spells, etc., as they are popularly called ; varying, however, according to the cir- cumstances of the moment and the condition of the patient. They fre- quently exist for a long time without the patient paying much atten- tion to them. In a gentleman now under my charge they occurred several times in the course of the day when walking, riding on horse- back, sitting quietly in his library, engaged in conversation, or eating. He did not consider them of much importance, and was surprised when I informed him they were epileptic. The continuity of his acts was scarcely interrupted, and those about him never noticed that any thing was wrong. In the case of a young lady they occur generally at the dinner- table. She drops her knife and fork, looks steadily to the front, ceases to eat, and in about two seconds resumes her occupation with a long- drawn inspiration. Those near her observe that her countenance be- comes very pale, and that she does not hear or see. Sometimes these attacks, slight as they are, are followed by pain in the head, vertigo, confusion of ideas, numbness, and other evidences of nervous derangement, which may last for several hours, and which be- come more pronounced as the epileptic condition becomes more con- firmed. 2. Unconsciousness, with Evident though Local Spasm.—In this variety the loss of consciousness is of longer duration than in the pre- EPILEPSY. 669 ceding, and is attended with convulsions light in character, but yet ap- parent to those around. The eyes are fixed, as in the first variety, the mind becomes a blank, and there is a sensation of vertigo immediately before the loss of consciousness, and at the time of its restoration. The face usually becomes pale first and then red, or either of these con- ditions may occur without the other being observed. The spasms may be very slight. Sometimes there is momentary strabismus, at others retraction of the angles of the mouth on one or both sides, rotation of the head or a sudden drawing of it backward, or the tongue is thrust forward and the jaws close on it, inflicting slight injury. Again, the chair in which the patient may be sitting is pushed back with some force, and the body is bent forward, or the muscles of the neck may be affected, and the circulation thus interrupted in the veins of the neck, causing a dark hue of the complexion. Sometimes the spasms have an appearance of being volitional. A patient under my charge tugs violently at his hand ; another walks about the room, but without taking any determinate course ; a young lady leaves her chair and stands upon another one at some distance from her, and another talks all kinds of gibberish. My experience of such cases is in accordance with that of Reynolds,1 to the effect that there is no recollection of these acts. These attacks are often preceded by prodromata of various kinds. The duration rarely exceeds a minute, and is generally much less. 3. Unconsciousness, with General Tonic and Clonic Convulsions. —Prodromata may or may not be present. In any event the paroxysm occurs suddenly. The first circumstance may be a cry of a very peculiar character, somewhat resembling the bleating of a young lamb. The eyes become fixed, and the patient falls to the ground, usually with a bound, as if he is shot. The loss of consciousness occurs with the cry, or with the fixedness of the gaze. The muscles are now thrown into a state of tonic contraction ; the respiration is impeded, or altogether arrested ; the face, if at first pale, becomes dark ; the pupils are dilated, and sensibility is entirely abol- ished. Careful examination of a patient in this stage of the paroxysm re- veals some important features : the body is rigid, but is usually inclined more to one side than the other, in the position of a tetanic patient with pleurosthotonos ; the eyes are open, and are twisted to one side ; the face is likewise more retracted on one side than the other; the sterno-cleido-mastoid muscles, and others of the neck, stand out like thick cords ; the carotids throb with force ; the veins of the head and neck are turgid with black blood, and the pulse is usually weak and fluttering. After this stage has lasted for a period varying from two or three 1 "System of Medicine," vol. ii., p. 261, article "Epilepsy." 670 CEREBRO-SPINAL DISEASES. seconds to half a minute, a great change ensues. The unconsciousness continues, but the general tonic spasm relaxes, and clonic convulsions take its place. These are general, but are ordinarily more strongly marked on one side of the body than on the other. The muscles of the face are alternately contracted and relaxed ; the tongue is often thrust between the teeth, and, the jaws being closed upon it, it is terribly in- jured ; the upper and lower extremities are in a state of continued agi- tation, and the contents of the bladder, rectum, and vesiculas seminales, may be evacuated. The respiration is forced and irregular, froth issues from the mouth, and, if the tongue has been bitten, it is colored with blood. The muscles of the neck do not relax to any considerable extent; consequently the veins remain distended, and the face continues to be livid. The pupils oscillate, sometimes being dilated and then contract- ed, or one may be contracted and the other dilated. The heart beats with great irregularity, both as to force and frequency. This stage may last from a few seconds to five minutes. Cases of longer duration are on record, but they are exceedingly rare. The third stage of the paroxysm is characterized by the gradual return of consciousness. The patient, though still somewhat convulsed, looks around him, and gives evidence of returning sensibility in other ways. The pupils cease their disorderly movements, and are contracted; the respiration and pulse become more regular, and he may even attempt to speak. It often happens that little spots of extravasated blood make their appearance under the skin of the forehead, eyelids, cheeks, and sometimes on the neck and breast. These disappear in a few days. The duration of this stage is from a few seconds to four or five minutes, and it is often so slightly marked as to escape observation. With the cessation of the convulsive movements the stage of stupor usually supervenes, though it may be entirely absent, especially in old cases of epilepsy. During this stage there are sometimes clonic spasms of no great degree of severity. It may last a few minutes or several hours. When the patient arouses from it, he generally has headache, and a feeling of lassitude and soreness of the muscles, from the violent contractions they have undergone. 4. Irregular or Aborted Paroxysms.—In these it may happen that the loss of consciousness is not complete, or that the patient has con- vulsive movements partial in character and accompanied simply by ver- tigo, or he may have unconsciousness lasting for an hour or more, during which he performs automatic acts, of which he has no recollec- tion, but which are not accompanied by any movements that can prop- erly be called spasmodic. In his interesting lecture on " Apoplectiform Cerebral Congestion,' Trousseau' cites a number of cases which were clearly instances of 1 Op. cit, Bazire's translation, pp. 19, et seq. EPILEPSY. 671 irregular or abortive epileptic paroxysms. Among them is that of a magistrate whose sister was an inmate of a lunatic asylum. He was president of a provincial tribunal. One day he got up all of a sudden, muttered a few unintelligible words, and went to the deliberating-room. The usher followed him, and saw him make water in a corner. A few minutes afterward he returned to his seat, and again listened with in- telligence and attention to the pleadings momentarily interrupted. He had no recollection of the incredibly incongruous act he had committed. This gentleman belonged to a literary society, which held its meetings at the H6tel-de-Ville, of Paris. At one of these, during the discussion of an important historical point, he was seized with vertigo. He ran quickly down to the Place de H6tel-de-Ville, and walked about for a few minutes on the quays, avoiding with success both carriages and the passers-by. On recovering himself he perceived that he had come out without his great-coat and his hat. He therefore returned to the meet- ing, and resumed with a perfectly lucid mind the historical discussion in which he had already taken a very active part. He retained no recol- lection whatever of what had occurred between the beginning of the attack and the moment he recovered himself. Many cases similar to these might be cited from other authors. From a number which have happened in my own experience I adduce the following: J. H. consulted me for epilepsy in the summer of 1869. His ordi- nary attacks were of the fully-developed form; but upon two occasions they were different from any with which he had previously been af- fected. On one of fhese, while overlooking some workmen, he was observed to put his hand to his head, and then sudddenly to run toward a fence, which he speedily climbed. Jumping down into the back-yard of the adjoining house, he seized a stick of wood near by, and made a furious onslaught on the door and windows. While thus engaged he was seized by several men, and forcibly held, notwithstanding his strug- gles. While thus being restrained he recovered his consciousness, but had no recollection of any thing which had taken place after he had put his hand to his head, which action he said was due to severe pain with vertigo. The duration of the attack was not over three minutes. On the other occasion he was seized with pain and vertigo while engaged in paying a bill at a coal-yard. He rushed into the street, and began to turn rapidly round. He was seized and held till he re- covered his consciousness. This attack lasted about four minutes. Subsequently he had a similar paroxysm in my consulting-room. His face suddenly became very pale, his eyes were fixed, and his pupils oscillated. Suddenly he rose from the chair, grasped the mantel-piece for an instant, and then rushed violently around the room, throwing his arms about, and uttering a peculiar inarticulate cry. I made no at- tempt to restrain him, and in about two minutes he became calm. 672 CEREBRO-SPINAL DISEASES. During the whole paroxysm his face was pale, and at its close the pu- pils were dilated. He had no recollection of any thing which had oc- curred after he rose from the chair, but was conscious then of vertigo. Another case is that of a girl brought to my clinic at the Bellevue Hospital Medical College during the summer of 1869. She had been severely injured in the skull by a fall against a mass of old iron. Ne- crosis subsequently ensued, and several large pieces of the external table were exfoliated. While before the class, she started to her feet, and walked several times around the closed area. She was unconscious, and to all appearance insensible. When the paroxysm was over she returned to her seat. The duration did not exceed a minute, and there was no excitement or delirium. Another patient, a partner in an extensive mercantile establish- ment, who was subject to attacks of both the grand and petit mal, left his office at about eleven o'clock for the purpose of getting a signature to a paper of some kind from a gentleman whose place of business was a few minutes' walk distant. Not returning by three o'clock, inquiry was made, and it was ascertained that he had visited the office, obtained the signature, and had left in apparently good health before half-past eleven. Since then nothing had been heard of him. He did not make his appearance at his own office till nearly five o'clock. The last thing he recollected was passing St. Paul's Church at the corner of Broadway and Vesey Street, just as the congregation was coming out after morning service. It was subsequently ascertained that he had gone to Brooklyn after getting the signature he wanted, had visited a newspaper-office and purchased a paper ; had returned to New York, entered an omnibus at the Fulton Ferry, left it at the corner of Twenty-third Street and Fifth Avenue, entered the Fifth Avenue Hotel, and while there recovered his recollection. But none of these cases, nor any of which I have seen any report, are equal in interest to one which occurred in my practice during the autumn of 1875. The patient, who was engaged in active business as a manufacturer, left his office at about 9 A. m., saying he was going to a florist's to purchase some bulbs. He remained absent eight days. He was tracked all over the city, but the detectives and friends were always an hour or more behind him. It was ascertained that he had been to theatres, to hotels, where he slept, to shops-where he had made pur- chases, and that he had made a journey of a hundred miles from New York, and, losing his ticket and not being able to give a satisfactory account of himself, was put off of the train at a way-station. He had then returned to New York, passed the night at an hotel, and on the eighth day, at about ten o'clock, made his appearance at his office. He had no recollection of any one event which had taken place after leav- ing his place of business, eight days previously, till he awoke on the morning after his return to the city, and found himself in an hotel at EPILEPSY. 673 which he was a stranger. It was ascertained beyond question that in all this time his actions had been entirely correct to all appearance, that his speech was coherent, and that he had acted entirely in all respects as any man in the full possession of his mental faculties would have acted. He had drunk nothing but a glass of ale, which he took with some oysters at a restaurant in Sixth Avenue. It could not be ascertained that this patient had ever had an epilep- tic paroxysm ; but he had a year previously been under my charge for cerebral symptoms, indicating the existence of chronic basilar menin- gitis, and only a week before his disappearance I had discharged him cured, after a month's treatment for severe pain in the head, dizziness, paralysis of the third nerve on the right side, and extreme insomnia. There were all the indications of specific cause, and I had treated him with large doses of the iodide of potassium, as on the former occasion. Relative to the mental disturbance which sometimes ensues upon epi- leptic paroxysms, Dr. Hughlings Jackson1 has recently given some inter- esting details relative to acts performed by epileptics during periods of unconsciousness. In his opinion such acts are automatic, not—to speak exactly—epileptic, but post-epileptic. " The condition after the parox- ysm is duplex : (1) there is loss or defect of consciousness, and there is (2) mental automatism. In other words, there is (1) loss of control, permitting (2) increased automatic action." The epileptic seizure may be so slight and transitory as to escape observation, but the slighter it is the more apt is the resulting automatism to be complex and elab- orate. Dr. Jackson gives a number of exceedingly interesting cases in illus- tration of his views, which in addition are enforced with much cogent reasoning. But, while in the main agreeing with him, I am scarcely prepared to deny that such unconscious attacks may not be substituted for the more fully-developed paroxysm instead of, as in his opinion, always following a seizure. Epileptic fits may take place at night during sleep, and the patient be unaware of their existence, unless he inflicts some injury on himself, such as biting his tongue, or is told of their occurrence by persons who may be in the same room with him. In two hundred and six of my cases the period of access is noted, and, of these, forty-seven were noc- turnal, and one hundred and fifty^nine diurnal. In the intervals between the paroxysms epileptics often exhibit cer- tain evidences of disordered mental, sensorial, and motor functions. Thus, as regards the first category, the memory may be impaired, and there may be diminished mental power. There are, however, many exceptions to this rule; and, even where there have been a great many attacks, the mind may preserve its normal degree of integrity. As 1 " On Temporary Mental Disorders after Epileptic Paroxysms," " West Riding Lu- natic Asylum Medical Reports," vol. v., p. 105. 43 674 CEREBRO-SPINAL DISEASES. Reynolds remarks, in regard to this point: " A patient may be epileptic and a lunatic; he may be epileptic and asthmatic, but there are some epileptics whose minds are as healthy as their lungs; and, so far as the natural history of epilepsy is concerned, it is a mistake to derive it from complicated cases." Still, in the majority of cases, it will be found that the mind sooner or later becomes involved, and it sometimes happens that a single attack causes marked intellectual deterioration. Derangements of sensibility are common from the beginning. Headache, a feeling of constriction around the forehead, and occasion- ally a pain at the back of the head, are noticed. Vertigo is also fre- quently present, as are also sensations of numbness in different parts of the body. The pupils are almost invariably dilated. The motor power of the patient is generally weakened without there being any decided paralysis. Twitchings of the muscles are not un- common, and there is often a general excitability of the reflex faculty of the spinal cord, by which jerkings of the limbs are produced by slight excitations. The circulation is generally sluggish, the extremities are cold, and the capillaries are turgid and inactive, so that, if the finger be pressed firmly upon the skin, a considerable period elapses before the white spot disappears by the refilling of the vessels. In examining with the ophthalmoscope the fundus of the eye in epileptics, we can often detect evidences either of cerebral congestion or of anaemia, and thus obtain valuable indications for treatment. For several years, in my lectures, I have constantly insisted on this point, and in my cliniques have exhibited several cases in which I had been guided to successful treatment by the ophthalmoscope. Drs. Kostle and Niemetshek,1 of Prague, consider that the brain in epileptics is always anaemic, and that this condition is invariably found by ophthalmoscopic examination. According to these observers, the venous pulse is pro- duced when the eye is made anaemic, and they assert that the retina is anasmic, and that there is consequently venous pulsation in every case of epilepsy. That this opinion is erroneous, both as to the facts and inferences, I am very sure. Venous pulsation, so far from being indica- tive of anaemia, really shows the existence of the very opposite con- dition. My observations are, however, to the effect that venous pul- sation is present in many cases of epilepsy, and that it accompanies dilatation of the veins. There is no invariable rule relative to the occurrence of any par- ticular form of epilepsy in the same person. It thus often happens that all the varieties of paroxysm mentioned, except the irregular or aborted form, which is more rare, are met with in one individual. The more severe forms may occur at longer intervals, and the milder forms 1 Prager Vierteljahrschrift, H. 106, 107, 1870, and Quarterly Journal of Psychologud Medicine, January, 1871, p. 128. EPILEPSY. 675 more frequently. As regards frequency, there are great variations. Some patients go a year or more without attacks, while others have several every day. It generally happens that the intervals become progressively shorter. As a rule, attacks of the milder forms are more frequent than the fully-developed paroxysm, and attacks of the latter are milder, as they are more frequent. Mania is sometimes a consequence of epilepsy. It comes on after the attack, and is rarely of more than a few minutes' duration. Those cases in which it precedes the paroxysm, and lasts several hours or days, are cases of mania conjoined with epilepsy—a combination which, as every insane asylum shows, is not uncommon. The mania of epi- lepsy is usually of a very exalted character, and during its existence the subject may commit homicide or other crimes. The mental state of epilepsy has been well studied by Falret,1 and a very interesting case has been recently reported by Dr. Thorne,2 in a paper entitled " Masked Epilepsy." In this instance the patient often returned to his home without being able to give any account of what he had been doing or where he had been. During these attacks he was frequently the subject of that form of mental derangement called klep- tomania. Generally they ensued on paroxysms either of the grand or petit mal, but sometimes they were substituted for the regular seiz- ures. He had no recollection of what occurred during the attacks. Sometimes he was furiously excited in them, and would endeavor to injure himself and others in his blind rage. Relative to the diagnosis of the remarkable paroxysms, the main feature of which is unconsciousness, or rather non-recollection of consciousness, in which the individual acts apparently automatically, great difficulties exist. Probably nothing short of a full history of the case, from infancy up, will suffice for the recognition of the real nature of the phenomena. There appears to be an idea in the minds of some physicians, that every outrageous criminal act is the result of epilepsy, and so wide-spread is this notion, that now the first plea of the murderer is, that he " knew nothing about it ; " and the fact that an individual who has perpetrated a murderous outrage is the subject from time to time of epileptic seizures, is regarded as sufficient to absolve him from all responsibility for his actions. The fact of a discolored spot on his pillow, or of an infantile convulsion, is seized upon as a valid reason for acquittal, or even for setting aside a verdict found after a full and fair trial. In the first place, it must be understood that an undoubted epileptic is just as capable of murdering for revenge or gain as is a healthy person, and that he is just as accountable, and should accord- ingly suffer the full penalty of the law for his conduct. At the same 1 " De l'etat mental des epileptiques," Archives generates de medecine, Decembre, 1860, et Avril et Octobre, 1861. 8 "St. Bartholomew's Hospital Reports," 1870. 676 CEREBRO-SPINAL DISEASES. time, it is not to be questioned that acts of violence may be perpetrated during seizures which are either epileptic or the direct consequence of an epileptic paroxysm. It is only by the most thorough and careful inquiry into all the motives for and circumstances attending upon the act, as well as all the antecedents of the individual, that a proper discrimination can be made. Each case must be determined for itself ; there are no rules applicable invariably to all. The medico-legal relations of epilepsy do not, however, come with- in the scope of the present treatise. Paralysis may follow epilepsy, but, unless the case is complicated with some organic disease of the brain or spinal cord, the loss of power is temporary. Causes.—Among the predisposing causes of epilepsy, hereditary tendency stands first. Reynolds ' states that, in about one-third of the cases under his observation, hereditary taint existed. He does not, by this statement, however, mean to assert that epilepsy existed in one- third of the parents, but that some disease of the nervous system, more or less closely allied to epilepsy, was present in either the parents, the grandparents, the aunts, uncles, brothers, or sisters. Only twelve per cent, of his cases gave a distinct history of epilepsy in either branch of their families. Herpin," of sixty-eight cases, found that ten were descended from epileptic ancestors. Delasiauve,3 of three hundred cases, found decided evidence of hereditary tendency in thirty-three. In one hundred and sixty-seven there were no data, and in one hundred and twenty hereditary taint was denied. Of the thirty-three cases, five were descended from epi- leptic ancestors. Sieveking 4 found that hereditary influence was present in 11.1 per cent, of his cases. In my own experience I have notes in regard to this point in three hundred and ninety-six cases. Of these, sixty-four had epileptic fa- thers, mothers, grandparents, uncles, aunts, brothers, or sisters, and forty-eight had relatives insane, hysterical, cataleptic, affected with severe neuralgia, or of remarkably irritable nervous systems. Sex does not appear to exercise any appreciable influence as a pre- disposing cause. Of five hundred and seventy-two cases noted by my- self, two hundred and ninety-eight were in males and two hundred and seventy-four in females. Other authors have, however, had directly opposite experience. Age has a very decided influence. Reynolds gives the following table of one hundred and seventy-two cases collected by himself : 1 Op. cit, p. 253. 1 " Du pronostic et du traitement curatif de l'dpilepsie," Paris, 1852, p. 325. 1 Op. cit, p. 189. * " On Epilepsy," etc., London, 1858, p. 74. EPILEPSY. 677 Age at Commencement. Males. Females. Total. Under 10 years......... Between 10 and 20 years Between 20 and 44 years Over 45 years........., Total........ 10 66 25 1 102 40 20 1 70 19 106 45 2 172 My own cases were as follows Age at Commencement. Males. Females. Total. 31 178 72 17 29 151 71 23 60 329 143 40 Total..................................... 298 274 572 It is thus seen that the period of life between ten and twenty years is that at which epilepsy is most apt to occur. The experience of oth- ers is to the same effect. The influence of temperament has been thought important by some writers. But, aside from the different opinions entertained relative to the characteristics of the temperaments, it is by no means established that, even when strictly defined, tempera- ment exercises any effect as a predisposing cause. I have no accurate records on this point, though so far as my memory serves me I have observed no marked predominance of epileptics with any temperament. The exciting causes may very properly be classified as psychical, eccentric, general organic changes, and physical influences. Relative to the influences of these causes, Reynolds gives the following table : Nature of Cause. No. of Cases. I. Psychical—such as fright, grief, worry, overwork............... 29 II. Eccentric irritation—dentition, indigestion, venereal excesses, dys- entery, etc.......................................... 16 III. General organic changes—fatigue, pregnancy, miscarriages, rheu- matic fever, scarlet fever, diphtheria, pneumonia............ 9 IV. Physical influences—blows on head, falls, insolation, cuts....... 9 In my own cases no exciting cause could be assigned in one hun- dred and seventy-seven. The remaining three hundred and ninety-five cases were, according to the evidence received, caused as follows : Fright....................................................... 35 Anxiety..................................................... 17 Grief........................................................ 30 Over mental exertion.........................;................. 48 Dentition.......,................ ....................... .... 21 Indigestion................................................... 83 Carried forward 184 678 CEREBRO-SPINAL DISEASES. Brought forward............................... 184 Venereal and sexual excesses................................... 60 Menstrual derangement........................................ 56 Blows on the head............................................ 24 Peripheral wounds and injuries.................................. 4 Falls........................................................ 13 Sunstroke.................................................... 17 Scarlet fever.................................................. 3 Measles...................................................... 3 Diphtheria................................................... 9 Pregnancy................................................... 3 Syphilis...................................................... 13 Malaria..................................................... 6 395 Diagnosis.—The diagnosis of epilepsy presents no difficulties to the careful observer. It may, however, be confounded with several condi- tions, the principal of which are cerebral congestion, cerebral haemor- rhage, hysteria, the convulsions of infancy and of Bright's disease, poisoning by opium and alcohol, syncope, and with the convulsions of epileptiform character which occur in the course of certain organic dis- eases of the brain. The diagnosis from cerebral congestion and cerebral haemorrhage has already been given in the chapters treating of those affections. In hysteria, the convulsions, which are sometimes epileptiform in charac- ter, are preceded or accompanied by other evidences of the hysterical state. Consciousness is rarely entirely lost, the tongue is not bitten, and there is no subsequent stage of stupor. The convulsions of infancy not epileptic are not repeated but from a readily-ascertained exciting cause, such as dentition, indigestion, falls, etc. So far as the paroxysm is concerned, I know of no specific points of difference; but it must be recollected that the paroxysm is not the only feature of epilepsy, and that it is the only feature of infantile con- vulsions. These latter may pass into epilepsy; but, if they do not, I have never been able to find a single case in my experience "n which epilepsy ensuing in adult life has been preceded by the ordinary infan- tile convulsions. In Bright's disease, though the convulsions may be epileptiform in character, coma is the principal feature, and the history of the case will further serve to render the diagnosis exact. The same remarks are applicable to poisoning by opium and alcohol. From syncope epilepsy is distinguished by the facts that the loss of consciousness is sudden and complete, that the pulse is not feeble, and that recovery is rapid. These remarks apply to the milder attacks with- out convulsions. From the more severe forms of the paroxysm the dis- tinction is too obvious to require amplification. In organic diseases of the brain, such as tumors, softening, sclerosis, etc., the accompanying symptoms, pain, paralysis, tremor, imbecility, EPILEPSY. 679 difficulties of speech, and derangements of the special senses, will serve to distinguish them from epilepsy. Epilepsy is often assumed by designing persons for purposes of fraud. In such cases the pretender usually overacts his part ; his sensibility is not abolished, as may readily be ascertained by putting the end of the finger on the conjunctiva, and the size of the pupils is not altered. Prognosis.—The prognosis depends to a great extent on the dura- tion of the disease. Recent cases can often be cured, but those which have lasted for several years are rarely brought to a favorable termina- tion. Among the other unfavorable elements are the existence of hereditary influence, the beginning of the disease late in life, the pres- ence of material mental weakness, and the existence of long intervals between the attacks. As regards the probability of the supervention of any form of in- tellectual derangement or debility, the most important ascertained point is that the mild paroxysms unattended by convulsions are more productive of mental decay than the severe form of seizure. The oc- currence of the first attack late in life is likewise a predisponent to dementia. I have never, in my own experience, known death to take place dur- ing a paroxysm of true epilepsy ; such cases, however, do occur. Usu- ally, some intercurrent affection carries the patient off, though even with this liability life is sometimes astonishingly prolonged. I am acquainted with the case of a lady who is now sixty-five years of age, and who, since her tenth year, has averaged six paroxysms daily, all of the severest character. Her mind is almost entirely gone, but physi- cally her health is excellent, and to all appearance she may live twenty years longer. I am not aware of any exact observations tending to show the rela- tive danger to life of attacks of the milder and severer forms ; though it is reasonable to suppose that, so far as regards the occurrence of death during the paroxysm, the convulsive form is more fatal. Morbid Anatomy.—In post-mortem examinations of persons dying epileptic, abnormal conditions are found in every part of the brain and spinal cord. Some of these lesions are undoubtedly secondary, others unessential, while those which may be considered primary vary in their seat and character. In a great many cases, perhaps the majority, no lesions are discoverable. No one has been more thorough in the search for the essential cause of epilepsy than Schroeder van der Kolk ; * though his observations can scarcely be regarded as yielding conclusive results, they serve to show, 1 " On the Minute Structure and Functions of the Medulla Oblongata, and on the Proxi- mate Causes and Rational Treatment of Epilepsy," "New Sydenham Society Transla- tions," London, 1859. 680 CEREBRO-SPINAL DISEASES. when taken in connection with the pathology of the disease in question, that its seat is mainly in the medulla oblongata, with secondary impli- cation of other parts of the cerebro-spinal nervous system. Oftentimes, in accordance with other pathologists, he found nothing to account for the affection, but at others he found hardening and contraction of the medulla oblongata, and again degeneration of the brain either as a con- sequence or cause of the disease. Microscopical examination some- times showed him the medulla indurated, sometimes softened, and, as a constant phenomenon, " whether the patient died in or out of the fit, great redness and vascular tension in the fourth ventricle, penetrating into the medulla oblongata sometimes to a considerable depth." These appearances were due to enlargement of the blood-vessels, as was shown by microscopical measurements. It is probable, however, as Schroeder van der Kolk asserts, that the lesions in question are the results, and not the causes, of the paroxysms. Still they suffice to indicate the main seat of the disease to be the medulla oblongata. Other observers have not so uniformly found this enlargement of the blood-vessels of the medulla. In three cases of death occurring in epileptics, in which I have had the opportunity of making post-mortem examinations, they certainly did not exist, nor was there any other le- sion detected by the most careful microscopical exploration. In one other case the vessels of the medulla oblongata were enlarged, and there was amyloid degeneration of the pituitary body. Fox] gives the following list of the post-mortem appearances : Foreign bodies developed on the meninges, in the ventricles, in the cortical substance ; increase of subarachnoid fluid or distention of the ventricles by serum, induration, softening, and general swelling of the cerebral mass ; general or partial hyperaemia, cysts, tubercles, cancers, exostoses, periosteal growths, thickening, or some change of the arach- noid or the pia mater ; abnormal thickness or abnormal thinness of the cranial bones ; excessive size of head, increase of the volume of the cranial cavity, deformities or abnormality in the conformation of this cavity ; caries of the cranial bones ; pus between the bone and the dura mater ; acute or chronic hydrocephalus, hydatids, ossification of the dura mater, tubercle of the dura mater or pachymeningitis, abscess in the cerebral tissue, spots or regions of haemorrhage ; various traumatic lesions ; alterations of the pineal gland ; inequality of weight and size of the cerebral hemisphere ; various lesions connected with blood-ves- sels—aneurism, embolism, atheroma, increase in size of the capillaries in the medulla oblongata, fatty degeneration of some portion of the medulla oblongata ; capillary dilatation in the pons and cerebellum; haemorrhage of pons; anaemia of brain, either from disease of vessels or dependent upon general anaemia, etc., etc. 1 " The Pathological Anatomy of the Nervous Centres," London, 1874, p. 805. EPILEPSY. 681 Indeed, no point is more thoroughly established than that epilepsy results from very different morbid conditions, and that they are simply the starting-points in the majority of cases. The true lesion has not yet been detected, and in fact, as we shall presently see when discuss- ing the pathology of the disease, there may be no necessary anatomical lesion whatever. Pathology.—The points which may be considered as to some extent established relative to the pathology of epilepsy are briefly summarized as follows by Reynolds : * " 1. That the seat of primary derangement is the medulla oblongata and upper portion of the spinal cord. " 2. That the derangement consists in an increased and perverted readiness of action in these organs, the result of such action being the induction of spasm in the contractile fibres of the vessels supplying the brain, and in those of the muscles of the face, pharynx, larynx, respira- tory apparatus, and limbs generally. " By contraction of the vessels the brain is deprived of blood, and consciousness is arrested; the face is or may be deprived of blood, and there is pallor; by contraction of the vessels which have been men- tioned, there is arrest of respiration, the chest-walls are fixed, and the other phenomena of the first stage of the attack are brought about. " 3. That the arrest of breathing lead's to the special convulsions of asphyxia, and that the amount of these is in direct proportion to the perfection and continuance of the asphyxia. " 4. That the subsequent phenomena are those of poisoned blood, i. e., of blood poisoned by the retention of carbonic acid, and altered by the absence of a due amount of oxygen. " 5. That the primary nutrition-change, which is the starting-point of epilepsy, may exist alone, and epilepsy be an idiopathic disease, i. e., a morbus per se. " 6. That this change may be transmitted hereditarily. " 7. That it may be induced by conditions acting upon the nervous centres directly, such as mechanical injuries, overwork, insolation, emo- tional disturbances, excessive venery, etc. " 8. That the nutrition-changes of epilepsy may be a part of some general metamorphosis, such as that present in the several cachexias— rheumatism, gout, syphilis, scrofula, and the like. " 9. That it may be induced by some unknown circumstances deter- mining a relative excess of change in the medulla during the general excess and perversion of organic change occurring at the periods of puberty, of pregnancy, and of dentition. 1 Op. cit, p. 275, and more fully stated in his " Treatise on Epilepsy, its Symptoms, Treatment, and Relations to other Chronic Convulsive Diseases," London, 1861, chapter v., p. 238. 682 CEREBRO-SPINAL DISEASES. " 10. That it may be due to diseased action, extending from con- tiguous portions of the nervous centres or their appendages. " 11. That the so-called epileptic aura is a condition of sensation or of motion, dependent upon some change in the central nervous system, and is, like the paroxysm, a peripheral expression of the disease, and not its cause." While admitting the correctness of these conclusions, they do not, in my opinion, tell the whole story of the theory of epilepsy. In very many memoirs Dr. Brown-Sequard has pointed out the dependence of the affection upon injuries of the upper part of the spinal cord, and upon irritations existing in various parts of the body. His researches, and facts observed every day by physicians who see many cases of epi- lepsy, show very conclusively that the starting-point is often in the sympathetic nerve—the nerve by which the calibre of the blood-vessels is regulated. Neither can I accept the view that the first intra-cranial condition producing a paroxysm is in all cases spasm of the blood-vessels and the consequent deprivation of the blood-supply to the brain. On the con- trary, I am very sure that the primary state is often paralysis of the cerebral blood-vessels and resulting hyperaemia. By this condition the medulla oblongata is thrown into a state of over-excitation, giving rise to convulsions, and consciousness is lost from the fact that the hemi- spheres participate. That convulsions, epileptiform in character, may be produced both by cerebral anaemia and cerebral hyperaemia, when either condition involves the medulla oblongata, is a fact which experiment has abundantly established, and that loss of consciousness follows either condition involving the hemispheres is equally certain. We have, con- sequently, two kinds of epilepsy—the one due to anaemia, the other to congestion—and it is to this fact that is due the circumstance that sometimes the paroxysms are prevented by measures which tend to in- crease the amount of blood in the brain, and at others by remedies which exercise a contrary influence. The existence of the two species of epilepsy is likewise shown by ophthalmoscopic examination—a point upon which I have already insisted. During natural sleep the amount of blood is, as I have elsewhere shown, decreased from the quantity which circulates in the cerebral blood-vessels during wakefulness. Epilepsy occurring during sleep is therefore of the anaemic variety. But it often happens that sleep passes gradually into stupor, from the fact that causes tending to in- crease the flow of blood to the brain, or to arrest its passage from this organ, are in operation. In such cases epilepsy of the congestive va- riety may be induced. In those cases in which the tongue is bitten, the medulla oblongata is probably always in a condition of hyperaemia ; and this state, as Schroeder van der Kolk has very conclusively shown, is mainly in the EPILEPSY. 683 course of the roots of the hypoglossal nerve. The intermissions be- tween the attacks are ingeniously explained by the same able observer, by likening the cells of the medulla oblongata to Leyden-jars charged with electricity, or to the electrical organs of the conger-eel and tor- pedo. After being discharged, time is necessary for the reaccumula- tion of sufficient electricity to discharge them again ; and, when the cells of the medulla have once discharged themselves in an epileptic convulsion, a period must elapse before another access can take place. Nothnagel' believes that the pons Varolii and the medulla oblonga- ta are the seat of epilepsy, and that it is in these centres that we are to look for the anatomical changes. Although, as his own experiments as well as those of Hitzig show that epilepsy may be produced by irri- tation of the cortical substance of the brain, the fact only proves that such irritation is an exciting cause, and is no more to be regarded as indicating the cortex as the seat of the disease than the fact that irritation of the sciatic nerve, followed by epilepsy, indicates that part of the nervous system as containing the essential lesion. The foregoing remarks apply in the main to that form of epileptic seizure characterized by convulsion. In the imperfectly-developed at- tacks the implication of the medulla oblongata must be very slight, the hemispheres being the organs mainly affected, and the condition being sometimes anaemic, at others hyperaemic. It must not be supposed, from what has been said, that simple cere- bral anaemia and simple cerebral congestion, attended with epileptiform convulsions, are identical with the anaemia and congestion of epilepsy. This disease is cerebral anaemia or congestion with another element, the exact nature of which we do not understand, but which is certainly of such a character as to constitute the main differential point between epilepsy and any other affection. • A chapter on epilepsy would be manifestly incomplete without a statement of the views held by Dr. Hughlings Jackson a relative to its pathology and natural history. According to this eminent authority those parts of the body suffer first and most, from convulsions or other manifestations of the disease, which are most frequently brought into volitional action, and those parts least which are most automatic in their operation. Thus he says, in a paper published in the lancet, February 1,1873: "There are three parts where fits of this group mostly begin : (1) in the hand ; (2) in the face, or tongue, or both ; (3) in the foot. In other words, they usually begin in those parts of one side of the body which have the most voluntary use. The order of frequency in which 1 " Epilepsie," in Ziemssen's " Handbuch der speciellen Pathologie und Therapie," zwblfter Band, " Krankheiten des Nervensystems," ii., zweiter Halfte, pp. 250, el seq. 2 " On the Anatomical, Physiological and Pathological Investigation of Epileptics," "West Riding Lunatic Asylum Medical Reports," vol. iii., 1873, p. 315. 684 CEREBRO-SPINAL DISEASES. parts suffer illustrates the same law. I mean that fits beginning in the hand are commonest; next in frequency are those which begin in the face or tongue, and rarest are those which begin in the foot. The law is seen in details. When the fit begins in the hand, the index-finger and thumb are usually the digits first seized ; when in the face the side of the cheek is first in spasm ; when in the foot, almost invariably the great-toe." As Dr. Jackson says, the spasm " prefers," so to speak, to begin in those parts which have the most voluntary uses; in other words, in those parts which have the more leading, independent, separate and varied movements ; in other words still, in those parts the movements of which are last acquired—" educated." Physiologically, a voluntary part, the hand, for instance, is one which has the greater number of different movements at the greater number of different intervals ; that is, the more " varied " uses. An automatic part, the chest, for exam- ple, is one which has the greater number of similar movements at the greater number of equal intervals; shortly, the more " similar" uses. Hence, convulsions which begin in the hand usually begin in the thumb and index-finger—in the most voluntary parts of the body. An epileptic paroxysm is a sudden, excessive, and rapid discharge of gray matter of some part of the brain. Instead of working off its force gradually and regularly, it explodes it, as it were. The gray mat- ter which is the seat of a " discharging lesion " is in a permanently ab- normal state of nutrition, and hence is permanently abnormal in func- tion. Thus a first fit is a discharge of a part which has for some time before been in a state of mal-nutrition. And a still further inference is that such " causes " of epilepsy as fright are only determining causes of the first explosion. In regard to this latter point, I am entirely in accord with Dr. Jack- son, We frequently see cases of epilepsy which, we are told, were ori- ginally caused by a mental shock of some kind. But if the shock were in reality the primary cause there should be no subsequent epileptic seizures. With the cessation of the cause the effect should cease. On the contrary, we find that after some time, generally quite long, which of itself is sufficient to show that the continuance is not due to the initial convulsion, a second occurs, and then, after a shorter in- terval, a third, and so on. It is very evident that if the fright were the cause the fits would be more frequent at first, and less so subse- quently. But to return to Dr. Jackson's views : " Epilepsy is not a particular grouping of symptoms occurring occasionally ; it is a name for any sort of nervous symptom or group of symptoms occurring occasionally from local discharge, whether the discharge puts muscles in movement or not—that is, whether there be a convulsion or not matters nothing for the definition. A paroxysm of subjective sensation of smell is an epi- EPILEPSY. 685 lepsy as much as is a paroxysm of convulsion ; each is the result of sudden local discharge of gray matter. " It does not matter for the definition whether there be loss of con- sciousness or not; loss of consciousness is a fundamental thing in most of the accepted definitions. If there be no loss of consciousness there is, according to most physicians, not epilepsy, and the term 'epilepti- form ' is used. But, even when using the term epilepsy in the ordinary sense of the word, the separation into cases where there is, and where there is not loss of consciousness, has no physiological warrant. It is an arbitrary distinction of psychological parentage. Loss of conscious- ness is not an utterly different thing from other symptoms. It is not to be spoken of as an epiphenomenon or as a complication. Conscious- ness has of course anatomical substrata as much as speaking has. The sensori-motor processes concerned in consciousness are only in degree different from others. They are the most special of all special nervous processes, the series evolved out of all other (lower) series. "To lose consciousness is to lose the use of the most special of all nervous processes whatsoever. If those parts of the brain be first af- fected by strong discharge where the most special of all nervous pro- cesses He, there will be loss of consciousness at the outset. If processes of subordinate series be discharged, loss of consciousness, of course, occurs later. For example, in cases of convulsions beginning in the hand, consciousness is in most cases lost as soon as or just before the leg is reached by the spasm. In these cases the internal process will be that consciousness is lost as soon as the most special of all processes are reached by the internal discharge (or since the sensori-motor pro- cesses underlying consciousness are evolved out of lower series), when as large a quantity of a subordinate yet important series is put hors de combat. But, of course, one does not locate consciousness so geograph- ically as the mere words we must use seem to imply. If a patient sud- denly loses, by any process, the use of any large part of either of the two highest divisions of the nervous system, he will lose consciousness. " The following are epilepsies : "(1) A sudden and temporary stench in the nose, with transient unconsciousness ; (2) a sudden and temporary development of blue vision ; (3) spasm of the right side of the face with stoppage of speech; (4) tingling of the index-finger and thumb, followed by spasm of the hand and forearm ; (5) a convulsion almost immediately universal, with immediate loss of consciousness ; (6) certain vertiginous attacks. " All these six seizures are alike, in that each results from an occa- sional and excessive discharge of unstable gray matter. This is the one functional alteration of nerve-tissue underlying the different phe- nomena." Dr. Jackson then goes on to state that though these six kinds of seizures are alike physiologically, they are very unlike anatomically. 686 CEREBRO-SPINAL DISEASES. That is, that the seat of the discharging lesion is different for each, and he urges that the efforts of physicians should be directed to the discovery of this seat from a consideration of the character and locali- zation of the manifestation. In a " destroying lesion," such, for in- stance, as is produced by cerebral haemorrhage, the scientific physician endeavors, by a careful study of the phenomena, to determine the situa- tion of the injury, but in cases of spasm the inquiries rarely relate to anything more than an attempt to ascertain the character of the con- vulsion. That this is true is not to be doubted. Further, Dr. Jackson asserts that by comparing the phenomena pro- duced by a " destroying lesion " with those which result from a " dis- charging lesion," we obtain very important data for further comparison. Thus, taking the left corpus striatum as the seat of the first or slight- est degree of alteration, and then of the second or severer form, and we have : T v V - • • ' ' ' First Degree. Corpus Striatum Palsy. Corpus Striatum Epilepsy. Mouth turns to left. Mouth drawn to right. Right arm paralyzed. Right arm convulsed. Right leg paralyzed. Right leg convulsed. Second Degree. Corpus Striatum Palsy. Corpus Striatum Epilepsy. Head turns to left. Head drawn to right. Two eyes turn to left. Two eyes drawn to right. Face turns to left. Face drawn to right. Trunk-muscles weaker on right. Trunk-muscles in spasm on right (£),x Arm and leg paralyzed on right. Arm and leg in spasm on right. But as there is a still higher degree of " destroying lesion," so there is a graver form of " discharging lesion." In the one the corpus stri- atum of one side may be so injured as to produce paralysis of both sides of the body. In the other a convulsion may originate in the hand of one side, pass over to the opposite side of the body, and be- come general. This is a brief statement of Dr. Hughlings Jackson's views on the pathology of epilepsy. Perhaps it would be too much to say that they should be adopted in their entirety, but, that they are in great part cor- rect every physician who has seen much of the very important disease to which they relate will readily admit. The point in regard to which I should be most disposed to differ with him is that in which he too sweepingly, in my opinion, classes all " occasional, sudden, excessive, rapid and local, sensorial or motor phenomena " as epileptic. Thus, I am quite sure I have repeatedly witnessed " tingling of the index-fin- ger and thumb, followed by spasm of the hand and forearm," result from injury of the eccentric nervous system, from pressure on, or other injury of, the brachial plexus, for instance. Now, although such lesion EPILEPSY. 687 may, under certain circumstances, produce such intra-cranial disorder as eventually to cause epilepsy, knowing what we do of the functions < of the nerves and the effects of injuries to their trunks, we need not go so far as the gray matter for an explanation of the phenomena. Ex- periments on animals—and indeed as I have repeatedly witnessed in the human subject—show us that, even when a nerve-trunk is divided, irri- tation of its peripheral extremity will give rise to just such phenomena as Dr. Jackson calls epileptic, except in the one point—not an essential one—of " tingling." In a patient whom I saw in the Presbyterian Hospital a year or so ago, in the service of Dr. Post, the median nerve was exposed for the space of over two inches, and when it was touched with a probe or the finger, tingling in the skin below and spasm of the muscles of the forearm were at once produced. In the present state of our knowledge it appears to me better to regard no spasm as epileptic, which is not accompanied with loss, or at least disturbance of consciousness. The experiments of Hitzig, Fer- rier, and others, certainly throw a great deal of light on the nature of the epileptic phenomena, and give great support to many of Dr. Jack- son's arguments ; but they also show us that irritation of the gray matter of the brain will cause spasms, which, though partaking to a superficial examination of the character of epilepsy, are clearly not this disease, even as Dr. Jackson regards it. It is true that such irritation repeatedly made will in time so alter the properties of the gray matter as to lead to the production of spontaneous spasms, which may be epi- leptic, but that is quite a different thing. The experiments made by Dr. Roberts Bartholow 1 on a patient under his charge, in the Good Samaritan Hospital in Cincinnati, show that both disorders of sensibility and spasm are produced in the human subject by irritation of the gray matter of the cerebral convolutions ; but in this case the phenomena disappeared as soon as the irritation ceased. Such transient results, clearly and distinctly due to an irrita- tion of the gray matter, may be epileptiform, but to my mind they are not epileptic. But quite recently Hitzig 2 has succeeded in producing true epilepsy in animals by irritating the cortical centres ; after a shorter or longer period—a day to five or six weeks—spontaneous, well-characterized epileptic convulsions ensued. The importance of such observations as those of Bartholow and Hitzig can scarcely be over-estimated. Brown-Sequard has -shown that epilepsy may be caused by irritation of the peripheral nervous system, and it is quite certain that the tin- gling and spasm of the hand, which are at first perhaps only due to ec- centric lesions or derangements, may result in epilepsy. A case is now under my charge—a young gentleman from North 1 American Journal of the Medical Sciences, April, 1874. 5 " Untersuchungen ueber das Gehirn," Berlin, 1874, p. 271. 688 CEREBROSPINAL DISEASES. Carolina, whom I saw first over two years since. At that time it was only necessary to touch the left side of his neck, over the middle third of the sterno-mastoid muscle, to induce spasm of the muscles of the neck, shoulder, and face, on the same side, unaccompanied by loss of consciousness. This condition had apparently been induced in the first instance by his wearing a high shirt-collar, and in the beginning con- sisted of nothing more than a slight twitching of the muscles at the left angle of the mouth. Probably, if he had then ceased wearing that kind of collar, the excessive hyperaesthesia of the eccentric nerves would have spontaneously ceased. As it was, an increase of all the phenomena took place; and finally, the least touch, even that of a camel's-hair pencil or a current of air, was sufficient to induce a spasm. Blistering, cauterization, and all kinds of local anaesthetics, were tried in vain, but eventually they ceased under the use of large doses of the bromide of sodium. But during all this time, unless an irritation of some kind—the lighter the more powerful, for strong pressure was not an efficient agent—there were no spasms. That such a condition was evidence of a strong epileptoid tendency I did not doubt, and my fore- bodings of the ultimate result were fulfilled, for after the lapse of about two years he returned to me with no hyperaesthsia of the skin of his neck, but with occasional fully-developed epileptic paroxysms, for which he is now under treatment. Inquiry, however, showed that they were the result of late hours and indiscretions in diet, and that apparently they had no connection with the former series of attacks. Relative to this subject of convulsion without loss of consciousness but appearing paroxysmally, I shall have some remarks to make in the next chapter, under the head of " Convulsive Tremor." It has been urged by some writers that migraine is a modified epi- lepsy. Dr. Hughlings Jackson would certainly regard such cases as those of Sir John Herschel, the astronomer-royal, the late Sir C. Wheat- stone, Dr. Hubert Airy, and, going farther back, those of Dr. Parry and Dr. Wollaston, as genuine epilepsy. Dr. Latham,1 in his very in- structive little book, from which I cite these examples, quotes as fol- lows Sir John Herschel's account of the phenomena observed in his own case, in which there were present in his field of vision irregular fortification-like figures, the margins of which were colored : " In one attack in myself, which occurred while I was conversing with an acquaintance, I soon became painfully sensible that I had not the usual command of speech ; that my memory failed so much that I did not know what I had said or had attempted to say, and tbatl might be talking to another." Dr. Airy, who has also described his own case, says : " Sometimes the speech is affected, and the memory at the same 1 " On Nervous or Sick Headache," Cambridge (England), 1873, p. 10; also, Philo- sophical Magazine, vol. xxx., p. 21. EPILEPSY. 689 time. On one occasion the mouth was seen to be drawn to one side." In a young female who came under Dr. Latham's observation, and who had colored spectra, there was a tingling of the arm and the side of the tongue, and on the same side with the spectra. Her sister and father were affected in precisely the same way. In another case the patient complained of a feeling of pinching and scratching on that side of the face corresponding with the glimmering. In most of these cases these spectra and sensations were followed by headache of severe character, attended with nausea and vomiting. But, notwithstanding the resemblance to epilepsy which all these phenomena of migraine suggest, Dr. Latham asserts that it differs widely from that terrible disorder in that it never threatens life, is never associated with unconsciousness, and that he has never known it to pass into epilepsy. On the contrary, with advancing age the at- tacks, as a rule, become much less frequent. They cease generally after fifty or sixty, and in women, not uncommonly, at the change of life. Dr. Latham holds the view that migraine is an affection of the sym- pathetic system; that the ocular spectra are the result of an anaemic condition of the brain due to a tonic contraction of the arteries; and that the pain which subsequently appears is the result of arterial relax- ation and consequent cerebral congestion. In his most thorough and valuable work Dr. Liveing2 discusses the whole subject of migraine in all its relations; and, while admitting with Marshall Hall, Sieveking and others that very intimate relations exist between sick-headache and epilepsy, and adducing several examples in which epilepsy has occurred to persons who were in previous years sub- ject to the former affection, nevertheless regards such occurrences as quite exceptional, and as instances only of that occasional metamor- phosis of neuroses so often witnessed. That migraine is an affection of the vaso-motor system is rendered very probable by the observations of Mollendorff,2 who reaches the con- clusion that it is the consequence of arterial hyperaemia. He found that ophthalmoscopic examination of the eye of the affected side re- vealed the existence of dilatation of the arteria centralis retinae as well as of the choroidal vessels and of a bright-scarlet color of the fundus, while on the other side the vessels were normal, and the fundus, of its usual dark-red color. This theory is adopted by Dr. Bergen s in a recent elaborate paper. It is the very opposite to that proposed by Dr. Bois-Reymond, accord- 1 " On Megrim, Sick-headache, and some Allied Disorders, a Contribution to the Pa- thology of Nerve-Storms," London, 1873. 8 "Ueber Hemicrania," Archiv. furpaihologische Anatomie, Band xl., p. 385. 8 "On the Pathogenesis of Hemicrania," translation from the German by Dr. H. Gradle, in the Chicago Journal of Nervous and Mental Diseases, vol. i., 1874, p. 296. 44 690 CEREBROSPINAL DISEASES. ing to which migraine is due to a tetanic contraction of the cerebral arteries. Neither of these authors regards migraine as a form of epi- lepsy. Mv experience with sick-headache has been quite extensive. I have frequently witnessed cases in which there were chromatic ocular spectra such as those described by Latham, Sieveking, and others, but I have never perceived anything more in the most marked forms of the affec- tion than a resemblance to some of the phenomena of the epileptic attack. One very noticeable difference is as regards the effect upon the mind. In epilepsy the slightest and most transient seizures gener- ally impair, after a time, the mental faculties, especially the memory, while in migraine, no matter how severe or how frequent may be the attacks, the mind in all its parts retains its full vigor. In an interesting lecture on the pathology of epilepsy, Dr. J. S. Jewell,1 of Chicago, expresses the opinion that the phenomena of an attack are due in the first instance to a spasm of the cerebral vessels by which anaemia is produced, which in its turn causes unconsciousness, and that the relaxation of the spasm causes cerebral congestion, the imme- diate consequence of which is convulsion of the voluntary muscles. This congestion, he believes, is mainly seated in the medulla oblongata, or at least that it is the congestion of this part of the encephalic mass that produces the convulsive movements. The starting-point in the pathology of the disease would therefore be in the vaso-motor system. This theory is similar to—in many respects identical with—that pro- pounded in the former editions of this work and given at the beginning of the present remarks. It is very obvious to my mind that epilepsy is something more than the result of a discharging lesion of gray matter, and, as I have said, I cannot accept the view that all such discharges are epilepsy. Treatment.—The treatment of epilepsy rests almost solely on ex- perience. To attempt the consideration of all the means which have been employed would be a fruitless task, even though it were possible. I shall therefore content myself with detailing the measures which I have found most useful. Among medical remedies the bromides stand preeminent, and should be thoroughly tried first in every case. The bromide of potassium, sodium, or calcium, may be used. Of these the bromide of sodium is the most advantageous in the majority of cases. Its taste—that of common salt—is not unpleasant, and it agrees better with the digestive system than the potassium compound. The bromide of calcium de- ranges the system still less, but its taste is not so pleasant, and it is much more expensive. Whichever one is preferred, the dose for an 1 " Pathology of Epilepsy," Chicago Journal of Nervous and Mental Diseases, vol. ii., 1875, p. 1. EPILEPSY. 691 adult in ordinary cases and in the beginning of the treatment is fifteen grains three times a day in solution. It must be clearly understood that the bromide, if successful in ar- resting the convulsions, must be taken for a long time, in order to increase the probabiUty of a cure. I never discontinue it under two years, and sometimes persevere "with it still longer, if in the mean time there have been attacks of vertigo, aurae, or other epileptoid manifesta- tions. After the initial doses have been given for about two months, if there are no symptoms indicating extreme bromism, or if there has been no paroxysm, I increase the doses by one-half. If there have been paroxysms in the mean time, I increase one-half after each paroxysm, until they are arrested, or until I am satisfied that the bromide is ineffi- cacious or injurious. I have sometimes been compelled to carry it to the extent of nearly two hundred grains a day, and to continue it at that quantity for eight or ten days. When the system is thoroughly under the influence of the remedy and the convulsions have ceased, the dbses may be reduced; but they should not be discontinued. The bromides are less efficacious in the nocturnal variety of epilep- tic seizures, and in those which consist mainly of loss of consciousness, than in the diurnal and strongly convulsive kinds. In the former, sometimes, they increase the number and severity of the attacks, and in such cases should of course be at once discontinued. A point connected with their action must not be overlooked, and that is, the cachexia which so generally attends their administration in large doses. In a memoir,1 published over six years ago, and which has been cited in another connection, I brought forward several cases in which this cachexia had been produced. Greatly-increased experience has convinced me that, though in general it never causes any perma- nently ill effects, frequently great constitutional disturbance is in- duced. In three cases large carbuncles were caused, in a few I have been obliged to suspend for a time the administration of the medicine, and in two cases death resulted, in one from the patient taking larger doses than were prescribed, and continuing them while not under my immediate care, and in the other from the supervention of pneumonia while under the full influence of the remedy. But, I am very sure that the bromic cachexia is favorable to the eradi- cation .of the epileptic tendency, and I therefore endeavor to produce it as soon as possible. It appears in many cases to alter the whole organ- ism of the patient to such an extent as to leave him, when it disap- pears, with his nutritive processes and his proclivities so modified that epilepsy is no longer possible. The physician will require all his firm- ness and courage to persevere in those cases in which the bromism is 1 " On some of the Effects of the Bromide of Potassium when administered in Large Doses," Journal of Psychological Medicine, January, 1869, p. 46. 692 CEREBRO-SPINAL DISEASES. extreme, but he should not yield unless the phenomena are so intense and tine strength of the patient so greatly reduced as to excite his gravest apprehensions. The phenomena indicative of bromism will be given further on under the head of toxic affections of the nervous system. It may be, however, mentioned here that in the peculiar faculty possessed by the bromides of lessening the reflex excitability of the pharynx we have a ready means of ascertaining the extent to which the system is under the ac- tion of the remedy. If the handle of a spoon be pressed gently against the posterior wall of the pharynx of a healthy person, slight nausea and efforts to vomit are at once excited; but, if such a person be subse- quently brought fully under the influence of any one of the bromides, the irritability of that part is destroyed, so that nausea or vomiting is no longer excited by pressure. Herpin 1 several years ago called attention to the salts of zinc in the treatment of epilepsy. He preferred the oxide, and for a long time I made extensive use of this preparation in the treatment of the disease in question. Latterly, however, I have used the lactate, and still more recently the bromide, with very definitely beneficial results. It is best administered in the form of a sirup—my formula is : $. Zinci bromidi, 3 j; syrupus simplicis, f j. M. ft. sol.—which may be given in doses of ten drops gradually increased to thirty or more three times a day. It should be given largely diluted, as being the less apt to excite nausea. In several cases the bromide of zinc has proved exceedingly effica- cious thus far in arresting the paroxysms where other bromides had failed. Bromism is not an attendant on its administration, and yet it is quite probable that the bromine of the compound exercises consid- erable curative influence. I have given it as long a time as six months consecutively without producing cachexia, and to the extent in some cases of forty grains a day. A troublesome feature which often attends the administration of the bromides—except the zinc compound—is the cutaneous eruption. Arsenic has been said to obviate the tendency to this complication, and to cure it where already present. In a few cases I have seen the use of the drug—four or five drops of Fowler's solution with each dose of the bromide—prove serviceable ; but in the majority of cases it has ap- peared to be inefficacious. Owing to the supervention of carbuncles with a strong predisposition to gangrene of the skin, I have been obliged in several cases to discontinue the bromide of potassium. The calcium compound is, I think, not so liable as those of potassium, sodium, or ammonium, to cause this trouble. In the nocturnal form of epilepsy strychnia is sometimes remarkably efficacious. It may be given in the beginning in the dose of the thir- tieth of a grain three times a day gradually increased. A good for- 1 " Du pronostic et du traitement curatif de l'6pilepsie," Paris, 1852. EPILEPSY. fi«J3 mula for its administration is: 3. Strychnia sulph., gr. ij; aqua dest., § j. M. ft. sol. Dose, eight drops three times a day for the first two weeks, then nine drops for the next two weeks, increasing a drop every two weeks for a year, and perhaps longer. Strychnia is also said to be useful in epilepsy of stomachal origin, that is, cases produced by gastric derangement. The nitrite of amyl, first proposed and used in epilepsy by Dr. Weir Mitchell, is certainly beneficial in arresting the paroxysm, when there is an aura sufficiently pronounced and slow to give the patient the time to employ it. Five to ten drops may be inhaled from a handkerchief with safety, and generally with success. As there is generally not time to pour it out, this quantity should always be kept on the person in a glass-stoppered vial ready for use at a moment's notice. Dr. McBride, of this city, has had made little hollow thin glass beads containing the proper quantity of the nitrite of amyl, and when the patient experi- ences the warning, one of these is crushed in a handkerchief and the vapor inhaled through the mouth. Dr. Crichton Browne x has not only used the nitrite of amyl in pre- venting individual paroxysms, but has given it with advantage with the view of breaking up the status epilepticus—a condition in which the fits succeed each other with scarcely an intermission, the patient being unconscious during such intervals as occur. The results of his expe- rience are such as to convince him that,it will be found invaluable in many cases, not only in postponing the paroxysm, but altogether pre- venting epileptic seizures. My own experience with this agent in epilepsy has been extensive and generally favorable, but only as an inhibiting power in preventing the full development of individual convulsions, and only in those cases in which the face ordinarily became pale in the very inception of the attack. I have given it systematically three or four times a day, with the object of curing the disease, and without reference to aur;v, but with no good result. In my hands it has only been useful in warding off a seizure which had already given warning of its presence. It may be stated that the effect of the nitrite when inhaled is to ac- celerate the action of the heart, to make the face red, and to cause a feeling of fullness in the head, and a sensation as if pins and needles were sticking into the skin of the face, neck, and chest. These phe- nomena disappear in a few moments. Several cases of epileptiform seizures clearly due to syphilitic infec- tion have been under my charge, and have been treated with benefit by the bromides in conjunction with the iodide of potassium. In five of these, cures are known to have been effected. As regards other medicinal remedies for epilepsy, I have but little 1 " Nitrite of Amyl in Epilepsy," " West Riding Lunatic Asylum Medical Reports," rol. iii., 1873, p. 151. 694 CEREBRO-SPINAL DISEASES. to say. Belladonna has never in my hands produced the least good effect, neither has the nitrate of silver, nor indigo, nor cotyledon um- bilicus, nor digitalis, nor any of the salts of copper. The same may be said of a hundred other substances less favorably known. Hydrate of chloral in three cases mitigated the frequency of the paroxysms, but only for a short time. Calabar bean was slightly beneficial in one case. But the whole treatment of epilepsy is not confined to drugs. Sur- gical and hygienic measures are often in the highest degree beneficial and the latter should be brought into action in every case. O n ^ Of the surgical means the excision of any cicatrix which, by entan- _. . gling a nerve, may be a source of reflex irritation, is occasionally a use- ^AJnu/Wi £uj measure# This point has recently been brought forward in an inter- esting memoir by Dr. F. D. Lente,1 in connection with cicatrices of the scalp, but the like reasoning and action are applicable to cicatrices ex- isting in any other part of the body from which an aura appears to start. In injuries of the skull, followed by epilepsy, trephining may be of great service. It has been aptly said that no blow upon the head is slight enough to be despised, and, so far as epilepsy is concerned, this is preeminently true. I have, during the past five years, trephined twenty-three times for epilepsy, which was apparently due to cranial injuries. In seven of these the fits ceased, and in two of the seven cases there was neither fracture nor depression. Of the remaining sixteen cases there was no cranial injury to be found in three ; and in thirteen, though there was such injury, the operation proved unsuc- cessful, though beneficial results in lessening the frequency of the at- tacks were obtained in the majority. In one of them the fits did not recur for over a year. The fact that in two of the successful cases no fracture or depression was found is a strong point in favor of Dr. Lente's view that epilepsy is sometimes the result of a cicatrix of the scalp, for, in both, the in- cisions in the scalp, as in all the others, were made so as to include the scalp-wound. As the result of my experience, I am decidedly of the opinion that, in all cases of epilepsy in which there is injury of the skull or scalp, trephining or excision of the cicatrix should be performed, as may be proper. In some cases counter-irritation to the nape of the neck is decidedly beneficial. It may consist either of a seton, which may be left in for several months, or the repeated application of the actual cautery. Counter-irritation is especially indicated in those cases in which the 1 " Neuralgia and other Neuroses arising from Cicatrices of the Scalp, and their Surgi- cal Treatment," " Transactions of the American Neurological Association," vol. L, New York, 1875, p. 157. EPILEPSY. 695 tongue is bitten, and instances in which internal remedies have failed till they were supplemented by this means are not uncommon. The hygienic management of the patient is important. A large por- tion of the day should be passed in the open air; bodily exercise should be regular, but not excessive; the food should be nutritious, but neither exciting nor indigestible. The importance of avoiding every aliment- ary substance, calculated to cause gastric or intestinal irritation, cannot be over-estimated. I have frequently seen paroxysms directly caused by nuts, dried fruits, pastry, heavy and badly-baked bread, excess in the use of alcoholic liquors, confectionery, and the like. And a diet consisting mainly of farinaceous substances is certainly preferable to one in which meat forms the larger part. I have in three cases effected entire cures by confining the patients for several months to a diet con- sisting at first of skim-milk, to which after a time a little bread was added. The bowels must be kept regular. Baths should be frequently taken, but should not be so cold as to cause severe shock or physical depression. Turkish baths, I am inclined to think, are useful in many cases, particularly in those occurring in persons of full and gross habit of body. Overheated and ill-ventilated apartments should be avoided. The clothing should be warm in winter and cool in summer. The mind should not be overtasked, and the emotions must not be unduly excited. Individual attacks may sometimes be prevented by other means than the nitrite of amyl. One gentleman under my charge assures me that he can often dissipate the premonitary symptoms, and thus stop the development of the paroxysm, by a strong exertion of the will. Another can arrest them sometimes by changing the position of his body. If standing, he lies down ; if lying down, he rises suddenly and paces the room violently. Another stops them by putting salt in his mouth, and two can frequently prevent them by tightening straps which I have instructed them to keep constantly around the wrist. In all these cases there is an aura, and in the two latter it appears to start from the hand. But, before resorting to any specific treatment for epilepsy, diligent search should be made for the cause, and this should be removed, if possible, without the least delay. Often an eccentric irritation,, such as worms in the intestinal canal, implication of a nerve in an injury, disorders of menstruation, etc., can be discovered, without the removal of which a permanent cure is impossible. In several of the cases cited, success in the treatment was in a great measure due to acting on this principle. The treatment during the paroxysm remains to be considered. It is simple, and, beyond a few obvious measures, consists in letting the patient alone. The head should be elevated, the collar and cravat loosened, a piece of soft wood put between the teeth so as to prevent 696 CEREBRO-SPINAL DISEASES. injury to the tongue, and the patient so placed that he cannot fall or otherwise injure himself in his struggles. During the subsequent stu- por he should be kept quiet. Bloodletting is never necessary, although it is recommended as proper in certain cases by Jaccoud. CHAPTER III. CONVULSIVE TREMOR. Under the designation of convulsive tremor, I propose to include all those cases of non-rhythmical tremor or clonic convulsive move- ments which are unattended with loss of consciousness, but which, nevertheless, are paroxysmal in character. As the affection has not yet found its way into the systematic trea- tises I shall, as in the matter of spinal irritation, devote a few words to its history, and, in so doing, shall draw largely from a paper of my own on the subject, published over eight years ago,1 and from a clinical lecture 2 delivered to the class at the Bellevue Hospital Medical College in the winter of 1871-'72. History and Symptoms.—In the year 1822 Dr. Pritchard,8 under the name of convulsive tremor, gave an account of two cases, presenting somewhat similar features to the one before us. His attention was first directed to the subject by noticing that, in some epileptic patients who had come under his observation, fits of tremor occurred in the in- tervals between the paroxysms and even appeared to take the place of the ordinary seizure. He then noticed several cases in which there were no epileptic attacks, but in which there were violent clonic spasms of the muscles, accompanied with severe pain in the head and profuse perspiration. Dr. Pritchard states that, previous to his observations, the affection had not attracted much attention ; but he cites a case from Tulpius of a young unmarried woman, of a pale complexion and phlegmatic temperament, who was afflicted during three years with what was called the shaking-palsy, which did not affect her constantly, but came on in periodical fits; each paroxysm lasted nearly two hours, and was accompanied by hoarseness and loss of voice, the consciousness being unimpaired. He also refers to other cases quoted by Sauvages from Bonetus, in which the symptoms were very similar, consisting of convulsive tremor, attended with headache and vertigo. This disorder was fatal in a few days, and after death a parasite was found in the brain. In this con- 1 "On Convulsive Tremor," New York Medical Journal, June, 1867, p. 185. 2 " Clinical Lectures on Diseases of the Nervous System," New York, 1874, p. 164. ' "A Treatise on Diseases of the Nervous System," London, 1822, p. 393. CONVULSIVE TREMOR. 697 nection it is interesting to recall the fact that the sheep is subject to a somewhat similar train of symptoms, due to the presence of an ento- zoOn in the brain. Dr. Pritchard then relates his own cases, of which the following ac- count is an abstract: John Pugh, a carpenter, of meagre habit, low stature, and dark hair, aged fifty, was admitted into St. Peter's Hospital March 1, 1820. About a month previously he had suffered from tonsillitis and subse- quently had some difficulty of breathing, which was supposed to be asthmatic. He had complained of headache for some time. On the 23d of February he was attacked with a violent tremor, which con- tinued for two or three hours, and then went off after he had taken an emetic. It recurred on the following day at the same time, and on every succeeding day about the same hour. At the time of his admis- sion he was laboring under a paroxysm. On first looking at the man, Dr. Pritchard supposed him to be in the cold stage of intermittent fever, but on closer and more careful ex- amination his affection was seen to be very different. All the muscles of the upper extremities, including those connected with the ribs, clav- icle, and scapula, were constantly agitated by a convulsive movement which was almost entirely confined to them. The lower extremities were quite free from disorder. The man was perfectly conscious, and able to answer any question distinctly. His pulse was quick and ap- parently irregular. Owing to the constant agitation of the tendons it was impossible to arrive at certainty on this latter point. The skin was warm, and there was no sensation of chilliness. The upper part of the body was in a state of profuse perspiration. He complained of ver- tigo and headache. Bloodletting was ordered; a large orifice was made, and the blood allowed to flow till thirty-eight ounces had escaped, when syncope en- sued. When half the above quantity had passed, the tremor became more general and severe. The gluteal muscles were so greatly con- vulsed that by their action the patient was thrown up from his seat with the motion of a man sitting on a trotting horse. When he became sick and faint, the arm was tied up and he was laid upon a bed. The tremor immediately ceased, except some slight and partial quivering. He was then strongly purged, and this operation was continued every night. On the 5th, at 11 A. m., the tremor returned. Cold effu- sion was directed ; as soon as the cold water was thrown over him the tremor ceased. On the 9th there had been no return of the tremor. Calomel and sulphate of magnesia were now prescribed and on the 11th the tremor returned, lasting, however, but about twenty minutes. From this time he was free from the affection, but, as might have been expected, when the character of the treatment is considered, he fell into a state of de- 698 CEREBRO-SPINAL DISEASES. bility. There were loss of appetite, cough, expectoration, and inflam- mation of the vein, ensuing from the bleeding. In the next case the paroxysms of tremor were the most remarkable feature, but there were also stupor and delirium. John Jones, a seafaring man, aged twenty-five, was brought to the hospital March 11, 1819, under a warrant of lunacy ; was in the habit of drinking spirituous liquors. Three weeks previously he was seized with rigors, attended with coldness, and followed by heat, headache, and wandering pains in the limbs. The symptoms ushered in a state of stupor and delirium, during which his countenance became distorted, the eyes rolled, the muscles of the face were slightly convulsed, and the body was generally agitated. After a time all these symptoms subsided and he became perfectly rational, but seemed a little stupid, as if roused from a sleep. The paroxysms returned at uncertain intervals and with the same succession of symptoms. He was bled and purged, and finally brought to the hospital. On admission he was in a state of delirium. He rolled his head about and was in constant motion. The temporal arteries beat rapidly and forcibly; the scalp was hot, the feet cold; face flushed and tongue a little furred. His head was shaved and covered with cold wet pads, his feet were immersed in hot water, twenty leeches were then applied to the head, and calomel and tartar-emetic with cathartic draught administered. The next day he was rational, but, as he complained of pain in the head and in the region of the liver, and as his pulse was 130, full and jerking, he was bled to the extent of eight ounces ; syncope followed. Twelve leeches and a blister were then applied to the right hypo- chondriac region, and calomel, cathartic draught, and low diet ordered. Notwithstanding the treatment, he continued to survive, and in the evening had two returns of the tremor followed by the usual symptoms. On the 14th had several paroxysms, and was again freely purged ; was occasionally bled from the temporal artery, and often leecbed freely. Nitrate of silver was subsequently administered, and on the 23d of June he was discharged cured. Dr. Pritchard states that he met with two other instances of parox- ysms of tremor unaccompanied with spasm, and occurring in persons who had suffered from an attack of paralysis. Evidently Dr. Pritchard has embraced two or three separate affec- tions under the designation of convulsive tremor. The first case I have quoted from him appears to be a distinct and not previously-described disorder; the second case was probably one of cerebral congestion or aborted epilepsy; and those which he states he had seen as the sequence of paralysis were doubtless to be classed under some one or other of the forms of sclerosis of the brain and spinal cord. The first case alone is to be regarded as one of convulsive tremor, as described in this chapter. CONVULSIVE TREMOR. 699 In his very excellent treatise on the shaking-palsy, Parkinson,1 in calling attention to the fact that several diseases characterized by tre- mor have been confounded with paralysis agitans, quotes the following case from Dr. Kirkland : " Mary Ford, of a sanguineous and robust constitution, had an invol- untary motion of her right arm, occasioned by a fright, which first brought on convulsion-fits and most excruciating pain in the stomach, which vanished on a sudden, and her right arm was instantaneously flung into an involuntary and perpetual motion like the swing of a pen- dulum, raising the hand at every vibration higher than the head ; but, if by any means whatever it was stopped, the pain in her stomach came on again, and convulsion-fits were the certain consequence, which went off when the vibration of her hand returned." Parkinson also quotes another case from the same source, resulting apparently from worms, and which is thus described : " A poor boy, about twelve or thirteen years of age, was seized with a shaking-palsy. His legs became useless, and, together with his head and hands, were in continual agitation ; after many weeks' trial of va- rious remedies, my assistance was desired. His bowels being cleared, I ordered him a grain of opium a day in the gum-pill ; and in three or four days the shaking had nearly left him. By pursuing this plan, the medi- cine proving a vermifuge, he could soon walk, and was restored to per- fect health. Toulmouche,2 in a paper which is very suggestive in the light of re- cent contributions to neurological pathology, cites a case which was evidently one of convulsive tremor : " A woman, whose respiration was convulsive, presented from time to time the following condition : Her nostrils were strongly dilated, the angles of the mouth drawn down, the shoulders and chest spasmodical- ly elevated, the inspiration strong and deep, the sterno-cleido-mastoid muscles were powerfully contracted. Duiing these paroxysms, which lasted several minutes, the patient was deprived of the faculty of speech and threatened with suffocation. Nevertheless, she could, if so direct- ed, move the head, the shoulders, and the muscles of the face, although the spasm continued. ... In another case the affection was almost en- tirely confined to the sterno-cleido-mastoid muscle. The patient could turn the head in either direction, but gradually it moved from right to left, without her ability to control its action, so that the right ear al- most rested upon the sternum. The other muscles of the shoulder con- tracted at the same time. He likewise reports another case in which the head was almost continually in motion, the patient executing twen- 1 "Essay on the Shaking-Palsy," London, 1817, p. 29. 8 " Observations de quelques fonctions involuntaires des appareils de la locomotion, et de la prehension," "M6moires de l'acade'mie royale de medecine," tome deuxieme, Paris, 1833. 700 CEREBRO-SPINAL DISEASES. ty-two rotations in a minute ; the movement was due to the alternate contraction of the sterno-cleido-mastoid and splenius muscles of each side ; respiration was not obstructed. The movements diminished and finally ceased after two or three attacks of haemoptysis. " The conclusions which the author draws from his own cases, and those which he cites from other authorities, are mainly interesting in relation to his theory of the pathology. They are— " 1. That there exist, for the movements of the different groups of muscles, different central motor forces. " 2. That the cerebellum only presides over the coordination of those complex movements which are necessary to the different acts of stand- ing and locomotion, and not at all over those that regulate the more sim- ple movements of the trunk and the members. " 3. That this nerve-centre supplies to vertebrate animals the power to maintain themselves in equilibrium and to exercise locomotion. " 4. That, if, in the species of neurosis I have described, the sensa- tion and the intellectual faculties experience no change, this fact is due to the circumstance that the lesions of the cerebellum have not yet in- volved the tubercula quadrigemina. That these last-named organs are in a state of dependence upon the brain ; since in the normal state ani- mals move through the impulsion of various motives of which the brain is the seat. " 5. That finally a number of affections called nervous, consisting in the most erratic derangements of the muscular functions, such as an irresistible tendency to go backward or to advance without rational motive, to leap, to perform other disorderly movements, constitute only a species of insanity or aberration of the locomotor functions depend- ing on an affection either organic or functional of the cerebellum." I have quoted the conclusions of Toulmouche in full more as evi- dence of the fact that he was disposed to locate the seat of these trou- bles in the cerebellum, than as intending to endorse his collateral hypotheses. At one time I also held the opinion that the seat of con- vulsive tremor was in the cerebellum, but I have for some time had a different idea on the subject. Up to the publication of my own paper, in 1867, there had been no attempt made to define accurately the features of the disease under no- tice. My description of the affection was based upon three cases. They were as follows : Case I.—J. S., a gentleman, aged thirty-five, single, and engaged in mercantile pursuits, consulted me on March, 14, 1867, for an affec- tion which, as he said, "was driving him mad." Ordinarily he had nothing to complain of on the score of health. His appetite was good, and all his functions were performed with regularity ; but two or three times during the course of the day he would be seized with severe and uncontrollable muscular tremor, involving his head and all the muscles CONVULSIVE TREMOR. 701 of the trunk and arms. At the same time there would be headache and an intense feeling of anxiety. There was no loss of consciousness, not even for an instant, or inability to walk or to direct any muscle, and no confusion of thought. After the paroxysm had lasted fifteen or twenty minutes it gradually passed off, leaving him in a profuse perspira- tion. While he was sitting in my library an attack came on. He was seized with as much suddenness as though he were struck with an epi- leptic fit. His head shook violently, the muscles of his face were con- vulsed, his arms and hands trembled, and his gluteal muscles contracted so powerfully as to cause him to move convulsively up and down on his chair. His lower extremities were altogether free from spasm or con- vulsion. Upon putting my hand on his wrist, I found that every ten- don was in action, and in the arm, hand, neck, and face, the vibration of the muscular fibres could be distinctly seen and felt. I thought the action was greater on the left than on the right side. The thermometer applied to the axilla marked 101° Fahr., and the aesthesiometer showed an increased sensibility of the skin of the face, neck, hands, and all the upper parts of the body I examined. The res- piration was quickened, and the pulse was increased from 80 to 95 per minute. During the continuance of the paroxysm he conversed rationally but with some difficulty, owing to the action of the muscles of the neck, mouth, and chest. The pupils contracted briskly under the influence of light, and dilated when it was shut off. Several times he rose from his chair and paced the room; his movements were perfectly well made. There was a little headache, confined to the occipital region, and a slight but persistent vertigo. I desired him to perform a few movements with his hands, such as buttoning his waistcoat. He had no great difficulty in carrying his hands to the buttons, but it was impossible for him to seize them, and the more his efforts were directed to this end the more difficult it was for him to accomplish it. The trouble was not in loss of strength, for, when I asked him to grasp my hand, he did it with great force, but the tremor was so constant that he could not keep the ends of his fingers at any one point. After the paroxysm had lasted about fifteen minutes it began to subside, and in ten minutes more had entirely passed away. The ther- mometer in the axilla now marked but 98° Fahr., and the hyperaesthesia had entirely disappeared, leaving the sensibility of the skin natural. The respiration and pulse became normal in frequency. Upon questioning this gentleman, I ascertained that he had in- dulged to excess in venereal pleasures, and that the first attack of tremor had begun during sexual intercourse. He said that, just as the orgasm was approaching its height, he had experienced a severe pain 702 CEREBRO-SPINAL DISEASES. in the back of his head, accompanied with tremor. That, notwith- standing, he had completed the act, but felt very greatly debilitated after it; the tremor continued for a few minutes, and then passed off. This was about four months before I saw him. Since the beginning of his disease he had entirely abstained from all sexual indulgence, but his tremors had not left him for a night or day. In consequence he was low-spirited, and apprehensive of losing his reason. Case II.—The second case was that of a young lady, aged twenty- one, who was sent to me March 21, 1867, by Dr. C. F. Taylor, to whom she had gone to be treated for lateral curvature of the spine. In addition to this trouble she had for four years been afflicted with a disorder, cer- tainly very singular in its characteristics, and for which she had been treated by many physicians of many systems of practice. The chief and most distressing feature was a spasmodic action of the diaphragm coming on every ten or fifteen minutes, producing convulsive respira- tion, a feeling of impending suffocation, and great mental anxiety. The paroxysms lasted four or five minutes, and then passed off with a long, deep-drawn sigh. None of the respiratory muscles but the dia- phragm were convulsed. By placing the hands over the abdomen this muscle could be distinctly felt in a state of rapid and irregular action. In the intervals of the diaphragmatic paroxysms, there were frequent tremors of the arms, legs, and head. There was almost constant head- ache extending across the crown to the cerebellar region. There was no fever or increased temperature, but great hyperaesthesia of the whole surface of the body. The menstrual function was normal in every respect, and there was no evidence of hysteria. Her appetite was bad, and what she did eat was not of a very nutritious character. Occasionally she was subject to fits of great mental and muscular ex- citement, during which she fought and bit all who came near her, but there was no mental aberration. She had never been subject to inter- mittent fever. In this case the convulsive tremor, though more prominently mani- fested in the diaphragm, was not confined to this muscle, for, as I have stated, when it was quiet the muscles of other parts of the body were in irregular but rapid action. There was not the entire cessation of tremor as exhibited in the first case, and the paroxysms were much less uniform and much less extensive in their character. In both cases the tremor was absent during sleep. Case III.—In a third case the patient was a young man aged twenty- five, and a clerk by occupation. He came under my care April 2,1867, to be treated for obstinate headaches, with which he had been affected for several years. On an average he had an attack twice a week of so severe a character as to unfit him for all occupation and to confine him to bed. The pain was limited to the back part of the head, and was exceedingly sharp and lancinating; vertigo and an indescribable twist- CONVULSIVE TREMOR. 703 ing sensation within the cranium accompanied the attack. In addition there was convulsive tremor of the muscles of the head, face, and neck, occurring in paroxysms at intervals while the headache lasted. There was no loss of consciousness and no confusion of thought. There were, however, great physical prostration, and an indisposition to make any mental exertion. In his youth he had, as he informed me, practised masturbation to excess, and since attaining to manhood had indulged freely with women. He was also addicted to the abuse of alcoholic liquors. He was thin, pale, and of deficient vital power. His digestive system was deranged, his appetite bad, his pulse weak and frequent. There was no disease of the lungs or heart. He had had gonorrhoea and stricture, but had never contracted a chancre. He had been under the charge of several physicians, but had never been able to subject himself to the regimen and restrictions in his habits of life which they recommended. Latterly he had undertaken to treat himself, and had done so mainly by inhalation of chloroform. This patient would not abstain from debauchery of all kinds, and I dismissed him. Case IV.—A fourth case formed the subject of a clinical lecture which I delivered three years since before the class of the Bellevue Hospital Medical College. The patient, a young man, aged about twen- ty-one, was well nourished, of general healthy appearance, and by oc- cupation a farmer. At periods varying from a few weeks to several months, he was sub- ject to violent convulsive movements in almost all the muscles of the body, and unattended, except in one instance, by loss of consciousness. The paroxysms lasted several hours, and during their continuance the patient, owing to the violent jactitations into which his limbs were thrown, was totally unable to execute voluntary movements. He was even unable to stand without support, and could not guide either his hands or feet. The muscles of speech were likewise affected, and he was consequently unable to articulate distinctly the words he might attempt to utter. While all this was going on, his body was bathed in cold perspiration, and the circulation was accelerated. The respiration was increased in frequency, and there was well-marked and persistent pain in the back of the head and nape of the neck. He was very posi- tive that, except in the one instance to which reference has been made, he had never lost consciousness during a paroxysm, but had always been possessed of his full reasoning faculties. On the occasion of loss of consciousness the paroxysm had lasted several hours ; he was in consequence very much exhausted, and there- fore he may have been suffering from simple syncope, still it is possible the attack in question was epileptic. When he came under my notice, he had been affected for about six years. 704 CEREBRO-SPINAL DISEASES. As he described his paroxysms, the muscles were affected very much as are those of a person suffering from chorea of very violent charac- ter. Case V.—A fifth case was that of a man thirty years of age, who, in November, 1875, came to my clinic for diseases of the nervous sys- tem at the University Medical College. At intervals through the day, as often as twenty or more times, he was seized with violent convulsive movements, tremulous in character, and mainly confined to the muscles of the trunk, neck, and upper extremities. As in the other cases, there was no loss of consciousness, nor was there any other mental disturb- ance. He had no power of control over these paroxysms and no warn- ing of their approach. They were unattended with disturbances of the respiration, circulation, or sensibility. The duration rarely exceeded ten seconds, and was generally shorter than this. It was impossible to say where the convulsive movements originated. They came more as an explosion than as a gradually-developed action. While the convulsion was at its height, he could always cut it short and prevent others for a time by smoking a pipe of tobacco, the requi- sites for which he kept constantly ready. He had been affected for seven years, but had in that time experienced an intermission of about six months. He had never had a paroxysm while asleep. Case VI.—This case was that of a lady from Ohio, who consulted me for paroxysms of convulsive tremor, coming on several times in the course of the week, and involving the upper and lower extremities and neck. There were also marked disturbances of the respiration and cir- culation, and pain in the nape of the neck. The movements consisted of rapid but limited flexions and extensions of the limbs and rotatory movements of the head. The duration of a paroxysm was rarely less than ten minutes, and sometimes was several hours. There was no mental disturbance or impairment of consciousness. The disease had existed for several years, and had proved unamenable to all medical treatment. After each seizure there was a very intense feeling of fa- tigue, but no tendency to sleep or stupor. No paroxysm had ever oc- curred during sleep. The general health was excellent, and the mind was active and strong. Several other cases similar in general features to the foregoing have been under my charge. From this history and description it will be seen that convulsive tremor is an affection characterized by paroxysms of clonic convulsions affecting the voluntary muscles and unattended by loss of conscious- ness or by mental aberration, though sometimes there is emotional dis- turbance. Vertigo and pain in the head are also occasional accompani- ments. Causes.—Nothing very definite is known relative to the etiology of the disease. In one of my cases it began during sexual intercourse ; CONVULSIVE TREMOR. 705 in another (Case V.) it ensued immediately after a sunstroke, the first paroxysm occurring while the patient was still in a comatose condition; in another (Case III.), sexual and alcoholic excesses appeared to be the cause. In none of the others could any approach to a relation of cause and effect be established. Diagnosis.—From epilepsy, convulsive tremor is distinguished by the absence of loss of consciousness. Many of the cases which Dr. Hughlings Jackson considers epileptic are, in my opinion, more prop- erly embraced under the present category. From chorea it differs in the facts that the muscular action is paroxysmal and not continuous, and that the movements are different in character, those of convulsive tremor being rapid and tremulous, while those of chorea are slower and more systematic. The paroxysmal nature of the actions serves to dis- tinguish it from athetosis, multiple cerebral sclerosis, multiple cerebro- spinal sclerosis, and paralysis agitans. From hysteria it is in uncom- plicated cases diagnosticated by the absence of other symptoms of the hysterical condition, by the fact that the convulsions are not marked by tonic spasms, and the circumstance that they have for each individual case a definite character. Prognosis.—The prognosis is generally favorable, the disease, in my experience, being quite amenable to medical treatment. All the cases under my care recovered except one in which the patient refused to submit to proper hygienic restraints, and in whom treatment was not therefore systematically pursued. Morbid Anatomy and Pathology.—In former papers I have stated my belief that convulsive tremor was an affection of the cerebellum, but in the light of the investigations of Fritsch and Hitzig, Nothnagel, Ferrier, and Bartholow, I am now disposed to consider it due to irrita- tion of nerve-centres in the cortical substance of the cerebrum, con- joined with a hyperaesthetic condition of the medulla oblongata and upper part of the spinal cord. And I am the more confirmed in this opinion by some recent experiments by which I have ascertained that a very similar disorder can be induced in dogs by the faradization of the parts mentioned. Ferrier1 produced epileptiform convulsions in rabbits by faradizing the greater part of a hemisphere. In one of my own experiments I exposed both hemispheres and applied to each a piece of chamois-skin thoroughly moistened with water, and cut to fit the surface. The electrodes—metallic buttons—were, then placed one on each piece of cha- mois-skin, and moved lightly over the surfaces for a few seconds. The animal was then allowed to emerge from the anaesthetic condition, and immediately general convulsive movements ensued without loss of consciousness. The result was, therefore, similar to that obtained by 1 " Experimental Researches in Cerebral Physiology and Pathology," "West Riding Lunatic Asylum Medical Reports," vol. iii., 1873, p. 30. 45 706 CEREBRO-SPINAL DISEASES. Ferrier, but so far as I can judge the convulsive movements were more general, and there was no pleurothotonos as in his cases. The parox- ysm lasted about ten seconds, and was repeated, though not to the same degree of intensity, after an interval of three minutes. During the next half-hour there were repeated localized convulsive movements in various parts of the body. In another dog I exposed both hemispheres, and also the upper part of the spinal cord, as far down as the fourth cervical vertebra. A piece of wet chamois-skin was then laid upon the brain, and one electrode—a thin plate of copper-—placed in contact with it, while the other—a thin copper wire doubled upon itself—was moved up and down upon the exposed spinal cord. During this operation the animal was in a state of general convulsion, the respiratory muscles, especially the dia- phragm, being involved. The current was passed in this manner for ten seconds. The animal was then allowed to recover consciousness. As soon as the effects of ether had measurably passed off, convulsive movements ensued throughout the body, the diaphragm being marked- ly affected with the other respiratory muscles, and the heart beating with great irregularity, both in regard to force and rhythm. In these experiments a Gaiffe's faradaic machine was employed, and the current was so feeble as barely to move the hammer and to be felt when the electrodes were applied to the tongue. I think with Dr. Hughlings Jackson that such convulsive movements are the result of "discharging lesions" of nerve-centres. The case of the patient to which I have referred under the head of epilepsy, in whom there was convulsive tremor of one side of the neck and face, induced by irritation applied to the skin of that side, shows, as well as others on record, that such instances may be developed into epilepsy under adequate circumstances, but, as there said, I cannot regard them as primarily epileptic. In another case—that of a young lady who has come under my care since the chapter on epilepsy was written, who is very excitable, has had two choreic periods, and once, certainly, an epileptic seizure—there are daily several attacks of convulsive tremor, in which the action starts from the right side of the neck, gradually invades the right side of the face, and eventually the muscles of the corresponding upper extremity. There is not for a moment the slightest impairment of con- sciousness. The face, however, is at first deathly pale, but soon be- comes flushed. There is no stupor, no mental confusion before, during, or after the attack. She laughs and talks during its continuance, and has a perfect recollection of every thing that takes place during the paroxysm. That such a case is very near to epilepsy is undoubted, but then congestion is very near to inflammation, and may exist for years without advancing to full development. There are certain morbid conditions usually classed as choreic, CONVULSIVE TREMOR. 707 which have more affinity with convulsive tremor than with chorea, though, perhaps, they are, with even greater propriety, placed under the head of hysteria. These are the turnings, salaam-convulsions, jump- ings, etc. It is quite probable that the lesion causing those disorders is similar to that producing convulsive tremor. The morbid anatomy of the affection under notice is entirely a matter of supposition, and indeed there are not many data for forming an opinion relative to the essential nature of the structural alteration. So far as we can judge from a consideration of the phenomena, the seat is in the cortical substance of the brain, and in the medulla oblongata and upper part of the spinal cord. The disturbances of the respiration and circulation point to these latter organs as a part of the anatomical substratum. In those cases in which there are spasms localized in various parts of the face, neck, or extremities, it is probable that the lesion exists entirely in a limited part of the cortical substance constituting the motor centre for the region involved. Treatment.—In the first cases that came under my observation, I employed counter-irritation in the form of a seton inserted into the nape of the neck, large doses of the bromide of potassium, and the primary galvanic current. Iron and quinine were given in two cases to relieve the general anaemic condition which existed. These measures were entirely successful, except in the third case, in which the bromide of potassium produced no perceptible effect. The tincture of hyoscya- mus was substituted for it with good results, but all treatment was subsequently abandoned as stated. In the fourth case the patient was treated with gradually-increasing doses of strychnia, with the effect of causing a complete cure. A solu- tion of the sulphate of strychnia, consisting of two grains to the ounce of water, was administered in doses of ten drops three times a day, the doses being increased by one drop every day, till the physiological effects of the drug were obtained. A return to the original dose of ten drops was then directed, and an increase as before. From thirty to thirty-five drops were generally necessary to cause slight rigidity of the muscles of the legs and neck. The patient continued treatment for several months, and had no further spasms. In the fifth, sixth, and other cases, I have relied for internal treat- ment entirely on the bromide of zinc given in solution in gradually- increasing doses. In all of these the result has been entirely satisfac- tory. In the fifth case, no paroxysm ensued after the first day of treat- ment. Four weeks afterward, the patient presented himself at my clinic, and announced the complete cessation of all convulsive move- ments, and that he had resumed his work, which had been interrupted for several years. In the sixth case I administered the zinc, and in addition applied 708 CEREBRO-SPINAL DISEASES. the actual cautery repeatedly to the nape of the neck. Only one paroxysm occurred after the treatment was begun, and that was in- duced by the excitement and irritation caused by the primary galvanic current applied to the spine. The patient, two months afterward, re- niained entirely well, though still continuing to take the zinc. In all the other cases, five in number, the bromide of zinc has suf- ficed to effect the cure. I have uniformly given it in solution, either in water or simple syrup, in the proportion of one drachm to the ounce. Of this mixture, ten drops were given three times a day for the first two weeks, then fif- teen drops three times a day for the next fortnight, and so on, increas- ing five drops for the doses of each subsequent two weeks. This course has been continued for from three to six months, and then the doses are gradually reduced, except in Cases V. and VI., in which I shall continue them for a much longer period, and in two others which have been but for a short time under treatment. CHAPTER IV. CHOREA. Although it is quite certain that several distinct affections are in- cluded under the term " chorea," these are analogous to each other, and, as we know little about the essential anatomical features of these disorders, and as they are allied by their symptoms, it will be advisable, for the present, to consider them together. Symptoms.—Even in simple, typical, and uncomplicated cases of chorea, the symptoms exhibit great variety. They are connected mainly with the mind, with motility, and with sensibility, though, at the same time, the functions of organic life are generally more or less deranged. Among the earliest symptoms of chorea are those referable to dis- ordered brain-action. The character and disposition of the patient undergo a marked change, and there is, besides, from the first, a very decided impairment of mental vigor. The emotions are easily excited, and the temper becomes fretful and irritable. Hallucinations are not uncommon, and these are generally connected either with the sight or hearing. Sometimes both these senses are involved. The sleep is generally disturbed by disagreeable dreams, sometimes reaching to the intensity of nightmare, and these are so-vivid that the patient often considers them realities. In a few cases there is decided mania, but this is not of a very aggravated form, and is of temporary duration. Three such instances CHOREA. 709 have recently been under my care, all occurring in young girls of about the age of puberty, and exhibiting in all other respects the typical characteristics of chorea. In two cases under my observation, the first notable event in the course of the disease was an epileptic paroxysm, which, however, was not repeated in either case. The most prominent symptoms of the disease are, in the great ma- jority of cases, exhibited in the irregular and disorderly muscular con- tractions which make their appearance at a very early period, and which have given it a name in nearly every language of the civilized world. Thus, we have the terms chorea (xopeia, a dance), St. Vitus's dance, St. Guy's dance, etc. In the beginning the foot of one side drags a little, and soon after- ward the corresponding upper extremity becomes affected with the choreic movements. These are manifested in the fingers, in the flexion, extension, and rotation of the wrist, and in the movements of the elbow and shoulder. No matter where the hand be placed, it cannot be kept steady, but it and the whole extremity are in a constant state of agita- tion. Before long the muscles of the neck and face participate, the head is jerked from side to side, and a continual series of grimaces is the result of the actions in the facial muscles. In some cases the involuntary movements are confined to one lat- eral half of the body, constituting the form known as hemichorea. This is the case in about one-fourth of the instances. Thus, of two hun- dred and thirty-five cases cited by See,1 the phenomena in sixty-four were limited to one side. This limitation has not, as was formerly supposed, any relation with hemiplegia, but is solely the result of the suspension of the progress of the disease. At first the movements are moderate, but they go on, becoming more and more severe, until, in extreme cases, the condition of the pa- tient becomes exceedingly pitiable. The arms, the legs, the face, and head, are in almost constant action. Every attempt to perform a vol- untary movement excites still more the disorderly actions, and thus the patient is unable to feed or dress himself, and sometimes even walking becomes impossible. __,== In one type of Cases the convulsive movements come on paroxys- n mally, and are often of the most astonishing character. The patient is, perhaps, lying quietly on the bed, when suddenly the head is thrown backward, the limbs set in involuntary motion, and the muscles of the trunk contract so violently as to throw the sufferer forcibly to the floor. Again, a series of gyratory motions ensues, and the patient turns round on one foot until complete exhaustion follows ; or there may be 1 " De la chor6e et des affections nerveuses en general, avec leurs rapports avec les diatheses, et principalement avec le rheumatisme," " Mem. de l'acad^mie de medecine," 1850, tome xiv., p. 343, et seq. 710 CEREBROSPINAL DISEASES. leaps and contortions of various kinds. Sometimes the movements are rhythmical. A lady, who a short time since was under my charge, was suddenly seized with an irresistible impulse to bend the left elbow. The arm continued in motion for half an hour, and then the right arm began a like movement. In a few minutes the head began to nod, then the left knee was alternately flexed and extended, and finally the right knee became similarly affected. For over an hour these move- ments continued, and then a regular alternation ensued—first the left arm, then the right, then the head, next the left leg, and finally the right leg. These actions were perfectly timed, and were all performed in exactly ten seconds, as I ascertained by determinations made on several occasions. As she sat in a chair, or lay on a bed, she was a curious sight. Though she was good-tempered with it all, her emo- tional system was in a state of great exaltation. She recovered in a few weeks. In another case a lady from New Jersey was affected in a still more extraordinary manner. While sitting sewing one day, after having been greatly fatigued the previous night, her leg began to tremble vio- lently. In a few minutes the arm of the same side became involved, and very soon the other limbs and the head were affected. She was now in a state of general tremor, and, on attempting to rise, fell to the floor. She was then seized with another kind of movement. Her legs were drawn up forcibly, and then suddenly extended, and this with inconceivable rapidity. She was placed on a bed, but was unable to stay there unless held by several persons, so strong were the con- tractions which took place. On one occasion she was thrown over five feet, her body coming to the floor with great violence. The following day a fresh series of phenomena ensued. She began to turn somersaults, and continued these actions for several hours with- out appearing to be greatly exhausted. Then she jumped suddenly to her feet, and rushed round in a circle with such swiftness that she could not direct her steps, and she several times knocked her body with great force against the walls and furniture. Then she danced for several hours, and toward evening became tolerably quiet, though there was still in- voluntary twitching of nearly all the muscles. In all the various move- ments she went through, every attempt to hold her only made her worse, and she begged that she might be let alone, as the effort to control her by physical force made her head swim, and gave her a severe headache. At night the paroxysms ceased, but they were renewed as soon as she awoke in the morning, and continued with but little intermission, and in every possible form, till she went to sleep. On the third day I visited her, and found her in the midst of a series of movements such as I have described. Her pulse was irregular, her respiration hurried, and her countenance evinced great anxiety. There was no evidence of any hysterical complication. CHOREA. 711 I at once proceeded to administer chloroform by inhalation, and in a few moments she was completely under its influence. The paroxysms ceased soon after the inhalation was begun. I kept her in a state of anaesthesia for half an hour. When she recovered consciousness she was perfectly composed, and remained so all the rest of that day. I left directions that the inhalation was to be repeated if there should be any returns of the choreic paroxysms, but there were none. She slept well all night, and the following morning was quiet till about eleven o'clock, when a slight tremor began, which was at once quieted by the chloroform. I saw her again that day, and began a treatment consist- ing mainly of strychnia in gradually-increasing doses, and renewed my directions in regard to the chloroform. After this she had a few at- tempts at paroxysms, but they were always stopped by the inhalation of the chloroform, and in a few weeks she was well. Chorea of rhythmical or uniform character has often prevailed epi- demically. The most authentic recorded visitation of the kind was one which occurred at Aix-la-Chapelle in 1374. This was in the form of a dancing mania, and is fully described by Hecker1 under the name of St. John's dance. The men and women subject to it met in the streets and churches, where " they formed circles hand-in-hand, and, appearing to have lost all control over their senses, continued dancing, regardless of the by-standers, for hours together in wild delirium, until at length they fell to the ground in a state of exhaustion. They then complained of extreme oppression, and groaned as if in the agonies of death, until they were swathed in cloths bound tightly around their waists, upon which they again recovered, and remained free from complaint until the next attack. This practice of swathing was resorted to on account of the tympany which followed these spasmodic ravings, but the by- standers frequently relieved patients in a less artificial manner, by thumping and trampling upon the parts affected. While dancing they neither saw nor heard, being insensible to external impressions through the senses, but were haunted by visions—their fancies conjuring up spirits, whose names they shrieked out ; and some of them afterward asserted that they felt as if they had been immersed in a stream of blood, which obliged them to leap so high. Others, during the parox- ysm, saw the heavens open and the Saviour enthroned with the Virgin Mary, according as the religious notions of the age were strangely and variously reflected in their imaginations. In the most fully-developed and best-marked instances of the dis- ease, it was often ushered in by an attack of epileptic convulsions. Such were probably cases of hystero-epilepsy, an affection to be pres- ently considered at greater length. The affection spread like wild-fire—being fed by that principle of imitation which appears to be so powerful an influence in causing the 1 "Epidemics of the Middle Ages," "Sydenham Society Translation," 1844, p, 87. 712 CEREBRO-SPINAL DISEASES. propagation of this and analogous disorders of the nervous system. Those affected were generally regarded as being possessed by evil de- mons, and consequently only to be cured by the exorcisms of the clergy. In 1418 it broke out in Strasbourg, and there received the name of St. Vitus's dance, from the fact that the most efficacious means of cure was thought to consist in the intercession of this saint. Similar attacks of dancing mania had occurred before that of St. John, but the details are more or less obscure, and several have occurred since. Among these latter must be placed the tarentism which over- ran Italy, and various more restricted epidemics of like disorders. In our own country we have had the Jumpers, and we still have the Shakers. In addition to these are many of the manifestations of witch- craft, which were choreic, and of which this country has had its full share, and of spiritualism, which it enjoys the doubtful honor of hav- ing initiated.1 In chorea, even of the ordinary simple kind, the speech is imperfect, owing to the incoordination of the muscles directly concerned in articu- lation, and those which effect respiration. There are, therefore, stutter- ing and stammering, and at times a peculiar difficulty of speaking, ow- ing to the attempt being made when the chest is empty; that is, when expiration has just been accomplished. The tongue and lips rarely escape being involved to a considerable extent. The muscles of mastication and deglutition are generally affected, and hence the food is imperfectly chewed, and often causes choking from difficulty of swallowing it. In some cases chorea is accompanied with paralysis—the chorea paralytica of authors. This loss of the power of voluntary motion is usually hemiplegic, and involves the same muscles, which are the seat of the irregular movements. Occasionally there are contractions of the limbs, but not to any great degree. Dr. Weir Mitchella has also called attention to disorderly move- ments supervening after paralysis, to which he applies the term of post- paralytic chorea. The propositions which he enunciates are : 1. That adults who have had hemiplegia, and who have entirely recovered, are often the subjects of choreal disorder. 2. That the younger the patient the more apt these choreal devel- opments are to ensue. Dr. Mitchell adduces several interesting cases in support of these propositions. Since my attention has been directed to the matter, I can recall several cases similar to those described by him, and have recently had two at my clinic at the University Medical College. Chorea is sometimes of very limited extent. It may be only shown i See the author's " Spiritualism and Allied Causes of Nervous Derangement," for more complete details on this and analogous subjects, and for accounts of other examples. 3 "Post-Paralytic Chorea," American Journal of the Medical Sciences, October, 1874. CHOREA. 713 in the hand or foot, but more frequently, when restricted in its topog- raphy, it is manifested in the head or face. There may be only a little twitching of the muscles at the angles of the mouth, or of those which raise the upper lip, or of the orbicularis palpebrarum, by which the eye- lids are closed, or of the levator palpebrae superioris, or of the corru- gator supercilii, or occipito-frontalis. Sometimes the head is rotated suddenly, or twitched to one side, or there is a shrugging of the shoul- ders. In several cases that have been under my care, the abnormal mani- festations were entirely confined to the organs of voice or speech. In one instance—that of a young girl from Illinois—while there was a general hyperaesthesia of the whole nervous system, there were no choreic movements except of the respiratory and laryngeal muscles. The res- piration was therefore exceedingly irregular, and at times inarticulate sounds were made; which were involuntary. Articulate speech was lost from inability to coordinate the muscles, but there was no paralysis, for the tongue could be moved freely in all directions, and the lips were as mobile as ever, except when the patient made an effort to speak. After a few weeks the sound from the larynx was made regularly at each expiration. There were no sounds during sleep. In this case there was a strong hysterical element present. The affection resisted all treatment, and finally I sent the patient home, scarcely improved except in her general health. One morning she awoke, began to speak, and there was no resumption of the laryngeal sounds. She has continued well ever since, now over two years. Again, there may be an irregular action of the muscles of speech, and in consequence words are uttered against the will of the patient, and often without any previous knowledge of what is going to be said. Several such cases have been under my observation, and I have alluded to two of them in a recent lecture 1 on chorea. Since then another remarkable case of the kind has come under my care. In this instance there is scarcely a minute during the day that the speech is not going on, and this without the least power on the part of the patient to arrest or direct it. If he is asked a question, he can only use a few apposite words, the others being altogether without relation to the subject about which he wishes to speak. The convulsive movements in chorea almost invariably stop during sleep. They are also sometimes temporarily arrested by intense men- tal occupation, but are always rendered worse by emotional disturbance or physical fatigue. On the contrary, they are diminished by mental and emotional quietude. Strange as it may appear, the sensation of being tired is scarcely ever experienced by choreic patients. Generally, however, there are wandering pains in the limbs, headache, and pain in the back. The 1 Journal of Psychological Me Jicine, January, 1871, p. 51. 714 CEREBRO-SPLNAL DISEASES. cutaneous sensibility is usually increased, but in some cases it is greatly lessened, and may be abolished altogether in some parts of the body. The functions of the several viscera are ordinarily more or less de- ranged. There are paroxysms of palpitation of the heart, and the action of this organ is to some extent irregular during the whole course of the disease. Endocardial murmurs are often present, either systolic or diastolic, but are the result of the anaemia which is so prominent a feat- ure of chorea. Respiration is imperfect; the stomach does not digest well; and there are nausea and vomiting. The bowels are constipated; the urine is loaded with phosphates, and is of diminished quantity; and the menstrual function in girls is imperfectly performed, either as re- gards quantity or quality. The skin is dry and harsh, the hair loses its gloss, the complexion is pale, the lips bloodless, the pupils dilated, and the sclerotic coat of the eye of more than normal whiteness. The tendency of chorea is to increase to a certain point, and then to gradually diminish. In favorable cases occurring in children, it runs its course in about three months. This period can be materially short- ened by appropriate treatment. Sometimes, it ceases very suddenly, and, in others, passes into a chronic condition, which may last for years or during the life of the patient. Occasionally, it terminates in death, either directly or in consequence of the supervention of some inter- current affection. Three fatal cases have come under my observation. One of these I saw several times in consultation with my friend Dr. T. G. Thomas. The patient was a young lady about twenty years of age, and her paroxysms were of the most violent character, sometimes being so strong as to cause her to throw herself off the bed, or to dash about the room with great force. No treatment appeared to exercise any re- straining effect, and, after about two years, she died of an abdominal affection. There was no post-mortem examination. In the other two cases, death ensued from exhaustion. Relapses are common in chorea, especially in children, and some- times as many as half a dozen attacks occur. Subsequent seizures are usually less severe than the first. Chorea is often complicated with hysteria—a combination which will be described hereafter. It may also exist in conjunction with rheu- matism and malarial fevers, and the exanthemata. Causes.—Chief among the predisposing causes of chorea is age. It is more frequent during the period extending from six to fifteen years than during all the rest of life. S6e, of five hundred and thirty-one cases, found four hundred and fifty-three of ages ranging from six to fifteen years. During the last ten years in my hospital and private practice, and at my clinics, many cases of chorea have come under my observation and treatment, but I have kept no systematic account of them since CHOREA. 715 the first edition of this work was published (1871). At that time I had full notes of eighty-two cases ; of these sixty-seven were of agesv be- tween six and fifteen years. Under the age of six, the disease is less frequent as we go toward birth. Cases have been met with in infants at the breast of six months old. The youngest case I have had was a girl of eighteen months. After fifteen, the disease, unless it occurs as an epidemic, is not very common. Cases are, however, met with in adults, and even in very old persons. I have seen four cases in individuals over thirty and three in persons between the ages of twenty and thirty. Of course, I refer to the origination of the disease at these ages : instances of its beginning in childhood, becoming chronic, and lasting through life, are not so rare. In those cases reported by authors of the affection origi- nating very late in life, we have every reason to conclude that they were instances of organic lesions of the brain or spinal cord—probably scle- rosis—giving rise to rhythmical movements or paralytic tremor. The female sex is much more liable to chorea than the male. Of SeVs five hundred and thirty-one cases, three hundred and ninety-three were girls and one hundred and thirty-eight boys. Of the eighty-two cases of which I have full records, seventy were females and twelve males. Rheumatism has been supposed to be a pre- disposing cause of chorea. Of one hundred and twenty-eight cases, See found sixty-one in association with rheumatism, but, when we come to inquire further, we find that only thirty-two of these were articular rheumatism, while the rest were cases in which there were wandering pains which may have been, and probably were, without the least affin- ity with true rheumatism. While it is certainly the case that chorea sometimes follows or exists coincidentally with rheumatism, I doubt if its influence is any more than that of a depressing agent to the organism. Of the eighty- two cases observed by myself, only sixteen were connected with rheu- matism, while eighteen were just as intimately related to other diseases. The affection appears to be more common in winter than in sum- mer. Of my cases, fifty-four occurred in the six months from October to March, and twenty-eight in the other six months of the year. Among the exciting causes, those connected with the emotions oc- cupy the first place. Twenty-seven of my cases were directly the result of fright, apprehension, anxiety, mental excitement, or some other cause of the kind. In eight it was induced by intense study at school, and in four from imitating others similarly affected. This latter factor is not of so general application as in former times, when social life was different. To it is, doubtless, to be ascribed the spread of choreiform movements through certain localities, and especially convents, such as occurred in the thirteenth, fourteenth, and fifteenth centuries, to some of which reference has already been made. 716 CEREBRO-SPINAL DISEASES. Among other causes, bad hygienic influences and exhausting dis- eases generally are to be mentioned. Pregnancy is also asserted to be a cause, and cases are on record in which the foetus has been born choreic of a choreic mother. Diagnosis.—There is not much danger at the present day that chorea will be confounded with many of the diseases from which, not long ago, it was not clearly disassociated. Thus from paralysis agitans, epilepsy, locomotor ataxia, multiple cerebral and cerebro-spinal scle- rosis, the fuller acquaintance which we have in recent years acquired of these maladies prevents the necessity of dwelling on their character- istics as distinguished from those of chorea. The course of the latter disease, and the symptoms, other than those connected with motility, are in the others so different that no one who has studied their phenom- ena could fail in making a correct diagnosis. With hysteria, some of the forms of chorea may be confounded, and the two affections are not infrequently blended in the same person. It must be confessed, too, that there are cases in which the diagnosis can- not be clearly made out. So far as the patient is concerned, the difficulty of forming a correct opinion in such cases is not a matter of much moment. The great majority of cases of chorea, such as are met with in chil- dren, are readily distinguished from hysteria. The facts of the disease occurring before puberty in so large a proportion of instances, that the emotional system is rarely disturbed as in hysteria, that the affection is not so paroxysmal, and that the accessions of hysteria are more sudden, will be sufficient to render the diagnosis accurate. From convulsive tremor—with which in some of its forms it is close- ly analogous—ordinary chorea is diagnosticated by the facts that it is not paroxysmal, but continues while the patient is awake, that the movements are more disorderly, while at the same time more purposive, that the natural tendency is toward spontaneous recovery, and that it usually occurs in children. But it must be admitted that it is difficult to determine to which disease certain rhythmical and paroxysmal disorders are to be ascribed. It would perhaps be more correct to place all such under the head of convulsive tremor or hysteria, with which affections they are certainly closely allied. Prognosis.—This is usually favorable in those cases which occur be- fore puberty. The chorea of adults is, however, in most instances, a very unmanageable affection, and generally either terminates in death or be- comes permanent. Cases in which death has ensued have been report- ed by various authors—among them, Dr. John W. Ogle, Dr. J. Hugh- lings Jackson,1 and Dr. G. S6e.a As already stated, three fatal cases 1 " Remarks on Chorea Sancti Viti, including the History, Course, and Termination of Sixteen Fatal Cases," etc., British and Foreign Medico- Chirurgical Review, January, 1868, p. 208 8 " The Physiology and Pathology of Hemi-Chorea," Edinburgh Medical Journal, Oc- tober, 1868. 8 Op. cit. CHOREA. 717 have occurred in my own experience. The tendency, however, in the chorea of young persons is decidedly toward recovery, even under un- favorable circumstances as regards hygiene or medical treatment. Morbid Anatomy and Pathology.—In many cases of persons dying, either from chorea or from intercurrent affection, no changes have been found which could, with probability, be regarded as constituting the disease. In other cases, morbid alterations from the healthy state have been found. The idea has, therefore, prevailed that there are two kinds of chorea—one which is entirely functional, belonging to the so-called neuroses, the other the result of organic disease of the brain or spinal cord, or both. In Ogle's sixteen fatal cases, congestion of the brain and its membranes was found in some, while in others the disease ex- isted in the spinal cord. In an analysis of one hundred cases, of chorea, Dr. Hughes * cites fourteen fatal cases. In all but four of these there was intra-cranial congestion with other structural changes, such as softening, opacities, and adhesions. The spinal cord was not examined in six cases. Of the remaining eight, it was healthy in three, and congested, softened, or with adhesions or opacities of the membranes in the remaining five. In seven fatal cases, collected by Romberg,3 there were softening and degeneration of different parts of the brain and of the spinal cord. Other similar cases have been reported, and in the majority there were fibrinous concretions on some portion of the heart's valves or lin- ing membrane. v In 1850 and 1863, Dr. Senhouse Kirkes3 published the details of a number of cases which went to show the association between chorea and rheumatism, and he made the prediction that " future experience will still more positively demonstrate that an affection of the left valves of the heart, with the presence of granular degeneration upon them, is an almost invariable attendant upon chorea, under whatever circum- stances the chorea may be developed." The relation is also insisted upon by S6e and other authors, and such cases as those of Ogle are cited in its support. But the doctrine is only applicable, with any probability, to the fatal cases, and, in those of Ogle, rheumatism was not always an antecedent. In regard to this point, I am entirely in ac- cord with the views expressed by Dr. Ogle in the following extract, which I make from his valuable paper : " Again it might be asked, if there was merely a mechanical cause (which, of course, would be constant in operation), such as embolism, why should the movements be so decidedly and universally interrupted during quiet sleep ? Or, why should certain peculiarities as to age or 1 " Digest of One Hundred Cases of Chorea," " Guy's Hospital Reports," vol. iv., 1846, p. 360. 8 "Lehrbuch der Nervenkrankheiten," Band ii. 8 London Medical Gazette, 1850, and Medical Times and Gazette, 1863. 718 CEREBRO-SPINAL DISEASES. sex be considered as predisposing influences? Recognizing the fre- quent existence of these fibrinous deposits, or granulations, on the heart's valves in chorea, I should be much inclined to look upon these post-mortem appearances rather as results of some antecedent condition of the blood, common also to the choreic condition. It is very freely recognized that this affection is frequently in some way or other con- nected with that condition of blood which obtains in what we call anae- mia, or that existing in rheumatic constitutions. In both of these states we know that the fibrine of the blood is much in excess (as also it is in pregnancy and other conditions looked upon as obnoxious to chorea), and in these states we know that the fibrine (with which the blood is surcharged) is very prone to be readily precipitated, either ow- ing to its superabundance or from other obscure and acquired proper- ties (possibly also from some interference with the relation of the fibrine and the other constituents of the blood), upon the heart's walls or valves. May not this hyperinosis be the explanation of the coincidence alluded to ? In most cases, the deposit is probably very slight, and, in many cases, so slight as to require search for it. May it not infrequently be that it is often only found in quite the dying state ? Speculation might suggest that the fibrinous deposits arise from some interference with the degree of solubility of the fibrine, induced by the presence of some ununited elements within the blood (some result of tissue-metamorpho- sis) produced by the excessive muscular action and other functional disturbance which exist in the choreic state, thus being not in any way related to this state as a cause, but as a consequence." In the paper to which reference has already been made, Dr. Hugh- lings Jackson associates hemi-chorea with the plugging by emboli of the vessels of the corpus striatum of one side, and, in a recent valuable paper, Dr. Charlton Bastian x says : " I need only hint at the important bearing which the possibility of the occurrence of minute embolisms of this kind may have in the eluci- dation of previously-obscure forms of so-called functional disease of the nervous system, as I hope shortly to publish the details of a fatal case of chorea, in which such embolisms led to ruptures and obliterations of small vessels throughout the corpora striata and in the course of the middle cerebral arteries generally—this being a case of bilateral chorea in which delirium was also present." As the result of our present knowledge of the morbid anatomy of chorea, while it cannot be said that we are able to define its seat with accuracy, we have strong evidence to support the view that it is not a neurosis or functional affection—if, indeed, there are any such—and that it is the result of changes taking place in the cerebro-spinal sys- tem. As previously stated, I am inclined to think that there are at 1 "On the Plugging of Minute Vessels in the Gray Matter of the Brain," etc., British Medical Journal, January 30, 1869, p. 96. CHOREA. 719 least two distinct diseases—one due to spinal and the other to cerebral lesion—the latter probably consisting of several forms—but that it is advisable to consider them as one disease of various types, until further investigation enables us to speak with certainty on the subject, and to classify them according to the morbid anatomical condition of each. In the paper already cited, Dr. Hughlings Jackson says of the cho- reic phenomena : " They are not mere spasms and cramps, but an aim- less progression of movements of considerable complexity, much nearer the purposive movements of health. They are not so much incoherences of muscles (like the ' fist' we see in a partial fit of those convulsions, which begin unilaterally where all the muscles of the hand are in action at once) as incoherences of movements of muscles. There is some method in their madness. They are not analogous to playing at once many keys of a piano in mere order of continuity, but to a random play- ing of harmonious chords. Again, they are successions of movements; moreover, they are successions of different movements." Dr. Jackson's theory of chorea is, that it is, like epilepsy, the result of " discharging lesions " of the cortical matter of the cerebrum, and the experiments of Fritsch and Hitzig, Nothnagel, Ferrier, and others, go very far to confirm his views. Two essential points of difference from epilepsy must, however, be noted—the facts that in chorea there is no loss of consciousness, and that the discharges are successive, not paroxysmal, and less automatic. Moreover, his hypothesis leaves out of consideration the spinal element of the disease. That there are dis- charging and inhibitory centres in the spinal cord is supported by many artificial and natural experiments. The " spinal epilepsy " of Brown- Sequard is doubtless often a chorea of spinal origin, and my own ex- periments, cited under the head of convulsive tremor, also show that there are motorial centres in the spinal cord. Treatment.—Diseases which are almost certain to terminate fatally, and those which ordinarily recover without medical treatment, are very sure to have a great many medicines used in their therapeutics. Cho- rea belonging, as it does, to this latter category, has a medical arma- mentarium almost equaling that of hydrophobia. I shall, of course, not even pretend to mention all these measures, but will merely cite those which the weight of evidence, and especially that derived from my own experience, indicates as the most effectual. Of the benefit to be de- rived from proper medical treatment in shortening the duration of the disease, and preventing chronicity, I have no doubt. In this country zinc is probably more used in chorea than any other single remedy. I have employed it in many cases, and sometimes with good results. My preference used to be for the sulphate, which I gave in gradually-increasing doses, from two or three grains up to twenty or thirty three times a day, dissolved in a sufficient quantity of water, to prevent gastric irritation. Latterly, however, I have used the bromide f20 CEREBRO-SPINAL DISEASES. with even better results. Ten drops of a solution of the salt, consist- ing of a drachm to the ounce, of water or simple syrup, may be given three times a day as an initial dose, the quantity being gradually in- creased as rapidly as the stomach will bear. When the choreic symp- toms begin to disappear, the doses should be diminished in the same gradual manner in which they were increased. Iron is also frequently administered as a sole remedy, and still more generally as an adjuvant. Indeed, no matter what special treatment may be adopted, iron is generally indicated to improve the quality of the blood. I rarely use it unless for this latter purpose. Arsenic enjoys a high reputation in the treatment of chorea, and by some is regarded as almost a specific. Although I have frequently given it with great advantage, I have repeatedly had it fail in my hands. I have administered it five times hypodermically for choreic movements involving the muscles of the neck, as recommended and successfully used by Dr. Radcliffe. In two of these it failed, but in the others it was thoroughly effectual. Five minims of Fowler's solu- tion, diluted with an equal quantity of water, were injected into the cellular tissue immediately over the belly of the left sterno-cleido-mas- toid muscle, the muscle which was affected. The following day six minims were injected, and so on till the quantity reached ten minims. By this time the jactitations had nearly ceased, and a few more injec- tions of ten minims each were sufficient to render the cure complete. In these cases zinc, electricity in the forms of the primary galvanic and induced currents, iron, morphia, and several other measures, had failed. Tartarized antimony, copper, sulphate of aniline, Calabar bean, and various other substances, have been employed with more or less suc- cess, according to reports, but I have little personal experience of their value, except as regards the Calabar bean, which I have several times employed as an adjuvant, but with doubtful results. I have used both the primary galvanic and induced currents in many cases. In my opinion they are inefficacious except in that form in which there is distinct paralysis. Without stopping to detail other means, I will describe the modes of treatment which my experience has convinced me are most effica- cious. As one of the remedies, I usually administer the bromide of potassium or sodium in moderate doses, so as to render the sleep sound- er. I do not regard this as an essential part of the treatment, and, if the patient is exceedingly anaemic, I do not urge it. My main reliance is on strychnia, which I think should be given in gradually-increasing doses, somewhat after the manner recommended by Trousseau. Two grains of the sulphate of strychnia are dissolved in an ounce of water, and for a child of from ten to fifteen years of age five minims should be given three times a day. This quantity rep- resents the one-forty-eighth of a grain of the salt. The following day CHOREA. 721 six minims are administered at each dose, the next seven, the next eight, and so on till the physiological effects of the medicine, as evi- denced by stiffness of the legs and neck, are obtained. Sometimes these are not perceived till twenty or twenty-five minims are taken at a dose. In other cases they follow on doses of ten minims. When they take place, the doses should be at once reduced to the original five minims, and the increase carried on as before. This plan of treat- ment certainly shortens the duration of the disease very materially, and causes great improvement in the general health of the patient. Sometimes the effect is so well marked, and is so immediate, that it is not necessary to increase the doses to the extent of causing muscular cramps, but generally the full therapeutical effect of the drug is not obtained till the calf of the leg, or the nucha, has slight tonic spasm. I have never seen the slightest ill consequence follow this mode of treatment, and the doses are increased so gradually that, with careful watching, danger need never be apprehended. I have carried it out in about seventy cases occurring in children under the age of fifteen, and in ten cases in persons of adult years, without a single failure, except in three of the latter category. In one of these, the affection was limited to the speech, there being an inability to utter words in accordance with the ideas. In this case the dose was increased to thirty-five minims before any rigidity of the legs was perceived, and then the command over the language began to appear, and by continuing the doses at thirty-five minims the patient was entirely cured within a month. In this case the initial dose was . ten minims. I have also made extensive use of the ether-spray to the spine as employed by Lubilski, Zimberlin, and others, and my success has been unequivocal. The whole spine is exposed, and the ether is thrown upon it from the occiput to the sacrum for about ten minutes every day, or every alternate day, according to the severity of the attack. Ten applications are the maximum number I have found it necessary to make, and thus in recent cases a cure has always been obtained within two weeks. I very rarely treat a case without using this means. An immediately quieting effect often results from a single application. Strychnia, zinc, or arsenic, has been given at the same time, but un- doubtedly the beneficial results are in great measure to be attributed to the ether. In the paroxysmal forms of chorea, ether or chloroform by inhala- tion is .often necessary to cut short or prevent an immediate seizure, but in other respects the treatment mentioned is entirely applicable. In all cases hygienic measures are of the utmost importance. Ex- ercise in the open air is indispensable ; the food should be of the most nutritious character ; the bedroom should be well ventilated ; bathing should be frequent; the bowels should be kept well regulated, and 46 722 CEREBRO-SPINAL DISEASES. the child, if at school, should be at once removed, and all study for the time be interdicted. Ridicule or threats, so often indulged in tow- ard choreic children, generally do harm, but at the same time they should be encouraged to use all reasonable effort to prevent a bad habit being formed. In the epidemic variety of the disorder, threats and even strong repressive measures are, on the contrary, decidedly benefi- cial in curing and arresting the further progress of the disease. CHAPTER V. ATHETOSIS. Under the name of athetosis ('A0eroc, without fixed position), I propose to describe an affection which, so far as I know, had not, pre- vious to the publication of the first edition of this work in 1871, at- tracted the attention of medical writers, and of which several cases have come to my knowledge. It is mainly characterized by an inability to retain the fingers and toes in any position in which they may be placed, and by their continual motion. From these phenomena, I have applied the term athetosis to the disease, having as yet had no oppor- tunity of ascertaining by post-mortem examination the nature of the lesion to which the symptoms are due. Since then the disease has been admitted to be well founded by several eminent pathologists, among them Dr. Clifford Allbutt,1 Dr. Gairdner,a Dr. Clay Shaw,3 Dr. C. C. Ritchie,* and Dr. Eulenburg.6 • These symptoms will be evident from the following histories: J. P. R.,6 aged thirty-three, a native of Holland, consulted me Sep- tember 13, 1869. His occupation was bookbinding, and he had the reputation, previous to his present illness, of being a first-class work- man. He was of intemperate habits. In 1860 he had an epileptic paroxysm, and, since that time to the date of his first visit to me, had had a fit about once in every six weeks. In 1865 he had an attack of delirium tremens, and for six weeks thereafter was unconscious, being more or less delirious during the whole period. 1 "Cases of Athetosis," Medical Times and Gazette, January 27, 1872. a Cited by Dr. Clay Shaw, who gives no reference and I have been unable to find the original. 3 " On Athetosis or Imbecility with Ataxia," " St. Bartholomew's Hospital Reports," vol. ix., 1873, p. 130. 4 " Note on a Case of Athetosis," Medical Times and Gazette, March 23, 1872. B " Athetosis," Ziemssen's " Handbuch der speciellen Pathologie und Therapie," zwolf- ter Band, " Krankheiten des Nervensystems," II., zweite Halfte, 1875, p. 389. 6 This patient was several times at my cliniques before the class of the Bellevue Hos- pital Medical College, first in the autumn of 1869 and last in January, 1871. I also ex hibited him to the American Neurological Association at its meeting in June, 1875. ATHETOSIS. 723 Soon after recovering his intelligence, he noticed a slight sensation of numbness in the whole of the right upper extremity, and in the toes of the same side. At the same time severe pain appeared in these parts, and complex involuntary movements ensued in the fingers and toes of the same side. At first the movements of the fingers were to- some extent under the control of his will, especially when this was strongly exerted, and as- sisted by his eyesight, and he could, by placing his hand behind him, restrain them to a still greater degree. He soon, however, found that his labor was very much impeded, and he had gradually been reduced, from time to time, to work requiring less care than the finishing, at which he had been very expert. The right forearm, from the continual action of the muscles, was much larger than the other; and the muscles were hard and developed, like those of a gymnast. When told to close his hand, he held it out at arm's length, clasped the wrist with the other hand, and then, exerting all his power, suc- ceeded, after at least half a minute, in flexing the fingers, but instanta- neously they opened again and resumed their movements. I treated him with galvanism, primary and induced, for four months, without notable result. His fits were, however, arrested with bromide of potassium. His memory began to be impaired soon after his attack of delirium tremens, and his intellect was manifestly weakened when I first saw him. . January 17, 1871, at my suggestion he attended the New York State Hospital for Diseases of the Nervous System, when the following points, which I cite from the report of Dr. Cross, the Resident Physi- cian, were noted: The head is symmetrical, but is peculiar in shape—the posterior portion rising to a much higher point than the anterior, while the latter slopes downward and forward, giving the cranium the form of that of a Flathead Indian. The special senses are normal. The intellect is somewhat impaired, and his ideas are not so vivid at one time as at another. His memory is much enfeebled. There is slight tremor of both upper extremities, but there is no paralysis of any part of his body. There are, however, involuntary grotesque muscular movements of the fingers and toes of the right side, and these are not those of simple flexion and extension, but of more complicated form. They occur, not only when he is awake, but also when he is asleep, and are only re- strained by certain positions, and by extraordinary efforts of the will. Thus, those of the fingers are arrested when the wrist is firmly grasped by a strong hand, or when it is less forcibly held in a vertical position. But, if the arm be extended horizontally, the fingers at once begin their movements. During their continuance the arm is hard and rigid, and 724 CEREBRO-SPINAL DISEASES. the calf of the leg is also in the same state of tonic spasm while the toes are in motion. The movements are somewhat paroxysmal, being worse at times than at others. During the remissions the power of the will over the muscles is more effective than when the paroxysms are at their height. Sensibility to touch, pain, tickling, and temperature, is normal in all other parts of the body. There is slight tremulousness of the tongue, but no difficulty of articulation. There are no oscillatory movements of the eyeballs (nystagmus). The involuntary contractions of the fingers and toes do not take place quickly, but slowly, apparently as if with deliberation and with great force. The numbness and pain in the arm, hand, leg, and foot, have increased in proportion to the increase in the contractions. The toes are not involved to the same degree as the fingers. Posi- tion does not, however, afford the same relief to them as to the fingers, and the spasms are more tonic in character. The muscular develop- ment is greater in the right arm and leg, from the almost continuous muscular action. The toes are kept restrained to some extent by the boot, but as soon as it is removed they become flexed and take on their peculiar movements. When, by a strong effort of the will, he succeeds for an instant in arresting the movements in the hand, the little finger at once becomes strongly abducted, the third finger participates to some extent, the second finger is slightly flexed, the index-finger is extended, and the thumb is extended to its very utmost. These are the positions in all cases in which he succeeds in quieting the actions, and they are well shown in the accompanying woodcut (Fig. 94) taken from a photograph. On account of the severe pain in the whole arm, caused by the spasms in the muscles, the patient is at times unable to go to sleep un- ATHETOSIS. 725 til quite exhausted. On awaking, however, after a few hours' repose, although the actions have continued during his sleep, they are not so severe as at any other time through the day or night. This state of comparative repose lasts for about half an hour. His habits are bad. He boasts that he has often drunk as many as sixty glasses of gin in a day, and it is therefore doubtful whether the tremulousness observed in the tongue and the muscles generally is the effect of the disease, or of drink, or of both combined. I have never, however, seen him drunk, or even under the influence of liquor. His mental faculties are decidedly more obtuse than when he first came un- der my observation. Under the use of the primary galvanic current to his brain, spinal cord, and affected muscles, and the internal use of chloride of barium, he improved for a short time, but I have no hope of any permanent result being obtained. His epileptic paroxysms are kept down with bromide of potassium. In May, 1873, on the occasion of reading a paper on athetosis be- fore the Medical Library and Journal Association, I brought this patient to the meeting, and at the meeting of the American Neurological Asso- ciation in this city, in June last, I again showed him as the case on which I had based my description of the disease. At that time he was in about the same condition as when he first came under my notice.1 The second case occurred in the practice of Dr. J. C. Hubbard, of Ashtabula, Ohio, who forwarded to me the following excellent report, dated January 11, 1870, and two photographs—one full length on a small scale, and another, from which the woodcut, Fig. 94, has been engraved : " H. S., aged thirty-nine years, a farmer by occupation, married. His father and paternal grandfather were free drinkers of ardent spir- its. His only brother died of phthisis pulmonalis, and I think he in- herits a tubercular tendency from his mother. The patient is short, muscular, is well made, and has always had good health till about eight years ago, when he had several attacks of headache, followed by ver- tigo and loss of power to maintain the upright posture, or to sit in a chair. After falling, he lost consciousness for a few moments. He had three of these attacks in two months. " Three years after the last one, being five years and a half ago, while at work on a hot day in the open air, he lost consciousness and fell to the ground. This attack was more severe than the preceding ones, and he was confined to his bed three days. The headache was very severe, and continued a week after he left his bed. Aphasia and the incoordination now affecting his right forearm and right leg were the sequence of this stroke. His powers of speech were gradually re- 1 " Transactions of the American Neurological Association," vol. i., 1875, p. 17. 726 CEREBRO-SPINAL DISEASES. established in the course of six weeks, but the impediment to normal voluntary muscular motion has remained to this day. " In June last [1869] he applied to me for relief from cephalalgia, pain in the right side of the chest, cough, and dyspnoea. He com- plained also of vertigo and of flashes of light before his eyes. His memory and judgment were slightly impaired, and he was gloomy and irritable. " His utterance of most words was perfect, but he stammered over at least one word in each sentence. It required a good deal of effort for him to connect his ideas and his sentences. He stumbled at mono- syllabic words, such as then, to, at, and, and other conjunctions, but in a moment, after considerable effort, he could speak these words and conjoin his sentences correctly. " On examining his right foot, I found that he had lost the normal antagonizing force between the flexors and extensors of the toes. The toes were ordinarily in a state of flexion, so as to present their ends to the floor. He could restore the balance in muscular action by a strong effort of the will, pressing at the same time the sole hard upon the ground, and drawing the foot backward a little. Soon, however, the extensors would be wearied by their extra work, and the toes would re- sume their abnormal position. The foot is slightly inverted at every step, and it is not exactly guided by the will. His gait is awkward— the foot being set down with a kind of pawing motion, as in talipes varus. " A similar incoordination is observable in the right hand and fin- gers. He cannot flex his fingers without the aid of the opposite hand, but when it is closed the grasp is as strong as ever. By an intense ac- tion of the will he can keep his fist closed for a few moments, till the apparently tired flexors give way. The little and ring fingers are but partially extended, and are strongly abducted. The abductor minimi digiti and the flexor b re vis minimi digiti are hypertrophied, firm, hard, and in a state of contraction most of the time, and the affected hand measures three-fourths of an inch more around the palm than its fel- low. Tactile sensibility is as perfect in the affected limbs as in the others. His muscular powers are good, and he thinks he can walk twenty-five miles without injurious fatigue. The temperature of the affected limbs is slightly lower than that of the opposite ones. Has slight headache frequently, generally at evening ; sleep relieves it. He sleeps well when undisturbed by pains in his limbs. Tongue clean and tremulous. Has slow-moving pains, from the hand and foot up to the body. They often last half a day, and are worse at night. Has no pain, tenderness, or feeling of weakness, in any part of the spine. " He had no systematic treatment till last June. The chest-symp- toms referred to were owing to subacute bronchitis. A seton was in- serted between the shoulders, and iodide of potassium was adminis- ATHETOSIS. 727 tered for ten days. His lungs being then better, phosphoric acid, cerium, cannabis Indica, sulphate of quinine, and sulphate of iron, were given till the first of December following. He then felt so much better that he discontinued the medicines. The seton continued to discharge till the date of this communication [January 11, 1870], and he presents at this time a very marked improvement. His headache is not severe, he has less pain in his limbs, and he speaks without hesi- tation. By a strong effort of the will he can close his hand without assistance. He came five miles on foot, in a driving snow-storm, to see me to-day." The accompanying woodcut (Fig. 95) is from one of Dr. Hubbard's photographs. The resemblance to the condition shown in Fig. 94 is very striking, and the histories of the two cases are so nearly identical, in regard to all essential points, as to leave no doubt that they describe instances of the same disease. Dr. Hubbard's case was probably, when he wrote the history, in a more advanced state than is mine at the present time. The distortion of the hand is certainly greater. In the other photograph, which is indistinct, the toes are seen fully flexed. Fig. 95. The symptoms of athetosis are clearly indicated in the foregoing histories. Both cases came on with epileptic paroxysms—a feature ac- companying other organic diseases of the brain and spinal cord. In both there are similar head-symptoms, tremulousness of the tongue, numbness on the affected side, pains in the spasmodically-affected mus- cles, and especially complex movements of the fingers and toes, with a tendency to distortion. In neither case is there any paralysis. Relative to the character of the lesion producing these symptoms, and its exact seat, I am not yet prepared to speak with the positiveness resulting from post-mortem examination. 728 CEREBRO-SPINAL DISEASES. But the recent researches of Fritsch and Hitzig, Nothnagel, Ferrier and others, as well as my own, cited under the heads of convulsive tre- mor and chorea, together with the results of observations of other cerebral and spinal disorders, afford us valuable indications relative to the nature and seat of athetosis. The movements appear to be due to a continuous discharging lesion, and to one which is clearly not of the same explosive intensity as epilepsy, convulsive tremor, or even chorea. This lesion may be situated either in the gray matter of the brain or spinal cord, or in that of both these organs. Till the question is defi- nitely settled, I have thought it better to retain the position for atheto- sis among the cerebro-spinal affections, with which it has many analo- gies. We know that there are lesions of the anterior tract of gray mat- ter which cause paralysis and atrophy. Why may there not be others causing hyperkinesis and hypertrophy ? Cases similar to the foregoing have recently come to my notice. My friends Profs. Gross, of Philadelphia, and Barker, of this city, have informed me that several years ago patients exhibiting the symptoms of athetosis were under their care. Dr. Clifford Allbutt1 has reported the following as a probable case of athetosis : The patient, an inmate of the Leeds General Infirmary, " was a re- spectable, temperate woman, of about fifty-five years of age, sallow in complexion, and a good deal wasted ; for some time she had been sub- ject to spasmodic restlessness of the extremities. These movements were best marked in the hands, as was seen in Dr. Hammond's cases; like his cases, also, so in Mrs. D., the feet were rather in a state of tonic flexion, the toes being so spasmodically pointed that she was unable to walk. For this reason she was made an in-patient under Dr. Clifford Allbutt, who took great interest in her. He pointed out that the case differed much from chorea and paralysis agitans, both in the character of the movements and in their limitation to the hands and feet. Unlike Dr. Hammond's patients, however, Mrs. D.'s spasmodic movements ceased, or almost ceased, during sleep. The toes, as aforesaid, were rather in a state of tonic spasm, and forcibly pointed downward ; there were, however, frequent slight alternate movements of flexion and ex- tension. In the hands the movements consisted chiefly of a curious alternation between abduction and adduction, the fingers being quickly agitated in a lateral plane. The district of the ulnar nerve was agitat- ed for the most part in alternation with the rest of the hand, so that many of the movements were of a spreading and closing character. There was, however, much irregularity in all this, and semi-flexions and extensions often occurred among the other agitations. The will had but a slight and transient effect in commanding the hands, and the pa- tient could never succeed in setting them at rest even for a second. 1 Medical Times and Gazette, January 27,1872. ATHETOSIS. 729 ' The urine was normal, and the bodily functions in fair order. During her short stay the continuous galvanic current was used, but with little or no benefit." Dr. Gairdner describes the phenomena with great accuracy : " Sometimes the wrist is strongly flexed, and at other times it is strongly extended, and very often the fingers are in precisely the oppo- site position to the wrist; sometimes individual fingers are flexed, while others are extended and all more or less rigid. Under favorable cir- cumstances he can perhaps control every muscle of his arm, but, when the rigidity or spasm comes on, particular groups are for the time being wholly withdrawn from the will or nearly so. They scarcely ever cease except in sleep. By using a certain amount of force you can always overcome the spasm in opening successively the fingers of the closed palm, but an attempt to overcome the spasm of one group of muscles is very apt to set it off in the opposite direction. It seems like uncon- trollable muscular impulse without paralysis and without permanent spasm or rigidity, a quasi rhythmic spasm somewhat resembling the peristaltic movement of the involuntary muscles in the alternating or successive affection of groups of muscles." In Dr. Clay Shaw's cases there were other movements situated in the muscles of the head, neck, and face, and marked mental impairment. Fig. 96. In some respects his instances, seven in number, are similar to those of athetosis, and they may be such with the imbecility superadded, or rather the athetosis superadded to the imbecility, just as epilepsy or chorea, for instance, may ensue in an imbecile person. As to the epi- lepsy with which the cases just observed began, it is by no means cer- tain that the relation is any thing more than accidental. The accom- panying woodcut (Fig. 96) represents one of Dr. Clay Shaw's patients in one of her attitudes. 730 CEREBRO-SPINAL DISEASES. Dr. Ritchie's case is undoubtedly a typical one, and others were mentioned by Drs. Clymer, Jewell, Hay, and Seguin, in the discussion which took place in the American Neurological Association, when my original case was presented. The case reported by Dr. Fisher * was probably not one. Since the original description of the disease, four other cases have been under my charge, presenting features almost identical with those of the first two cases, with the exception that in only one were there previous epileptic attacks. All my cases, with two exceptions, have been men. As to the cause, nothing definite is known, and no case that has come to my knowledge has been materially benefited by treatment. CHAPTER VI. HYSTERIA. A large volume might be written on hysteria—and many such have been published—and there would still be points in its clinical his- tory unconsidered. It is difficult, therefore, in a general treatise like the present, to give a full view of a disease which plays so important a part in nervous pathology, and which is so varied in its manifestations. The most that I can hope to do is to lay down certain broad principles and features, and leave the recognition of details to the intelligence and discrimination of those who read this work. Symptoms.—The phenomena of hysteria may be manifested, as re- gards the mind, sensibility, motility, and visceral action, separately or in any possible combination. Thus it is not uncommon to meet with cases in which the. only evidence of the disease is seen in abnormal mental action ; others are characterized solely by derangements of sen- sibility, such as hyperaesthesia or anaesthesia ; others by aberration of the faculty of motion, such as paralysis, spasms, contractions. Again, all of these categories may be witnessed in the same person, giving rise, among other phenomena, to coma and convulsions ; and again, some one or more of the viscera may be deranged in their functions, and thus the appearance of organic disease be simulated. As there is such a marked want of uniformity in the character cf hysteria as it affects different persons, I will not endeavor to present a typical case of the disorder, but will consider separately the principal phenomena which may have an hysterical origin. But, in setting out to make the attempt, I am reminded of Dante's despair at the thought of his inability to describe the horrors of the ninth gulf : 1 Boston Medical and Surgical Journal, May 30, 1872. HYSTERIA. 731 " Chi poria mai pur con parole sciolte Dicer del sangue, e delle piaghe appieno, Oh'io ora vidi, per narrar pici volte? Ogni lingua per certo verria meno, Per la nostra sermone, e per la mente, C'hanno a tanto comprender poco seno." The Hysterical Diathesis.—Though it is very common to hear the hysterical diathesis or temperament mentioned by medical authors, I have never been able to recognize its existence by any external traits. The fact that it has been so very differently described by writers, from Hippocrates and Galen to our own day, is good evidence that it is not readily detected. Thus, Hippocrates and Galen recognized the existence of the hys- terical temperament, but each gave it different characteristics. Lou- yer-Villermyx had very decided views of its features, and he described it as follows : " Every hysterical woman is stout, short, dark, plethoric, full of life and of health. The complexion is brunette and ruddy, the eyes black and sparkling, the mouth large, the teeth white, the lips of a carnation red, the hair luxuriant and of the color of jet, the sexual organs well developed, and the spermatic liquid abundant." Aside from his physiological error relative to the spermatic liquid, these are the characteristics of the women of the south of Europe. If he had lived in the north, where hysteria is fully as common, he would have found that his description of the hysterical temperament would not have held good. Indeed, Sydenham, Whyte, Copland, and other English authors, represent the hysterical predisposition with almost the very opposite characteristics. As Briquet2 remarks, there is no hyster- ical constitution appreciable by the study of external appearances. The disease takes women as it finds them, blondes, brunettes, stout, thin, strong, weak, ruddy, or pale, there is no choice. Some hysterical women have delicate figures and intelligent minds, but there are others whose dull, stolid faces give evidence of their stupidity ; and others, again, whose thin, fleshless, and wan faces tell us that the Greek type of female beauty is not to be regarded as predisposing to the develop- ment of hysteria. While, therefore, admitting the existence of the hysterical diathesis, I know of no marks by which its presence can be determined, other than the acts of the patient, which go to make up the clinical history. Mental Symptoms.—These are very various, but generally consist in emotional disturbance, an inability or indisposition to exert the will, and in the existence of illusions, hallucinations, or delusions. Attacks ■Quoted by Briquet, "Traite' clinique et th6rapeutique de l'hysterie," Paris, 1859, p. 91. 8 Op. cit, p. 92. 732 CEREBROSPINAL DISEASES. are often characterized by no other prominent symptoms than those connected with mental action, and they may assume every possible character. At times, the patient is depressed in spirits, and sheds tears profusely ; a few minutes afterward, she has forgotten her grief, and laughs immoderately, without adequate cause. Sometimes she laughs and cries at the same time. Or, there may be a total insusceptibility to any emotion, a listless insouciance, which contrasts strongly with her natural disposition. Or, again, an emotion the exact opposite of the proper one is excited. This is quite a common form of manifestation. A mother, for instance, is informed that her daughter has contracted an improper marriage, and is immediately seized with immoderate laughter, and shows every ex- pression of pleasure, when the rest of the family are overwhelmed with grief and shame. Another draws the chief prize in a lottery, and be- gins at once to cry and wring her hands. A third, hearing that bur- glars have entered the house and have stolen all her jewelry and silver, sits stolidly in her chair, her hands folded in her lap, and her whole ex- pression indicating the most complete indifference. During either of these conditions, she may be entirely silent, or excessively voluble, or she may exhibit other hysterical phenomena. As regards the will, the manifestations of disorder are sometimes very remarkable. That the patient is, for the time being, unable to exert it, is evident, but, under the influence of some strong exciting cause, she frequently astonishes those about her by suddenly reacquir- ing her lost volitional power. A young lady came under my charge for what was supposed to be a disease of the spinal cord. She had taken to her bed suddenly, soon after striking her back rather gently against the edge of a table, declar- ing that she could not walk. On examination, I was convinced that there was no disease whatever of the spine, other than that of a purely hysterical character, and I so expressed myself to her. She, neverthe- less, insisted upon it that her spine was seriously injured, and she con- tinued to keep her bed, lamenting daily her sad fate at being compelled to pass so long a time shut out from the enjoyments of life. There was no paralysis or even simulation of it, for she moved her legs about freely enough in the bed. But, one evening, her brother, who had long been absent, returned home. She heard the bustle in the house attend- ant upon his arrival, but all were too busy to pay any attention to her in her chamber up-stairs. Suddenly exclaiming, " I can stand this no longer," she sprang from her bed, rang for her maid, and, hurrying on her clothes, proceeded down-stairs and entered the drawing-room, to the great surprise of all the family. In another case, a lady closed her eyes, and declared that she could not open them. She was brought to me as a case of double ptosis. There was no spasm of the orbicularis palpebrarum on either side, and HYSTERIA. 733 I had no difficulty in opening the eyes by gently raising the lids. The pupils were normal; there was no diplopia, and there were no evidences of such cerebral lesions as are generally met with as causes of ptosis. Moreover, she was subject to paroxysms of hysterical syncope. Under the circumstances, I had no hesitation in expressing my opinion to her friends that the case was one of hysteria. I advised the use of the in- duced, current to the eyes, and she found this so disagreeable, not to say painful, that two applications were sufficient to restore her volitional power, so that she opened her eyes without difficulty. In my remarks on aphasia, I have cited a case (p. 166) in which the power to speak suddenly returned under the influence of excitement, and was suddenly lost again, to be gradually recovered. Many cases of this loss of volition in hysteria have been under my care, and most physicians have witnessed similar instances. Illusions are very common phenomena of hysteria, and these may be connected with any or all of the senses. A ball rolling over the floor is taken for a rat; the sound of rain falling on the roof is mistaken for ' the noise of burglars in the next room; the knives used at table all " smell fishy;" every thing tastes sour or bitter or sweet, as the case may be, and a draught of cold air on the hand is supposed to be the touch of a person or a spirit. Hallucinations of various kinds are equally frequent. Images are seen where there is nothing; voices are heard where there is absolute silence; odors are smelt where there is nothing to smell; and strange tastes are perceived when the mouth is empty. Thus one patient sees angels, another demons, another animals of various kinds. One hears voices whispering to her, another musical sounds, and another noises like the breaking of glass or dishes. Another is constantly sensible of a smell as if something is burning, and another always has a taste of turpentine in her mouth. It is not often the case that these erroneous perceptions impose on the intellect, but sometimes they do, and then delusions are enter- tained, or these may, as in cases of absolute insanity, be formed with- out the intervention of the deranged perceptive faculties. They differ however, from the delusions of insanity, such as have been already described, in the facts that they do not last long and that they rarely exercise any powerful influence over the actions of the patients. Besides these mental phenomena indicative of cerebral disturbance, there are, sometimes, an extraordinary acuteness of understanding and readiness at reasoning and speech quite beyond the natural powers of the patient. At other times, on the contrary, the intellect is dulled, and the conversational power reduced to a low point. Sensibility.—This may be affected so as to result in the production either of hyperesthesia or anaesthesia. Hyperaesthesia, caused by hysteria, is characterized by the facts that 734 CEREBRO-SPINAL DISEASES. it is never permanently fixed in one place, that it is generally exces- sively acute, and that it is unaccompanied by evidences of serious dis- ease of the nervous centres or the nerves. A common seat is the skin, and its favorite region is the trunk, especially the skin over the mam- mary glands, and that covering the labia majora. Another situation frequently affected is the skin of the face. Cutaneous hyperaesthesia may consist either of spontaneous pain or of tenderness to impressions made upon the surface of the body. Mus- cular hyperaesthesia, or myalgia, is likewise common. Dr. Inman1 has investigated this branch of the subject very carefully, and has ascer- tained that the painful spots correspond to the origins and insertions of the muscles. Muscular pains due to hysteria are often mistaken for pains of the viscera. Thus the headache which is so frequent a phenomenon of the hysterical condition is very seldom located within the cranium. It may be of very limited extent, constituting the form known as the clavus hystericus, or may be of more extensive limits. Its ordinary situations are the frontal regions, occupying, in this case, the occipito-frontalis and corrugator supercilii muscles ; the temporal regions, being then located in the temporal muscles; the vertex, being then seated in the tendon of the occipito-frontalis muscle; and the occipital region, in the occipito-frontalis, trapezius, splonius, and complexus. Briquet states that, of three hundred and fifty-six hysterical patients whom he ques- tioned on the subject, three hundred were constantly subject to head- ache. I have very rarely met with a case of hysteria in which it was not almost constantly present, and never one in which it was not a symptom at some time or other. Pains are often felt in the muscles of the chest, abdomen, and back. This latter is a favorite situation, especially in the region between the shoulders, and in the muscles on each side of the vertebral column in the lumbar region. ' Pains in the joints are common manifestations of hysteria, and they are often mistaken for serious organic disease. When, as is sometimes the case, they are accompanied with contractions of the muscles, the liability to error on the part of the practitioner is increased. Sir Ben- jamin Brodie," several years ago, pointed out the true nature of certain affections of the joints occurring in hysterical women ; and, since his time, others, among whom Barlow' and Skey4 are to be mentioned, have called special attention to the subject. The pain may be attended with swelling, but there is no accumulation of fluid in the cavity of the 1 "On Myalgia: its Nature, Causes, and Treatment, etc.," London, 1860. * " Illustrations of Certain Local Nervous Affections," London, 1837. 8 " A Treatise on Diseases of the Joints," London. 4 " Hysteria, etc. Six Lectures delivered to the Students of St. Bartholomew's Hos- pital, 1866," London, 1867. HYSTERIA. 735 synovial membrane. The knee is more frequently affected than any other joint. Quite recently a young lady has been under my charge whose knee had been for two years kept in a steel apparatus for the purpose of preventing motion. Careful examination convinced me that this was a case of hysterical joint. I therefore flexed and extended the limb several times to its utmost limits, told her to throw away the steel rods, and to walk on the leg as much as she pleased. Within six months she walked as well as she ever had, and was even able to waltz with ease, with no other treatment than daily passive movements of the joint. In regard to these neuroses Meyer 1 has lately communicated much interesting information, and has indicated the leading phenomena which suffice to distinguish them from organic diseases. Thus the pain ceases at night, light handling is more painful than severe pressure, transient swellings are apt to occur, the temperature of the part is subject to changes, there is no tendency to atrophy of the muscles in the vicinity, and they are often cured spontaneously, or by prayer, or by sudden movements of the joint, or by some powerful physical cause. Neuralgia often has a hysterical origin, and may be in the form of toothache, pleurodynia, sciatica, or pain in the course of any other nerve. The viscera are likewise frequently hyperassthetic; the stomach, bowels, the kidneys, bladder, uterus, and ovaries, are the organs most frequently affected. And of these the most common seat of hyperaesthesia in hys- terical women is the ovary, and, according to Chairou,3 the left ovary more frequently than the right. I have several times succeeded in causing hysterical attacks by moderate pressure on the ovary, and have rarely failed to find one or both the seat of marked tenderness in cases of the affection. Indeed, so common is it to find ovarian tenderness in hys- terical women, that I am almost disposed with Chairou to regard this condition as a pathognomonic sign. Charcot 8 also lays great stress on the symptom. The organs of the special senses rarely escape having their sensi- bility exalted, and, consequently, there are increased power of vision, morbid acuteness of hearing, and an abnormal sensitiveness of the smell and taste. Sometimes with these hyperaesthetic conditions there is pain. Anaesthesia.—Though not so common as hyperaesthesia, anaesthesia is frequently a manifestation of hysteria. One of its most common seats is the skin. In the days of witchcraft, many a hysterical woman with anaesthetic spots on her skin, went to the gallows or the stake on sus- 1 Berliner klinische Wochenschrift, No. 26, 1874. Also Psychological and Medico Legal Journal, September, 1874. * " Eludes cliniques sur la hyst^rie," Paris, 1870, p. 7. 3 Op. cit, p. 283. 736 CEREBRO-SPINAL DISEASES. picion of being leagued with the devil. The belief was that, wherever the hand of the arch-fiend or his assistants touched the skin, the spot at once lost its sensibility. Two patients are now under my charge in whom there is hemi-anaes- thesia, paroxysmal in its character. When it is at its height, no irri- tation applied to the skin is felt, not even the wire brush of a powerful induction-coil. In neither case are the attacks preceded or accompanied by numbness. Sometimes the location is very limited, and the loss of sensibility may be partial or complete. In the former case there is numbness, and the full extent can only be exactly ascertained by the aesthesi- ometer. The mucous membranes may become anaesthetic. One frequently affected is that which lines the genital canal. In such a case, the sexual passion is entirely extinguished, coition is unattended with pleasure, and may even excite disgust. The organs of the special senses may be the seat of anaesthesia, and thus blindness, deafness, loss of the senses of smell and of taste, may be caused, more or less complete in character, in different cases. Chairou 1 has, however, shown that in all cases of hysteria the reflex excitability of the larynx is abolished. If in a hysterical woman the finger be passed down the throat so as to be brought in contact with the epiglottis, it will be found that this part is absolutely insensible, and that it can be rubbed or even scraped with the nail without caus- ing irritation of any kind. Or the superior orifice of the larynx may be similarly treated with the finger or with a probang, a feather, a roll of paper, or any similar instrument, without exciting either cough or efforts to vomit. Since becoming acquainted with Chairou's observations I have inva- riably made such an operation as that described a part of my examina- tion of hysterical persons male or female, and have never failed to verify his statements. It is somewhat astonishing that his observations have attracted so little attention. Anaesthesia of the muscles is occasionally met with, and has, at times, been the occasion of much discussion in medical and theological circles. Many of the phenomena observed in the Jansenist convulsion- naires were the result of muscular anaesthesia. In an essay2 recently published, I have called attention to the symptoms, and have adduced several cases from the records of my own experience. The extent of the anaesthesia is sometimes remarkable. In some of the cases that have been under my care, the most powerful induced currents which it was safe to use, failed to cause pain in the muscles to which they were applied. 1 Op. cit., p. 12. * "The Physics and Physiology of Spiritualism," New York, 1871. HYSTERIA. 737 Alterations of Motility.—These may be evidenced in the way of paralysis or of clonic or tonic spasm. Hysterical paralysis has long been known, and is quite a common manifestation of the affection. It may appear in the character of hemi- plegia, paraplegia, or of much more restricted extent. I have a case, now under care, in which it is limited to the index-finger, and I have had several in which a single muscle of the eyeball, or in which the leva- tor palpebrae superioris, was alone affected. Hysterical aphonia is due to paralysis of one or more muscles of the larynx. Like the loss of power in other muscles from a similar cause, it often comes on very suddenly, and as suddenly disappears. Paraplegia, hysterical in its character, may be partial or complete as regards a muscle, group of muscles, or a limb. When incomplete, the patient, if it involves the lower extremities, drags her limbs slug- gishly along, or shuffles her foot over the floor, using a cane or crutches or holding on to articles of furniture that may be in the room. There is nothing about the gait like that of locomotor ataxia or, in fact, of any other of the diseases of the cord already considered ; and careful observation will generally reveal the fact that, during one interview and examination, the patient walks very unequally, according to the state of her mind at the time, or the influences which act upon her. Spasms may be either tonic or clonic, and may affect any muscle of the body. In the pharynx, tonic spasm causes the sensation to which the term globus hystericus is applied, and which gives rise to the sen- sation of a ball in the throat. In the oesophagus, spasm may continue for a long time, and may thus simulate stricture. It may also be seated in the stomach, intestines, or bladder. Fig. 97. In the limbs spasm of the tonic character causes contraction, and thus, especially when combined with paralysis, may give the appear- 47 738 CEREBROSPINAL DISEASES. ance of organic lesion. I have frequently known hysterical contrac- tions to last several months at a time, and have had many cases of the kind under my charge in which the actual cautery had been applied to the back for supposed inflammation of the cord. In some cases the duration is even longer than this. Charcot cites an instance in which a woman, aged fifty-five, was seized, eighteen years previously, with a hysterical paroxysm followed by paraplegia and contraction. At first this latter phenomenon disappeared from time to time to reappear again and again, but for the past sixteen years there had been no change. The extensors and adductors, as will be seen from the accompanying woodcut (Fig. 97), are the muscles mainly affected. The muscles of the legs and thighs were notably atro- phied, and the faradaic contractility was lessened. For several years this patient had ceased to exhibit hysterical phenomena. The subject of permanent hysterical contraction is well considered by MM. Bourneville and Voulet,1 and the foregoing case is detailed at length in their memoir. In such instances there is probably, as in Case XIII. of their work, in which there was a post-mortem examination, and which has already been cited in this treatise—page 570—symmetrical lateral spinal sclerosis. Clonic spasms simulate chorea or epilepsy. They are especially common among the women who attend spiritualistic gatherings, and indeed I have seen several cases at such places among the weak-minded men who believe in the nonsense called spiritualism. The functional actions of the viscera are exceedingly liable to de- rangement in hysteria. Any organ of the body may be affected, but the stomach appears to be the favorite one. There may be obstinate vomiting, or persistent flatulence, or acidity, or indigestion in some other form ; or the bowels may be the seat, giving rise to intestinal in- digestion, diarrhoea, or obstinate costiveness ; or the kidneys may be involved, and there may be an enormous secretion of pale, limpid urine, or the quantity may be reduced to a minimum ; or the uterus or the ovaries may be the seat. Not infrequently organic disease of the heart is simulated, there being palpitation and general irregular action of this organ. Besides these several manifestations of hysteria, there are parox- ysms of the disease, characterized by emotional disturbance, spasm, convulsions, partial loss of consciousness, and sometimes coma. All these phenomena may be manifested during an attack, or a seizure may consist of any one or more of them. The convulsions sometimes bear a resemblance to epilepsy, sometimes to tetanus, sometimes to hydro- phobia, sometimes to catalepsy, sometimes to chorea. But, though simulating these diseases, the essentially hysterical paroxysm can be readily distinguished from either of them, mainly by the facts of its 1 "De la contraction hyste>ique permanente," Paris, 1872. HYSTERIA. 739 lack of consistency, the absence of the constitutional disturbance which attends the others, and by the presence of emotional excitement, and the consequent irrational laughing or crying. Attention will be again directed to some of these conditions in the ensuing chapter. Mania may be simulated, but the false can scarcely be mistaken for the real disease by any practitioner with his wits about him. Causes.—Of the predisposing causes, sex stands first. Of the many cases of hysteria which have been under my charge or seen by me in consultation, but four were in males. In one of these the affection was apparently induced by excessive study, and was characterized by fre- quent paroxysms of laughing and crying. One was a physician, and the disease took the form of coma ; one was a lawyer in this city, the disease in him simulating epilepsy ; and the fourth was a shopkeeper from New Jersey, who had tetanoid paroxysms attended with fits of sobbing, crying, and laughing, and in whom it was excited by mastur- bation. But, while there is this great predominance of females as the sub- jects of hysteria, I do not believe that the fact is due to any particular influence of the uterus or other generative organs. It is probably the result of the delicacy of organization, and the greater development of the emotional system, acted upon by the exciting causes to be presently mentioned. Age is another predisposing cause. The period of life at which hysteria is most common is that extending from sixteen to twenty-five. After the latter age there is a gradual decline until the age is reached at which the menstrual function begins to become irregular, and then the number of cases increases. The civil condition, as regards marriage or celibacy, is to be taken into consideration among the predisposing causes. Undoubtedly the disease is much more frequent among the single than the married, but it is by no means confined to them. In my opinion the increased pro- clivity of single women to hysteria is not to be attributed to ungrati- fied sexual desires, or even to the non-fulfillment of the functions of the generative organs, but rather to that lack of aims in life, and the consequent reflection of the thoughts and emotions upon self, which are so inseparably connected with the present condition of single women. Certainly those celibates who have made for themselves objects in ex- istence are no more subject to hysteria, in my experience, than married women. Want of occupation is one of the powerful predisposing causes of hysteria, and it is to a great extent through the direct influence of this factor acting upon a more impressionable organization that, in my opinion, hysteria is more common in women than in men. In those savage and semi-savage countries where women work, hysteria is un- heard of. It used to be almost unknown among the negro women in 740 CEREBRO-SPINAL DISEASES. the South, but since their emancipation, if my inquiries have ascertained the truth, it is becoming quite common among them. Hereditary influence is undoubtedly an important predisposing cause of hysteria. My own statistics are not complete on this point, but they are full enough to show that the majority had either hysterical mothers, aunts, or grandmothers, and many of the others had relatives affected with other nervous diseases. Briquet speaks very emphatically of the decided influence of hereditary tendency as deduced from his inquiries. The luxurious habits of life attendant upon refinement and educa- tion conduce to the development of hysteria. Attendance at theatres and operas, the cultivation of music, the reading of poetry and novels, the study of art, and any other influence capable of developing the emo- tional system at the expense of the purely physical or intellectual, fa- vor the growth of hysterical tendencies. Of exciting causes, sudden emotional disturbance ranks first. Anx- iety, grief, disappointment, the intense desire of self-gratification, a fit of ill-temper, with other similar factors, often induce paroxysms of the disease. Mental or physical fatigue, menstrual derangement, or uterine or ovarian disorders, may also act as exciting causes. But probably, above all these, is the contagion set in action by the contact with a hysterical person. I have seen a whole hospital ward of women thrown into paroxysms of hysteria by one patient suffering from an attack. Diagnosis.—To detail the diagnostic marks which distinguish hys- teria from other diseases would require more space than is proper in a work like the present, and would, moreover, be rather a work of super- erogation. The physician has simply to recollect that all hysterical affections have a family resemblance, and that, although almost every known disease may be simulated, yet that the counterfeit is never a good one. Attention to the symptoms of the several diseases already, and to be described, with a careful observation of the case, and due inquiry into the antecedents of the patient, will prevent a mistake be- ing made. He must also recollect that the hysterical patient always tries to impress others with the belief that she is very ill. She craves S}rm- pathy, and feeds on it with the effect of nourishing her disease. If she can cajole her medical attendant by appealing to his kindly emotions, she will do it, but failing in this she will try her power over his fears, and will leave no stone unturned to deceive him. Careful watching, with thorough skepticism, will either result in her detection, or in her defeat from sheer weariness. Prognosis.—As regards the prospect of recovery from any particular manifestation of hysteria, or from a paroxysm of any kind, the prog- nosis is favorable, provided proper treatment be employed, but, as re- gards the liability to further attacks, much depends on the circum- HYSTERIA. 741 stances which surround the patient and the time during which she has been subject to the affection. If she can be submitted to proper treat- ment, without the interference of herseK or her friends, the prospect of recovery, even in bad cases, is good ; but if she is to be allowed to do as she pleases, or if injudicious friends are constantly lavishing the sym: pathy and mistaken kindness which keep her disease alive, there is not much use in medicine or hygiene, and, as Reynolds says, the " case is hopeless, and might as well be left alone." Morbid Anatomy and Pathology.—Hysteria contributes absolutely nothing to the science of morbid anatomy. The brain, the spinal cord, the sympathetic nerve, give no evidence of its former presence. It is true, hysteria very rarely causes death, but hysterical patients have died of intercurrent affections, and post-mortem examinations have been made, and nothing which could reasonably be regarded as the essential cause of the disease has been found. Several of the older writers im- agined that they had discovered the lesion in the genital organs, in the stomach and intestines, in the brain, and even in the spleen ; but mod- ern research teaches us differently. At present, then, we are in total ignorance of the character of the lesion. From the symptoms, which are so obviously indicative of disordered brain and spinal cord, I have felt myself justified in classing it, provisionally at least, among the cere- bro-spinal diseases. The pathology or morbid physiology of hysteria is beginning to be better understood as our knowledge of the cerebral and spinal actions becomes more complete. Looking at the brain as a complex organ evolv- ing a complex force—the mind—we can understand the possibility of certain parts of it becoming disordered, as regards excess, diminution, or quality, in the results of their actions. We have seen, under the head of insanity, that the mind is made up of certain sub-forces—the perception, the intellect, the emotions, and the will—and that these, when disordered, constitute varieties of insanity, which are easily recog- nized. Hysteria essentially consists in the predominance of the emotions over the intellect, and especially over the will, and this exaltation may be so intense as to interfere with the sensibility of various parts of the body, or to derange the contractility of muscles. At the same time, in the paroxysms of the disease, the reflex and automatic functions of the spinal cord are involved to a great extent. We daily witness examples of the influence of emotions on sensi- bility and motility. Fear renders the sensibility more acute and pro- duces trembling, which is simply clonic spasm ; grief causes tonic con- tractions of the muscles ; surprise, terror, or horror, paralyzes them ; joy or anger destroys sensibility to pain, and so on. At the same time that there is this exaltation of emotional power in hysteria, the power of the will is not only relatively but is absolutely 742 CEREBRO-SPINAL DISEASES. diminished. The two factors, acting together steadily and persistently, induce many of the manifestations of hysteria. The disease is, there- fore, a partial insanity—an insanity, however, in which the patient does not entirely lose the power of control, and which is capable of being overcome by the voluntary effort of the patient, provided a sufficient stimulus to normal volition be brought to bear. It thus happens that, through the influence of such stimulus, every symptom of hysteria dis- appears as if by magic. The spinal cord is often secondarily affected, and it is likewise fre- quently primarily involved. The gray or the white substance, the pos- terior or the antero-lateral columns may be implicated, the symptoms varying accordingly. Through the spinal cord, in its abnormal condi- tion, we have the convulsions of various kinds, the spasms, contrac- tions, and the paraplegic and hemiplegic phenomena connected with motion and sensation. As to the influence of the vaso-motor system, though I admit its existence, I am convinced that it is simply a link in the chain, and is secondary to the emotional disturbance already mentioned. Treatment.—No cases are so well calculated to test the patience and tact of the physician as those of hysteria. For he has an affection to deal with, which not only requires proper medical treatment, but in which he must often exert the highest mental qualities, in order to cure the disease. A great deal, therefore depends on the knowledge of hu- man nature and the force of character of the physician ; and it is doubt- less owing to this fact that some physicians, with all their medical knowledge, fail in curing hysterical affections, while others, with no superior science, succeed at once. The first thing to be done is to gain the confidence and, what is of still greater importance, the respect of the patient. Having done this, any treatment, moral or medical, calculated to relieve her, will be much more apt to produce the desired effect. During the period between the paroxysms, the treatment must be directed mainly against symptoms. If the patient can be made to be- lieve that her case is thoroughly understood, and that she is not sus- pected of shamming, and that, with her assistance, the hyperaesthesia, or anaesthesia, or paralysis, will be removed, the effect which is desired will probably be produced. For putting a hysterical patient into a proper frame of mind, I know of nothing equal to the bromides, of either potassium, sodium, calcium, or zinc, given in large doses, repeated three or four times a day, till the full effect is obtained. This, of itself, will generally relieve hyperaesthesia wherever it may be seated, and the in- fluence over the mental phenomena of the disease is usually very de- cidedly shown. If anaesthesia be the prominent condition, electricity is to be used, and it is almost a specific. I have never seen a case of hysterical an- HYSTERIA. 743 sesthesia resist it. A few days ago, I was consulted by a young lady who was entirely anaesthetic over the whole of the surface of one side of the body, and who had suffered for several weeks. Three applica- tions of the induced current through the wire brush, which was passed, at each seance, over the whole anaesthetic region, entirely cured her. For hysterical paralysis, strychnia and phosphorus are the best in- ternal remedies. They may be taken together in the form recommended on page 54, and rarely fail to produce a cure. Their effect is, how- ever, greatly increased by the use of electricity, both of the primary and induced forms—the first being applied to the spine, and the latter to the paralyzed muscles. In cases of spasm, I prefer the bromides, internally, and the primary galvanic current, applied to the contracted muscles. Visceral derangements are best treated by strychnia and phospho- rus, as recommended for paralysis. Counter-irritation, in the form of blisters, is almost always of service. For gastric troubles, the subcar- bonate of bismuth, in doses of fifteen or twenty grains, after each meal, will generally prove of service. In a very obstinate case of hysterical vomiting, under my charge, every thing failed but hydrocyanic acid. Recently, in several extreme cases of hysterical vomiting, and nota- bly in one I saw in consultation with Dr. C. T. Whybrew, I have ob- tained very prompt results from the valerianate of caffeine in doses of three grains repeated in a half-hour if necessary. Paret1 adduces sev- eral examples of its beneficial effects in like cases. Hysterical paroxysms are best treated with ether or chloroform, ad- ministered by inhalation. I have repeatedly used the hydrate of chlo- ral, but it has not in my hands been as speedy or as effectual in its action as either of the other agents. I give them to the extent of pro- ducing complete insensibility, and repeat them again and again, if there are any evidences of a return of the seizure. Whether in the purely emotional paroxysms or those characterized by muscular spasms of various kinds, or any possible combination, nothing is equal, according to my experience, to ether or chloroform by inhalation. I have tried every other known means, from cold water, dashed in the face, to moral suasion, and none of them are comparable to ether or chloroform. I have also found decided benefit from the mono-bromide of cam- phor in breaking up what may be called the status hystericus. In a recent communication2 I called attention to its good effects in such cases. It may be given in pill or emulsion in doses of from three to five grains every hour or two, as may be required. In those cases in which ether or chloroform is contraindicated the mono-bromide of cam- phor is particularly valuable. 1 " De l'emploi de valerianate de cafeine," Paris, 1876. 8 " Note relative to the Mono-Bromide of Camphor," New York Medical Journal, vol. xiii., 1871. 744 CEREBRO-SPINAL DISEASES. But, for the dissipation of the hysterical tendency, long-continued treatment is necessary. Medicines which are ordinarily regarded as antispasmodics, such as valerian, asafcetida, musk, and the like, I have never seen produce any benefit in any form of hysteria, and, for the purpose of causing any radical change in the organism, they are worse than useless. As medicines for this object, I know of nothing superior to phosphorus, in some one of its forms, and strychnia. They should be taken for months in small doses, and should be supported by all hy- gienic measures calculated to improve the tone of the system. Travel is of inestimable advantage, and, above all, association with persons of both sexes, whose intellects control their emotions, and who are en- dowed with sound common-sense and that tact and knowledge of human nature which, for the purposes of every-day life, are of more value than many other qualities often ranked above them. It is very certain that in most cases of hysteria the exhibition of sympathy is exceedingly injudicious and is generally taken advantage of by the patient to impose still further on those around her. Thus a lady to whom-1 was called had gotten into a morbid condition attended with frequent paroxysms of weeping, because, as she said, she no longer cared for her husband or children, and that she wished they were dead, etc. All the arguments of her friends failed to convince her that she was a good wife and mother, but, on my telling her husband in her pres- ence that I was afraid it would be necessary to send her to a lunatic asylum, her interest was at once awakened, and the next morning she was entirely free from all hysterical phenomena. She subsequently told me that nothing had roused her but the fear of being put in a hospital for the insane. In another case a lady had terrified her friends and excited the greatest commotion by threatening to put an end to her life by jump- ing out of the window. When I saw her she was strapped down to a bed and was being supplicated by half a dozen people in the room not to kill herself, to which she was energetically replying that she would. I loosened the straps, opened the window, and told her to jump out. She walked to the window, looked out for a moment, and then, apply- ing no very polite epithet to me, went back to bed, and I heard no more of her suicidal desires. A still more remarkable case is given by M. Charcot.1 The pa- tient, a woman, had been for at least four years the subject of con- traction of one of the lower extremities, as shown in the woodcut (Fig. 98). In consequence of her insubordination on one occasion, he spoke to her very sharply, and threatened to send her out of the hos- pital. The next morning the contraction had entirely disappeared. In the face of facts like these it appears absurd to invoke supernatural agencies. 1 "Lecons sur les maladies du systeme nerveux," Paris, 1872-73, p. 313. CATALEPSY. 745 It is, perhaps, scarcely necessary to state that the society of other hysterical persons must be rigidly eschewed, and that even the casual meeting with such individuals is dangerous. Fig. 98. CHAPTER VII. HTSTEROID AFFECTIONS—CATALEPSY, ECSTASY, HYSTERO-EPILEPSY. There are certain disorders so very like hysteria in some of its manifestations, and often existing with it in the same individual, that they might with propriety have been considered in the last chapter, es- pecially as by some high authorities the scope of hysteria is so enlarged as to be made to embrace them within its limits. But, though they may owe their existence to the same peculiar condition of the nervous system, to which the ordinary phenomena of hysteria are due, there is sufficient individuality about them to warrant their being studied separately. At the same time there will be no difficulty in our bearing in mind that they are decidedly of such general and special character- istics as to impress us very forcibly with the idea that they are essen- tially hysterical. We may, therefore, with propriety, class them to- gether in the present chapter as hysteroid. I. CATALEPSY. Although there are no post-mortem appearances characteristic of catalepsy, the phenomena of the disease observed during life point to 746 CEREBROSPINAL DISEASES. its seat in the brain and spinal cord. Like epilepsy, therefore, it is a symptom representing an unknown morbid change in the nervous centres. Symptoms.—Catalepsy is an affection marked by the occurrence of peculiar paroxysms at regular or irregular periods. The seizures usu- ally come on with suddenness, and are characterized by more or less complete suspension of mental action and of sensibility, and by the supervention of muscular rigidity, causing the limbs to retain, for a long time, any position in which they may be placed. The phenomena, therefore, relate to the mind, to sensation, and to motion. The suspension of mental action is, in general, complete, but in some cases there are an imperfect consciousness and an ability to appreciate strong sensorial impressions. Thus, in a case quoted by Dr. Chambers from Dr. Jebb—which, however, was clearly a case of catalepsy compli- cated with hysteria—the patient, before emerging from the paroxysm, sang " three plaintive songs in a tone of voice so elegantly expressive, and with such affecting modulation, as evidently pointed out how much the most powerful passion of the mind was concerned in the production of her disorder, as indeed her history confirmed." 1 The aspect of a cataleptic patient is very striking. The eyelids are sometimes wide open, at others gently closed; the pupils are dilated, and do not respond to strong light; the respiration is slow, regular, but generally so feeble as to be perceived with difficulty; the pulse is usu- ally almost imperceptible, but is rhythmical and sluggish ; the face is pale, the mouth is half open, and the rigidity of the body and the cold- ness of the extremities add to the death-like appearance which im- presses all beholders. The cutaneous sensibility is ordinarily completely abolished. Pins may be stuck into the skin, and they are not felt; but, owing to the abolition of the power of motion and of reflex action, it is possible that in some cases, at least, the patients would give evidence of sensation if they could. Cases are on record in which tears have been caused by excessive emotional disturbance excited by the words or actions of per- sons surrounding the patients, thus showing that the senses of sight and hearing were capable of being exercised. Such instances are, however, rare, and are probably imperfectly-developed paroxysms, or those com- plicated with hysteria or ecstasy. The symptoms relating to the muscles are very remarkable. Com- ing on, as the paroxysm usually does, without warning of any kind, the patient is at once arrested in any act which is being performed, and the whole body assumes a condition of extreme rigidity. The power of the will over the muscles is lost, and the limbs preserve any position in which they may be placed by the by-standers. Thus, if the arm be raised from the side, it remains extended, and may keep this position 1 Article " Catalepsy," in Reynolds's " System of Medicine," vol. ii., p. 100. CATALEPSY. 747 for an hour or longer before it sinks slowly back to its original situ- ation. No matter how awkward or irksome the position may be, it is retained till the exalted irritability of the muscles becomes thorough- ly exhausted. The ability to swallow is not lost, and the electric contractility of the muscles is not perceptibly affected one way or the other. The paroxysm may last a few minutes or hours, or may be prolonged to several days. The temperature of the body, in all the cases that have come under my observation, was reduced from two to four degrees below the nor- mal standard, and in the extremities much more than this. The paroxysm generally disappears with as much abruptness as marked its accession. A few deep inspirations are taken, the eyes are opened, or lose their fixedness, the muscles relax, and consciousness is restored. In fully-developed seizures the patient has no knowledge of what has occurred during the attack. Ten cases of true catalepsy, uncomplicated either with hysteria or ecstasy, have been under my professional care. In two of these the seizures were more or less imperfectly developed, and strong sensorial excitations were, in a measure, perceived and recollected after emer- gence from the attack. But in every instance the character of the im- pression was misinterpreted. A bright light thrown upon the eyes with a mirror was spoken of as an " angel's wing which brushed across my face," and the scratch of a pin was remembered as " a piece of ice being drawn over the skin." In these cases there was the consciousness of mental action during the paroxysm, but it was difficult for the patients to describe the thoughts which took place. They appeared to be somewhat of the nature of dreams. In both cases the muscular rigidity was well marked but was not excessive, and appeared to be mainly manifested in the ex- tensors. It was not difficult to extend the arm or the leg, but flexion required the exertion of a good deal of strength. In the other eight cases the paroxysms were completely formed. Consciousness was entirely abolished ; there was no sensibility any- where, and no reflex actions could be excited except those of degluti- tion. In one of these cases, seizures several times occurred in my con- sulting-room, and I had the opportunity of ascertaining the effect of electricity. If the arm was extended, the strongest induced current I could apply to the biceps, though causing contraction, failed to procure flexion, but relaxation of the extensors was at once produced by the application to them of the primary current. I likewise, in this case, repeatedly examined the fundus of the eye with the ophthalmoscope, and invariably found the choroids pale, and the retinal vessels straight and attenuated. In none of these cases was there any knowledge of what passed 748 CEREBRO-SPINAL DISEASES. during the paroxysms, and no consciousness of there having been any mental activity. Besides these, several instances have occurred in my experience in which cataleptic phenomena were exhibited in the course of other dis- eases. In one of them, a young man whom I saw in consultation with Dr. Max Herzog, of this city, there was well-marked mania—a second attack. On my entering the room in which he was seated I observed that he had a rapt expression of countenance, and that his limbs were quiet, and apparently rigid. In an undertone I remarked to Dr. Her- zog that the patient had a somewhat cataleptic appearance. Seizing his arm I raised it from the body and it remained extended; the other arm was also elevated and continued in that position. I then lifted the legs alternately from the floor, and they were kept in their appar- ently uncomfortable positions. During the consultation, probably a half-hour, the extremities remained as I had placed them. A few days afterward, he became so violent that it was necessary to send him to a lunatic asylum. In another case the patient, a young lady of this city, was brought to me by her father for examination and advice. As she entered my consulting-room, I saw that there was a high degree of mental exalta- tion present—her eyes were raised to the ceiling, her hands were clasped, and her lips were moving as if in prayer. I raised her left arm from the body, and then the right ; both remained extended, and con- tinued so till I changed the positions, which I did by bending the elbows, bringing them to the front, putting them behind her, and so on. I then again extended them, and she left the house with them in this position; but, on getting into the street, and feeling a cold wind that was blowing at the time, they fell to her side and she began to use them to draw her shawl around her. She had been subject to epi- lepsy for several months, but had never before exhibited cataleptic phenomena. In the former of these cases there was no possibility of ascertaining the mental associations of the patient with the muscular rigidity; in the latter the patient said that she had a very distinct recollection of my extending her arms, but why she had kept them so she did not know, and that she was not conscious of fatigue, or of any other sensation. It will have been noticed that in both these cases the paroxysms were not spontaneous, but were excited by outside interference. The particulars of a very interesting case of catalepsy have been recently given to me by Dr. M. B. Early, late house-physician to Belle- vue Hospital. The patient, a German, a cigar-maker, aged twenty-three, had served in the army, entered the hospital October 4, 1872. In the previous July he had been drunk, and, quarreling with some rough people, was severely beaten and kicked on the head and other parts of his body. CATALEPSY. 749 On the 27th of September he had an attack resembling a convul- sion. He was smoking at the time, and, while thus engaged, his mother noticed that the cigar began to shake, then his whole body quivered. She attempted to take the cigar from his mouth, but the jaws were tightly closed, and the cigar was bitten through. He swallowed the portion that was left in his mouth. He seemed to be conscious, for when requested by his mother to go to bed he shook his head. He did not sleep, but, when spoken to, nodded or shook his head in assent or dissent as the case might be. He did not foam at the mouth or bite his tongue. His feet were very cold. The attack lasted about five minutes. He then vomited the piece of cigar he had swallowed, and went to bed, sleeping all afternoon. The following day he had a similar attack, not so severe as the first. During the five following days he was free from paroxysms, but would not talk, although he ate and seemed to understand what was said to him, and would do any little thing his mother requested. On the sixth day, soon after breakfast, he had another paroxysm, but of a different character from the others. While the previous seizures were charac- terized by tremor, this was marked by a rigidity of all the voluntary muscles in the body. The attack lasted a few minutes, and the next day he was taken to the hospital, where he came under Dr. Early's observation. On admission, October 4th, he lay in a stupid condition, his eyes sometimes open and sometimes closed. Occasionally he looked around, and appeared to understand what was said to him, but could neither speak nor move. The pupils were dilated. When his limbs were placed in any position they continued there for a considerable period. The muscles were rigid, temperature 100° Fahr. On being slapped smartly on the buttocks with a book, the patient got up, looked about him, and walked around the ward. He then drank a glass of milk and went back to bed. Just before getting up he smiled, and answered a question. During the night he went to the water-closet. In the morning he arose, looked around him, and drank some more milk. When slapped with a book shortly afterward, he did not move a muscle; seemed more stupid, did not swallow when food was placed in his mouth, and apparently did not feel the prick of a pin. The patient continued in this state for several days. On the 12th he was photographed. The accompanying woodcuts, Figs. 99 and 100, show the positions of his limbs at the time. Under the treatment the patient gradually improved, and on the 9th of November was discharged cured. An ophthalmoscopic examination, made November 3d, showed an anaemic condition of the disk. Cataleptic persons are usually of dull and sluggish mental and phys- ical organization. Such has certainly been the case in all the in- 750 CEREBRO-SPINAL DISEASES. stances that have come under my observation. The disease does not ordinarily show any decided tendency to become worse, either as regards the severity or frequency of the paroxysms, providing the ex- citing causes be avoided. On the contrary, there is often a well- Fig. 99. marked natural tendency to spontaneous cure, or at least to a cure through the influence of purely hygienic influences, moral as well as physical. In the majority of cases catalepsy is complicated with hysteria or Fig. 100. ecstasy, and sometimes with epilepsy. Of this latter combination I have seen two cases, and in one of these ecstasy was also a feature. This case I have alluded to in another communication.1 The patient 1 " The Physics and Physiology of Spiritualism," New York, 1871, p. 55. CATALEPSY. 751 was a young girl, was cataleptic on an average once a week, and epileptic twice or three times in the intervals. Five years previously she had spent six months in France, but had not acquired more than a very slight knowledge of the language—scarcely, in fact, suffi- cient to enable her to ask for what she wanted at her meals. Immedi- ately before her cataleptic seizures, she went into a state of ecstasy, during which she recited poetry in French, and delivered harangues about virtue and godliness in the same language. She pronounced at these times exceedingly well, and seemed never at a loss for a word. To all surrounding influences she was apparently dead; but she sat bolt upright in her chair, staring at vacancy, and her organs of speech in constant action. Gradually, she passed into the cataleptic paroxysm, in which she usually remained for from one to three hours. Many cases of the combination of catalepsy with hysteria and ecstasy have become celebrated in other relations than those of true science. Causes.—Among the predisposing causes, sex is, in my experience, the most efficient, though other writers have denied any influence due to sex. Of one hundred and forty-eight cases cited by Puel,1 sixty- eight were males and eighty females. Seven of my cases were in females. Hereditary influence is generally apparent. Of the ten un- complicated cases under my observation, all had relatives affected with some well-marked disease of the nervous system. In four cases, there were near relatives insane; in three, the mothers were hysterical; in one, a brother was epileptic; in one, the father was similarly affected; and, in one, a sister was cataleptic. It rarely begins after the age of twenty-five. Of exciting causes, emotional disturbance stands first. Four of my cases were directly the result—one of fright, one of anger, one of grief, and one of the shock caused by a boy starting out sud- denly from behind a door where he had been concealed. In one other case, the cause was worms in the intestinal canal; in two, business troubles; in one a severe fall; and, in the other two, I could not ascer- tain with certainty what the cause was, though I had strong reasons for suspecting it to be masturbation. The Diagnosis is not a matter of the least difficulty to any one who has even an imperfect knowledge of the phenomena, except, perhaps, as regards its discrimination from hysteria, that simulator of almost every nervous disease. In those cases complicated with hysteria, the distinction is of no importance; in others, the uniformity of the charac- teristics which indicate catalepsy, with a consideration of the general history of the case, will serve to make the diagnosis sufficiently precise. It must, however, be borne in mind that the two diseases are near of kin, and that the discrimination is important more as a matter of ab- stract science than as one of any bearing on the therapeutics. It is, however, sometimes a matter of moment to distinguish between the 1 "De la catalepsie," "Memoires de 1'Academie de Medecine," tome xx., 1658, p. 409. 752 CEREBRO-SPLNAL DISEASES. cataleptic paroxysm and death. In former times, instances were not uncommon in which the mistake was made, to be discovered after life had really become extinct in the coffin. Such fatal errors would prob- ably be impossible now with the stethoscope for examining the heart, the thermometer for determining the temperature, electricity for acting on the muscles, and, above all, the ability to place the limbs in posi- tions which they maintain against the laws of gravity. Moreover, our knowledge of diseases in general is such as to enable us to determine with great certainty the course they are liable to take, and the manner in which death occurs in each. Prognosis.—This is usually favorable, even in severe cases. All my patients recovered under the treatment to be presently mentioned. Morbid Anatomy and Pathology.—There is not much to say relative to the morbid anatomy of catalepsy. In some cases in which death has taken place, other diseases were present, and the lesions found were rather to be associated with them than with catalepsy. Puel,1 in his very elaborate treatise, says that the first report of a post-mortem examination of a patient dying while subject to the dis- ease in question is that of Hollerius, made in 1596. The patient, a man, had but one paroxysm, and died the same day. The lungs and liver were gangrenous, a collection of reddish serum was found in the posterior part of the brain, and sanguineous concretions (thrombi) in the superior longitudinal sinus. Deidier, in 1811, reported the case of an elderly man who had but one paroxysm, lasting a day, and who died eight days afterward. In this instance there were found, on each side of the longitudinal sinus, two little glandular bodies which were described perfectly, and to which the catalepsy was attributed. These were nothing more than the granu- lations of the dura mater, now known as the Pacchionian bodies. In a maniac who was subject to catalepsy and who died at Charen- ton, in 1834, the report by Georget and Calmeil states that the pia mater was found thickened and injected ; the cortical substance of the brain was reddened and softened, and the white substance contained enlarged vessels. In another case the same observers found the cortical substance discolored, and the white tissue injected. As they remark, however, these are the lesions of insanity with general paralysis. In other cases no alterations which could normally be associated with the cataleptic phenomena were discovered. The pathology of catalepsy is very imperfectly known. The symp- toms indicate that the brain and spinal cord are involved, and there is some evidence to show that they are in a state of anaemia. But there is a condition induced in these organs which is the essential feature of the disease, and of this we know nothing. There is a possibility, that the affection may be a masked form of epilepsy, and this view is borne 1 Op. cit, p. 518. CATALEPSY. 753 out by the fact that the treatment which is most successful in this lat- ter disease is most efficacious in catalepsy. But recent researches have served to give us perhaps some inkling of the real nature of catalepsy, and to supply us with examples of arti- ficially-induced cataleptiform phenomena which are of great interest as analogical to instances of the natural disease. The investigations which have been made relative to motor centres in the brain lead us to sup- pose that there are likewise inhibitory centres in the cerebro-spinal sys- tem, probably both in the brain and spinal cord. We often meet with cases in which there is complete paralysis of one or more parts of the body, and which are suddenly caused by some strong impression pro- duced upon the emotions. Now, catalepsy is, for the time being, a pa- ralysis of the will, a condition in which, while the muscles have not lost their power to contract, there is a loss of volitional influence over them. They are still capable of responding to stimulation from without, but, in the absence of stimulation from within, they retain whatever degree of contraction may be given to them. Some of the results which follow experiments made to induce what is called the hypnotic state, are very suggestive of catalepsy. A craw- fish, as Czermack * has shown, can be thrown into the cataleptic condi- tion, during which he is rigid and immovable. And I have repeatedly put frogs, lobsters, and hens, into a similar state. The full considera- tion of these interesting phenomena would be out of place in a practi- cal treatise on diseases of the nervous system.8 There may thus be in catalepsy inhibitory lesions just as in epilepsy there are discharging lesions. But, as in this latter disease there is something more than the convulsive movements, so in catalepsy there is a morbid element in addition to the muscular inhibition. Treatment.—The bromide of potassium, or one of the other bro- mides previously mentioned under the head of epilepsy, is the most effi- cient agent in the treatment of catalepsy. I have never yet failed to cure the disease with this remedy, combined with the oxide of zinc, and with the simultaneous use of strychnia and other tonics. I have never, however, had occasion to give it in larger doses than twenty grains, three times a day, or to continue it beyond eight months. In no disease of the nervous system, not even excepting hysteria, is it more necessary that the mind should be brought under proper disci- pline and kept as far as possible from the operation of all causes calcu- lated to promote emotional excitement. At the same time a well-regu- lated system of hygiene, as regards all the physical requirements of the body, is indispensable. 1 " On Hypnotism in Animals," translated from the German by Clara Hammond, Popular Science Monthly, September and November, 1873. 8 For a more complete account of the phenomena and physiology of catalepsy, ecsta> sy, somnambulism, etc., the reader is referred to the author's work on " Spiritualism and Allied Causes of Nervous Derangement," New York: G. P. Putnam's Sons, 1876. 48 754 CEREBRO-SPINAL DISEASES II. ECSTASY. Though closely allied to catalepsy, ecstasy differs from it in several important particulars. One of the main points of difference is, that the patient recollects the train of thought which has been going on during the seizure, and this of itself is sufficient to warrant their being sepa- rately considered. It often happens, however, that the two diseases alternate or coexist. Symptoms.—In ecstasy there is muscular immobility rather than rigidity, although the latter is sometimes present ; the eyes are open, the lips parted ; the face is turned upward, the hands are often out- stretched ; the body is erect and raised to its utmost height, or else is extended at full length in the recumbent posture. A peculiar radiant smile illumes the countenance, and the whole aspect and attitude is that of intense mental exaltation. The mind is so filled with some particular train of thought, that ex- citations of the senses, if of moderate intensity, are not perceived. We meet with this fact often in normal conditions, when the mind is deeply engaged in reflection, or when it is engrossed with some powerful emo- tion. Sometimes there is complete silence, the mind being apparently ab- sorbed with meditation or with the contemplation of some beatific vision. Again, there may be mystical speaking, prophesying, singing, or the lips may be in motion as if in speaking, but without any sound escap- ing. At times various attitudes are assumed which are in consonance with the ideas passing through the ecstatic's mind. Again, stigmata or spots of blood appear in the hands or other parts of the body, and which are supposed to represent the wounds made by the nails in the hands and feet of Jesus, or the thrust of the spear in his side ; and, again, a real or assumed abstinence from food exists. Among the ecstatics of a former period, St. Francis of Assisi, St. Catherine of Sienna, St. Theresa, Joan of Arc, and Madame Guyon, are to be mentioned, and whole sects, both among Catholics and Protes- tants, exhibited all the manifestations of the disorder. Most of the religious impostors who have at various times made their appearance, and many very sincere and devout persons, have been ecstatics. In its combinations with catalepsy, chorea, and hysteria, ecstasy has frequently played an important part in the history of the civilized world —at one time, leading to a belief in witchcraft; at another, to demoni- ac and angelic possession ; at another, to mesmerism and clairvoyance; and, in our day, to spiritualism. The consideration of these follies, ECSTASY. 755 though interesting, scarcely comes within the scope of the present treatise. But within the last few years several very remarkable examples of ecstasy have been observed, and some references to two or three of them will probably not be out of place. First among them, as well on account of the interesting phenom- ena manifested as from the fact that the patient was regarded by a great many religious enthusiasts—physicians among them—as the sub- ject of miraculous interference, must be placed Louise Lateau.1 With- out going into the full details of the case, a short account will probably prove both interesting and instructive : Louise Lateau was born at Bois-d'Haine, a small village in Belgium, on the 30th of January, 1850. She was reared in the utmost poverty, was chlorotic, and did not menstruate till she was eighteen years old. She loved solitude and silence, and when not engaged in work—and she does not appear to have labored much—she spent her time in medi- tation and prayer. She was subject to paroxysms of ecstasy, during which, as many other ecstatics, she spoke very edifying things, of char- ity, poverty, and the priesthood. She saw St. Ursula, St. Roch, St. Theresa, and the Holy Virgin. Persons who saw her in these states declared that, while lying on the bed, her whole body was raised up more than a foot high, the heels alone being in contact with the bed. The stigmatization ensued very soon after these seizures. On a Fri- day she bled from the left side of her chest. On the following Friday this flow was renewed, and in addition blood escaped from the dorsal surface of both feet ; and on the third Friday not only did she bleed from the side and feet, but also from the dorsal and palmar surfaces of both hands. Every succeeding Friday the blood flowed from these places, and finally other points of exit were established on the forehead and between the shoulders. 1 For the theological view of this remarkable case the reader is referred to the follow- ing works, a part only of those written in support of her pretensions: " Louise Lateau de Bois-d'Haine, sa vie, ses extases, ses stigmates; etude medicale," par le Dr. F. Lefebvre, professeur de pathologie gene>ale et de therapeutique a la universite catholique de Lou- vain, etc., Louvain, 1873; " Les stigmatisees Louise Lateau de Bois-d'Haine, sceur Ber- nard de la Croix, etc.," par le Dr. A. Imbert-Gourbeire, professeur a l'ecole de medecine de Clermont Ferrand, Paris, 1873 ; " Biographie de Louise Lateau, la stigmatisee de Bois- d'Haine," par H. Van Looy-Tournai, Paris and Leipzig, 1874 ; " Louise Lateau la stigma- tisee de Bois-d'Haine d'apres des sources authentiques, medicales et theologiques," par le professeur docteur A. Rohling, translated from the German by Dr. Arsene de None, Bruxelles et Paris, 1874; "Louise Lateau, ihr Wunderleben und ihre Bedutung im deutscher Kirchenconflicte," von Paul Majuncke, Berlin, 1875. Among the treatises in which the miracle is denied, and the phenomena attributed to either disease or fraud, are : " Louise Lateau, Rapport medicale sur la stigmatisee de Bois- d'Haine fait a l'academie royale de medecine de Belgique," par le Docteur Warlomont, Bruxelles and Paris, 1875 ; " Science et miracle, Louise Lateau, ou la stigmatisee beige," par le Dr. Bourneville, Paris, 1875 "Les miracles," par M. Virchow, Revue des cours scientifqucs, January 23, 1875 756 CEREBRO-SPINAL DISEASES. At first these bleedings only took place at night, but after two or three months they occurred in the daytime, and were accompanied by paroxysms of ecstasy, during which she was insensible to all external impressions, and acted the passion of Jesus and the crucifixion. M. Warlomont, being commissioned by the Royal Academy of Medi- cine of Belgium to examine Louise Lateau, went to her house, accom- panied by several friends, and made a careful examination of her per- son. At that time, Friday morning at six o'clock, the blood was flow- ing freely from all the stigmata. In a few moments the sacrament would be brought to her, and then the second act of the drama would begin. The scene that followed can be best described in M. Warlo- mont's own words : " It is a quarter-past six. ' Here comes the communion,' said M. Niels [a priest], ' kneel down.' Louise fell on her knees on the floor, closed her eyes and crossed her hands, on which the communion-cloth was extended. A priest, followed by several acolytes, entered ; the penitent put out her tongue, received the holy wafer, and then re- mained immovable in the attitude of prayer. " We observed her with more care than seemed to have been hith- erto given to her at similar periods. Some thought that she was simply in a state of meditation, from which she would emerge in the course of half an hour or so. But it was a mistake. Having taken the commun- ion, the penitent went into a special state. Her immobility was that of a statue, her eyes were closed ; on raising the eyelids the pupils were seen to be largely dilated, immovable, and apparently insensible to light. Strong pressure made upon the parts in the vicinity of the stigmata caused no sensation of pain, although a few moments before they were exquisitely tender. Pricking the skin gave no evidence of the slightest sensibility. A limb, on being raised, offered no resistance, and sank slowly back to its former position. Anaesthesia was complete, unless the cornea remained still impressionable. The pulse had fallen from 120 to 100 pulsations. At a given moment I raised one of the eyelids, and M. Verriest quickly touched the cornea. Louise at once seemed to recover herself from a sound sleep, arose and walked to a chair, upon which she seated herself. ' This time,' I said, «we have wakened her.' ' No,' said M. Niels, looking at his watch, < it was time for her to awake.' " She remained conscious ; the blood still continued to flow ; the an- aesthesia had ceased, her pulse rose to 120, and at the end of half an hour she was herself. " Our first visit ended here. At half-past eleven we made another. The poor child had resumed her attitude of extreme suffering, against which she contended with all the energy that re- mained to her. The wounds in the hands still continued to bleed. M. Verriest auscultated with care the lungs, heart, and great vessels, and found the bruit de souffle which he had detected in the morning at the ECSTASY. 757 apex of the heart and over the carotids. The handle of a spoon pressed against the velum, the base of the tongue, and the pharynx, provoked no effort at vomiting. The glasses of our spectacles,, as they came in contact with the air expired, were covered with vapor. As the patient appeared to suffer from our presence, we went away. " We made our third visit at two o'clock. There were still fifteen minutes before the beginning of the ecstatic crisis, which always took place punctually at a quarter-past two and ended at about half-past four. The pupils at this time were slightly contracted, the eyelids were almost entirely closed; the eyes, looking at nothing, were veiled from our view. We tried in vain to attract her attention ; her mind was otherwise engaged, and her pains were evidently becoming more in- tense. At exactly a quarter-past two her eyes became fixed in a direc- tion above and to the right. The ecstasy had begun. " The time had now come to introduce those who were prompted by curiosity. This could now be done without inconvenience, for the ec- static, for the ensuing two hours, would be lost to the appreciation of what might be passing around her. The room crowded could hold about ten persons, but enough were allowed to enter to make the total twenty- five. These placed themselves in two ranks, of which the front one kneeling allowed the rear one to see all that was going on. All this was done under the direction M. le Cur6, who took every pains to give us a good view of what was going to happen. "Louise was seated on the edge of her chair; her body, inclined forward, seemed to wish to follow the direction of her eyes, which did not look, but were fixed on vacancy. Her eyes were opened to their fullest extent, of a dull, lustreless appearance, turned above and to the right, and of an absolute immobility. A few workings of the lids were now observed and became more frequent if the eyelids were touched. The pupils, largely dilated, showed very little sensibility to light, and all that remained of vision was shown by slight winking when the hand was suddenly brought close to the eyes. The whole face lacked ex- pression. At certain moments, either spontaneously or as a conse- quence of divers provocations, a light smile, to which the muscles of the face generally did not contribute, wandered over her lips. Then the face resumed its primitive expression, and thus she remained for the half-hour which constituted the ' first station.' "The 'second station' was that of genuflection. It had failed at one time, but had again appeared. The young girl fell on her knees, clasped her hands, and remained for about a quarter of an hour in the attitude of contemplation. Then she arose and again resumed her sit- ting posture. " The ' third station ' began at three o'clock. Louise inclined her- self a little forward, raised her body slowly, and then extended herself at full length, face downward, on the floor. There was neither rigidity 753 CEREBRO-SPINAL DISEASES. nor extreme precipitation ; nothing, in fact, calculated to produce in- juries. The knees first supported her body, then it rested on these and the elbows, and finally her face was brought in actual close contact with the tiled floor. At first the head rested on the left arm, but very soon the patient made a quick and sudden movement, and the arms were ex- tended from the body in the form of a cross. At the same time the feet were brought together so that the dorsum of the right was in contact with the sole of the left foot. This position did not vary for an hour and a half. When the end of the crisis approached the arms were brought close to the sides of the body, then suddenly the poor girl rose to her knees, her face turns to the wall, her cheeks become colored, her eyes have regained their expression, her countenance expands, and the ecstasy is at an end." Further particulars are given, and an apparatus was constructed and applied to Louise's hand and arm so as to prevent any external exp- ortation of the haemorrhage. It was apparently shown that there was no such interference, for the blood began to flow at the usual time on Friday. In addition to the stigmata and the paroxysms of ecstasy, Louise declared that she did not sleep, had eaten or drunk nothing for four years, had had no fecal evacuation for three years and a half, and that the urine was entirely suppressed. M. Warlomont examined the blood and products of respiration chemically, and satisfied himself of their normal character, except that the former contained an excessive amount of white corpuscles. When being closely interrogated, Louise admitted that, though she did not sleep, she had short periods of forgetfulness at night. On M. Warlomont suddenly opening a cupboard in her room, he found it to contain fruit and bread, and her chamber communicated directly with a yard at the back of the house. It was therefore perfectly possible for her to have slept, eaten, defecated, and urinated, without any one know- ing that she did so. The conclusions arrived at by M. Warlomont were, that the stigma- tisations and ecstasies of Louise Lateau were real and to be explained upon well-known physiological and pathological principles, that she ' worked, and dispensed heat, that she lost every Friday a certain quan- tity of blood by the stigmata, that the air she expired contained the vapor of water and carbonic acid, that her weight had not materially altered since she had come under observation. She consumes carbon and it is not from her own body that she gets it. Where does she get it from ? Physiology answers, ' She eats.' " MM. Mauriac and Verdalle 1 give a very interesting account of an ecstatic woman who daily enacted the passion of Jesus, terminating in the usual manner with the representation of the crucifixion. This worn- 1 " Etude medicale sur l'extatique de Fontet," Paris, 1875. ECSTASY. 759 an, Beguille, was of nervous temperament, had had many visions of the Virgin and of angels, and was accustomed to prophesy. When visited by MM. Mauriac and Verdalle, Berguille was lying in bed. She is described as a woman of about forty-five years old, brown complexion, muscles and limbs well developed but without much fat, eyes blue, widely open, and staring vaguely. She smiled kindly when questions were put to her, and answered with sufficient intelligence. On being asked why she was in bed, she answered that she was in pain night and day ; and, when requested to state where she felt the most pain, she answered, the backs and palms of the hands, the tips and soles of the feet, and the right side. (It will be remembered that Louise Lateau had her pain and haemorrhage in the left side, a differ- ence which the miracle-believers ought to find it difficult to reconcile.) Relative to her visions and what she heard during her ecstasies, she said that she saw Jesus Christ in his passion, that she heard voices, but she could not repeat what was told her. Her pulse was from 68 to 72. At about one o'clock the ecstasy began. Her pulse rose to 80. She clasped her hands on her heart, her gaze became fixed, her eyes were widely opened, her lips moved as if she were murmuring prayers, and there were frequent movements of deglutition. Her pupils were slightly dilated, but contracted when a light was brought to them. Her limbs were rigid, but it was noticed that she flexed them very read- ily when she altered her position a little or arranged her dress. In a few minutes she raised herself somewhat awkwardly on her knees, her hands still being clasped and her eyes fixed. Then began the passion or the way to the cross, during which she walked on her knees around the bed, changing her position twelve times, and falling three times in the traditional manner. To make this journey required thirty-six minutes, and, this done, the next act, the crucifixion, was in order. Suddenly she threw herself back on the bed, extended her arms from each side, and remained immovable. The pulse was 112, the res- pirations 100. The muscles of the chest seemed to be paralyzed, only the diaphragm acting. The eyes were closed. The limbs were in a state of forced extension and very rigid ; the cutaneous sensibility to pinchings, prickings, and to the electrical stimulus was abolished. The latter, a very strong induced current, caused muscular contractions but no sensation. There was not the least flinching. Things went on in this way for over three hours, and then she sang the Salve Regina, exclaimed " Oh, what sorrow ! " and gradually recovered her senses. M. Bourneville2 cites the case of Ler., a hystero-epileptic, to whom reference will be again made, who at one time had a cruciform par- oxysm. ' Her head was strongly thrown back ; her eyelids, half open, 1 "Louise Lateau," etc., Paris, 1875, p. 13. 760 CEREBRO-SPINAL DISEASES. Fig. 101. ECSTASY. 761 were in continual motion ; the muscles of the jaws were contracted, and the muscles of the neck were hard and tense. The superior extremities were extended at right angles from the trunk, the hands closed, and the fingers flexed so strongly on the palms as to render it impossible to open them. The inferior extremities were stretched out to their full length, the sole of one foot in contact with the dorsum of the other. In a word, the rigidity was such that the body could have been raised from either end like a bar of iron (Fig. 101). The attack lasted about four hours ; then Ler. opened her eyes and recovered consciousness, exclaiming, " O my God, I was so happy !" Two other interesting cases are described by M. Billet,1 but the fore- going are sufficient to give the reader some idea of ecstasy as it ap- pears in Catholic countries. But the phenomena exhibited by Protestant ecstatics have been and are to this day fully as remarkable pathologically as those just de- scribed. Calmeil,a speaking of the Protestant theomaniacs of Langue- doc and Cevennes, says : " In general, they gave the name of ecstatic period to the agitation and improvisation which characterized the attack. All the inspired were fully persuaded that the Holy Spirit had entered into their breasts at the moment when they felt themselves constrained by an overwhelm- ing power to prophesy. All expressed themselves as if the Spirit of God spoke to them the words they uttered." Elizabeth Barton, called the " Holy Woman of Kent," announced, during an attack of hysteria, that a child then sick with a brain- fever would die. As she predicted, the event took place soon after- ward, and the fulfillment of this prophecy at once gave the holy woman a great reputation. On this she announced that she was illumined by the Holy Spirit. She had numerous ecstatic paroxysms, during which she, according to her own account, was transported to heaven, and on her emergence she sang hymns, prayed, and made many predictions which astonished her admirers. At last, in obedience to an asserted command of the Virgin, she renounced Protestantism and took the veil. She continued to prophesy, and, growing bold, she predicted the speedy death of the king for his putting aside his wife Catharine of Aragon for Anne Boleyn. Henry VIII. was not of the temper to submit to this sort of holiness, so he had Elizabeth Barton beheaded as a pesti- lent woman, who was better out of the world than in it. An ecstatic, in a paroxysm of rapture, having lost his speech, thus describes his regaining the faculty :3 "At length, after nine months of sobs and convulsions without 1 " Contributions a l'etude des nevroses extraordinaires," Paris, 1874. 5 " De la folie," etc., tome ii., Paris, 1845, p. 288. 1 Calmeil, op. cit, p. 289. 762 CEREBRO-SPINAL DISEASES. speech, one Sunday morning as I was praying in my father's house, I fell into an extraordinary ecstasy, and God opened my mouth. During the ensuing three days I was constantly under the operation of the Holy Spirit, neither eating, drinking, nor sleeping, and I spoke often with more or less power, according to the nature of things. All in the family were convinced, as well by the extraordinary state in which they now saw me, as by the wonderful fasting of three days, during which I felt neither hunger nor thirst, that it was surely by the Sovereign Power that such astonishing things were done." In our own day, instances of ecstatic trance during camp-meetings, revivals, and the like, are common enough, and the number is greatly increased by spiritualism, mesmerism, and such like absurdities.1 As we have seen, many ecstatics pretend that they do not eat. Cases of the kind are reported very often, and have been noticed from an early period. Thus Schenckius s quotes from Paulus Lentulus the "Wonderful History of the Fasting of Appolonia Schreira, a Virgin, in Bern," in which it is stated that, being carefully watched by the orders of the magistrates of Bern, it was ascertained that there was no fraud, and she was dismissed as a genuine case of ability to live with- out food. During the first year of her fasting she scarcely slept, and in the second year not at all. Another, and still earlier case, was that of Margaret Weiss, aged ten years, who lived in Rode, a small village near Spires, and whose history is given by Gerardus Bucoldianus.3 Margaret is reported to have ab- stained from all food and drink for three years, in the mean time grow- ing, walking about, laughing and talking, like other children of'her age. She, however, during the first year suffered greatly from pains in her head and abdomen, and, all four of her limbs were contracted. She passed neither urine nor faeces. Margaret played her part so well that, after being watched by the priest of the parish, and Dr. Bucoldianus, she was considered free from all juggling, and was sent home to her friends by order of the king, "not without great admiration and princely gifts." The circumstances seem to have somewhat stag- gered Dr. Bucoldianus, for he asks, " Whence comes the animal heat, since she neither eats nor drinks, and why does the body grow when nothing goes into it ? " Of the cases that have been recently reported, that of the so-called Welsh fasting-girl * is one of the most remarkable, and a few years ago an account of its tragical ending excited a good deal of comment in the 1 For a full discussion of this subject the reader is referred to the author's work on "Spiritualism and Allied Causes of Nervous Derangement," New York, 1876. 2 " naparnpfiffeav, sive observationum medicarum, rararum, novarum, admirabilium et monstrasarum volumen, tomis septem de toto homine institutum," Lugduni, 1606, p. 306. 3 " De Puella quae sine cibo et potu vitam transigit," Parisiis, ann. MDXLII. * " A Complete History of the Welsh Fasting Girl, with Comments thereon and Obser- vations on Death from Starvation, by Robert Fowler," London, 1871 ECSTASY. 763 medical journals of Great Britain. Like the others, this was a case of hysteroid disease, and when she was so strictly watched that deception was no longer possible, she died in a few days of starvation. The startling heading to an editorial notice in the Lancet1—" Starved to Death "—expressed no more than the actual truth. In regard to the rarity of defecation and urination in cases of hys- teroid disease there is no doubt. Such cases are often accompanied with vomiting, and then the matter ejected from the stomach contains urea and sometimes even fecal matter. A lady, not long since under my charge, in whom there were no other very decided hysterical symp- toms, had an operation from her bowels never more frequently than once a month, and generally not so often. Every time she ate any- thing she vomited soon afterward, and the vomited matter always con- tained urea. She urinated about a tablespoonful every eight or ten days. The vomiting of fecal matter in cases of hysteroid disease is not so common. Briqueta reports a case as occurring in his own experi- ence, in which there was no doubt that substances administered as enemas were vomited a few minutes afterward. Among other experi- ments, and in order to remove all doubt arising from the use of house- hold substances, an injection of tincture of litmus was given immedi- ately after it was brought from the pharmacy. The patient was told that coffee was to be injected. Twelve minutes afterward the tincture of litmus was vomited, its blue color turned to a red through the action of the gastric juice. Less authentic, perhaps, is the following from Henricus ab Heeres: s " A certain gentleman has lived several years without having had any operation from his bowels. About the middle of the day he sits down to his dinner, usually inviting several noble persons to eat with him. In an hour he rises from the table, after having eaten and drunk to his satisfaction, and retiring, vomits the dinner he had eaten the day before, but retaining all the dinner he has just taken. It is ejected putrid and filthy, differing in no respect from other excrement. He vomits with ease, and at once, throwing up the contents of the stomach which have remained from the previous day. Then he washes his mouth with clean water and returns to his friends to finish his repast. He eats no supper or breakfast, and thus he has done for about twenty years." Stigmata, as occasional symptoms of the hysteroid condition, are well known to dermatologists, many cases of bloody sweat having been noticed. Those observed in the case of Louise Lateau were well studied by M. Worlomont, and they were found to differ in no essential respect from those previously observed, except in regard to the periodicity of 1 Lancet, December 25, 1869. 2 " Traite clinique et the>apeutique de l'hysterie," Paris, 1859, p. 316. 3 " Observationes medicae," Lipsiae, 1645, lib. 1, ob. 29. 764 CEREBRO-SPINAL DISEASES. the haemorrhages—a circumstance, however, easily accounted for by the fact that the stages of excitement were regular. Heemidosis or bloody sweat, is to be regarded as one of the neuroses of the skin. An interesting case is reported by Wilson.1 Mason Good cites authorities to show that it has taken place during coition, violent terror, and great bodily agony. Its occurrence in the hands, feet, and side, is to be ex- plained by the fact that the attention is strongly concentrated on these parts, and it is in all probability kept in these situations by manual irritation. It is by no means certain that this latter was not the case with Louise Lateau, for M. Warlomont's apparatus was not of such a character as to prevent such action. Causes.—Ecstasy, though not entirely confined to the female sex, is very much more common in women than in men. It appears to be produced in those who are of delicate and sensitive nervous organiza- tions by intense mental concentration on some one particular subject— generally, one connected with religion, or some other abstract train of thought. It was formerly quite common among the inmates of con- vents, and is now not unfrequently met with at camp-meetings and spiritualistic gatherings. There are no points about the Diagnosis requiring special considera- tion, and the Prognosis is always favorable, if the subject can be sub- mitted to proper moral and physical treatment. As the disease is never fatal per se, we know nothing of its Morbid Anatomy. The pathology, as indicated by the symptoms, points to the implication of both the brain and spinal cord, but there is no satisfactory theory of the disorder other than that which refers it to cerebral and spinal pre- occupation—a kind of setting of the current in one direction, whereby all other occupation is for the time prevented. Treatment.—The means of treatment, though not differing essen- tially from those proper for catalepsy, require, nevertheless, special mention of some particulars. The influence of moral force in prevent- ing and curing ecstasy is well marked, and many instances are on record in which epidemics of it have been arrested by arguments addressed to the fears of the subjects. I have several times aborted and prevented ecstatic manifestations by making preparations to cauterize the region of the spine with a red-hot iron. A great deal can be done by giving as little notoriety to ecstatics as possible. They glory in the idea that they are of sufficient impor- tance to excite attention and discussion, and they are accordingly stimulated to continue their performances so long as they are noticed and an air of mystery is attached to them. Removal from all associations calculated to continue the exciting and morbid train of thought which has developed the disease under notice, should, of course, be a point in the treatment. 1 " On Diseases of the Skin," American edition, Philadelphia, 1863, p. 551. HYSTERO-EPILEPSY. 765 Electricity, and the other measures of treatment recommended for catalepsy, will prove serviceable in ecstasy. By galvanization of the sympathetic nerve, I, on one occasion, immediately cut short a parox- ysm of ecstasy, and, by continuing the practice every alternate day for about six weeks, effectually cured the patient, who for several years had been subject to seizures every two or three days. As means for improving the general health are almost invariably required, iron, quinine, and strychnia, in the combination recommended on page 54, may be administered with advantage. I have great confi- dence in the bromides, and the patient should be to a moderate extent brought as soon as possible under the influence of some one of those previously mentioned. III. HYSTERO-EPILEPST. The combination of hysteria with epilepsy has long been recognized as existing and as giving rise to one of the most frightful affections to be found in the whole range of neurological medicine. In the present state of our knowledge it would, perhaps, be going too far were we to pronounce positively in favor of its being a distinct pathological entity with a different anatomical substratum from either hysteria or epilepsy, and yet the phenomena are so distinct that we certainly are warranted in considering it separately from either of these diseases. Symptoms.—An attack of hystero-epilepsy is characterized by the occurrence of convulsions more or less resembling those of epilepsy. There is usually in the first place a well-marked tetaniform spasm, though, sometimes, this is not very decided, and occasionally is not observed at all. Then follow clonic convulsions, during which the patient froths at the mouth and may pass the urine or bite the tongue, though these phenomena, especially the latter, are rare. Loss of con- sciousness exists during this stage. Next ensues a remarkable series of movements, at the beginning of which, or during their continuance, the patient recovers consciousness to such an extent as to answer questions, although there is no after- recollection of the incidents that may have occurred. These move- ments are apparently voluntary, and consist of the most extraordinary contortions of the muscles of the face, neck, trunk, and extremities, so that superstitious people might well imagine the existence of an inter- nal or external diabolical agency. During the continuance of this part of the paroxysm the patient tears with the hands and teeth any thing tearable that comes within reach, and continually utters inarticulate sounds or words apparently in relation with the ideas passing through the mind. Finally, the purely hysterical element ceases to predomi- nate, and the patient alternately weeps and laughs, and gradually ac- quires a knowledge of what is passing around. 766 CEREBRO SPINAL DISEASES. During the whole of the paroxysm the face is flushed, the pupils are moderately contracted, the pulse is accelerated, the perspiration is in- creased in quantity, and the respiration is hurried and irregular. But there are numerous deviations from this type of a seizure. Sometimes the tetanic spasm is wanting, and again it, or some modifi- cation of it, may constitute the most marked part of the convulsive period. Thus in a lady, who was lately under my charge, the paroxysm began with an opisthotonos, which was immediately relaxed, and again renewed, to be again relaxed, and so on, for over half an hour. In a woman whom I saw in the Pennsylvania Hospital several years ago, in the service of Dr. Pepper, the convulsions consisted of a series of rapid movements produced, as the patient lay on her bed, by the bending back of the body, so as to throw it into an opisthotonotic posi- tion, the head and heels alone touching the bed, and then, the muscles being suddenly relaxed, allowing the buttocks to fall with force on the bed. These actions were continued with great rapidity, and without intermission for an hour or more, and were succeeded by a period dur- ing which there were alternate laughing and weeping. Such cases are what Sauvages designated as hysteria libidinosa. But, in a case now under my care, the patient, a woman, has daily attacks at about the same hour—three o'clock p. M.—which are more dis- tinctly tetaniform in the beginning than any that have come under my observation. They consist of a series of opisthotonotic spasms, during which the body is extremely rigid. The convulsion is, however, unlike the others referred to, very slowly developed. The body extended at full length in the recumbent posture gradually becomes rigid, the legs are slightly abducted, the arms are pressed strongly against the sides, Fg. 102. the jaws are tightly closed, and the gaze fixed (Fig. 102). Respiration is entirely suspended, and the heart beats rapidly, sometimes as fre- quently as one hundred and sixty per minute. Then the body is slowly bowed, so that the head and heels alone touch the bed, and is so rigid and strongly arched that no ordinary force, such as a powerful man can exert, suffices to overcome the tonicity of the muscles. In about a minute from the beginning of the rigidity, the spasm suddenly relaxes, and with a long-drawn inspiration the paroxysm ends—to be again re- HYSTERO-EPILEPSY. fgf sumed in a few minutes with a like sequence. In the accompanying woodcut (Fig. 103) is an exact representation of this patient when the tetanic spasm is at its height. Fig. 103. In this case there is a distinct aura starting from the left ovary, and strong pressure exerted upon this organ suffices generally, though not always, to cut short the series of paroxysms. Under the name of demonomania many cases of hystero-epilepsy have been described, and the disease, like chorea, has at times prevailed epidemically. At Loudun, in France, it led to the death at the stake of Urbain Grandier, the nuns, who were its subjects, accusing him in their delirium of having bewitched them. At Marseilles, Father Louis Gaufridi, a man of education and of strict morality, was accused by two Ursuline nuns of having debauched them through diabolical agency. At the time of the accusation, these nuns, one of them only nineteen years old, were suffering from attacks characterized by hallucinations and illusions, fearful epileptiform and cataleptiform convulsions, and delirious ravings—all of which were ascribed to the devil moved and in- stigated by Louis Gaufridi. At first, the accused denied the charges made against him, and endeavored by arguments to show the real nature of the seizures. But the effort was in vain, just as is the at- tempt now to convince the credulous and ignorant of the real nature of the seizures of Louise Lateau, Bernadette Soubirous—who evoked Our Lady of Lourdes—and of the hundreds of mediums, ecstatics, and hysterics, who pervade the world. Gaufridi became insane, and con- fessed all that was laid to his charge, with numerous other offenses which had not been imagined. He declared that he had worshiped the devil for fourteen years; that the demon had given him power to render amorous of his person all women on whom he should breathe, and that he had thus overcome several thousand women! Gaufridi, after horrible tortures, was burned at the stake; and the two nuns "continued to be delirious," as well they might. As showing the nature of the phenomena exhibited in cases of de- 768 CEREBRO-SPINAL DISEASES. moniacal possession and their resemblance to the symptoms of hystero- epilepsy and other forms of hysteria, I subjoin the following questions as proposed by Santerre, priest and promoter of the diocese of Nimes, to the University of Montpellier : Question 1. Whether the bending, moving, and removing of the body, the head touching sometimes the soles of the feet (opisthotonos), and other contortions and strange postures, are a good sign of posses- sion? 2. Whether the quickness of the motion of the head forward and backward, bringing it to the back and breast, be an infallible mark of possession ? 3. Whether a sudden swelling of the tongue, the throat, and the face, and the sudden alteration of the color, are certain marks of pos- session ? 4. Whether dullness and senselessness or the privation of sense, even to be pinched and pricked without complaining, without stirring, and even without changing color, are certain marks of possession ? 5. Whether the immobility of all the body, which happens to the pretended possessed by the command of their exorcists, during and in the middle of the strongest agitations, is a certain sign of a truly dia- bolical possession ? 6. Whether the yelping or barking like that of a dog, in the breast rather than in the throat, is a mark of possession ? 7. Whether a fixed, steady look upon some object, without moving the eye on either side, be a good mark of possession ? 8. Whether the answers that the pretended possessed make in French to some questions that are put to them in Latin are a good mark of possession. 9. Whether to vomit such things as people have swallowed be a sign of possession ? 10. Whether the prickings of a lancet upon divers parts of the body without blood issuing therefrom are a certain mark of possession ? All these questions, to the credit of medical science—which has always, notwithstanding the weakness of some of its professors even in our own day, been steadily opposed to supernaturalism—were answered in the negative. No one can read them without being struck with the facts that Father Santerre was at least a good symptomatologist, and of the absolute identity of the phenomena cited, in all essential char- acteristics, with those which in our day are said to be of mystical origin, but which in reality are hysterical or hysteroid. We might reproach Father Santerre and his coadjutors more forcibly, if we had not our- selves killed witches and presided at the birth of spiritualism. No one has written with greater effect in regard to the manifesta- tions of hysteria and hystero-epilepsy than Charcot. As a most strik- HYSTERO-EPILEPSY. 769 ing case of the latter affection, I cite from him the following instance' already referred to in another connection under the head of ecstasy. Ler., aged forty-eight years, is a patient well known to all physi- cians who visit the Salpetriere as one of the most remarkable instances extant of hystero-epilepsy. Her menstruation has ceased for four years and yet all the neurotic symptoms persist. She is a demoniac, a Fig. 104. possessed, and presents a striking example of that type of hysteria manifested by the " Jerkers " in " Methodist camp-meetings," and who exhibit in their paroxysms the most frightful attitudes. The probable origin of these nervous phenomena in Ler. deserves to be noted. She has had, as she says, a series of frights. At eleven years of age she was terrified by a furious dog. At sixteen she was 1 "Lecons sur les maladies du syst^me nerveux faites a la Salpetriere," Paris, 1872—"73, p. 301, et seq. 49 770 CEREBRO-SPINAL DISEASES. frightened at the sight of the corpse of an assassinated woman, and again about the same time, when going through a wood, by robbers who attacked her and took her money. With her there are local hysterical manifestations consisting of hemi-anaesthesia, ovarian tenderness, paresis, and at times contraction of the limbs on the right side. Sometimes these symptoms are shown on the left side also. The attacks, which are announced by a well-marked ovarian aura are characterized at first by epileptiform and tetaniform convulsions ; Fig. 105 after which come extensive movements of an intentional character, in which the patient assumes the most hideous postures, recalling the attitudes which history ascribes to demoniacal possession (Figs. 104 and 105). At the moment of the attack she is seized with delirium, which evidently turns on the events which have produced the initial seizures. HYSTERO-EPILEPSY. 771 She hurls invectives at imaginary persons. " Scoundrels ! robbers! brig- ands. Fire, fire ! Oh, the dogs, they bite me ! " When the convulsive part of the accession is over, there ensue, gen- erally, hallucinations of sight—she sees frightful animals, skeletons, and spectres ; a paralysis of the bladder ; a paralysis of the pharynx; and a contraction, more or less permanent, of the tongue. It is therefore necessary for several days to feed her through a tube, and to empty the bladder with a catheter. Later, M. Bourneville' has given an account of Ler., somewhat fuller than that of M. Charcot, to which, as showing how Ler. had at one time exhibited phenomena of ecstasy similar to those present in Louise Lateau, reference has already been made. In further illustra- tion of the period of contortions in her case I take from M. Bourneville's excellent monograph the accompanying woodcut (Fig. 106), made from a sketch taken on the spot by M. Charcot. Fig. 106. In the intervals between the paroxysms the subjects of hystero-epi- lepsy generally exhibit some of the phenomena of hysteria such as hemi- anaesthetic contractions, ovarian tenderness, paralyses, etc. Relative to the Causes, the Prognosis, Diagnosis, Morbid Anatomy and Pathology, and Treatment, there is nothing to add to the remarks already made when hysteria, catalepsy, and ecstasy, were under con- sideration. 1 "Louise Lateau, ou la stigmatisee beige," Paris, 1875, p. 38, el seq. 772 CEREBROSPINAL DISEASES. CHAPTER VIII. MULTIPLE CEREBRO-SPINAL SCLEROSIS. We have already considered the subject of sclerosis as it affects the brain and spinal cord separately. We have still to treat of it as exist- ing in these nervous centres simultaneously. Although recognized, over thirty-five years ago, by Cruveilhier and Carswell, it is only re- cently, mainly through the observations of Charcot and Vulpian, that attention has been again directed to sclerosis of the cerebro-spinal variety, a form which differs from those already described in this treatise, both in its extent and in the symptoms by which it is charac- terized. Symptoms.—The initial symptoms vary according as the morbid process begins in the brain or spinal cord. In the former case, the first prominent manifestation of disease may be an epileptic fit. In other cases, there are headache, vertigo, ocular troubles, such as ptosis, diplo- pia, or amblyopia, failure of the hearing, and, very often, defective articulation. The mind does not participate to any considerable extent, unless the hemispheres be involved in the lesion. Or, there may be hemiplegia as a consequence of cerebral conges- tion, and even mania, from a like cause. These attacks are sometimes frequent, and usually leave more or less mental weakness after them. Tremor is often first seen in the tongue, more frequently in the eye- ball, of one or both sides, which oscillates when the patient is told to turn it inward or outward, but which is steady when he looks directly to the front. This tremor is called nystagmus, and is, as we have already seen, met with in other diseases of the nervous system. Ac- cording to Ferrier'sl observations, it is due to lesion of the cerebel- lum, and when met with in the disease under notice points to this organ as one of the seats of the morbid process. In the case of a woman who attended my clinic at the Bellevue Hospital Medical College, nystag- mus was the only symptom observed for over a year, and then gradu- ally other phenomena of the cerebro-spinal form of sclerosis made their appearance. Tremor is indicative of loss of power, and it gradually becomes more strongly marked and extends to other muscles of the body as other parts of the cerebro-spinal system become involved. It is never, how- ever, a constant phenomenon in any form of sclerosis affecting the spinal cord alone. Its presence is peculiar either to cerebral disease or to lesions occurring at the same time in the brain and spinal cord. After a time, which is subject to great variation in different cases, the loss of power extends to the limbs, and this feature is often accom- 1 " Experimental Researches in Cerebral Physiology and Pathology," " West Riding Lunatic Asylum Medical Reports," vol. iii., 1873, p. 69. MULTIPLE CEREBRO-SPINAL SCLEROSIS. 773 panied with aberrations of sensibility. If, as is generally the case, the membranes of the cord are congested or inflamed, there are spasmodic jerkings or twitchings of the limbs, but in some cases these are never observed. In the case of a gentleman from South Carolina, who con- sulted me at the instance of my friend and colleague Prof. J. T. Darby, and who was obviously affected with multiple cerebro-spinal sclerosis, there had never been the slightest involuntary movement, independent of the peculiar form of tremor in the limbs which constitutes so promi- nent a feature of the disease. The lower extremities are generally very much more paralyzed than the upper, and, when they become involved, festination often makes its appearance. The gait of the patient, thus, becomes similar to that of a person in whom the lesion is limited to the brain. If the sclerosis begins in the brain before attacking the spinal cord, tremor precedes the paralysis—the affection being then entirely cere- bral in character; but, when, as is generally the case, the lesion appears primarily in the spinal cord, paralysis is noticed before the tremor. In fact, there is never, as previously insisted on in my remarks on multiple cerebral sclerosis, any tremor, unless the superior ganglia of the cere- bro-spinal system are involved. The fact that it is only shown when a voluntary movement is made also assists us to distinguish it from the tremor of multiple cerebral sclerosis, as well as from that of paralysis agitans. In the cerebro-spinal form of the disease, therefore, the pa- tient remains without tremor so long as he is quiescent. But, if he attempts to cross one leg over the other, or to carry a glass of water to his lips, the extremity executing the movement is at once seized with tremor, and the act is performed with great difficulty. The ability to place the fingers on any part of the body, unassisted by the eyesight, is impaired, as in the cerebral form of the disease, and in sclerosis affecting the posterior columns of the spinal cord. As the disease advances, the paralysis becomes more strongly marked ; the limbs are permanently contracted ; the bladder loses its expulsive force ; its sphincter no longer completely closes the orifice ; the bowels become obstinately constipated, and there is a strong ten- dency developed to the formation of bed-sores. The head-symptoms likewise increase in intensity, but the mind remains clear to the last in the great majority of cases. Indeed, my observation of many cases has convinced me that in the cerebro-spinal form of sclerosis the hemi- spheres are not often involved, even when the disease has lasted several years. The difficulties of articulation notably increase, and the muscles of deglutition likewise become involved. In consequence, the saliva is not swallowed as often as it should be, and it therefore dribbles from the mouth. Mastication is difficult, and the facial muscles gradually become involved. The countenance of the patient at this period is 774 CEREBRO-SPINAL DISEASES. not unlike that of a person suffering from glosso-labio-laryngeal paral- ysis, as in fact might be expected, the same nerves and muscles being involved. Finally, the patient dies from exhaustion, or from some in- tercurrent disease. Few diseases are so irregular and ununiform in their phenomena as the cerebro-spinal form of sclerosis. This is due to the fact that the organs liable to be the seat of the disease are numerous and of varied functions. The essential feature of the affection is tremor occurring generally after paralysis, and only manifested during the performance of voluntary movements. It is not always necessary, however, that the movements should be of the partially-paralyzed limbs, for I have seen cases in which tremor was excited in a paretic leg by the act of executing voluntary movements with a sound hand. The following histories will contribute to a fuller understanding of the subject: Cruveilhier l reports the case of a cook, aged thirty-seven, who six years before coming under observation noticed that he was losing power in the left leg, so that he nearly fell in the street. Three months sub- sequently the right leg became similarly affected, and then the superior extremities followed. They were tremulous and weak, but the patient was still able to use them to some extent. The sensibility remained intact, and the reflex faculty of the cord was unimpaired. In other respects the patient was condemned to immobility. There were no spasmodic retractions of the limbs, and no painful contractions. The articulation was imperfect, but the intelligence was unaffected. There appear to have been no marked head-symptoms in this case. " Point de cephalalgie, jamais de cephalalgie, le malade entendait a merveille." After death there was found gray degeneration of the spinal cord, of the medulla oblongata, of the pons Varolii, of the right cerebral pedun- cle, of the right optic thalamus, of the corpora callosa, and of the for- nix. The hemispheres were not involved. Two other cases, similar in general character to the foregoing, are given, in neither of which were the hemispheres involved. Another case, that of Josephine Pajet, is cited by Cruveilhier.2 In this there was almost complete insensibility of the inferior extremities, though the patient was able to move the toes, the feet, and the legs. There were no cramps and no contractions. There was also diminished sensibility of the superior extremities. All the limbs were weak, and the arms were affected with tremor. The patient could walk and sew when first seen. The right hand was stronger than the left. There was a sensation of a tight band around the abdomen. After death there was gray degeneration of the cord, and of the pons Varolii. 1 " Anatomie pathologique du corps humain," Paris, 1835, 1842, tome ii., liv. xxxii., Fig. 4, PI. 2. 2 Op. cit, liv. xxxviii., Fig. 1, PI. 5. MULTIPLE CEREBRO-SPINAL SCLEROSIS. 775 In none of these cases were there spasmodic jerkings or tonic con- tractions of the limbs. Two cases have been reported by Friedreich.1 In one of these a man, aged twenty-one, was the subject. Among the first symptoms were mental excitement, vertigo, pain in the head, and weakness of the lower extremities. The gait was unsteady, and there was tremor upon any emotional excitement, or on the attempt to exe- cute movements. This affected the upper and lower extremities, the head, and the eyeballs. After death, patches of sclerosed tissue were found on the tubercula mammillaria, the cerebral peduncles, the pons Varolii, and the medulla oblongata. The other case was that of a woman, aged twenty, who was attacked, when seventeen years of age, with weakness of the right leg. Soon afterward the left became affected, and subsequently the arms. These latter were rendered tremulous at every attempt to move them. The speech was implicated, and there was nystagmus. The mind was weak- ened, and the sensibility was impaired. In the first of these cases the disease appears to have begun in the brain ; in the second in the spinal cord. Vulpian,8 under a title which goes to show how even the best au- thorities have confused the whole subject of sclerosis, describes an in- teresting case communicated by Charcot. In this instance a woman, aged forty-three, of nervous temperament, had been subject to frequent attacks of facial neuralgia, and had often suffered from vague pains without determinate seat. In 1856, she suffered from attacks of ver- tigo, which, from being rare at first, subsequently came on five or six times a day. Sometimes she fell, but never lost consciousness, or had any convulsive movement. Shortly afterward, during the night, she was seized with vomiting, cramps in her limbs, and a numbness of the right side. In the morning she was hemiplegic. Ffteen days afterward motion reappeared in the arm, but the leg remained paralyzed. In 1859, she had another attack of hemiplegia, and this time was deprived of speech for fifteen days. After this seizure, there were contractions of the flexors of the fingers, and of the forearm of the right side. In 1861, she had a third attack. In 1862 (January 1st), she came under M: Charcot's care. The intellectual faculties were not involved. The right superior extremity was almost entirely paralyzed, and was in a state of rigidity and contraction. The lower extremities were permanently extended, and could not be flexed but by great effort. Sensibility was perfect throughout, and reflex movements could still be excited. She died February 9th. 1 "Deutsche Klinik," No. 14, 1856. a "Note sur la sclerose en plaques de la moelle epiniere," Z'Union Medicale, No. 70, Juin 14, 1866, p. 507. Like other writers, Vulpian, in this paper, brings together cases which have no affinity except as regards the general character of the lesion. 776 CEREBRO-SPINAL DISEASES. On post-mortem examination, patches of sclerosed tissue were found in the right middle cerebral peduncle, the pons Varolii, the medulla ob- longata, and the cervical region of the spinal cord. The hemispheres were perfectly healthy. In this case, it is probable that the contractions were mainly due to secondary degeneration of the cord, a condition which, as we have seen, is analogous to sclerosis. It will be observed that there were no tre- mors, either with or without voluntary motions. Another important case has been reported by M. Magnan :' A woman, aged thirty-four, came under observation in July, 1869. In 1848, when thirteen years of age, she had an attack of typhoid fever, from which she lost her sight. The first symptom of her disease oc- curred in 1867, and consisted of trembling of the hands and arms when- ever she endeavored to execute any difficult movement. Before long, the tremor involved the lower extremities ; but there was no paralysis till about eight months previous to her admission to the hospital. At this time, every effort at motion caused tremor. The hands, arms, legs, eyeballs, and even the muscles of the trunk, were involved. The articu- lation was defective, and there were various painful sensations in differ- ent parts of the body. Ophthalmoscopic examination showed atrophy of the optic disks and nerves. The diagnosis in this case was multiple cerebro-spinal sclerosis— an opinion which I do not think is warranted by the facts. The lesion was probably entirely confined to the brain. The main reason which leads me to entertain this view is, that the tremor appeared before the paralysis. I cite the case for the purpose of showing how little accord there is among authors relative to the association of symptoms with lesions in the several forms of sclerosis. Thirty-one cases of what the symptoms indicated to be the cerebro- spinal form of sclerosis have been under my care ; and, though I have not had the opportunity of verifying my diagnosis in a single instance, I think the symptoms have been of such a character as to indicate the existence of the lesion so graphically described by Charcot, Friedreich, and Bourneville and Gu6rard.a The fact, that several of the histories were written out before Charcot's investigations gave me a clew to their real import, will tend, I think, to increase their value. Mr. M., a gentleman fifty-three years of age, consulted me April 8, 1865, at the instance of my friend Prof. Fordyce Barker, M. D., for partial paralysis with tremor, mainly affecting the right arm and leg. Two years previously he had suffered from vertigo and headache, which were followed by a slight attack of hemiplegia of the right side, unat- tended by loss of consciousness. He gradually recovered from this, 1 " Memoires de la society de biologie," Paris, 1869. a " De la sclerose en plaques disseminees," " Nouvelle etude sur quelques points de la sclerose en plaques disseminees," Bourneville, Paris, 1869. MULTIPLE CEREBRO-SPINAL SCLEROSIS. 777 but, about six months before he came under my observation, he no- ticed that his right leg began to drag, and, soon afterward, that the arm of the same side became weak. About the same time he had head- ache, vertigo, and weakness of sight. A short time subsequently— about a month as well as he could recollect—the arm was seized with tremor while attempting to carry a glass of wine to his lips. The agi- tation continued to grow more violent on any voluntary movement of the arm, and gradually his speech became involved. When I saw him he was still suffering from occasional attacks of vertigo and headache ; the lips were agitated whenever he attempted to move them, the tongue was tremulous, and his speech was conse- quently halting and jerking. There was also nystagmus, a symptom which he had not noticed. The right arm was unaffected with tremor so long as he allowed it to rest on his knee or to hang by his side ; but, in the act of moving it, the whole extremity was agitated by a series of short, vibratory mo- tions, consisting of flexions and extensions, which continued so long as he persevered in the movement, or kept the arm in any position requir- ing muscular exertion. The right leg was weak, and dragged so that he struck his foot against any slight obstruction. There was a little tremor in it when he attempted to cross it over the other as he sat in a chair. I treated him solely with the primary galvanic current, which I passed through the brain and spinal cord—the first time such an opera- tion was performed in this country for the treatment of disease. My diagnosis was incipient softening of the ganglia at the base of the brain and of the upper portion of the spinal cord. My opinion was, that the hemispheres were not involved, as there were no symptoms indicat- ing mental weakness or disturbance. I made an application of about fifteen minutes' duration every day. He gradually but rapidly improved, and to such an extent that on the 19th of April he wrote to me as follows : " Yesterday must be marked with a white stone as the best day yet. Foot active, hand and arm steady, and spirits good. If we can manage to fix these good effects, cure is certain. " I hope the magic pile will be ready to repeat its good work on Saturday next." He continued to improve for several weeks, then gradually went back to his former condition, and from that rapidly grew worse. The paralysis invaded the other side, then tremor followed, the speech became much more difficult, and he died in the country two years sub- sequently. Miss H., of Connecticut, aged thirty-five, consulted me January 20, 1870, for paralysis and tremor. About two years previously, she had noticed a weakness of the right arm, which had been preceded by oc- 773 CEREBRO-SPINAL DISEASES. casional attacks of not very severe headache and vertigo. The arm gradually became weaker, and in the course of a few months began to shake whenever she attempted to use it. Before the year had expired, the right leg began to drag a little, and lost a good deal of its natural strength. Her speech also became difficult, not from any failure to re- member words, but from tremor of the tongue and weakness, with a little rigidity of the lips. When I saw her, the articulation was halting and syllabic ; there was nystagmus in both eyes ; the right arm was very weak ; she could only move the index of my dynamometer four degrees, equivalent to a pressure of. two pounds and a half, while with the left hand she ,could move it twenty-eight degrees. Every attempt to move the arm caused trembling of the whole extremity. So long as she refrained from any exertion of voluntary power, it remained free from agitation. She could not write, owing to the tremor which the effort to do so ex- cited. There was slight tremor in the leg, when she slowly raised the foot from the ground. The mind was perfectly intact, and she was entirely free from any emotional weakness. In this lady's case I diagnosticated multiple cerebro-spinal sclerosis —the " sclerose en plaques disseminees " of Charcot. I treated her with the chloride of barium and the primary galvanic current. By the following autumn she had improved so much that she could walk several miles without fatigue, lifted her foot clear of the ground, could move the index of the dynamometer to thirty degrees, was free from tremor, except when she attempted to write, and then it was only manifested to a slight extent. I now ceased using the gal- vanism, but continued the chloride of barium. On the 28th of January, 1871, she paid me a visit. She was then walking well, but there was still a very slight tremor when she attempted to execute delicate or difficult movements with the right arm. I directed the continuance of the barium. Mr. H., of South Carolina, a highly-educated and intelligent gentle- man, consulted me, September 12, 1870, for paralysis and tremor. As he entered my consulting-room, the tendency to festination was exceed- ingly well marked. On examination, I found his mind perfectly clear. There were nystagmus and syllabic articulation. On moving the left arm or left or right leg, the limb became tremulous. There had never been any head-symptoms. On the 19th, at my request, he wrote a short account of his disease', which I here transcribe: " I was never robust in health, but, on the other hand, I have never had, since childhood, a serious spell of sickness. My manner of life has been sedentary—that of a student. I was always careful not to over- task myself until I became engaged, in the year 1864, in a mathemati- MULTIPLE CEREBRO-SPINAL SCLEROSIS. 779 cal research. I was for a considerable length of time very much ab- sorbed in this work, and allowed it to encroach seriously upon my hours of recreation and sleep. " In the fall of 1865, after having accomplished the above work, I observed a slight lameness in my left foot—a tendency to strike the toe against the inequalities of the ground—an inability to raise quickly enough the front part of the foot. "After my return home, summer of 1866, from Europe, where I had spent five or six years, the lameness in my foot increased rapidly, and in the winter of 1866-'67 a lameness in my left hand was very percep- tible—an inability to move the fingers quickly, and a tremor, particu- larly of the thumb, when I attempted to do so. " The above symptoms have gradually grown worse, and within the last year the right leg has become involved, to the extent that it begins to shake when I stand upon it, and it shakes even while sitting, when I am under excitement, or when I execute difficult voluntary motions with my hands. " The disease seems to make greater progress in hot weather. I have at no time suffered pain, my appetite and digestion are good, and I generally sleep well." This gentleman improved greatly through the use of the primary galvanic current, chloride of barium, and tincture of hyoscyamus, during the two weeks that he remained in New York under my care. On his return to South Carolina he took a primary-cell battery with him. On the 11th of January, 1871, he wrote to me as follows: " Sometimes I thought I was improving slowly, or at any rate not losing ground, and then again, for several days together, I would feel confident that I was falling back. But now I think I can certainly say I am growing worse. All my symptoms have been worse—lamer, more nervous, and the disease more general in its effects. My right hand, which has*heretofore been comparatively unaffected, is now seriously implicated, and yet I still manage to write after a fashion. I find it very difficult to dress myself, and I must make several attempts before I can get up from a sitting or a lying posture. " What could have caused the improvement that took place while I was under your immediate treatment ? " In this case I diagnosticated multiple cerebro-spinal sclerosis, and I think those acquainted with the disease will agree with me in my view of the case; and yet there was as strongly-marked festination as I have ever seen. The gentleman could trot well, could mount a staircase with- out much difficulty, but walking slowly, or descending staiss, troubled him greatly. According to some authors, this symptom would, of itself, have been sufficient to contraindicate the existence of sclerosis, and to have placed the disease among the neuroses. My views on this point have already been expressed under the head of multiple cerebral sclerosis. 780 CEREBRO-SPINAL DISEASES. J. F., a gentleman of this city, forty-two years of age, consulted me November 29, 1870. On the 4th of July previously he had indulged rather freely in champagne, and the following morning awoke with severe headache, vertigo, and nausea. Although he recovered from this attack, he never felt quite as well as before, and was frequently subject to headache and vertigo—symptomatic, as he thought, of gastric disorder. About a month after his first symptoms he was sud- denly conscious of a singular sensation about his left eye, and on look- ing in the glass discovered that the upper lid had dropped, and that he could not raise it. This was about five o'clock in the afternoon, and by ten that night the lid entirely covered the pupil. The following morn- ing it was not so low, but he found that he saw double. He continued to attribute all his troubles to the stomach, and began taking some quack remedy recommended to him for dyspepsia. In the course of a few days, feeling no better, he went to the sea- shore, and while there noticed that his right arm became weak, and that he frequently let things drop from his hand. He had difficulty in shav- ing and in dressing himself, from inability to coordinate the muscles, and there was numbness of the ends of the fingers. During all this time he had suffered more or less from headache, vertigo, and double vision, and the ptosis still continued. Gradually the left arm became involved, and, by the time the paresis in this extremity was well estab- lished, the right arm was affected with tremor, but only when he at- tempted to execute movements with it. Thus, as he said, he could place the hand on a table and it would continue perfectly quiet ; but, as soon as he took a pen to write, or even endeavored to raise the hand from the table, it was seized with tremor. The left arm soon became similarly affected, and eventually the left leg lost strength and was rendered tremulous by any attempt at muscular exertion. He noticed also, what, as I afterward learned, his friends had perceived several weeks before, that his articulation was imperfect, and that* is was ne- cessary for him to make a mental effort to talk distinctly. He returned to the city about the middle of October, and employed a " rubber " to restore, as he said, the circulation to his limbs. Con- tinuing to get worse, he consulted me. At this time there was festination. The speech was syllabic and accentuated, the tongue and lips were paretic and tremulous, there was nystagmus in both eyes, ptosis and diplopia from paralysis of the left sixth nerve, and dilated pupil of the right eye. There were also occa- sional headache and vertigo, but not to the same extent as at first. Both arms and the left leg were partially paralyzed. He could not raise either upper extremity out from the side, owing to the complete paralysis of the deltoids, but he could flex both forearms, and move his hands and fingers tolerably well. There was no tremor while he re- frained from using them, but the least attempt at voluntary motior MULTIPLE CEREBRO-SPINAL SCLEROSIS. 781 excited them to agitation. The same was true of the left leg. Exami- nation with the ophthalmoscope showed both optic disks to be white, and the retinal vessels small and straight. With the dynamometer he could only exert a pressure of nine de- grees with the right hand and eleven with the left. The line made with the dynamograph was descending, showing his inability to main- tain, even for a short time, a uniform muscular contraction. There was no loss of sensibility, except in the upper extremities. He had occasionally suffered from pains in the back, about the region of the shoulders. The power over the sphincters was intact. This gentleman could stand and walk as well with his eyes shut as with them open. On rising from his chair, which he did with difficulty, he always felt impelled to take a few steps forward, which were a stag- ger rather than a voluntary movement. In walking, the body was in- clined forward, and he went in a kind of jog-trot. He attributed his disease to dissipation of all kinds, in which opinion I expressed my concurrence. Under treatment with galvanism, hyoscyamus, and chloride of bari- um, this patient has improved, but not as yet sufficiently to warrant any strong hope of a permanent cure. A gentleman from the northern part of the State of New York con- sulted me in January, 1871, and again in March. His symptoms, though decided, were not very severe in character. Gradually, however, there had been for two years a loss of power supervening in the muscles of the right side of the body, and lately ocular troubles had made their ap- pearance. Tremor, on making any voluntary movement, was just be- ginning to appear when I last saw him. Its influence over his hand- writing is seen in the following facsimile: Fig. 107. One patient, with multiple cerebro-spinal sclerosis, attends the out- door department of the New York State Hospital for Diseases of the Nervous System. He has marked head-symptoms. And another, from Philadelphia, who was supposed to be suffering from cerebral disease; consulted me a few days ago. In this case the affection probably re- sulted from a fall. The remaining cases do not present any such peculiar phenomena as to warrant their histories being given in detail. Causes.—Nothing very definite is known of the etiology of the affec- tion in question. It probably is induced by such causes as give rise to 782 CEREBRO-SPINAL DISEASES. the purely cerebral form of the disease. Age does not, however, ap- pear to exercise so important an influence. Eleven of my cases were over fifty years, and one of them, the gentleman from Philadelphia, was over sixty ; seventeen were over forty and under fifty, and three were between thirty and forty. All were males but four. In seven cases, it was apparently caused by excessive mental appli- cation, in two by anxiety, in one by a fall, in six by dissipation. In the remaining cases I could discover no obvious cause. In none of them was there a rheumatic, syphilitic, or other morbid diathesis. Diagnosis.—The facts of the tremor making its appearance after the paralysis, and of its only—or, at least, with rare exceptions, and then only in the latter stages of the disease—being manifested when volun- tary movements are being made, will suffice to distinguish the cerebro- spinal form of sclerosis from either of the other varieties. The points to recollect are these : that, in simple cerebral sclerosis, the tremor ap- pears before the paralysis, and does not depend on the voluntary con- traction of muscles for its excitation ; in simple spinal sclerosis there is no tremor at all. I have already insisted on these distinctions in my remarks on the other forms of sclerosis of the nervous centres. Prognosis.—This is very generally unfavorable. In only one case have I had reason to expect a cure. It often happens that amendment very decided in its character takes place soon after the beginning of the treatment with galvanism and barium. This has been the case in every instance of the disease that has been under my charge ; but in only one has it been permanent. In those now under treatment, there has as yet been no relapse ; but the time is too short to speak with any confi- dence in regard to the ultimate result. Morbid Anatomy and Pathology.—The remarks made under this head, when the cerebral and spinal forms of sclerosis were being con- sidered, apply to the cerebro-spinal variety. Charcotx has considered the subject of sclerosis mainly in its histological relations. The main points are—and these have already been stated several times—that the morbid process essentially consists in hypertrophy of the neuroglia at the expense of the proper nerve-substance, and that this is a conse- quence of inflammatory action. In the present form of the disease, the sclerosed tissue appears in the form of plates or nodules in different parts of the brain and spinal cord. Treatment.—The treatment of multiple cerebro-spinal sclerosis is more palliative than curative. Galvanism to the brain and vertebral column, chloride of barium, and hyoscyamus, have very generally caused improvement for a time, but my experience goes to show that this is not permanent. The galvanic current should be used of less tension when applied to the head, but as strong as the patient can endure, to the spine. 1 Gazette dos Hopitaux, Nos. 102, 103, 140, 141, 143, 1868. PARALYSIS AGITANS. 783 The chloride of barium should be given in solution in water, in doses of a grain three times a day—the hyoscyamus in doses of from one to two teaspoonfuls of the tincture. I have sometimes given the nitrate of silver in fourth-of-a-grain doses, three times a day, and very generally recommend cod-liver oil with each meal. Occasionally I have administered iodide of potassium and the bichloride of mercury, with the view of counteracting a possible syphilitic diathesis. Whatever measures are adopted should be continued for several months at least, and, if the improvement persists, for a much longer period. CHAPTER IX. PARALYSIS AGITANS. Under the term paralysis agitans, several affections have been in- cluded which are very different in character. I have already considered two of them—multiple cerebral sclerosis and multiple cerebro-spinal sclerosis; a third I propose to treat of under the name of paralysis agitans. Though the objections to its use are many, it possesses the advantages of being already known, and of expressing two of the main features of the disease to which it is applied. It is to be understood, however, that the disease to which I apply the term is altogether dif- ferent from that which Charcot,1 Ordenstein,2 and other writers, call paralysis agitans. The affection which Parkinson3 described, and to which he applied the name " shaking palsy," has since been very carefully studied by many writers, and the fact has been clearly made out that it is not a single disease. Charcot, in numerous memoirs and lectures to which reference has already been made, has very definitely shown that the affection which he designates sclerose en plaques disseminees—considered in this trea- tise under the name of multiple cerebro-spinal sclerosis—must be re- garded as a distinct morbid condition ; and in the first section of this work I have made the same claim for multiple cerebral sclerosis. The term paralysis agitans I apply to a very different affection from either, but one which I am confident will be recognized as presenting well-de- fined characteristics. Ordenstein4 has included it with multiple cerebral sclerosis, and denies it any fixed seat; but Jaccoud5 locates it in the 1 " Lecons sur les maladies du systeme nerveux," Paris, 1872—'73, p. 139. 2 '4 Sur la paralysie agitante," etc., Paris, 1868. 8 "Essay on the Shaking Palsy," London, 1817. * Op. cit. 5 Op. cit, p. 424. 784 CEREBRO-SPINAL DISEASES. pons Varolii, without, however, in my opinion, having any good reason for so doing. Of all writers Dr. Handheld Jones J appears to have the clearest ideas of the affection now under notice. Thus, he says : " It appears to me a question whether two distinct affections are not often comprehended under this name. For on the one hand it appears pretty certain that there is one form which is met with in old persons, is quite incurable, and is associated with, if not dependent on, organic wasting changes in the nervous centres ; while another form occurs in younger persons, is more curable, and therefore is presumably not de- pendent on organic change." It is this latter disease which I propose to consider at present. The other embraces cases of multiple cerebral sclerosis and cerebro-spinal sclerosis. Symptoms.—The primary manifestation is tremor, and this, like the same symptom in the severer forms of disease already considered, in which it forms an essential feature, may begin in a very restricted or more extensive region of the body. It is present whether voluntary movements are performed or not with the affected limbs, but is in- creased by mental excitement of any kind, by physical exertion, or by any cause capable of depressing the powers of the system. It is not generally the case that the tremor shows any tendency to advance much beyond its original limits, however small or extensive these may be. When it does exhibit such a disposition, contiguous muscles are first attacked, and then the corresponding ones on the op- posite side of the body. From the very first there is muscular weakness, not to any very great extent, but still sufficiently evident to careful examination with the dynamometer. As the tremor increases in violence or extent, the paralysis becomes more obvious. Sensibility is rarely affected, there is no bending of the body for- ward, no festination, and no head-symptoms. The tremor always ceases during sleep, except in very extreme and long-continued cases, and there may be intermissions of longer or shorter duration while the pa- tient is awake. Causes.—Paralysis agitans may result from emotional disturbance, from continuous or severe muscular exertion, from some exhausting disease, such as dysentery, typhoid or typhus fever, or rheumatism, or from blows, falls, or other injuries. In many cases the cause cannot be ascertained. Of twenty-five cases of which I have records, ten were apparently due to mental causes, four to excessive physical exertion, four to dis- eases of various kinds, two to injuries, and in five no cause could be discovered. Two cases of mercurial trembling, the symptoms of which affection 1 " Studies on Functional Nervous Disorders," London, 1870, p. 382. PARALYSIS AGITANS. 785 are very similar to those of non-toxic paralysis agitans, are not included among the foregoing. Diagnosis.—From multiple cerebral sclerosis, paralysis agitans is distinguished by the facts that there are no head-symptoms, no festina- tion, and no derangements of sensibility. It is more apt to occur in persons under the age of fifty, and may be met with in quite young persons. The reverse of both these circumstances is true of multiple cerebral sclerosis. From multiple cerebro-spinal sclerosis, it is diagnosticated mainly by the absence of any head-symptoms, by the fact that the tremor usu- ally comes on before the paralysis, and is independent of voluntary movements. From convulsive tremor it is readily distinguished by the facts that the tremor is not paroxysmal, and that it is accompanied by paresis of the affected muscles. The character of the muscular action, and the history of the case, will prevent its being confounded with chorea. Prognosis.—Paralysis agitans rarely terminates fatally, and when it does it is because the tremor has become so general that death results from exhaustion. It, however, often happens that all measures fail to relieve the agitation. Of the twenty-five cases occurring in my own experience, eight were cured, five partially so, and in the rest no per- manent effect was produced by any means I employed. Morbid Anatomy and Pathology.—Nothing is known of the morbid anatomy. In a few cases, patients have died either from the disease or from some intercurrent affection, and post-mortem examinations have been made with negative results. Petraeus, quoted by Dr. Handfield Jones, relates two severe cases, one of which proved fatal. At the autopsy nothing was found but fatty degeneration of the heart and pneumonic consolidation of the right lung. He remarks on the tremor not being constant in many cases, ceasing for some days and then re- turning with fresh force, or changing its seat from one part to another. In my opinion, the disease under consideration is due to an irregular and diminished evolution of nerve-force from the motor nerve-cells in relation with the nerves supplying the muscles in which the agitation exists. The pathology of tremor, not the result of structural lesions, is a subject which is beginning to be studied, but which is not yet clearly understood. We know that, when we have strongly exerted an arm, for instance, the muscles are tremulous for some time afterward, and that the agitation is rendered very evident when we attempt to write or do any other act requiring delicate muscular adaptation. A period of rest must take place before steadiness is regained. Now, in such a case the agitation is not probably due to any cause inherent in the muscle, but is the result of exhaustion in the nerve-cells and the disengagement of insufficient force in an intermittent manner. I sup- 50 786 CEREBRO-SPINAL DISEASES. pose paralysis agitans to be due to some such action in the motor nerve- cells in Jhe gray matter of the spinal cord. In those cases in which the tremor becomes permanent, structural lesions of profound character—as in permanent hysterical contractions and epilepsy—doubtless occur. Treatment.—I .have used electricity, both of the galvanic and fara- daic kinds, in all the cases of paralysis agitans that have been under my charge, and in conjunction have employed many internal medicines, such as arsenic, iron, manganese, zinc, copper, phosphorus, strychnia, and sedatives of various kinds, including opium, bromide of potassium, conium, stramonium, Indian hemp, and many others. I am very de- cidedly of the opinion that the best treatment consists in the use of the constant primary current to the spinal cord, sympathetic nerve, and the affected muscles, while at the same time strychnia and phosphorus, ac- cording to the formula given on page 58, are administered internally. By these means four of my eight successful cases were entirely cured within two months. One of these was sent to me by my friend Dr. F. N. Otis. The affection was confined to the right arm, and was probably due to inordinate gymnastic exercise; the other was a gentleman from St. Louis, in whom the disease was also confined to the right arm, and had apparently resulted from writing excessively. Both had lasted several months. Another was a railway engineer, in whom the disease was the result of over-mental excitement; and the fourth was a distinguished clergy- man of the Catholic Church in whom a like origin existed. The six other cases were, two of them, consequent on other diseases, and four were without known cause. Three were women ; the tremor in two was in both arms, and in two in one leg in each. The duration of the treatment was from three to seven months. A full and nutri- tious diet, and the avoidance of all mental excitement or strong physi- cal exertion, are important features in the treatment. CHAPTER X. ANAPEIRATIC PARALYSIS. There is a class of paralyses produced by the habitual use of a par- ticular class of muscles in the same way for a long time. Thus we have writer's paralysis, telegrapher's paralysis, hammer paralysis, and so on. To describe these as separate and distinct affections is scarcely, in the present state of our knowledge, permissible. I shall, therefore, em- brace these under the designation of anapeiratic (Avaneipdo), to do or ANAPEIRATIC PARALYSIS. 787 attempt again) paralysis, as being caused by the frequent repetition of some particular muscular action. Symptoms.—The first symptom usually observed is a feeling of fa- tigue experienced in the muscles which have been grouped together for frequent use in some especial way. Thus in writers, engravers, violinists, type-setters, and telegraphers, the tired sensation is felt in the muscles of the hand, forearm, arm, and shoulder. The thumb is especially affected, and is also the seat of a dull, aching pain. Pains, not very severe or fixed, are also common in the muscles higher up ; this fatigue the patient endeavors to correct by grasping the pen or burin, for instance, more firmly, or by making an intense mental effort to regulate the muscular contractions by which the instruments are held, the type seized, or by which the fingers are moved over the strings of the violin, or the lever of the telegraph-instrument. But he only thereby adds to the difficulty, for the weariness and pain are increased, the muscles become weakened, and moreover irregular and incoordi- nate actions ensue which render the results of either writing, engraving, etc., more or less imperfect. If he perseveres day after day in his occupation he soon reaches that stage of the disease in which the ability to direct the pen, for in- stance, in accordance with his will, is lost, and the automatic actions, which are of great importance in writing, are likewise very much di- minished. For a time, then, he writes better when his mind is not occupied in directing the formation of every letter, but in which he allows the muscles as it were to. take care of themselves. Constantly, however, he feels the necessity of mental action, and this action invari- ably increases the trouble, until, at last, the moment the attempt is made to write, the pen, actuated by the muscles of the fingers, executes such disorderly movements as to bear, in extreme cases, little or no analogy to the words attempted to be written. A distinct paroxysm is thus induced, which lasts as long as the patient persists in the attempt to write. When he discontinues, the spasm ceases, and he can perform any other act with the fingers without there being the slightest convul- sive movements. In some cases there is pain in the fingers, the muscles between the metacarpal bones, and in those of the forearm. The spasm is much worse if the patient be excited or particularly anxious to do his best. In the accompanying woodcut (Fig. 108) are represented three attempts of a patient to write the name "James Ely." At first some resemblance to the letter J is made, but in the second trial it is less distinct, and in the third is lost altogether. All of my patients had resorted to various expedients to obviate the spasms, under the idea that they were produced by metallic pens carry- ing off the electricity from the arm ; several had, for a time, made use of quills, or hard rubber pens, and for a time relief had been ob- 788 CEREBRO-SPINAL DISEASES. tained, but the paroxysms soon became as bad as ever. Others had used very thick pen-holders, and this expedient was also, for a time, successful. In the end, however, all such efforts to prevent the spasms proved futile. In one case under my charge, the patient, an engraver, was utterly incapable of using his burin, although he could write for hours perfect- ly well, and those who had contracted the disease by excessive writing could execute any other delicate movements, such as drawing, playing the piano or violin, threading needles, etc., without inconvenience. In several cases the individuals had acquired the power to write with the left hand, but before long this was also affected. Dr. G. V. Poore J has recently published an interesting memoir on the affection as produced by excessive writing, and argues that, although it is true that patients can execute other actions than writing with the affected hand, the muscles employed in these movements are not the same as those used in writing. This is doubtless true of advanced stages of the disease, but it certainly is not so of early periods. I have a patient at this time under my charge who cannot write without great inconvenience, but who uses a pencil in drawing with the greatest fa- cility and precision. Dr. Frank Smith a describes the disease I have designated anapei- 1 " Writers' Cramp, its Pathology and Treatment," The Practitioner, June, July, and August, 1873. 2 Lancet, March 27, 1869, also " On Hephaestic Hemiplegia or Hammer Palsy," British Medical Journal, October 31, 1874. ANAPEIRATIC PARALYSIS. 789 ratio paralysis, as it occurs in workmen who use the hammer almost continually in certain processes, and gives it the name of hepha;stic (H0a«7roc, Vulcan) hemiplegia. " There are numerous varieties of manufactures in which the rapid use of a light or heavy hammer plays a chief part, such for example as table-blade forging, scissors-making, saw-straightening, razor-blade striking, engineering, file-forging, etc." " The pen-blade forger uses a hammer about three pounds in weight. A pen-blade receives in the process of forging and joining to the piece of iron by which it is attached to the haft, on an average, one hun- dred blows. The forger, if an industrious man, anxious perhaps to save, by working overtime, enough money to join a building-society, or to commence business on his own account, will work twelve or thirteen hours a day. He will make as many as twenty-four dozen blades in a day, and in so doing will deliver twenty-eight thousand eight hundred accurate strokes. The rapidity and accuracy with which these blows rain upon the slender piece of iron are wonderful to the onlooker. Sup- posing him to work three hundred days in a year, and to continue this for ten years, he will in that period have delivered eighty-eight million four hundred thousand strokes, and just so many discharges of nerve- force will have occurred in the motor ganglia which are engaged in the. action, and in the higher ganglia which calculate the distance and judge of the amount of force necessary to be evolved." In several of the cases adduced by Dr. Frank Smith there were head-symptoms, and in all more or less extensive hemiplegic paralysis. There were also twitchings of muscles, pains, and difficulty of speech, in some of the cases. M. Onimusx was, I think, the first to call attention to the disease as met with in telegraph-operators. The trouble appears usually to mani- fest itself in the first place by a difficulty in coordinating the muscles so as to make dots or points with the instrument. After a time the same restraint is experienced in the formation of lines. The disease appears to be rare in this country, which—as, according to M. Onimus, the Morse machine is especially apt to induce it—is somewhat remarkable. In several of my cases there have been symptoms indicative of dis- order of the central nervous system. These have consisted of headache, pain in the back, and occasional tremors of the limbs. In one case there is marked inability to coordinate the muscles of articulation so as to speak clearly. The trouble seems to be more in the lips than in the tongue, and there is decided mental impairment. In this case there is no doubt that the affection has originated from the excessive uses of the muscles of the right hand and arm in writing. Causes.—The disease is more apt to attack persons somewhat ad- vanced in life, than the very young. All my patients were over forty 1 Gazette Medicate ; also Chicago Journal of Nervous and Mental Diseases, 1875. 790 CEREBRO-SPINAL DISEASES. years of age. All were males', though this proclivity of men to the af- fection is not absolute, as several cases are on record in which women, seamstresses especially, have been its subjects. It is apparently some- times induced by using the fingers in constrained positions. In one of my cases, the patient, who had been in the habit of writing with the hand supported by the little finger, cured himself by allowing the whole hand to rest on the desk. The principal cause—the habitual perform- ance of certain restricted movements—has already been sufficiently con- sidered. The opinion which Poore expresses, that it is due in writers to the use of steel-pens, is not borne out by my experience. I have seen it in persons who always wrote with quill-pens, and, as we know, the disease occurs in individuals from other causes than writing. Diagnosis.—Attention paid to the characteristic symptoms of ana- peiratic paralysis, and inquiry into the clinical history, will prevent its being mistaken for lead-paralysis, progressive muscular atrophy, or any other disease. Prognosis.—In the early stage anapeiratic paralysis, by whatever cause induced, admits of cure. When it has existed a long time, and when the patient cannot rest, a cure is almost impossible. A majority of the cases that have come under my notice had lasted too long to admit of cure, and the patients had, notwithstanding the imperfections of their work, persisted in using the affected muscles in the actions which had led to the causation of the disease, and then when this was no longer possible had used the other hand in like manner, till it also had become affected. In such cases permanent cures are almost out of the question, although relief can be obtained to such an extent as to allow of occasional writing. Morbid Anatomy and Pathology.—As regards the morbid anatomy, there are no data, and the lesion is probably not one which can be de- tected by our present means of observation. The affection is, however, doubtless due to disorder in the normal action of the motor cells, and this disorder is the result of over-exertion of a particular set of muscles in a particular way. Examples of cerebral exhaustion by the predomi- nance of one idea, or a series of ideas for a long time, are often wit- nessed. Writer's spasm is, I conceive, the result of a similar action in spinal motor cells and cerebral nerve motor centres. Poore, however, does not believe that the affection, as met with in writers, can be of central origin, but certainly the symptoms are of a character to militate against his view. He has looked at the disease from too restricted a stand-point. No one can read the report of Dr. Frank Smith's cases without at once perceiving that they are the re suits of central lesions. Treatment.—The most indispensable means of cure is rest, and, un less this can be secured, it is useless for the physician to undertake the EXOPHTHALMIC GOITRE. 791 treatment. In some cases it has succeeded without any assistance. The abstinence from the labor causing the disease, and sometimes from all continuous muscular exertion, should be absolute during at least six months. The constant galvanic current has proved the most effectual agent in my hands: I apply it to the sympathetic nerve, the spinal cord in its upper part, and to all the muscles and nerves of the upper extremity. A half an hour three times a week, with a current of considerable inten- sity (forty cells), will be sufficient. Faradization, in my experience, is more productive of harm than benefit. ^ With the galvanism I have administered the combination of phos- phide of zinc, and extract of nux-vomica, recommended on page 54 of this treatise. The bromide of zinc in incipient cases is a most efficacious agent in restoring tone to the nervous system, and in conjunction with rest will often effect a cure. It should be used in gradually-increasing doses as recommended for convulsive tremor and chorea. When a cure cannot be effected, well-devised prothetic apparatus will enable the patient to write or perform other actions requiring skill rather than strength; but I am not sure that they do not lead to the further extension of the disease, especially in its cerebral relations. Division of tendons or muscles is not admissible. CHAPTER XI. EXOPHTHALMIC GOITRE. It is with hesitation that I have ventured to include the remarkable disorder called Graves's disease, Basedow's disease, exophthalmic goitre, and by several other designations, under the head of cerebro-spinal affections. But, after a careful consideration of all the points in its clinical history and morbid anatomy, as they have been observed by others, and studied by myself, I find it difficult to place it in any other category. The reasons which have governed me in this decision will be stated under another division of this chapter. Symptoms.—The first phenomenon to make its appearance, in a case of exophthalmic goitre, is irregular and excessive action of the heart. The organ is far more irritable than when in a state of health, and thus slight emotional disturbance or moderate physical exertion readily affects its action. Even when the patient is mentally and physically quiet, the pulsations are rarely below a hundred in a minute, and the least excite- ment, mental or bodily, will send them up to a hundred and twenty, a hundred and fifty, a hundred and sixty, or more, in extreme cases. 792 CEREBRO-SPINAL DISEASES. With the increase in frequency there is generally an augmentation of the force of the heart. The patient feels its pulsations against the wall of the chest, feels them as the whole body is shaken by them, and hears them in the murmur which is constantly in the ears. The carotids and abdominal aorta can be seen to have their action increased, and the jugular veins, always dilated, are sometimes the seat of pulsation. Physical examination does not in general indicate the existence of any organic disorder. Sometimes, however, the heart is found to be enlarged, but rather as a consequence than a cause of the disturbance. A systolic murmur is often heard, which may be either arterial or ventricular. In the former instance it is anasmic, in the latter it is due to a relative insufficiency of the auriculo-ventricular valves. The next symptom in order is usually an enlargement of the thyroid gland, an enlargement which is variable, and which is greater or less in accordance with the excessive or moderate action of the heart. Not- withstanding this capacity for change in size, there is a permanent augmentation in the volume of the body, below which the decrease does not take place. If the hand be laid over the swollen thyroid, a peculiar sensation like that derived from stroking a purring cat—frbmissement cataire—is felt with every systole of the heart, and a bellows-murmur is heard when the ear is applied to the part. Next, the third essential phenomenon makes its appearance, and this consists of a prominence of the eyeballs. Usually this is symmet- rical, but occasionally one protrudes more than the other. In the early stage of the affection the lids can be closed over the eyes, but in ex- treme cases they cannot be brought together, and the conjunctivas are therefore exposed to the atmosphere and to particles of dust, which cause excessive lachrymation and sometimes troublesome inflammation. The pupils rarely exhibit any deviation from the healthy state. I have sometimes found them abnormally dilated, never contracted, and always sensitive to light. Graefe l has called attention to a circumstance which accompanies the protrusion of the eyeballs, and that is the disassocia*tion of the movements of the upper eyelid from those of the eyes. In the nor- mal condition, when the globe of the eye is raised, the lid is also ele- vated, and when the globe is depressed the lid likewise falls. In exoph thalmic goitre these automatic movements do not take place. These three phenomena, excessive action of the heart, enlargement of the thyroid gland, and protrusion of the eyeballs, may be said to constitute the pathological trinity of which the disease consists, but there are cases in which the goitre is scarcely if at all present, and 1 "Bemerkungen iiber Exophthalmos mit Struma und Hezzleiden," Archiv fur Oph- thalmologic, 1857. EXOPHTHALMIC GOITRE. 793 others in which the exophthalmos is absent, and probably others, again, in which both these phenomena are wanting. Again, there is no definite relation between the degrees of severity characterizing these symptoms. Sometimes the heart is most tumultu- ous in its action, the goitre large, and the eyes very slightly prominent, or the eyeballs may protrude to the utmost and the goitre be small, and the heart not excessively deranged, and so on. But though these three phenomena constitute the most marked feat- ures of the disease, there are others which, though not so obvious to others, add greatly to the distress of the patient. Thus there are gen- erally cough, nausea, oedema of the extremities, increase of tempera- ture, profuse sweating, and occasional haemorrhages from the nose, lungs, or bowels. The emotional excitability I have always found increased, sleep is generally disturbed and insufficient, there are headache, vertigo, and noises in the ears, the character often undergoes a marked change, and individuals who were quiet and gentle become excited, suspicious, and irritable. Quite recently Dr. Bulkley,1 of this city, has reported two cases in which there was urticaria. Anaemia is generally the predominant physical condition, and with it there is more or less mental weakness. The body is usually much emaciated, probably in part from defective appetite and defective as- similative power, which ordinarily exist. In woman, the menstrual dis- charge is almost always either entirely suppressed or greatly dimin- ished. It rarely happens that there are any marked disturbances of vision, and the movements of the eyeball do not appear to be impeded. The fundus of the eye, when examined with the ophthalmoscope, is gener- ally found to be normal; occasionally there are venous dilatation and pulsation. For the following history of a case of exophthalmic goitre, and the accompanying illustration from a photograph, I am indebted to Dr. J. B. Crawford, of Wilkesbarre, Pa. The case is particularly interesting from the fact that it occurred in a man, was remarkably acute in char- acter, terminated fatally, and that, notwithstanding the excessive action of the heart during life, there was no cardiac hypertrophy. "July 2, 1872.—Visited Colonel E. B. H., occupation, lawyer, fifty- three years of age, and of nervo-sanguine temperament. Has been afflicted with muscular rheumatism for ten years, contracted in military service in Virginia, in 1861 and 1862. Has been engaged in active business until within the past two weeks. He has at times been con- scious of rapid and forcible beating of the heart, increased by either 1 " Two Cases of Exophthalmic Goitre associated with Chronic Urticaria," Chicago Journal of Nervous and Mental Disease, October, 1875, p. 513. 794 CEREBRO-SPINAL DISEASES. physical or mental effort. During the past two months this has been steadily increasing in severity. He has had much pain in the abdomen for a long time. Has had a slight cough and expectoration for more than a year. " About six weeks ago he first observed a distinct enlargement of the thyroid gland. He remembered, however, that during the past year or more, he has had difficulty in buttoning his shirt-collar. " The gland is now two and a half inches in diameter, and very prom- inent. He has marked prominence of the eyes, giving to his features a staring, wild expression. (Fig. 109.) The eyeballs seem projected directly forward. There is no strabismus, nor perversion of sight. The eyelids are scarcely sufficient to cover the eyeballs. Slight compression returns Fig. 109. the eyes to their normal position in their sockets ; but upon removal of pressure they are immediately protruded to the extent of their former prominence. The lachrymal secretion is as free as usual. The action of the heart is exceedingly violent, its beating being distinctly observa- ble by the movements of the patient's clothing, and numbering 123 per minute. " Examination by percussion and with the stethoscope discloses no symptoms of hypertrophy nor evidence of valvular lesion. Area of pre- cordial dullness not increased. Distinct bellows-murmur is heard over the left ventricle—much more distinct over the arch of the aorta and left carotid. Fine venous murmur is heard over both thyroids, and distinct arterial impulse observed over abdominal aorta on palpation. EXOPHTHALMIC GOITRE. 795 Breathing is vesicular, respiration twenty per minute. The skin is pale, the face becoming flushed when under mental excitement. The lips and membrane lining the mouth exceedingly pallid. The bowels are constipated. The patient has slept very little during the past four months. He appears nervous and agitated. His hands are exceedingly tremulous. He has lately found it difficult to write legibly or to even hold a pen. " A saline cathartic was prescribed—one-sixtieth grain of aconitia, to be given every six hours. Diet to be light and nutritious. Quiet, mental and physical, was enjoined. " 3d.—Patient slept several hours last night. Bowels have acted freely. He feels better. Pulse, 120 per minute. « 5^.—Has rested well. Pulse, 100. Treatment continued. « ^th.—Pulse, 90 per minute. Has had short paroxysms of palpita- tion, but no pain. His appetite is poor. Treatment continued, with addition of citrate of iron and extract of gentian. "Qth.—Symptoms unchanged. Examination of urine shows its specific gravity to be 1019, and strongly acid. A few small tube-casts are noticed. Numerous small crystals of triple phosphate, quantity normal. Aconitia continued. Elixir pyro-phosphate of iron and cin- chona, one drachm before each meal. «12th.—Has slept better. Pulse, 95. No recurrence of palpitation. Appetite better. Protrusion of eyes less conspicuous. Patient rode out a short distance to-day. «15th.—Pulse, 100. Condition nearly same as before. Tempera- ture, 98° Fahr. Exophthalmia less marked. Gradual emaciation. «ient, remains in a more or less irritable state, during which it is par- ticularly liable to a fresh outbreak, and, even when this does not occur, it is quite common for the patient to be reminded, on any little extra excitation or exposure to cold, that he has a master ready on the least sign of rebellion to put the screws to his refractory subject. These remarks are applicable to all neuralgias, but they appear to me to be specially so to sciatica. Sometimes, even when the individual remains perfectly still and has committed no indiscretion, there are sharp, shooting pains, which follow the course of the sciatic nerve and its branches. The affection generally lasts two or three months, and is liable to recur. Causes.—The etiology of sciatica is not materially different from that of other neuralgias, except so far as it is modified by local circum- stances. Among these latter, are enlargement of the prostate gland, by which pressure is exerted on the nerve, various tumors of the ab- dominal organs, the pressure of the foetal head in childbirth, accumula- tions of faeces in the large intestine, etc. It is also occasionally in- duced by the pressure on the nerve which results from sitting long NEURAL HYPERESTHESIA. 833 on a hard chair. Several cases of this kind have come under my obser- vation. I have also noticed the fact that sciatica is often developed with great suddenness on the patient making some unusual exertion of the limb. In such cases the effort is probably only the spark which lights up the flame. The Diagnosis is not a matter of any difficulty, though I have many times seen cases mistaken for diseases of the spinal cord, and vice versa. The Prognosis depends greatly on the ability to remove the cause. Morbid Anatomy and Pathology.—The remarks which might be made under this head have already been expressed to some extent in the foregoing pages, and there is not much more that could be said without entering the domain of pure speculation. I may, however, state my opinion that neuralgia, not directly the result of some physi- cal cause interfering with the integrity of the nerve in which it is situ- ated, is almost invariably induced by a depressed state of the system. Its existence in such cases is evidence, therefore, of deficient physical stamina, and of the fact that the nervous system is not duly nourished. The remote factor may be malaria, syphilis, rheumatism, gout, or some other cause capable of lowering the vitality of the organism, and, as a consequence, that of the nerves. It is of course of the utmost importance with reference to the treatment, to ascertain whether there is, or is* not, any such constitutional taint, but, whatever the result of our inquiries in this direction, that system of therapeutics is best which, in addition to special medication, embraces restorative means. Treatment.—The measures which it is proper to employ in neu- ralgia may be divided into two categories, the constitutional and the local. Among the constitutional remedies must be included those which are for the correction of any taint which may be present. If there is reason to suspect the existence of syphilis, iodide of potassium is an indispensable remedy, and should be given in large doses. It is also advisable in rheumatic neuralgias, especially of the cervico-occipital region. If malaria can be ascertained to have exerted an influence, quinine must be administered; and, indeed, it is safe to act upon the theory that this has been the cause, unless some other can be clearly made out. It must be recollected that malaria may give rise to neu- ralgia, especially in the facial nerve, without there having been any other manifestation of its toxic effect; and that the affection is often cured by large doses of quinine, when the patient has not apparently been subjected to the malarious influence. Should there be no relief after three or four ten-grain doses of quinine, it should still not be de- cided that the disease is not of malarious origin, but the quinine .should 53 834 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. be given in still larger doses, as in Dr. Clinton Wagner's own case, in which fifty grains were taken in eight or ten hours.1 If there is still no improvement, arsenic should be administered. I have seen many cases of supraorbital neuralgia, undoubtedly the result of miasmatic poison- ing, effectually cured by arsenic, when quinine had failed. From my own experience, I am very well convinced that it acts much more effica- ciously when administered by hypodermic injection than by the stomach. Four drops of Fowler's solution, diluted with an equal quantity of water, should be given twice a day, and the quantity should be gradu- ally increased to eight or ten drops at a dose. Even in cases not malarious, arsenic will often be found to be a most valuable therapeutic agent. If a gouty diathesis is present, colchicum should be used ; and, if rheumatism be clearly made out, the blood should at once be rendered alkaline by liquor potassae. Whether any specific trouble be discovered or not, general tonics are always indicated ; among them cod-liver oil occupies the front rank, and iron is not far behind it in value ; strychnia is also very generally useful. Among constitutional remedies, ergot has proved of very de- cided benefit in my hands, and this especially in sciatica. It should be given in large doses, a drachm or more of the tincture three times a day. A full and nutritious diet is of great value in the treatment of neu- ralgia, as are likewise sunlight, and pure and fresh air. In addition to these purely constitutional measures, there are others which, though administered to act upon the system at large, are given for the purpose of arresting a paroxysm, or deadening sensibility, so as to prevent the pain being felt. The medicines embraced in this cate- gory are included among the stimulants, narcotics, and anaesthetics. Opium and its various preparations are preeminent as palliatives of the neuralgic paroxysm, and morphia stands first among them. It is most efficaciously administered hypodermically, in doses varying from one- sixth grain to half a grain, or even more in extreme cases. Great care should be exercised in its use, and the smaller quantity mentioned should not be exceeded except by regular gradations. It is immaterial in what part of the body the injection is made, so far as its influence over the pain is concerned. But in sciatica it appears to me to be advantageous to follow a plan of treatment which the size of the affected nerve renders admissible, and that is, the injection of morphia into the tissue of the nerve, or, if that should not be effected, as near to it as possible. The prepa- ration I use is a solution of the sulphate of morphia, consisting of ten 1 " Proceedings of the New York Neurological Society," Psychological Journal, Am- gu&t, 1874, p. 126. NEURAL HYPERESTHESIA. 835 grains of the salt to two drachms of water as proposed by Dr. Lawson.1 This mixture is partially solid at ordinary temperatures, and must be warmed before administration, so as to cause complete solution of the separated crystals. Every six minims of this solution contain one-half of a grain of the sulphate of morphia. Two minims, equivalent to the sixth of a grain, are sufficient for a first injection, and this may be gradually increased, if necessary, to half a grain. One injection a day is generally sufficient, but two may be required in extreme cases. Dr. Lawson carries the point of the syringe to the depth of an inch or an inch and a half, without regard to the nerve further than that he recom- mends the injection be given in its neighborhood. I think it is better, if possible, to strike the nerve with the point of the syringe, and then to inject. To do this is no difficult matter. Select a point on the pos- terior aspect of the thigh, about four inches below the trochanter ma- jor, and an inch exterior to the median line, push the point of the syringe perpendicularly, and at a depth varying from one to two inches the nerve will generally be reached, as will be evidenced by the pa- tient feeling a slight thrilling sensation in the parts below. Then the requisite quantity is to be injected, and the syringe withdrawn. If the nerve should not be touched, the injection may, nevertheless, be made. The effects of this treatment—especially if the injection be made into the nerve—are generally very decided at once. I have had pa- tients, who walked with the utmost difficulty, leave my consulting-room with an elastic step and free from pain a few minutes after such an in- jection has been made ; and others, who could not even turn in bed or move the affected limb, get up and walk about the room after a like period. The pain, however, usually returns, and the injection must be repeated, and in slightly larger doses. But the treatment is not only palliative ; it is often positively cura- tive. Dr. Lawson himseK was permanently cured by it, and many cases within my own experience have been equally successfully treated. In other neuralgias, notably in the cervico-brachial—brachialgia— and the dorso-intercostal—lumbago, and pleurodynia—it is also re- markably efficacious. Among other medicines of this class are belladonna, or its alkaloid atropia, Indian hemp, aconite, bromide of potassium, hydrate of chloral, hyoscyamus, conium, and some others of minor importance. Of very great value are chloroform and ether, administered by in- halation, and the various forms of alcoholic liquors. It not unfrequent- ly happens that an attack of neuralgia can be at once aborted by an ounce or two of whiskey or brandy, especially in a person not habitu- ated to their use. 1 "Sciatica, Lumbago, and Brachialgia," London, 1872, p. 93. Dr. Lawson uses the muriate of morphia, but, the sulphate being the compound generally employed in this country, I have made the change mentioned. 836 DISEASES OF THE PERIPHERAL NERVOUS SYSTEM. A somewhat different class of remedies for neuralgia are those which are either tonic to the nervous or general system, without, as quinine and arsenic, being antagonistic to malaria. Among these are strych- nia, phosphorus, and iron. Of these strychnia is, I think, most efficacious when administered hypodermically in doses of from the one forty-eighth grain to the one thirty-second grain twice daily ; or it may be given internally in some- what larger doses three times a day. I have long used phosphorus in the treatment of neuralgia. I at one time extensively employed the phosphoretted oil, but more recently have substituted the phosphide of zinc, which, I think, is altogether a preferable form for administration. The formula given on page 54 will fulfill every indication for phosphorus and strychnia. These two reme- dies are particularly beneficial in neuralgia occurring in persons who have exhausted the vital powers by dissipation and excesses of various kinds. Iron is especially valuable in cases of neuralgia due to, or accom- panied with, an anaemic condition of the system. Anstie speaks highly of the tincture of the chloride, and ascribes to it a marked and direct influence upon the nervous centres different from that produced by other preparations of the mineral. It should be given in doses of thirty or forty minims, properly diluted in water, three times a day. While recognizing the benefit to be derived from this agent, I have generally preferred the sesquioxide in powder, which can be taken without in- jury to the teeth or probability of stomach derangement. Large doses —twenty to forty grains three times a day—should be employed. The chief local means of treatment in neuralgia are counter-irritation —preferably in the form of repeated blisters, which should be applied over the course of the painful nerves, and which are especially valuable in sciatica—and the local application of tincture of aconite, and of ve- ratria in the form of an ointment, or an alcoholic or ethereal solution. Dr. W. II. Thomson,1 in a recent clinical lecture, ascribes very bene- ficial results to the local application of water of from 85° to 95° to the skin in cases of sciatica. He considers it especially useful in those in- stances in which the muscles are contracted. But, above all local means, not only for relieving the pain of any particular paroxysm, but also for effecting a permanent cure, electricity stands first. I have employed it in every possible form, and am satis- fied that the primary galvanic current is the preferable agent. Indeed, I very much doubt if the induced current, unless in a few cases, when the wire-brush has been employed, has ever, in my experience, accom- plished any very decided benefit. In the employment of the primary current, the positive pole should be applied over the seat of the pain, and not more than fifteen or twenty Smee's cells should be used. The 1 "On the Treatment of Sciatica," "American Clinical Lectures," vol. i., No. 6, 1875. NEURAL HYPERESTHESIA. 837 application should be continuous for at least half an hour, and should be repeated every day for several weeks, and in extreme cases longer. I have cured a number of severe cases of nearly every kind of neural- gia by the aid of electricity when other means had entirely failed. I rarely, however, employ it without at the same time insisting on such constitutional treatment as the case seems to require. I have several times used acupuncture with success, and have like- wise employed electro-puncture with decided benefit in ten cases of sciatica. In either operation the needles should be introduced at the most painful parts, and, when galvanism is also used, the current should be passed continuously through the needles. In a notable case of sci- atica which I saw in consultation with my friend Dr. John Gallaher, of this city, a severe attack was at once cut short by electro-puncture. Two or three cells will afford a current of sufficient tension. As to surgical operations on the affected nerves, either of section or excision of a portion of their continuity, the success which has hith- erto followed them has not been such as, in my opinion, to warrant their repetition. SECTION V. TOXIC DISEASES OF THE NEKVOUS SYSTEM. There are certain substances which, when taken into the body gradually and for a long time, manifest their poisonous influence more especially upon the nervous system. Among these, lead, alcohol, bro- mine, mercury, and arsenic, may be particularly mentioned. Several of these substances are used as slow poisons with criminal intent, others are habitually employed by many persons as stimulants, sedatives, or cosmetics, others are used in the arts, and hence enter the systems of those who are brought in contact with them, and some are prescribed in such doses in the treatment of disease as to produce upon the patient their characteristic physiological effects. It seems important that the peculiar phenomena which these sub- stances are capable of causing, with the rationale of their mode of ac- tion, and the treatment best adapted to obviate their deleterious effects, should receive some attention, and I shall therefore devote a few pages to their consideration. CHAPTER I. PLUMBISM Symptoms.—The phenomena manifested in the nervous system, as consequences of lead-poisoning, are lead-encephalopathy, paralysis, a spasmodic and painful affection called lead-colic, anaesthesia, and hy- peresthesia. a. Lead-Encephalopathy.—The symptoms referable to the brain, due to lead-poisoning, may be slight or severe. In the first case the PLUMBISM. 839 patient suffers from headache, vertigo, and various other abnormal sen- sations, such as fullness, and constriction, and is at the same time in- capable of much intellectual exertion without suffering an increase of his physical symptoms. His mind is irritable and depressed, and his sleep is usually disturbed with unpleasant dreams. The digestion is generally deranged, and the whole appearance may be cachectic. Tre- mor may exist, especially in the hands. It is generally not exten- sive, consisting ordinarily of slight tremulous movements, which, though present when the muscles are at rest, is more distinctly manifested when the muscles are put in voluntary action. This condition may undergo no further development, but it is often the precursory state of the more severe form'of the affection. In the severe form the symptoms may be manifested by delirium, convulsions, or coma, or by any two or all of these phenomena. This last was the case in a patient, a master-plumber, in whose case I was consulted in the summer of 1873. The attack began with acute deliri- um, lasting several days, and then alternating with paroxysms of con- vulsions. The seizure ended, after about two weeks, with profound coma of forty-eight hours' duration. In the delirious form the patient may either present the symptoms of acute mania with excitement, or there may be a melancholic condi- tion present. In either case there are illusions, hallucinations, and delusions. After a variable period a remission generally takes place, and this may go on to a complete disappearance of the symptoms, or be succeeded by a renewed exacerbation. . In the convulsive form, the paroxysms may or not be marked by loss of consciousness. They may be limited to a particular part of the body, as the face, neck, or arms, or they may be general. They may present somewhat the characteristics of tetanus or of epilepsy, or of both these diseases. In some cases the seizures are not distinguishable from idio- pathic epileptic attacks ; the patient has tonic and clonic convulsions, froths at the mouth, bites the tongue, may evacuate his urine or faeces, and passes into a soporous condition. Or there may be repeated at- tacks succeeding each other with such rapidity as to constitute a status epilepticus. In the comatose variety, the stupor is sometimes developed with great suddenness, but is not often so profound as to prevent occasional manifestations of partial sensibility. Thus, if the patient be spoken to in a loud voice he opens his eyes, or if the skin be pinched he withdraws the part or contorts the countenance. The pupils are generally dilated and insensible to light, and the cheeks and lips are puffed out in expiration. If, in cases in which these symptoms occur, the gums be examined, a blue line running along their margins will be discovered. Sometimes the whole extent of the gums is tinged, but generally the discolored portion is the edge in 840 TOXIC DISEASES OF THE NERVOUS SYSTEM. contact with the teeth, and about a line or at most two lines in width. Besides the discoloration, the tissue of the gums becomes soft and spongy, and it may become absorbed, leaving the roots of the teeth ex- posed. All these changes are more marked in the lower than in the upper jaw. The breath is usually of a peculiar odor, and, if what is called the lead-cachexia be present, the complexion is pale, the hair lustreless and dry, and the body emaciated. It not unfrequently happens that the individuals who suffer from lead-encephalopathy have also been the subjects of some one or more of the other manifestations of lead-poi- soning. b. Lead-Paralysis.—Symptoms.—Before the occurrence of paralysis, the patient has probably suffered from attacks of lead-colic, or some other affection due to lead-poisoning, though this is not invariably the case. The immediately precursory symptoms connected with the loss of power are slight numbness and tremors in the muscles of the upper extremities. Occasionally, the muscles of the trunk and lower extremi- ties become involved in the trembling. Ere long the patient observes that he has difficulty in extending the fingers or wrist, and that there is a general loss of strength in one or both hands. These symptoms go on increasing in severity, and eventually he loses the power to raise the hand or fingers. In extreme cases, the ability to extend the forearm, or to raise the arm from the side, is lost through the paralysis of the triceps and. deltoid, or, as in a case before my clinique, in. January, 1876, the biceps may be paralyzed. Occasion- ally, the extensors of the lower extremity are involved in the paraly- sis. The predominance of the loss of power in the extensors has led to the idea that they alone are affected. The dropping of the hand, the flexion of the forearm on the arm, the hanging of the arm against the side of the body, and, when the lower extremity is affected, the inability to raise the toes so as to avoid striking them aginst the ground in walk- ing, all give countenance to this supposition. But careful observation shows that the difference is merely one of degree, and that there is a very considerable loss of power in the flexor muscles. Indeed, of many cases of the disease that I have observed in hospital and private practice, I have never seen one in which the flexors were not implicated with the extensors. Owing to the disuse of the muscles, atrophy takes place, and this is frequently exceedingly well marked, and, from the disturbance of the normal equilibrium between the several groups of muscles, con- tractions and distortions ensue. The circulation in the affected limbs becomes languid and weak, and painful swellings result in consequence. It is generally supposed that the right arm is more apt to be af- fected than the left; such, however, does not appear to be the case. PLUMBISM. 841 Thus, Tanquerel des Planches,1 of seventy-nine cases in which the upper extremities were the seat of the paralysis, found both affected in fifty- one, the left twenty-three times, and the right twenty-four. Of thirty- two cases of lead-paralysis occurring in my own practice, the upper ex- tremities were affected in all; in twenty-seven both limbs were the seat; and, of the remaining five, three were in the left, and two in the right. The left upper extremity was therefore affected thirty times, and the right twenty-nine. In some cases, the muscles of respiration become very seriously paralyzed through the influence of lead, and death then soon takes place. In two of my cases there was aphonia, and in several the voice was materially weakened. Cases of hemiplegia, the result of lead-poi- soning, have been observed by Stoll, Andral, and Tanquerel des Planches. The electric sensibility and contractility are always greatly reduced in all cases of lead-paralysis. In the majority of cases, no faradaic cur- rent, which it is safe to employ, will produce contractions, and strong primary currents are necessary. The cutaneous sensibility is rarely impaired. The saturnine cachexia is almost always present, and the blue line on the gums can readily be distinguished. c. Lead- Colic.—This is probably the most common affection caused by the toxic influence of lead, and has been recognized from a very early period. Symptoms.—Lead-colic is particularly characterized by the presence of pain, the apparent seat of which is at or near the umbilicus, although it may exist at the epigastrium, the hypogastrium, or some other part of the abdomen. The character of the pain is somewhat peculiar, being a twisting sensation of great agony, which appears to revolve around the umbili- cus. In some cases the distress of the patient is extreme, and he gives utterance to loud cries of anguish, and tosses himself about with the utmost violence. Nausea and vomiting are generally present, and the bowels are almost invariably constipated. The respiration is ordinarily hurried and irregular, but the pulse, notwithstanding the physical and mental excitement, remains of its normal force, frequency, and rhythm, sometimes becoming markedly slower during the height of a paroxysm. The abdomen is usually hard and retracted, especially during the height of a paroxysm. Occasionally the abdomen is painful to the touch, and the suffering is aggravated by very slight pressure, but as a rule this is not the case. On the contrary, the pain, so far from being increased by pressure, is greatly relieved by it, especially if the force be exerted in a uniform 1 "Traite des maladies de plomb," Paris, 1839, tome ii., p. 39. 842 TOXIC DISEASES OF THE NERVOUS SYSTEM. and gradual manner. Patients often discover this fact for themselves, and will lie on the belly or press it with their hands, or beg that others will do so. The duration of a paroxysm is variable. It may last only a few minutes, or may be prolonged for an hour or more. A period of com- parative calm then ensues, during which the exhausted patient may sleep a little, but his slumber is soon disturbed by another seizure, and this sequence may continue for several days. Paroxysms are more com- mon and more severe during the night than the day, and sometimes the relation is observed with sidereal punctuality. In consequence of the treatment adopted, or spontaneously, the series of attacks is broken, and the patient, for the time at least, re- covers his ordinary state of health. It is exceedingly rare that death ensues from simple, uncomplicated lead-colic. d. Lead-Anaesthesia.—Anaesthesia, as a condition due to the toxic influence of lead, may exist without complication with other manifes- tations, although such ■ an event is not common. In the majority of cases it is the optic nerve which is affected, and as a consequence more or less complete blindness is produced. Some of the cases formerly reported were probably, as Stellwag1 observes, simply instances of ciliary paralysis, but this author admits the existence of an organic affection of the nerve, terminating in atrophy, and recognizable by the ophthalmoscope. Again, the anaesthesia may affect the skin of the trunk or extremi- ties, or the muscles of these parts. It is developed generally with great rapidity, reaching its height in a few hours. e. Lead-Hyperaesthesia.—The pains in the limbs and trunk are among the most common of the phenomena of lead-poisoning. The lower extremities are generally their seat, and by preference the flex- ures of the joints. Thus the groin and the popliteal space are favorite situations in the lower limbs; the axilla and bend of the elbow in the upper extremities. The back and thorax are also often affected, and sometimes the scalp, face, and neck. The pains may be either of a dull aching character, acute, like the sensation from the thrust of a sharp instrument, or hot, as if a coal of fire were in contact with the part. They occur in paroxysms, and are apparently excited by cold, movements, or emotional disturbance. Oc- casionally there are spasmodic contractions of the muscles of the painful part, either en masse, singly, or in the form of fibrillary contractions. Like the pains of lead-colic, they are generally relieved by steady and gradual pressure, but occasionally this is not the case, any kind of touch, light or heavy, causing an aggravation in their intensity. 1 " A Treatise on the Diseases of the Eye," Hackley and Roosa's translation, New York, 1868, p. 668. PLUMBISM. 843 There is no increased heat of the painful region, no redness or swell- ing, and the pulse is generally normal. In some cases the pains appear to be seated in the bones ; usually, however, the skin and muscles seem to be their situation. Causes.—The fact that such affections as those mentioned follow the introduction of lead into the system admits of no doubt. This intro- duction may take place through the stomach, the air-passages, or the skin. The two latter are the more common channels for contamina- tion. They are, of course, more frequently encountered among those who work in lead, such as lead-founders and smelters, the makers of white and red lead, painters, plumbers, printers, etc.; although they may occur among those who are only temporarily or accidentally exposed to the toxic influence. Thus, they may be caused by drinking water which has passed through lead pipes, or been kept in lead vessels, or by using to- bacco which has been wrapped in lead-foil. Two cases in which paral- ysis was produced by the latter cause have happened in my experience,1 and it is so common a cause that, in France, Belgium, and Prussia, strong laws have been passed against packing tobacco in lead. The use of hair-dyes containing lead is, I think, quite a common cause of plumbism. Three cases of paralysis and two of anaesthesia, in which this was the cause, have come under my observation, and I am inclined to think that a case in which there were vertigo, slight delirium, and one epileptic convulsion, owed its origination to the application of lead to the hair. The employment of powders and enamels to the face is a not infre- quent cause of plumbism in women, as most of those substances called cosmetics contain lead. Three cases of paralysis and one of pains in the body and limbs, caused by lead applied to the face, neck, and arms have occurred in my experience. The use of plasters and lotions containing lead has also been known to give rise to plumbism. The majority of cases, however, occur in this country in painters, probably for the reason that workers in white and red lead, though more exposed, are aware of their danger, and take effectual measures to prevent absorption. Though the carbonate is probably the most actively poisonous prep- aration of lead, it is very certain that all forms—not even excepting the sulphate—are capable of producing the characteristic phenomena of plumbism. Diagnosis.—The hjstory of the case, including a knowledge of the occupation of the patient, or of his exposure to the action of lead, will generally prevent error of diagnosis in regard to any of the manifes- 1 See my translation of Meyer's "Electricity in its Relations to Practical Medicine," New York, 1870, p. 181, for reference to other cases. 844 TOXIC DISEASES OF THE NERVOUS SYSTEM. tations of plumbism. The presence of the peculiar cachexia and the existence of the blue line around the gums will tend still further to ren- der the diagnosis accurate. Again, it has been ascertained, by the researches of Melsens, that the iodide of potassium has the faculty, when taken into the system, of de- composing the albuminates with which the lead is united, and of setting this substance free. It, then, at once appears in the urine, and can be detected by examination with sulphuretted hydrogen. A ready meth- od is that proposed by Reeves. A piece of sulphide of potassium is inclosed in a piece of thin white linen, and suspended in a vessel con- taining the urine suspected to contain the lead set free by the previous administration of the iodide of potassium. It is left there for five or six minutes. If the urine contains any salt of lead, it is decomposed, and the metal is deposited on the linen in the form of the sulphuret, staining it of a dark, almost black, color. As regards the several affections separately, it is to be remarked that most difficulty will be experienced relatively to the encephalopathy produced by lead. Jaccouda has pointed out that in the condition of the bodily temperature we have an additional point toward discrimi- nating between acute cerebro-spinal meningitis and the affection under notice. In the former the temperature rises to 104° Fahr., or even higher, while in the latter there is no augmentation, or at least a very slight rise. In lead-paralysis the fact that the loss of power mainly affects the extensors, especially those of the hand, together with the antecedents of t;he patient, and the presence of other evidence of plumbism, will generally suffice to render the diagnosis certain. I have recently, how- ever, had a case at my clinique at the University Medical College, in which there was some doubt. The patient had paralysis of the exten- sors of both wrists. Several weeks before its appearance he had broken his ankle, and had been obliged to walk on crutches. There was, there- fore, a question as to whether the case was one of " crutch-paralysis," from pressure, or of lead-paralysis. The man was a laborer, and had never, to his knowledge, been exposed to lead in any way. But the facts that there was no anaesthesia, that the paralysis was greatly pre- dominant in the extensors, and that the muscles of the arm above the elbow were not affected, decided me in concluding that the case was not one resulting from pressure on the brachial plexus. The further fact that there was a slight blue line visible along the gums convinced me that, notwithstanding the absence of any history of contamination by lead, the case was one of that disease. The patient was a beer-drinker, and might, I conceived, have become poisoned in that way, as had others in my experience. In lead-colic the character of the pain and its situation may be of a " Lecons de clinique medicale," Paris, 1869, p. 492. PLUMBISM. 845 service in the formation of a diagnosis, but the main reliance must be upon the antecedents of the patient, and the coexisting evidences of plumbism to which attention has already been directed. These circumstances are likewise what must govern us in lead-anaes- thesia and hyperaesthesia. Prognosis.—This is not unfavorable except as regards the cerebral manifestations, provided the patient can be submitted to proper treat- ment and removed from all exposure to lead-poisoning. Lead-encepha- lopathy is the most serious of all the forms of plumbism, and this is es- pecially the case when there is a combination of delirium, convulsions, and coma. Of seventy-two cases observed by Tanquerel des Planches, sixteen were fatal. It was probably more apt to terminate in death in his day than now, when the hygienic and therapeutical relations of plumbism are better understood. Recovery ensued in all of the cases occurring in my experience. In lead-paralysis the prospect of recovery depends altogether on the ability to produce contractions in the paralyzed muscles by electricity. If the induced current will effect them, the cure will be rapid ; if the interrupted primary current is required, a longer time must elapse be- fore success is attained ; but, if the muscles will not react to either the induced or primary currents, a favorable result is not to be expected. The extent of the atrophy is also an important element in the prog- nosis. In lead-colic, hyperaesthesia, and anaesthesia, the prospect of recov- ery is good, provided the necessary hygienic and therapeutical indica- tions can be fulfilled. Morbid Anatomy and Pathology.—Very little is known relative to the morbid anatomy of plumbic affections. In the several forms with which we are acquainted, the nervous system rarely presents evidences of any lesion which can be regarded as characteristic. In some cases of lead-encephalopathy, however, there has been found a flattened, indu- rated, and atrophied condition of the brain, and in others the indications of inflammation and softening. In the case of a painter who had suf- fered from repeated attacks of lead-colic, and who finally died with head-symptoms—delirium, epilepsy—reported by MM. Gueneau de Mus- sy and L6maire, the post-mortem examination showed the existence of a large extravasation, which had broken through the cerebral tissue from the circumference to the fourth ventricle. Gombault1 recently reported a case of lead-paralysis, in which, on post-mortem examination, the spinal cord and the nerve-roots were found to be unaltered, but in some of the peripheral nerves the medul- lary substance was separated into granules, though the axis-cylinder was normal. 1 Archives de physiologie, 1873. 846 TOXIC DISEASES OF THE NERVOUS SYSTEM. Westphalx has discovered, in a case of lead-paralysis, a similar con- dition of the radial nerve. In this case the spinal cord and the nerve- roots were unchanged. In a case of lead-poisoning in which there had been, during life, colic, vomiting, diarrhoea, and finally collapse, Kussmaul and Maiera found sclerosis of the cceliac and superior cervical ganglia of the sympathetic and periarteritis in the brain and spinal cord. Lead has been detected, in cases of plumbism, in the tissue of the brain, spinal cord, and nerves. In fact, it appears to have a special affinity for the nerve-substance. It is probable that, except in extreme cases, or in very exceptional instances, the changes in the brain, spinal cord, nerves, and sympa- thetic system are not such as are discoverable by our present means of research, just as are the alterations produced by opium, alcohol, hydro- cyanic acid, strychnia, and other substances. The muscles, in cases of lead-paralysis, have been examined by An- dral,3 Gendrin,4 Tanquerel des Planches,6 and others, and analogous results obtained. The fibres have been found to be pale and yellowish, to be friable, atrophied, and desiccated. I have repeatedly removed small portions with Duchenne's trocar, and have always found the transverse striae disappearing, and fatty degeneration making its ap- pearance. The hypothesis, that the affection is, primarily, one of the muscles, is not supported by facts. Such a thing as muscular paralysis, inde- pendent of nervous derangement somewhere, is unknown in the whole range of pathology. And those cases of apparent loss of muscular irritability, resulting from certain poisons, adduced by Longet, Bernard, Mitchell, myself, and others, were simply instances in which the loss of nervous irritability took place from the periphery to the centre. The present state of our neurological knowledge is altogether against the idea of muscular irritability independent of the nerves. When a mus- cle is no longer capable of contracting, it is because the nerves are dead. Facts, too, are against the notion that the lead acts by contact with the muscles, and the circumstance of the paralysis occurring so gener- ally in the hands of painters, for instance, is adduced in proof. But we have seen that the left hand is just as frequently affected as the right, while it is certainly less in contact with the lead. Moreover, those cases of paralysis in the extensors of the hand which have resulted 1 Archiv fur Psychiatrie, Band iv., 1874. 2 Deutsches Archiv fur klin. Med., Band ix., H. 2. 3 " Clinique Mddicale," tome ii., p. 227. 4 " Maladies de l'encSphale," par Abercrombie, traduction, second Edition, p. 576 ? Op. cit, pp. 77, 144, 149. PLUMBISM. 847 from hair-dyes and other cosmetics, are altogether against the hypothe- sis in question. In cases of lead-colic there appear to be no anatomical changes in the intestines which can be reasonably associated with the phenomena of the disease as their cause. Treatment.—In the treatment of plumbism there are certain princi- ples to be acted upon in all the affections embraced within its limits. One of these, the prophylaxis, belongs to the domain of hygiene, and therefore need not be here considered; the other, the removal of the lead from the system, demands our first care. The researches of Melsens have shown that in the iodide of potas- sium we have an agent which separates the lead contained in the tis- sues from its combinations, and forms with it an iodide of lead, under which form it is excreted from the organism by the kidneys. Some authors advise caution in the use of the iodide of potassium, on the ground that the resulting compound is very poisonous, and may produce highly-deleterious effects. In a great many cases of lead-pa- ralysis and other consequences of lead-poisoning in which I have given the iodide, I have never seen the least untoward result, and I always use it in large doses from the beginning. In many cases the lead can be readily detected in the urine, and the blue line around the gums disappears quickly under its use. If there is great debility, or if the cachexia be marked, iron, quinine, and strychnia, may be employed with advantage. In the treatment of lead-encephalopathy, the free administration of the iodide of potassium combined with the bromide affords the best prospect of success. In attacks of lead-colic, the hypodermic injection of morphia, in doses sufficient to keep the pain in check while the iodide of potassium is doing its work, with an occasional purgative, will generally be all the treatment required. But in lead-paralysis the loss of power remains, and would continue indefinitely, without the use of measures directed specially against it : chief among these is electricity. The induced current, if it will cause the muscles to contract, is to be preferred. Each paralyzed muscle must be acted on for two or three minutes every alternate day, so that for both upper extremities the duration of a stance would vary from a half to three-quarters of an hour. In ordinary cases two months will suffice to effect a cure. But it often happens that the electric contractility of the paralyzed muscles is so completely abolished that the induced current is without effect. In such cases the primary interrupted current must be used, and continued till, as will eventually be the case, the induced current causes contractions. I have never seen a case in which the primary current would not produce contractions. One of the worst examples 848 TOXIC DISEASES OF THE NERVOUS SYSTEM. of the affection in question I ever saw was the patient who formed the subject of a clinical lecture to the class at the Bellevue Hospital Medi- cal College.1 His improvement under the circumstances was rapid, and he eventually was able to earn his living again. Induced currents of great power failed to produce contractions, and but for the use of the primary current he would have been incurable. If the primary current fails to act on the muscles, success is out of the question. In addition to electricity, frictions, kneading the muscles, and pas- sive exercise, are useful. Contractions may be overcome by suitable prothetic apparatus. In a case under the care of Prof. Sayre, and which I had the opportunity of seeing, the patient, a young lady, was able to play the piano—though paralyzed in both hands—by means of an admirable ap- pliance devised by Dr. E. D. Hudson, of this city. In the treatment of lead-anaesthesia and hyperaesthesia, the iodide of potassium conjoined with the use of the galvanic or faradaic current to the affected parts will generally prove sufficient to effect a cure. CHAPTER II. ALCOHOLISM. Alcoholism—under which term I do not now propose to embrace the condition called drunkenness, the immediate result of the ingestion of a large quantity of alcohol—is exhibited under two somewhat differ- ent forms. One of them is the permanent state which exists in persons who habitually imbibe excessive amounts of alcohol, and is known as chronic alcoholic intoxication or chronic alcoholism. The other is a paroxysm, the result of still greater excess, or the sudden stoppage of the stimulus to which the system has become habituated, and is desig- nated by various names, such as delirium tremens, mania apotu, or more properly acute alcoholism. a. Chronic Alcoholism.—The attention of the medical profession was first prominently directed to the subject of chronic alcoholism by Dr. Magnus Huss,2 of Stockholm, in 1849. In my description of the 1 Journal of Psychological Medicine, January, 1871, p. 43. 2 Dr. Huss's work, being printed in Swedish, is to a great extent unread outside of Scan- dinavia. Two very excellent articles, embracing a full synopsis of his work, were pub- lished in the British and Foreign Medico-Chirurgical Review, in 1851 and 1852. I shall also draw largely from an address on " The Effects of Alcohol upon the Nervous System," which I delivered May 4, 1874, on assuming the presidency of the New York Neurological Society, and which was published in the Psychological and Medico-Legal Journal, for July, 1874. ALCOHOLISM. 849 disorder, I shall, to a great extent, avail myself of his thorough obser- vations. Symptoms.—In one group of cases resulting from the long use of intoxicating liquors, the principal manifestations of the disease relate to the muscular system. Tremor and unsteadiness, especially of the up- per extremities, are among the first symptoms. Subsequently the lower limbs are affected, and then the muscles of the trunk. These phenom- ena are most marked in the morning, before the patient has had his accustomed dram. In other cases the tremor is not a very prominent feature, though, as far as my experience goes—and it is by no means inconsiderable— no patient with the disorder in question is free from a tremulous agita- tion of his muscles when he attempts to make a voluntary movement. But it may not be well marked, and, instead of it, the individual observes that he cannot hold things as well as he once did. Objects which he takes hold of fall from his hands without his being able to retain them. If he does exert himseK to avoid this inconvenience, the hands are seized with an involuntary trembling, which he calls " nervousness," and which he endeavors to cure by fresh potations. From this feeble- ness or paresis the distance to paralysis is not great. I had, not long ago, a case under my charge in which the patient, a gentleman of admitted eminence in his profession, clearly suffering from chronic alcoholism, could hold nothing in his hands unless he kept his eyes fixed upon them. The moment he ceased to look, the object fell to the ground. In the present treatise I have referred to several in- stances of this curious condition which were due to other causes. The lower extremities eventually become affected, and the patient may entirely lose the power of locomotion. The nerves of sensation also become involved, and there are various abnormal feelings, consti- tuting one or more of the forms of anaesthesia. Vertigo and dimness of vision may also be present. This type of the disease Dr. Huss calls the paralytic. In the next form, or the anaesthetic, the phenomena are more di- rectly connected with perverted or lost sensibility from the outset. The extremities first become affected, and subsequently the central parts of the body. In the beginning the patient experiences a difficulty in de- termining from the feel the nature of the object he has laid hold of, or against which his foot may have struck. But in a more advanced stage he loses all sense of pain, and pins may be thrust into his skin, or a coal of fire dropped upon it without his experiencing any discomfort. With the anaesthesia there is always loss of motor power. The aesthesiometer, the application of which instrument to practical medicine is of more recent date than Dr. Huss's observations, enables us to detect incipient loss of sensibility at a very early stage of the affection. 54 850 TOXIC DISEASES OF THE NERVOUS SYSTEM. Symptoms connected with this category of cases which I have no- ticed, but which are not alluded to by Dr. Huss, are that the senses of sight, hearing, smell, and taste, are also often involved. Another singular phenomenon which I have observed in these cases, which is referred to by Magnan,1 and also quite recently by Virenque," is that the loss of sensation involves only one lateral half of the body. This hemi-anaesthesia is met with in several other morbid conditions, notably as we have seen in hysteria. The other special senses are gen- erally implicated. Thus the patient loses the sight of one eye ; cannot hear with one ear ; can taste the most strongly sapid substances with only one half of the tongue, and perceive the most penetrating odors with only one nostril. In one case cited by Magnan, the patient, who had long been addicted to the excessive use of alcoholic liquors, and subsequently to the use of absinthe, had hallucinations and delusions in addition to the hemi-anaesthesia, and, what is unusual, complete loss of sensation in the cornea of one eye, although tears were excited in both eyes when the affected one was touched by the finger. In the third form of chronic alcoholism, convulsions constitute a prominent feature, though they are not generally among the first symp- toms. I have, however, witnessed several cases in which epileptiform seizures were the immediate and direct consequence of the excessive use of alcoholic liquors, and in which there had been no well-marked premonitory symptoms. But in the great majority of instances there are derangements of motility and of sensibility, such as have just been described, and then the gradual supervention of convulsive jerkings of the muscles, similar to those which occur in convulsive tremor and chorea, combined with painful tonic contractions or cramps. After a time the spasms are accompanied with loss of consciousness, and hence are more truly epileptic in character. Dr. Huss noticed that as the condition of chronic alcoholism became more profound there was a ten- dency toward the disappearance of the convulsions, and that at last they ceased entirely. In the next and last variety of the affection there is a general hyper- aesthetic condition of the skin and other special organs of the senses. The least touch causes intense pain ; bright lights are unendurable, and even the diffused light of a moderately illuminated room is pain- ful. Very gentle noises cause great discomfort, and loud sounds are agonizing. Even the smell and taste are exaggerated, and occasionally perverted to the extent of illusions. In whatever form chronic alcoholic intoxication may manifest itself, there are occasionally notable symptoms present which do not con- 1 " De l'alcoolisme, des diverses formes, du desire alcoolique et de leur traitement," Paris, 1874. 2 " De la perte de la sensibilite gdnerale et speViale d'un c6t6 du corps," etc., Paris, 1874. ALCOHOLISM. 851 stitute ordinary features of the disease. Thus there may be double vision, from paralysis of one of the ocular muscles, usually the internal rectus, in which case there is ptosis also ; or the muscles concerned in articulation are involved, and speech becomes imperfect or impossible ; or those by which swallowing is effected are paralyzed, or there is vio- lent palpitation of the heart, or intense neuralgic pain in one or more parts of the body. To touch on all these complications would require more space than I have at my disposal. But the mental symptoms which form more or less prominent characteristics of all cases of chronic alcoholism require a somewhat extended notice. The perceptions, the emotions, the intellect, and the will, are all implicated to a greater or less extent. Attention has already been called to the aberrations of the perceptions constituting illusions and hallucinations. The emotions assume an undue prominence, especially those of a sorrowful character, and thus the individual becomes maudlin, a condition which I should describe as consisting in a disposition to lament and shed tears over imaginary or greatly exaggerated griefs. It is rarely the case in my experience that the subject of chronic alcoholism is changed from a peaceable to a quarrelsome person, or from a timid to a brave one. The alteration is almost always in the other direction. At the same time it is not to be denied that individuals, whose passions are vicious and not held in complete subjection, are rendered still more vicious and uncontrollable by chronic alcoholism. Perhaps the most characteristic feature, as regards the emotions which persons suffering from the dis- ease in question exhibit, is irritability of temper. This is shown in the fact that slight circumstances, which in a state of health would cause no annoyance, now give rise to great vexation. At the same time, though there is not, as I have said, much tendency to quarrelsomeness, there is nevertheless a proneness to take offense, and to regard, as slights and insults, acts which have no bearing in that direction. Again, there is intense melancholy, without the existence of delu- sions, and during which the individual may attempt suicide ; or there may be indefinable fear, despair, terror, or shame, leading to the perpe- tration of self-destruction. The more purely intellectual qualities of the mind rarely escape being involved in the general disturbance. The power of application, of appreciating the bearing of facts, of drawing distinctions, of exercis- ing the judgment aright, and even of comprehension, are all more or less impaired. The sense of right and justice which the individual may have had is so weakened or destroyed that he will lie, steal, murder, or com- mit other outrages, even when there is no provocation. Indeed, the existence of motive is generally a counteracting circumstance. The memory is among the first faculties to suffer. But in addition to these evidences of mental deterioration there may be actual aberration of mind, as shown by the existence of delusions. 852 TOXIC DISEASES OF THE NERVOUS SYSTEM. These are generally of a depressing character, and may or may not have their origin in false perceptions of the senses. These delusions may prompt to suicide or other act of violence. The will is always lessened in force and activity. The ability to determine between two or more alternatives, to resolve to act when action is necessary, no longer exists in full power, and the individual becomes vacillating, uncertain, the prey to his various passions, and to the influence of vicious counsels. With these troubles of the mind there are almost invariably head- ache, vertigo, and persistent wakefulness, all of which give evidence of the extent to which the nervous system is affected. All writers of systematic treatises upon insanity have called atten- tion to the frequency with which mental aberration is caused by the excessive use of alcoholic liquors, but, in a recent monograph, M. Mar- faingl has given some interesting data relative to the characteristics of the insanity produced by alcoholism. Thus, he has observed that the hallucinations and delusions are almost always of a painful character. The patient sees frightful or repulsive objects, armed men or horrible animals; he sees persons lying in wait for him, or a thousand obstacles are interposed between him and his desires; he hears menacing voices, and the supplications of his friends for help from dangers which en- compass them. Occasionally, however, the imaginings are of a more pleasant char- acter. He is surrounded with flowers and fountains ; beautiful women are his companions, and, though his generative power may be entirely extinct, he brags of his conquests, and the favors which are showered upon him. Another characteristic of the hallucinations and delusions of the mania of alcoholism is, their changeability. Scarcely has he expressed one delirious conception when another is uttered, and so on for days at a time. A somewhat peculiar variety of chronic alcoholism is that produced by the drinking of absinthe, a habit which prevails to a great extent in France, and which, though barely naturalized in this country, has a large and increasing number of votaries. The condition in question has been well studied by M. Magnan9 by experiments on the lower animals as well as by observations in man. The main fact appears to be that absinthe has an especial proclivity to produce epileptic convulsions, in addition to causing the other phenom- ena due to the highly-concentrated alcohol it contains. Death may ensue in chronic alcoholism, from the accompanying 1 "De l'alcoolisme considere dans ses rapports avec l'ali^nation mentale," Paris, 1875. * " Etude experimentale et clinique sur l'alcoolisme," Paris, 1871; also " De l'alcoo- lisme," Paris, 1874. ALCOHOLISM. 853 morbid conditions, induced in the brain or other parts of the nervous system ; from exhaustion, owing to the direct effects of the poison, or to the inability of the stomach to digest, and the assimilative organs to ap- propriate the food taken ; or, as is commonly the case, from the super- vention of some intercurrent affection to which, owing to the depressed condition of the system, the patient is particularly liable. b. Acute Alcoholic Intoxication, Delirium Tremens. Symptoms.— Among the first symptoms of acute alcoholism, gastric and intestinal derangements are to be noticed. Thus there are anorexia, nausea, and vomiting, especially in the morning, and either diarrhoea or obstinate constipation, and the tongue is furred and dry. The pulse is usually rapid and feeble, the skin cold and clammy, and the general powers of the system much reduced. The sleep is deficient in amount and is dis- turbed by frightful dreams, and there are often vertigo, headache, and confusion of ideas. At a very early period tremor is present, and is especially manifested in the tongue, which, when protruded from the mouth, cannot be held steady, and the continual action of which is further shown in the de- fective articulation which always exists. The upper extremities and sometimes the head are also the seat of tremulous movements. These symptoms gradually increase in intensity, and other phenom- ena are soon developed. The countenance assumes a wild expression, the manner becomes hurried and anxious, the illusions, hallucinations, and delusions, become more vivid, and they are almost invariably of a terrifying character. Frightful objects, such as reptiles, demons, and other horrible figures, are perceived, and the patient covers his head in the bedclothes in the vain endeavor to shut out the sight of them, or may even commit suicide in the effort to escape from the imaginary dangers which threaten him. Hallucinations of the other senses are also sometimes present. The temper becomes still more irritable, and the motility is increased to an extreme degree. Sleep is no longer pos- sible, and day and night the visions and delusions are ever present in some form or other. The body becomes hot, but the extremities still remain cold and clammy. The pulse ranges from 100 to 120 or more, and is small and weak. The urine is scanty and high-colored, the bow- els constipated. During all this period the patient talks incessantly, generally with reference to his hallucinations and delusions. These latter, though well marked, and constant, are, like his erroneous perceptions, changeable ; and it rarely happens that they cannot, for the moment at least, be dissipated by a few words from those around. The pupils are usually strongly contracted, and if the fundus of the eye be examined with the ophthalmoscope,- the disk and retina will be found congested. Dr. Clifford Allbutt' states that he makes it a rule 1 " On the Use of the Ophthalmoscope in Diseases of the Nervous System," London and New York, 1871, p. 258. 854 TOXIC DISEASES OF THE NERVOUS SYSTEM. to examine the fundus in all cases of delirium tremens which come un- der his observation, and that in the great majority of cases he finds congestion and opalescence of the disk, and full retinal veins. In some cases—especially in those which are the direct result of the excessive use of alcoholic liquors, and not the consequence of a sudden deprivation of an accustomed stimulus—convulsions of an epileptiform character may occur ; usually these are repeated again and again. Death may take place during their continuance, and they always add greatly to the gravity of the situation. An attack of acute alcoholism lasts ordinarily for from three to five days. If recovery is to ensue the patient obtains a little sleep, and awakes with a decided mitigation in the violence of all his symptoms. If, on the contrary, death is to result, his physical powers become rap- idly exhausted, the delirium becomes low and muttering, he picks at the bedclothes, he passes into a state of coma, the pulse rises still higher in frequency, while it becomes correspondingly weaker, the bodily tem- perature falls, and he gradually sinks or dies from a renewal of the con- vulsive seizures. Causes.—Though the abuse of alcohol as a beverage is the essential cause of alcoholism, chronic or acute, it is not to be supposed that these conditions are induced in all persons who use alcoholic liquors to ex- cess. Some individuals are not only able to indulge to an extreme degree with impunity, but may even live to old age in the enjoyment of apparent good health. Indeed, when Huss published the results of his observations, it was strongly questioned whether the sj'mptoms which he had noticed were not due to the impurities which the whiskey generally used by the lower classes in Sweden is known to contain, rather than to alcohol. Huss admits that since liquor made from potatoes came into use, and especially since it has been distilled from rotten po- tatoes, chronic alcoholism has become much more frequent. This was attributed to the fusel-oil and a peculiar substance called stick y but it was ascertained that, though these substances may have aggravated the symptoms, they were, in the main, produced by the alcohol. Many will doubtless call to mind that in this country a like charge has been made against fusel-oil, and that even strychnia has had the reputation of poisoning whiskey and inducing most of the evil effects of exces- sive alcoholic potations. It is very certain, however, that alcoholic intoxication very rarely, if ever, ensues on the moderate use of the light German or French wines, or of those made in this country, when they are not fortified by the subsequent addition of spirit, and that it is still less apt to occur from the temperate use of malt liquors. In those countries in which wine or beer is the chief alcoholic bev- erage, the peculiar conditions which have been described are rarely met with. Thus Niemeyer omitted from the earlier editions of his work on ALCOHOLISM. 855 the " Practice of Medicine " all reference to either chronic or acute alco- holism, and a chapter was afterward specially added in order to render the work more useful to American and English physicians, for whom it was translated by Dr. C. E. Hackley, of this city. In France, also, be- fore the recent increase in the consumption of the stronger alcoholic liquors and absinthe, neither form of the affection under notice had attracted much attention. Marfaing begins his monograph, to which reference has already been made, with the statement that previous to the last twenty-five years alcoholism was hardly known. But in the northern European countries, in Great Britain, and in the United States, where whiskey, gin, rum, and brandy, have been the more common forms under which alcohol has been ingested, delirium tremens has always been a prominent disease, and the chronic form doubtless existed long before Huss pointed out the features by which it was to be recognized. It appears, therefore, that what are called the spirituous liquors are more powerful in causing alcoholism than either the malt or vinous. This is probably due to the facts that more alcohol is imbibed with the former than the latter, more than can promptly be eliminated, and that, owing to its concentrated form, greater derangement of the tissues, with which it comes in contact, is produced. It is thus with alcohol as with all other powerful agents taken into the system. That acute alcoholism or delirium tremens results directly from the excessive ingestion of alcohol is admitted by all writers on the subject, but they are not so generally agreed that it may ensue indirectly from such excessive use, by the individual being suddenly deprived of the ac- customed stimulus. Thus Aitken ' denies in very positive terms that delirium tremens may occur as a consequence of cessation from drink- ing, but to my mind any one who has seen the disease in soldiers, sail- ors, or prisoners, will be slow to confirm his statements. I have fre- quently seen delirium tremens occur in soldiers whose debauches have been suddenly interrupted by confinement in the guard-house, and I am quite sure that most army, and navy, and prison medical officers have had similar experience. Watson,3 on the other hand, assigns no other cause than that the " habitual stimulus has been diminished or abandoned ; " but he subsequently, without seeming to notice the bearing of the case, • refers to an instance in which the patient was constantly under the influ- ence of alcoholic liquor. Dr. Flint,3 however, distinctly recognizes this dual causation, but the fact does not appear to influence his views of pathology or treatment. 1 " The Science and Practice of Medicine," third American edition, vol. ii., p. 847, Philadelphia, 1872. 2 "Lectures on the Principles and Practice of Physic," American edition, Philadel- phia, 1872, vol. i., p. 347. 3 " A Treatise on the Principles and Practice of Medicine," third edition, Philadel- phia, 1868, p. 735. 856 TOXIC DISEASES OF THE NERVOUS SYSTEM. The one form occurs at the height of an alcoholic debauch ; the other results when the system, habituated to large and repeated doses of alcohol, is suddenly deprived of a stimulus to which it has become thoroughly habituated. We see a like condition induced in those who, having become accustomed to the ingestion of opium, suddenly or too rapidly leave off the use of the drug. In their therapeutical relations the distinction between these two modes of causation is, as we shall hereafter see, important. Diagnosis.—The clinical history as well as the peculiar symptoms will prevent any mistake being made relative to the real character of a case of alcoholic intoxication, either chronic or acute. Prognosis.—The chronic form is generally successfully treated if the patient can be made to abstain from the further use of alcohol. A paroxysm of the acute form is also usually recovered from, provided there have not been many previous attacks. The occurrence of con- vulsions is, however, a serious complication, and almost invariably cases in which they take place terminate fatally. If the patient abstains from the further excessive use of alcohol, it is not at all probable that other attacks will ensue. Of course, these remarks refer to alcoholism, and not to the lesions in the stomach, liver, intestines, heart, and other organs, which may have resulted from the abuse of alcoholic liquors, but which are not directly connected with the nervous system. Morbid Anatomy and Pathology.—The most common patho-ana- tomical condition of the nervous system met with in cases of alcoholism, chronic or acute, is congestion of the cerebral meninges and of the sub- stance of the brain. This alteration is especially liable to affect the vertical surface. An effusion of serum is a general concomitant, partic- ularly in the acute form of the disease—and this may be either in the subarachnoid space or in the ventricles. At a later period, if the ex- cesses be continued, the dura mater may become chronically congested, and eventually pachymeningitis and haematoma are developed. Or the repeated or continual congestion of the pia mater and arachnoid may result in the production of a chronic inflammatory pro- cess, attended with thickening and opalescence of these membranes. The vessels, especially the veins, are gorged with blood, and there may be various morbid products, such as serum, pus, or sero-pus effused. The brain, however, presents the most characteristic alterations. These appear to be the result of irritation and degeneration, the latter process consisting of a granular or fatty disintegration of the cerebral tissue, generally most marked in the cortical substance. Dr. John C. Peters,1 of New York, was among the first to make careful and systematic observations of the post-mortem appearance of 1 " On the Pathological Effects of Alcohol," New York Journal of Medicine, vol. Hi., 1844, p. 335. ALCOHOLISM. 857 individuals who had died from the excessive use of ardent spirits. As regards the brain, he found that " invariably there was present more or less congestion of the scalp and of the membranes of the brain, with considerable serous effusion under the arachnoid, while the substance of the brain was unusually white and firm, as if it had lain in alcohol for an hour or two, and the ventricles were quite empty. In not more than eight or ten instances did we find more red spots upon the cut surface of the brain than usual. The peculiar firmness of the brain was noticed several times, even when decomposition of the rest of the body had made considerable advance." Such changes as are described cannot result entirely from conges- tion, but must be ascribed, in great part, to the direct action by contact of alcohol on the brain-substance. It will presently be shown how strong is the affinity of alcohol for this tissue. As Carpenter' remarks, alcohol passes into the brain and changes both its chemical and physi- cal properties. It would be strange indeed, therefore, if with alteration of structure there were not also aberrations of function. The experiments of Dr. Percy a have often been brought forward as proving something in regard to alcohol which was not true of any other substance. This observer injected strong alcohol into the stomachs of dogs. The quantity varied from two to six ounces. Death followed, and upon examining the blood and brain for alcohol it was always found. The presence of alcohol in the blood and brain, to those who look superficially or ignorantly at the matter, has rather a horrible aspect; but when we know that there is no substance capable of being absorbed by the stomach and intestines which cannot also, by proper means, be detected in the blood and viscera, the subject loses much of its striking character. Dr. Percy used alcohol of 850° specific gravity, which represents a mixture containing about eighty per cent, of absolute alcohol. As the strongest brandy and whiskey contain but about fifty- four per cent, of alcohol, the concentrated character of the liquor used by Dr. Percy is at once seen. In one case six ounces were injected into the stomach of a dog, a quantity amply sufficient to cause death in an adult man. Many other physiologists have detected alcohol in the blood and viscera of animals after its ingestion into the stomach. I have several times performed experiments with reference to this point, and have never failed to recognize the presence of alcohol in the blood, brain, the stomach, expired air, and urine of dogs to which I had administered strong alcohol; but, when using liquors containing from eight to fifteen per cent, of alcohol, such as the German, French, and 1 " On the Use and Abuse of Alcoholic Liquors in Health and Disease," London, 1870. 2 " An Experimental Inquiry concerning the Presence of Alcohol in the Ventricles of the Brain," etc., London, 1839. 858 TOXIC DISEASES OF THE NERVOUS SYSTEM. Spanish wines, I have never been able to find it in the solids, though detecting it readily in the products of respiration. It is not to be doubted, therefore, that alcohol, like other sub- stances, is absorbed into the blood, and exerts its influence on the sys- tem through the medium of this fluid. Pure alcohol is a violent poison. In the dose of less than one ounce I have seen it cause death in a medium-sized dog, and many cases are on record of fatal effects being immediately produced in the human subject after comparatively small quantities have been swallowed. When diluted, its effects are not so rapidly manifested, and from this form, when taken in sufficient quantity, the condition known as intoxi- cation is produced. Previous to this point being reached the nervous and circulatory systems become excited, the mental faculties are more active, the heart beats fuller and more rapidly, the face becomes flushed, and the senses are rendered more acute in their operation. If now the further ingestion be stopped, the organism soon returns to its former condition, without any feeling of depression being experienced ; but, if the potations are continued, the complete command of the facul- ties is lost, and a condition of temporary insanity is produced. If further quantities be imbibed, a state of prostration, marked by coma and complete abolition of the power of sensation and motion, follows. Such is a brief outline of the obvious symptoms which ensue upon the use of alcoholic liquors in considerable quantities. When taken in amounts less than are sufficient to induce any marked effect upon the circulatory and nervous systems, there is, nevertheless, an influence which is felt by the individual, and which is mildly excitatory of the mental and intellectual faculties. The very important physiological relations of alcohol scarcely come within the scope of this treatise ; but the pathological conditions which result from it are of importance in the present connection, and may therefore profitably engage a share of our attention. The general action of a large dose of this substance is shown in the following experiment : I caused a dog to take into its stomach three ounces of strong alco- hol, diluted with a corresponding quantity of water. Immediately on receiving it, the animal retired to a corner of the room and lay down. At the end of five minutes I endeavored to make it walk about the apartment, but it did so with evident reluctance, though up to this time the gait was not staggering. I should have stated that I detected alcohol in the expired air in forty-eight seconds after administering the liquid. After eight minutes the dog walked with some difficulty, and on carefully examining the gait I found that the posterior extremities were beginning to be paralyzed. This paralysis gradually increased, the gait became more and more staggering, and at the end of fourteen minutes ALCOHOLISM. 859 the animal could no longer stand. The paralysis had now reached the anterior extremities. Sensibility was still present, though evidently lessened in acuteness; loud noises were perceived, and the eyes were involuntarily closed when the motion of striking was made before them. The respiration was hurried, and the action of the heart was greatly accelerated. The pupils were at first contracted, but became dilated in about fif- teen minutes, and remained in that condition throughout the experiment. • In thirty minutes the animal was in a state of profound coma. Sensi- bility, even of the cornea, was abolished; the limbs were in a state of com- plete resolution; the respiration was hurried; the heart beat rapidly but feebly ; the urine and faeces passed involuntarily, and the temperature, as indicated by a thermometer placed in the rectum, had fallen from 101° Fahr., which it was before the ingestion of the alcohol, to 98.5° Fahr. The animal remained in a comatose condition, and died one hour and twenty-two minutes after the ingestion of the alcohol. In this experiment the alcohol was administered in such a large dose that the period of excitation, which generally follows in a few minutes, was masked or altogether prevented. In the following experiment, the quantity was smaller, and the sequence of phenomena was more regular. I introduced into the stomach of a large dog one ounce of alcohol, diluted as before. Nothing occurred worthy of notice during the first five minutes. Then the heart was accelerated, as was also the respiration, and the pupils became contracted* Sensibility and the power of motion were unaffected. In twelve minutes the gait of the animal became uncertain, the limbs were lifted higher than was natural, and the body swayed from side to side, and occasionally strong efforts had to be made to maintain the erect position. The pupils were still contracted, and sensibility ap- peared to be intact. This condition lasted twenty-two minutes, and then the pupils began to dilate. The posterior extremities were so far weakened as to render locomotion impossible, and the sensibility of the posterior parts of the body was materially impaired ; the respiration was very irregular, some- times being quite rapid, then ceasing for several seconds, and then be- coming slow. The pulse was still rapid, but weaker than at first. In a little less than an hour the animal was in a state of light coma, which lasted about twenty minutes. Recovery took place gradually, the phe- nomena of intoxication disappearing in an inverse order to their super- vention. Observation of the symptoms which ensue when alcohol in sufficient quantity is given to animals shows that the condition of intoxication may, as Marvaud1 proposes, be divided into three periods or stages : » " L'alcohol: son action physiologique," etc., Paris, 1872, p. 28. 860 TOXIC DISEASES OF THE NERVOUS SYSTEM. 1. Period of Excitation.—Uncertainty in the movements, accelera- tion of pulse and of respiration, contraction of the pupils. 2. Period of Perversion.—Muscular paralysis, beginning in the pos- terior extremities, irregularity of pulse and of respiration, dilatation of the pupils. 3. Period of Collapse.—Complete paralysis of motion, anaesthesia, feebleness of the pulse and of respiration, stoppage of respiration and of the heart's action, death. Now, I was desirous of knowing how much of this condition was due to the presence of alcohol in the brain, and how much to disturb- ance in the quantity of blood normally present in this organ. In other words, I wished to ascertain whether alcohol increased or diminished the amount of blood circulating within the cranium. For this purpose I performed the following experiment : I trephined a dog, and secured a cephalohaemometer into the open- ing made by the trephine in the skull. I then administered an ounce of alcohol, diluted as in the previous experiment. In fifty seconds I detected alcohol in the expired air ; in four and a half minutes the res- piration was accelerated, the action of the heart became more rapid and strong, and the pupils were beginning to contract. Still there was no increase in the intracranial pressure, and I therefore knew that up to this time the amount of blood in the brain had not been increased. In six minutes and a half the dog's gait was staggering, and, though his movements were uncertain, there was no paralysis. The intracranial pressure was still unaltered. The fluid remained stationary in the tube of the instrument till sev- enteen minutes had elapsed. Then it began to rise slowly, and, with this increase in the intracranial pressure, paralysis of the posterior ex- tremities supervened. As the amount of blood contained in the crani- um became greater, the paralysis extended, the pupils dilated, and coma ensued. The return to sensibility and the power of motion was attend- ed with a diminution of the intracranial pressure, and was probably di- rectly dependent thereon. I repeated this very instructive experiment twice with similar re- sults. The deductions to be made from them are, that the first symptoms which result from the ingestion of alcohol are due to the presence of this substance in the brain, while the latter phenomena are, in part at least, the results of cerebral congestion. Note.—In these and other experiments detailed in this chapter, the presence of alco- hol in the expired air was determined by causing the breath to pass through a solution of bichromate of potash in sulphuric acid, a test suggested by Masing,1 and not by Lalle- mand, Perrin, and Duroy, as generally supposed. 1 " De mutationibus spiritus vini in corpus ingesti," 1854. ALCOHOLISM. 861 In man a like sequence is observed. A single glass of wine induces an exhilaration and activity of mind before there is any evidence of an increase in the amount of blood circulating in the cerebral blood-vessels. In several subjects particularly sensitive to the action of alcohol, I have observed that the flushing of the face and increased vascularity of the fundus of the eye, as shown by the ophthalmoscope, were second in order of occurrence to others indicating mental excitement. But, as is well known, the immediate effects of a large quantity of alcohol, when taken into the human stomach, are not limited to mental excitement and flushing of the face. It does not come within the scope of this chapter to consider all of them ; but so far as the nervous sys- tem is concerned they properly oome under notice. Levy1 divides the phenomena of alcoholic intoxication, as they relate to the nervous system, into three stages : excitement, perturba- tion, and destruction of the functions of the brain and spinal cord. The stage of excitement is characterized by a sensation of heat in the skin of the whole body and by redness of the face. The eyes appear to be larger and more brilliant, the ideas flow more readily, the ten- dency to talk is generally increased, but the articulation is usually not so distinct and exact as is natural. The disposition becomes more gen- erous, and perhaps more reckless as to consequences, although the bounds of propriety of conduct and truth of expression are not ex- ceeded. Occasionally a different set of symptoms results. The individual, from being naturally talkative, becomes taciturn and stolid, and a gen- erous disposition is changed to one of which churlishness and selfish- ness are the chief features. If the quantity of alcohol taken has been small, or if the individual now ceases to drink it, the subsequent stages do not supervene, and the equilibrium is soon restored without the occurrence of any abnor- mal condition. But, if the amount ingested has been large, or if the potations are continued, the second stage, that of perturbation, ensues. There are now vertigo, disturbances of sight—such as result from paralysis of one or more of the ocular muscles, and giving rise to double vision—contraction of the pupils, noises in the ears, and increased red- ness of the face. The sense of taste becomes weakened, the voice loses its natural inflections and becomes rough and monotonous, and the articulation is indistinct from partial paralysis and defective coordina- tion of the muscles of speech. The gait, from like causes, becomes weak and uncertain, and hence, if the individual attempts to walk, he staggers. The movements of the upper extremities are irregular, and often exhibit marked tremor like that which constitutes so prominent a feature of paralysis agitans, or of some of the forms of sclerosis affecting the brain and spinal cord. > "TraitS d'hygiene," tome ii., Paris, 1862, p. 63. 862 TOXIC DISEASES OF THE NERVOUS SYSTEM. Still greater alterations from the normal standard are shown in the mind than in other manifestations of nervous action. The most striking change occurs with the emotions, which generally assume an undue prominence and dominate over other of the mental faculties. And it not infrequently happens that the feeling which is most conspic- uous is the very opposite of that which is natural to the individual. Thus the brave man becomes cowardly, the timid courageous, the peace- able quarrelsome, the modest shameless, etc. Usually, however, the emotions, which the subject in his normal condition is able to control and to keep in proper subordination to the intellect and will, become exaggerated, and are no longer held in subjection. It therefore hap- pens that, when this stage of alcoholic intoxication is reached, the indi- vidual, who while in his natural state is high-toned and spirited, is ready to take offense and engage in quarrels upon the slightest provo- cation, and often when no cause for his emotion and conduct exists. It is in this stage that outrages against the law are most apt to occur. The more purely intellectual part of the mind does not escape. The judgment is weakened, the memory impaired, the imagination exalted or perverted, and delusions, often having their origin in disordered sensations, and often arising in the mind without any accompanying illusion or hallucination, may assume the government of the thoughts and actions. The ability to grasp the details of a subject, and to com- prehend them, is greatly injured, or even altogether destroyed, and hence study or continuous and systematic thought is no longer pos- sible. In the third stage the full action of the alcohol is attained. The mental, sensorial, and motor functions are more or less completely abol- ished, and death, generally the direct result of suspension of the respir- atory movements, may ensue. When this degree of alcoholic intoxi- cation is at its height, the individual is dead to all external impressions. Boiling water may be poured on his body, but he does not feel it; speech is impossible ; the sphincters are relaxed, allowing the contents of the bowels and bladder to escape ; the pupils are largely dilated ; the breathing is slow, heavy, and often stertorous ; the face is swollen and purple from the circulation of non-oxygenized blood through the vessels ; and the power of thought is extinct. With the exception of that part of the cerebro-spinal axis which presides over the functions of respiration and circulation, the individual is to all appearance dead. It not infrequently happens that this region is so fully affected that life is abolished. Such are the immediate effects of large quantities of alcohol when ingested into the human stomach. No one can fail to observe that most of the remarkable phenomena which follow on the administration of this liquid are connected directly or indirectly with the nervous sys- tem. Indeed, experiments performed upon animals, with reference to ALCOHOLISM. 863 this point, as well as careful observation of the effects of alcohol on the human organism, show that this substance has a signal affinity for the nervous tissue, and that it is even capable of acting powerfully on the brain, the spinal cord, and the sympathetic system, without the inter- mediation of the blood. Instances are on record, and I have myself witnessed one such, in which a large quantity of alcoholic liquor taken into the stomach has produced death in a few minutes ; and Orfila 1 cites a case in which a man died immediately from the effects of an excessive dose of brandy. I have several times killed rabbits in less than a min- ute by introducing an ounce of pure alcohol into the stomach. In such cases the action is not exerted through the medium of the blood, but directly on the sympathetic system or medulla oblongata by the ter- minal nerve-branches in the stomach. Indeed, if, as I have frequently done, a like amount of alcohol be injected into the blood directly, death does not ensue with so great a degree of rapidity. Marceta says : " By experimenting on frogs I have shown, in a paper read to the British Association, in 1859, that a sudden temporary suspension of sensibility or shock is occasionally brought on when the hind-legs of these animals are suddenly immersed in strong alcohol; and I have ob- tained positive proof that this phenomenon is due to an influence ex- erted exclusively on the extremities of the nerves supplying those limbs, by observing this same effect to take place after the circulation of the parts in contact with alcohol had been entirely arrested. When, on the contrary, the nerves of the limb immersed in alcohol were severed from their centre, the circulation being left undisturbed, a shock never happened. In the experiments in question it was obvious that the sud- den occurrence of insensibility or anaesthesia was due to an action of the alcoholic fluid on the extremities of the cerebro-spinal nerves, which action had been transmitted by these nerves to the brain ; the phenom- ena of reflex action continued, for the respiration appeared unimpaired, and after the lapse of some minutes the shock passed off with a return of sensibility, although the frog's hind-legs had not been removed from the alcohol." I have repeated Marcet's experiments, with every possible precau- tion to guard against fallacy, and am satisfied that his conclusions are correct. In one experiment I divided all the tissues of both posterior limbs of a large frog, except the sciatic nerves. I then placed small slips of thin glass under these nerves, and moistened them with a few drops of pure olive-oil, so as to prevent the alcohol acting by imbibi- tion. I then plunged both limbs up to the thighs in absolute alcohol. Shock ensued in eleven seconds, and lasted about five minutes. Dur- ing its continuance the animal was insensible and anaesthetic. 1 " Toxicologic," tome ii., p. 528. 2 " Chronic Alcoholic Intoxication," New York, 1868, p. 10. 864 TOXIC DISEASES OF THE NERVOUS SYSTEM. In another instance I performed the converse experiment of exsect- ing the sciatic nerves, leaving the other tissues of the extremities in- tact. I then, as before, inserted both legs into absolute alcohol. No shock ensued, and the animal was not apparently affected by the alco- hol till twenty-two minutes had elapsed. Absorption of alcohol from the stomach is sometimes greatly de- layed, and yet many of the effects of the substance are observed. Most of us have seen an intoxicated man relieved immediately by the full action of an emetic. Of course the emetic in such a case can only remove the non-absorbed alcohol still remaining in the stomach, and yet the symptoms of inebriation disappear on its ejection. It can only have acted through the nervous system, without the intermediation of the blood. Observations and experiments such as these are very striking and important. They tend to show that the action of alcohol is exerted upon the nervous system in a twofold manner, and they are evidence of the remarkable affinity which the substance in question has for the nerve-tissue. Post-mortem examinations of persons who have died directly from the effects of alcohol, or who were during life habitual drunkards, also show how powerfully the nerve-centres are influenced by this agent. In extreme cases it has not infrequently happened that the brain, on being exposed, has evolved a strong odor of alcohol. It is true that the experiments of Dr. Hutson Ford1 appear to show that alcohol is a normal constituent of the blood ; but it is very certain that the quan- tity is altogether too small to give the characteristic odor of this sub- stance, although the reaction with chromic acid, and the distillate being capable of ignition and burning like alcohol, are affirmative evidences of great significance. He did not, however, examine the brain for alco- hol, and my own experiments on this point, with the brains of dogs and oxen, and of men not addicted to the use of alcoholic liquors, have given negative results. Aware, however, of the great affinity which the cerebral and other nerve-tissues have for alcohol, it seems to me that if this substance is normally present in the blood it ought to be found as well in the brain as in the lungs and liver, unless, as may have been the case, the alcohol discovered by Dr. Ford in these organs and in the blood was a post-mortem production. With the view of still further elucidating this subject, I fed a rabbit largely every day with bread soaked in whiskey. In the course of that time the animal received nearly a pint of the liquor, but beyond being somewhat stupefied it did not appear to be seriously inconvenienced. At the end of ten days the animal was killed. I then removed the brain, the spinal cord, and all the large nerves, 1 "Normal Presence of Alcohol in the Blood," Journal of the Elliott Society of Natural History, vol. i., Charleston, 1859. ALCOHOLISM. 865 and treated them separately with distilled water after cutting them into small pieces. They were then thrown upon a filter and strongly pressed. The three separate portions of liquid extract were then distilled several times, and finally treated with quicklime and again distilled. The odor of the distillates was almost sufficient of itself to establish the presence of alcohol, but, when the vapor from each was passed through the solution of bichromate of potash in sulphuric acid the characteristic green color resulting from the action of alcohol was at once produced. So far as I am aware, no previous experiments had established the existence of alcohol in the spinal cord and the nerves. A portion of the blood of the same animal treated in like manner failed to exhibit evidence of the presence of alcohol. The experiments, therefore, showed that the nervous tissue had a greater affinity for this substance than the blood.1 Besides the morbid conditions which exist in the nervous system as the direct result of the ingestion of alcohol in large quantities, this sub- stance is capable of causing other patho-anatomical states which have already been described in this treatise. Treatment.—In the first place, in the treatment of chronic alcohol- ism, the physician should insist upon entire cessation from the use of alcoholic liquors. It usually happens that the bowels are deranged by constipation or diarrhoea. In either case a mild purgative will be found of service. I know of nothing better than the following : B:. Aloes, ext. fel. bovis exsic, aa grs. xv; resinae podophilli, grs. ij. M. ft. in pill no. v. Dose, one every alternate day. For the special treatment of the condition the oxide of zinc in doses of two or three grains three times a day has been strongly recom- mended by Marcet, and is certainly possessed of great power in this direction. Under its use the symptoms soon begin to disappear, and the patient to resume his normal condition of mind and body. But in my experience it is far inferior to the bromides of potassium, sodium, calcium, or ammonium, which, when given in doses of from fifteen to thirty grains in solution three times a day, are exceedingly efficacious. Even they, however, are inferior to the bromide of zinc, which may be administered in the dose of two grains in solution in water or simple syrup three or four times a day—gradually increased, as rapidly as the stomach will permit, to two or three times that quantity. In some cases, especially in those in which insomnia is a prominent feature, the zinc compound may be advantageously given with either of the other bromides mentioned. 1 These experiments were performed before the New York Neurological Society, May 4 1874, and are detailed at length in the Psychological and Medico-Legal Journal for July, 1874. 55 866 TOXIC DISEASES OF THE NERVOUS SYSTEM. I am very sure that in digitalis we have an important adjunct to the treatment mentioned. It not only acts as a tonic to the heart, but it is the most active agent we possess as an eliminant of alcohol through the kidneys. I prefer the infusion in doses of a tablespoonful three or four times a day. The tincture may be given in doses of from fif- teen to thirty drops, as often. In acute alcoholism, or delirium tremens, the treatment depends very much upon the mode of origin of the disease. In those cases which have resulted from the sudden cessation from the use of alcoholic liquors, opium with brandy or whiskey should be given. The main indication is to procure sleep as soon as possible, and I am aware of no means so effectual in cases of this kind as the hypodermic injection of large doses of morphia—one-fourth to half a grain—as often as may be required, combined with the internal admin- istration of brandy or whiskey in moderate quantities. When, however, the affection has come on during a debauch, noth- ing can be much worse than either of those substances. They add fuel to the flame. In such cases the bromides, in large doses, combined with digitalis, are the most effective remedies. A drachm of the bromide of potassium, for instance, may be given in solution in a tablespoonful of infusion of digitalis every hour or two, and it will generally happen that sleep will follow, with the cessation or mitigation of all the perma- nent symptoms. The hydrate of chloral has been recommended in delirium tremens, but I have no personal experience of its use. The monobromide of camphor has been used successfully in delir- ium by M. Seneffe, of Belgium, and by Dr. O'Hara, of this country. I have also recently employed it in one case—administering four grains in capsule every hour. After the eighth dose the patient slept four hours. The remedy was again given as before, and after six doses another period of sleep, this time of six hours' duration, was obtained. The further administration was not necessary. With the medical treatment in either form of delirium tremens the strength should be supported with beef-tea, and, after convalescence, quinine, iron, and strychnia, will prove of service. BROMISM. 867 CHAPTER III. BROMISM. In view of the facts that the bromides of potassium, sodium, calcium, lithium, and ammonium, are necessarily administered in several diseases of the nervous system, notably in epilepsy, in large doses and for long periods, and that a peculiar condition is thereby induced, it is impor- tant that the resultant phenomena should be recognized. In adults it is rarely the case that any decided symptoms of bromism are caused by doses of less than thirty grains daily, and not often that forty-five grains a day produce them in any great intensity. In chil- dren, however, and sometimes in weak individuals, smaller quantities will give rise to very well-marked phenomena. Symptoms.—The first symptom to make its appearance in cases of bromism is drowsiness. The patient sleeps not only at night, but in the day, and often under circumstances in which sleep would appear to be almost out of the question. Feebleness of the arms and legs, espe- cially of the latter, is generally the next sign. The gait becomes titu- bating, and falls are apt to occur, especially in children. The grasp of the hands is weak, and there appears to be an anaesthesia of what may be called the muscular sense, for articles held are dropped unless the sight be kept upon them. Articulation is very early interfered with, so that the speech becomes thick and indistinct. Words are omitted and others are clipped of their final syllables, or are slurred over in a tangled mass of incomprehensible utterances. The action of the heart is weakened, and at the same time rendered more frequent ; the skin is cold and clammy, the countenance is pale, and the pupils, from being at first somewhat contracted, become widely dilated and somewhat insensible to light. The tongue is reddened, thickly coated, dry, and sometimes sore. The breath has the odor of bromine or is otherwise offensive ; the bow- els are usually constipated, and the urine is ordinarily increased in quan- tity. The skin, even in cases in which the other symptoms of bromism are not very evident, is the seat of numerous pustules, especially that covering the face, neck, back, and chest, and occasionally large boils or carbuncles make their appearance. The fauces are often intensely congested, and aphthous patches ap- pear on the mucous membrane of the buccal cavity. The respiration becomes hurried, cough is often induced, and bronchitis or congestion of the lungs may ensue. The sensibility of the pharynx is markedly impaired, and its reflex excitability is almost if not entirely abolished. It requires a mental 868 TOXIC DISEASES OF THE NERVOUS SYSTEM. effort for the patient to swallow, and manual irritation of the fauces fails to excite nausea or efforts to vomit. Finally, locomotion becomes impossible, the patient is in a state of continual stupor, incapable of making known his wants—in fact, hav- ing no wants—and unable to recognize those about him ; the urine and faeces are passed involuntarily, the lungs are engorged, the heart be- comes still weaker, and if the administration of the bromide be not sus- pended death ensues. In a paper which I published * several years ago, I called attention to this remarkable condition, and adduced several cases in illustration of the points then brought forward. They were noticed by Huettea many years ago, though not very perfectly. He was the first to ob- serve the effects of bromide of potassium upon the generative function in the abolition it causes of sexual desire and power. Before the extreme influence of the bromides is attained, a patient under their influence presents phenomena very similar to those exhibit- ed by a drunken person. A case which formed one of the series given in the paper referred to is so apposite in the present connection that I cite it here : A gentleman consulted me in January, 1867, for severe headache, with which he had suffered for many years. He informed me that he had once fallen from the rigging of a vessel, had struck his head, and was rendered insensible for several hours. Subsequently he had a sun- stroke in Texas. I considered this a suitable case for the administra- tion of the bromide of potassium, and accordingly prescribed for him a teaspoonful three times a day of a solution containing one ounce of the medicine to four ounces of water. He thus took about fifteen grains at a dose. The effects of this were so pleasant to him, and yet not alto- gether so strong as he desired, that he began to increase the dose. Be- ing absent from the city for two or three weeks at that time, I did not witness the phenomena. I was informed, however, that he had exhib- ited symptoms of mental aberration. These wore off on the cessation of the medicine, and when I returned he was comparatively well. His headaches, however, soon came back with all their original vio- lence, and at his earnest solicitation, and under his promise not to ex- ceed the prescribed dose, I again gave him the bromide. He very soon began to increase the quantity, and finally seemed to have lost all con- trol of his appetite for it. At this time I ascertained that he was in the habit of having his four-ounce vial containing an ounce of the bromide filled every day. The first obvious effect was an unsteadiness of gait. So great was this that he was frequently taken for a drunken man, and on one occasion was arrested by the police, confined in a cell all night, 1 " On some of the Effects of the Bromide of Potassium when administered in Large Doses," Quarterly Journal of Psychological Medicine, vol. iii., 1869, p. 46. 2 Gazette Medicale, June, 1850. BROMISM. 869 and fined the next morning, notwithstanding my statement of the facts to the police superintendent. On another occasion I met him in the street, as I was going to visit him. He was now decidedly insane ; had delusions that lewd women had got into his mother's house ; that he was-pursued by the police ; that his life was threatened by members of the family ; that he had thousands of dollars of gold sewed up in his clothing, etc. When I met him his appearance and manner were very similar to those of a drunken man, except that his face was exceedingly pale. This gentleman was a total-abstinence man as regarded intoxi- cating liquors of all kinds. His manner was excited and rambling, and his hands were constantly busy either in fumbling in his pockets, tying his shoes, picking threads from his clothing, or in reaching for the gold which he believed was concealed in the lining of his coat. His charac- ter had also undergone a radical change. From having been very frank and brave, he had become excessively timid and suspicious of every trifling circumstance. Up to this period I was not quite sure that he was suffering from the effects of bromide of potassium. His symptoms were in many re- spects so much like those of an ordinary attack of acute mania, and his antecedents were of such a character as to predispose him to an acces- sion of the kind, that I had reasons for my doubts. Nevertheless, I en- deavored to stop his use of the bromide. This was a difficult task, for, notwithstanding all efforts, he continued to get hold of it. At last it was ascertained that he had secreted large quantities of it in various out-of-the-way places about the house. His mental derangement had now become so prominent and con- stant that his friends became alarmed for his own and their safety. He had several times attempted to throw himself from the window, and had battered down a door with an axe in order to escape from some imagi- nary danger. Under these circumstances I recommended his committal to a luriatic asylum, and he was accordingly removed to Sanford Hall, at Flushing. Here his symptoms gradually disappeared, and in a month he returned to his home well. He has continued so to this day, with the exception that his headaches, which had disappeared while he was under the influence of the bromide, became as severe as at first, and still continue. This was certainly an extreme case, but others fully as well marked have come under my notice. The effects due to the continued administration of the bromide of potassium have not been more clearly, fully, and at the same time succinctly stated than by Dr. E. H. Clarke.1 He says: "The principal phenomena following the continued dose are: acne; 1 " The Physiological and Therapeutical Action of the Bromide of Potassium and Bro- mide of Ammonium," by Edward H. Clarke, M. D., and Robert Amory, M. D., Boston, 872, p. 36. 870 TOXIC DISEASES OF THE NERVOUS SYSTEM. salivation and salt taste in the mouth; irritation of the fauces, generally with oedema and redness, and sometimes with paleness of those parts; moderate anaesthesia of the pharynx; laryngo-bronchial weakness, some- times with cough and sometimes with a changed or whispered voice, rarely with aphonia; a fetid or bromized breath; occasional stammer- ing; increase of renal secretion; diminution of mucous secretion gen- erally; slight constipation, and, in a few rare cases, diarrhoea; sense of mental and physical languor or weakness; sometimes temporary impairment of the memory, general aspect of hebetude or indifference; more or less somnolence; repression, and occasionally temporary aboli- tion of sexual desire and power; impaired locomotion, which, when the dose is excessive, resembles the gait of locomotor ataxia; diminished nervous sensibility in general, and especially diminution of reflex sensi- bility; and, finally, an increase of destructive without a corresponding increase of constructive metamorphosis, and consequent emaciation." When administered in larger quantities than are just sufficient to produce the foregoing symptoms, the phenomena, as detailed by Dr. Clarke, are: "The fetid breath becomes nauseous; oedema supervenes on conges- tion of the uvula and fauces; the whispering voice sinks into aphonia; sexual weakness degenerates into impotence; muscular weakness be- comes complete paralysis; reflex, general, and special sensations dis- appear; the ears do not hear, or the eyes see, or the tongue taste; the expression of hebetude becomes first that of imbecility, and then that of idiocy; hallucinations of sight and sound, with or without mania, pre- cede general cerebral indifference, apathy, and paralysis; the respira- tion, without the stertor of opium or alcohol, is easy but slow; the tem- perature of the body is lowered; as the bromism becomes more pro- found, the patient lies quietly in his bed, unable to move, or to feel, or swallow or speak, with dilated and uncontractile pupils, and scarcely any change of the color of the skin or face; the extremities grow gradually colder and colder; the action of the heart becomes feeble and slower, till it ceases altogether." Dr. Clarke reports one death, in which this result was probably due to bromism. Three have come under my observation, in which bromism was probably instrumental in hastening a fatal termination. In one of these the patient, a young lady, was the subject of epilepsy. She resided out of the city, and I prescribed the bromide of potassium in doses of fifteen grains three times a day. While taking it, and fully under its influence, she contracted pneumonia ; but, without my knowl- edge, the medicine was continued, and she died. The second case was that of a lady forty years of age, also subject to epilepsy, for whom I prescribed the bromide of sodium in doses of fifteen grains three times a day. The bromic cachexia soon became strongly marked, but, as I saw her every day, I did not think it advis- BROMISM. 8T1 able to reduce the doses. She went out every day, and on one occa- sion crossed the North River ferry to meet some friends. She caught a severe cold, pneumonia supervened, and, though the administration of the medicine was at once stopped, she died in the second stage of the disease. In both these cases the bromide probably was indirectly the cause of death by the asthenia which it produced. In the third case the patient, a lady from the South, also an epi- leptic, visited New York to consult me relative to her disease. I pre- scribed for her as in the last-named case, and, after remaining a fort- night in the city, she returned home with no great degree of bromism. But, after her departure, the toxic influence became more strongly marked, and, before I could be written to and my answer obtained, the medicine being continued all the time, death occurred. In this instance the result was doubtless entirely due to bromism. Causes.—For the production of bromism, more or less prolonged administration of a bromide—the continued dose of Dr. Clarke—is necessary. In my experience the potassium and sodium salts equally cause it; the lithium, calcium, and ammonium compounds, less readily; the bromide of zinc not at all; but this result may be due to the fact that this preparation is not administered in as large doses as the others. Great differences exist among individuals in regard to the capacity to be brought under the full influence of a bromide; but I know of no signs by which these differences can be previously ascertained, except those of age and sex; children and women being more readily affected as a rule. The administration of a bromide in a largely diluted form facilitates the action of the drug on the system, and consequently leads more readily to the promotion of bromism. This is probably due to the fact of its greater endosmotic power, and consequent more rapid absorption into the blood. The Diagnosis of bromism scarcely calls for remark. The Prognosis is almost invariably favorable if the administration of the drug be stopped when the phenomena become profound and there are no serious superadded affections present. Of the Morbid Anatomy nothing is known, and the Pathology is, therefore, based entirely on what has been ascertained relative to the physiological and therapeutic action of the bromic compounds. Chief among these are the facts that it diminishes the amount of blood circu- lating in the cerebral blood-vessels, and that it lessens the irritability of the whole cerebro-spinal and sympathetic nervous systems. These effects were set forth in a paper' published more than ten years ago, and have been generally confirmed by subsequent observers, and by my- 1 " On Sleep and Insomnia," New York Medical Journal, 1865. 872 TOXIC DISEASES OF THE NERVOUS SYSTEM. self in various iremoirs.1 Relative to the influence which the bromides exert in augmenting the quantity Of blood in the brain, the fact admits of actual demonstration by means of inspection through the trephined skulls of animals and by the use of the cephalohaemometer described in the introduction to this work. Many of the most striking phenomena of bromism are the result of . the cerebral anaemia which the bromides produce. The paleness of the countenance, the dilatation of the pupils, the mental and physical weak- ness, the somnolence, the cardiac debility, all result from the intra- cranial condition. Among the secondary effects are those cited by .Bartholow :2 the retardation of the process of destructive metamorphosis, the diminution of the sexual desire and power, and gastric derangement. M. Laborde s has performed a number of experiments on man and other animals with the bromide of potassium. Four or five minutes after the administration of from three to six grains to frogs, a slight general excitement, with moderate tetanic movements, was produced. Weakness followed, and then there was a condition of flaccidity, during which reflex action was entirely abolished. The heart was but slightly affected, and continued to contract for several hours after this loss of reflex power. Laborde concludes, therefore, that bromide of potassium has no special action on the heart, muscles, encephalon, or nerves, but that it mainly and primarily injures the spinal cord. These views are doubtless true as regards the frog, in which animal the spinal cord is mainly the seat of the mind, and therefore any cere- bral influence must be very slightly manifested ; but they certainly are not correct so far as man and the superior animals are concerned. Other observers have written relative to the physiological effects of the bromides, among whom MM. Damourette and Pelvet * may be men- tioned. In the work of Drs. Clarke and Amory, to which reference has al- ready been made, Dr. Amory enunciates, among other propositions, the following : " The loss of reflex action is due to the diminution of blood in the periphery of the nerves and also of the central nervous system, this last occurring after the first. " The action of bromide of potassium on the nervous system may be explained by its action on the capillary, arterial, or central circulation." These propositions are supported by various experiments, and ap- pear to be well established. 1 " On some of the Effects of the Bromide of Potassium," etc., Quarterly Journal of Psychological Medicine, January, 1869. 2 Cincinnati Lancet and Observer, 1865. 8 Compies Rendus, July 8, 1868. 4 Bulletin generate de therapeutique, 1867, pp. 241, 289. HYDRARGYSM. 873 The recent work of Voisin ' adds nothing to our previous knowledge of the subject. Treatment.—There is no special treatment for bromism beyond that which consists in suspending at once the administration of the medi- cine, facilitating its elimination from the system, and sustaining the •strength. Dr. Clarke9 has shown that the faeces do not contain an ap- preciable quantity of the bromide of potassium, even when it is being taken in large quantity. He found that it is mainly eliminated by the kidneys and by the skin. It is difficult to avoid the opinion, in view of the odor of the breath of persons taking a bromide, that bromine is eliminated with the expired air, but Dr. Clarke's experiments appear to establish the negative. The indication, therefore, is to administer diu- retics and diaphoretics. Nothing is better for the first than digitalis, which not only acts upon the kidneys, but is also a tonic to the heart, and for the latter than warm drinks, such as infusion of flaxseed, lemon- ade, etc., which are also more or less diuretic. The strength of the patient should be sustained with brandy or wine, quinine, beef-tea, etc. CHAPTER IV. HYDRARGYSM. Symptoms.—The consequences to the nervous system, from the slow absorption of mercury into the organism, have been known for many years. The principal phenomenon witnessed is tremor, but there are other symptoms which serve for the recognition of the nature of the disorder. Thus the gums are swollen and tender, the breath fetid, the teeth become loose, especially those of the lower jaw, and there is a metallic taste in the mouth. The lining membrane of the mouth and throat be- comes inflamed, and ulcerations very generally occur in the fauces. The quantity of saliva is greatly increased. These symptoms exist mainly in the first stage of hydrargysm, and constitute what is generally called salivation. But, if the mercury con- tinues to be taken into the system, another series of phenomena ap- pears. Or, if the absorption has been extremely slow, the foregoing may be in great part, or entirely, absent. The symptoms referred to are paleness or lividity of the counte- nance, the frequent occurrence of nasal haemorrhages, and marked mental weakness. The physical strength gradually becomes less, and tremor makes its appearance, mostly confined, in the early stages at 1 "De l'emploi de bromure de potassium dans les maladies nerveuses," Paris, 1875. * Op. cit, p. 139. 874 TOXIC DISEASES OF THE NERVOUS SYSTEM. least, to the superior extremities and the head. Finally, the lower limbs are affected, and, in addition, are generally the seat of oedema. Pains in the bones, and caries, and necrosis, especially of the maxillary bones, may occur together with ulcerations of the soft parts. The mental symptoms are generally strongly marked. There are hallucinations and delusions, accompanied sometimes with a high de- gree of maniacal excitement. Epileptiform convulsions may occur, as may also paralysis of various parts of the body, and finally, unless re- lief be afforded, death ensues. Causes.—Mercury may be taken into the system and be the cause of slow poisoning, through the skin, the stomach and intestines, and the lungs. Fire-gilders, looking-glass manufacturers, barometer-makers, the workers in quicksilver-mines, bronzers, the makers of artificial flow- ers, and photographers, exposed as they are to the vapor, the fine pow- der, or a solution containing mercury, are therefore liable to its toxic influence. Hydrargysm has also been known to be induced by the long- continued administration of preparations of mercury in medical prac- tice, and even from the filling of a tooth with an amalgam. I have known of a case of mercurial tremor, produced in a young lady by the use of a solution of corrosive sublimate as a cosmetic to remove pimples from the face. The Diagnosis of hydrargysm is in general much elucidated by the clinical history of the case and the knowledge that the patient has been exposed to mercurial emanations. In addition, the tremor, the fetid breath, loosening of the teeth, caries of the bones, and the muscular weakness, are diagnostic signs of value, while the absence of the blue line on the gums—although it is stated that such a line is sometimes present—and the fact that the extensors are not especially the seat of paralysis will suffice for the discrimination of hydrargysm from plumb- ism. But the diagnosis is rendered quite certain by the administration of the iodide of potassium, which, as Melsens has shown, separates mer- cury from its combinations with the tissues of the body, forming with it a new compound—the iodide of mercury—which is eliminated with the urine. All that is necessary, therefore, is to give the iodide of potassi- um in large doses to a patient suspected to be suffering from hydrar- gysm, to put a few drops of the urine, excreted during the second day, on a bright copper plate, and then add a drop of hydrochloric acid. A bright metallic stain will be found on the plate if mercury be present. The iodide of mercury is decomposed and the metal is precipitated as stated. The Prognosis is generally favorable if the patient can be removed from further contamination with mercury and be subjected to proper treatment. Morbid Anatomy and Pathology.—There are no data by which we HYDRARGYSM. 875 can form an opinion relative to the anatomical changes induced in the nerve-tissues by the action of mercury. It is probable, as M. See as- serts, that this substance, like lead, forms an albuminate of mercury both in the blood and the solid parts of the body. Beyond this fact we have nothing except the gross alterations found in the stomach, the kidneys, and other organs, when mercury has been taken into the sys- tem in large enough quantities to cause death. It is perhaps scarcely necessary to say that the accounts which have been given of metallic mercury being found in globules in the brain and other organs are not correct. A curious circumstance, which has sometimes been observed, is the occurrence of salivation in the cases of persons who have taken mercu- ry, but who have not exhibited any indications of hydrargysm previous to the administration of iodide of potassium. It appears that the mer- cury set free from its albuminate compounds is enabled, while travers- ing the system in its exit through the kidneys, to exert a toxic power. I have never witnessed cases of the kind, and they must be rare. It will be recollected that a like action is claimed for lead. Treatment.—The special means of treatment consists in the free ad- ministration of the iodide of potassium in accordance with the discovery of M. Melsens, already alluded to. Under the action of this remedy the symptoms of hydrargysm speedily disappear, and the patient re- gains his normal or almost his normal condition. The worst case of the affection that has come within my experience, was that of a look- ing-glass maker of this city, in whom the tremor and other evidences of cachexia were exceedingly striking. He was unable to write, from paralysis, and barely able to shuffle about his room. I gave him at once thirty grains of the iodide a day, in divided doses, and in the course of a week doubled the quantity. He immediately began to mend, and was well in less than five weeks. Of course, while under treatment the patient must not be subjected to continual poisoning from mercury. Tonics—iron, quinine, and strychnia—are useful adjuncts. CHAPTER V. AR SENICISM. The Symptoms indicative of slow poisoning by arsenic are generally quite characteristic. There are vomiting, a sensation of heat in the throat and stomach, colicky pains, weakness of the limbs, tremor, ver- tigo, haemorrhage from the nostrils, puffiness of the face, especially about the eyes, attacks of syncope or of epileptiform convulsions, pains 876 TOXIC DISEASES OF THE NERVOUS SYSTEM. in the joints and contractions of the fingers and toes, numbness some- times amounting to complete anaesthesia, and paraplegia. In addition there are sometimes ophthalmia and various papular and vesicular eruptions on the skin. Death is the almost inevitable consequence if the exposure to toxication continues, or speedy relief be not afforded by medical treat- ment. The Causes of arsenical cachexia are, like those of lead and mercury, to be found generally with those whose occupation requires exposure to contact, through the lungs, skin, or alimentary canal, with arsenical preparations. It is thus met with in furriers, who use arsenious acid as a preservative; in taxidermists, who employ it for a like purpose; in naturalists, who sprinkle it over their zoological specimens, and who in handling them absorb the powder through the lungs; in the manufact- urers of paper-hangings; in dressmakers, who are obliged to handle green tarlatan ; in makers of artificial flowers, and in the workers in chemical manufactories, where arsenical preparations are made; and in those who labor in arsenic-mines. It has also occurred in persons occupying rooms hung with the brill- iant green-velvet paper into the manufacture of which arsenic enters in large quantities. Notwithstanding the general susceptibility of mankind to the dele- terious influence of arsenic, it appears that the system may become so habituated to its use as actually to thrive under it. This is the case with the arsenic-eaters of Styria, who take habitually from two to four or five grains daily, and who, nevertheless, are extremely healthy, and even rugged-looking people. The Diagnosis is not a matter of difficulty, especially if the clinical history be inquired into, and the Prognosis, except in extreme cases, is not unfavorable after the patient is removed from further contact with arsenic. The Morbid Anatomy and Pathology, so far as the nervous system is concerned, are not known, and except in acute cases of arsenical poisoning, with which, however, we are not now concerned, there are no definite lesions discoverable in other parts of the body. The Treatment consists in removing the patient from further expos- ure, and subjecting him to the most favorable hygienic influences, the strength being maintained by tonics. If there are contractions of any of the limbs, passive motion, frictions, and electricity, are indicated. INDEX. PAGE Abscess, chronic cerebral.............. 259 Acute alcoholism...................... 853 symptoms......................... 853 Acute cerebral congestion.............. 33 varieties of........................ 33 symptoms......................... 34 causes............................ 42 diagnosis......................... 45 prognosis......................... 47 morbid anatomy................... 48 pathology......................... 49 treatment......................... 50 Acute cerebral meningitis.............. 205 symptoms......................... 205 causes............................ 209 diagnosis......................... 210 prognosis......................... 210 morbid anatomy................... 211 pathology......................... 211 treatment......................... 213 Acute general myelitis................. 441 symptoms......*.................. 441 Acute mania with depression........... 353 Acute myelitis........................ 441 Acute neuritis......................... 804 symptoms......................... 804 causes............................ 805 diagnosis......................... 805 prognosis......................... 805 morbid anatomy and pathology..... 805 treatment......................... 806 Acute partial myelitis.................. 443 symptoms......................... 443 causes............................ 445 diagnosis......................... 446 prognosis......................... 447 morbid anatomy and pathology..... 447 treatment.........................448 Acute spinal meningitis................ 425 symptoms.........................425 Affections, hysteroid.................. 745 PAGE Alcoholism........................... 848 symptoms......................... 848 causes............................ 858 diagnosis......................... 856 prognosis......................... 856 morbid anatomy and pathology..... 856 treatment......................... 865 Alcoholism, acute..................... 853 Alcoholism, chronic................... 848 Amyotrophic lateral spinal sclerosis___ 574 symptoms......................... 575 causes............................ 578 diagnosis......................... 578 prognosis......................... 579 morbid anatomy and pathology. ... 579 treatment......................... 585 Anaemia, cerebral...................... 56 Anaemia, partial cerebral................ 116 Anaemia, spinal....................... 385 Anaemia of antero-lateral columns of cord 409 symptoms......................... 410 diagnosis.........................411 prognosis......................... 411 morbid anatomy and pathology.....412 treatment.........................416 Anaesthesia, lead...................... 842 Anaesthesia, neural.................... 823 Anaesthesia of cutaneous nerves........ 823 symptoms......................... 823 causes............................ 825 diagnosis......................... 825 prognosis......................... 825 morbid anatomy and pathology..... 825 treatment......................... 826 Anaesthesia of fifth pair................ 826 symptoms......................... 826 causes............................ 827 diagnosis.......................... 827 prognosis ........................ 827 morbid anatomy and pathology..... 827 treatment......................... 827 878 INDEX, PAGE Anapeiratic paralysis................... 786 symptoms......................... 787 causes............................ 789 diagnosis......................... 790 prognosis......................... 790 morbid anatomy and pathology..... 790 treatment......................... 790 Antero-lateral columns of the cord, anae- mia of.......................... 409 Anterior columns, inflammation of...... 568 Anterior and posterior tracts of gray matter, inflammation of.......... 555 Anterior tract of gray matter, inflamma- tion of.......................... 449 Aphasia.............................. 166 Athetosis............................. 722 Atrophy, neural....................... 807 Arsenicism............................ 875 symptoms......................... 875 causes............................ 876 diagnosis......................... 876 prognosis......................... 876 morbid anatomy and pathology..... 876 treatment......................... 876 Basilar meningitis, chronic............. 225 Brain, tumors of....................... 292 Bromism.............................. 867 symptoms......................... 867 causes............................ 871 diagnosis......................... 871 prognosis......................... 871 morbid anatomy................... 871 treatment......................... 738 Catalepsy............................. 745 symptoms......................... 746 causes............................ 751 diagnosis......................... 751 prognosis......................... 752 morbid anatomy and pathology.....752 treatment......................... 753 Cerebral abscess....................... 259 Cerebral anaemia...................... 56 symptoms........................ 56 causes............................ 59 diagnosis......................... 61 prognosis........................ 61 treatment........................ 63 Cerebral anaemia, partial............... 116 Cerebral arteries, embolism of.......... 126 Cerebral arteries, thrombosis of........ 116 Cerebral blood-vessels, obliteration of.. 116 Cerebral capillaries, embolism and thrombosis of................... 138 Cerebral congestion.................... 33 Cerebral congestion, active............. 33 Cerebral congestion, passive........... 40 PAGE Cerebral haemorrhage.................. 66 symptoms........................ 67 causes............................ 78 diagnosis......................... 81 prognosis......................... 85 morbid anatomy................... 86 pathology......................... 90 treatment......................... 103 Cerebral meningeal haemorrhage.......108 symptoms......................... 109 causes............................ 110 diagnosis......................... Ill prognosis......................... Ill morbid anatomy and pathology..... 112 treatment......................... 114 Cerebral meningitis, acute............. 205 Cerebral meningitis, chronic........... 215 Cerebral softening..................... 145 symptoms.........................145 causes............................ 153 diagnosis......................... 153 prognosis......................... 154 morbid anatomy................... 154 pathology......................... 156 treatment......................... 160 Cerebral sclerosis, diffused............. 265 Cerebral sclerosis, multiple............. 276 Cerebria.............................. 263 Cerebritis............................. 253 Cervical hypertrophic pachymeningitis.. 429 Cerebro-spinal diseases................ 642 Cervico-occipital neuralgia............. 830 Chronic alcoholism................... 848 symptoms......................... 849 Chronic basilar meningitis............. 225 symptoms......................... 226 causes............................ 233 diagnosis......................... 234 prognosis......................... 234 morbid anatomy................... 235 pathology......................... 237 treatment......................... 241 Chorea............................... 708 symptoms.........................' 708 causes............................714 diagnosis......................... 716 prognosis......................... 716 morbid anatomy and pathology..... 717 treatment......................... 719 Chronic cerebral abscess............... 259 Chronic cerebral meningitis............ 215 Chronic neuritis....................... 807 Bymptoms......................... 807 causes............................ 807 diagnosis......................... 809 prognosis......................... 809 morbid anatomy and pathology..... 809 treatment......................... 809 INDEX. 879 PAGE Chronic spinal meningitis..............426 symptoms......................... 426 causes............................ 427 diagnosis......................... 428 prognosis.........................428 morbid anatomy and pathology..... 428 treatment.........................435 Chronic verticalar meningitis........... 215 symptoms......................... 215 causes............................ 220 diagnosis......................... 221 prognosis......................... 221 morbid anatomy and pathology..... 222 treatment......................... 224 Classification of insanity............... 317 Colic, lead............................ 841 Columns, anterior, inflammation of.....568 Columns of Goll, sclerosis of........... 616 Columns, lateral and gray matter, in- flammation of................... 574 Columns, lateral, inflammation of....... 569 Columns of Tiirck..................... 568 Congestion, neural.................... 502 Congestion, spinal..................... 377 Convulsive tremor..................... 696 history and symptoms............. 696 causes............................ 704 diagnosis......................... 705 prognosis......................... 705 morbid anatomy and pathology..... 705 treatment......................... 707 Crural neuralgia....................... 832 Cutaneous nerves, anaesthesia of........ 823 Definitions of insanity................. 315 Delirium.............................. 324 Delusion..............................321 Dementia............................. 363 Diffused cerebral sclerosis.............. 265 symptoms......................... 265 causes............................ 273 diagnosis......................... 273 prognosis......................... 274 morbid anatomy................... 274 pathology......................... 275 treatment......................... 275 Diseases of peripheral nervous system.. 801 Disseminated inflammation of the spinal cord............................ 618 symptoms......................... 618 causes............................ 620 diagnosis......................... 621 prognosis......................... 621 morbid anatomy and pathology..... 621 treatment......................... 624 Dura mater, pachymeningitis and haema- tomaof......................... 114 PAGE Eccentricity........................... 314 Ecstasy...............................754 symptoms......................... 754 causes............................ 764 treatment......................... 764 Embolism of cerebral arteries.......... 126 symptoms......................... 126 causes............................ 129 diagnosis......................... 129 prognosis......................... 131 morbid anatomy and pathology..... 131 treatment......................... 133 Embolism of cerebral capillaries........ 138 Embolism, fat........................ 141 Embolism, pigment................... 139 Emotional insanity.................... 335 Emotions............................. 313 Encephalitis, suppurative.............. 253 Epilepsy.............................. 663 symptoms......................... 663 causes............................ 676 diagnosis......................... 678 prognosis......................... 679 morbid anatomy................... 679 pathology......................... 681 treatment......................... 691 Exophthalmic goitre...................791 symptoms........................ 791 causes............................796 diagnosis......................... 797 prognosis......................... 797 morbid anatomy and pathology.....797 treatment......................... 799 Facial atrophy, progressive............. 543 Facial paralysis....................... 812 symptoms......................... 812 causes............................ 815 diagnosis......................... 815 prognosis......................... 815 morbid anatomy and pathology..... 816 treatment......................... 816 Facial spasm.......................... 820 symptoms......................... 820 causes............................ 820 diagnosis......................... 821 prognosis......................... 821 morbid anatomy and pathology..... 821 treatment......................... 821 Fat embolism......................... 141 Fifth pair, anaesthesia of............... 826 Fifth pair of nerves, neuralgia of....... 828 General acute myelitis................. 441 General paralysis...................... 355 Glosso-labio-laryngeal paralysis........ 502 symptoms......................... 503 880 INDEX. PAGE Glosso-labio-laryngeal paralysis, causes. 509 diagnosis......................... 509 prognosis......................... 510 morbid anatomy and pathology..... 511 treatment......................... 517 Goll, sclerosis of columns of........... 616 Haematoma of the dura mater.......... 114 symptoms......................... 114 causes............................ 114 diagnosis......................... 115 prognosis......................... 115 morbid anatomy and pathology..... 115 treatment......................... 116 Haemorrhage, cerebral................. 66 Haemorrhage, cerebral meningeal....... 108 Haemorrhage, meningeal............... 418 Haemorrhage, spinal................... 418 Hallucination.......................... 321 Hydrargysm.......................... 873 symptoms......................... 873 causes............................ 874 diagnosis......................... 874 prognosis.......................... 874 morbid anatomy and pathology..... 874 treatment......................... 875 Hydrophobia.......................... 642 symptoms......................... 642 causes............................. 649 diagnosis......................... 651 prognosis.......................... 653 morbid anatomy................... 654 pathology......................... 659 treatment......................... 661 Hyperaesthesia, lead................... 842 Hyperaesthesia, neural.'................ 827 Hysteria.............................. 730 symptoms......................... 730 causes............................. 739 diagnosis......................... 740 prognosis......................... 740 morbid anatomy and pathology..... 741 treatment......................... 742 Hystero-epilepsy...................... 765 causes............................. 771 diagnosis......................... 771 prognosis.......................... 771 morbid anatomy and pathology..... 771 treatment......................... 771 Hysteroid affections.................... 745 Idiocy................................. 262 Illusion.............................. 320 Incoherence........................... 324 Infantile spinal paralysis............... 451 symptoms......................... 451 causes............................ 454 diagnosis......................... 454 PAGl Infantile spinal paralysis, prognosis.....455 morbid anatomy................... 455 treatment......................... 466 Inflammation of anterior columns....... 568 Inflammation of anterior tract of gray matter.......................... 449 Inflammation of anterior and posterior tracts of gray matter............. 555 Inflammation of columns of Goll........ 616 Inflammation of lateral columns........ 569 Inflammation of motor cells............ 502 Inflammation of motor and trophic cells. 450 Inflammation of posterior tract of gray matter.......................... 553 Inflammation of the spinal cord........ 441 Inflammation of trophic cells........... 518 Insanity............................... 309 causes............................. 364 diagnosis......................... 365 prognosis.......................... 866 morbid anatomy and pathology..... 366 treatment......................... 370 classification of.................... 317 definition of...................... 315 emotional......................... 335 intellectual........................ 328 perceptional....................... 325 volitional......................... 342 Intellect.............................. 312 Intellectual insanity................... 328 Intra-spinal haemorrhage and pachymen- ingitis.......................... 429 Lateral columns and anterior gray mat- ter, inflammation of.............. 574 Lateral columns, inflammation of....... 569 Lead anaesthesia....................... 842 Lead-colic............................ 841 symptoms......................... 841 Lead encephalopathy.................. 838 Lead hyperaesthesia................... 842 causes............................. 843 diagnosis......•................... 843 prognosis.......................... 845 morbid anatomy and pathology..... 845 treatment......................... 847 Lead-paralysis......................... 840 Locomotor ataxia...................... 585 Lumbo-abdominal neuralgia............ 532 Mania................................ 350 acute, with depression............. 353 Meningitis, acute cerebral.............. 205 chronic basilar.................... 225 chronic cerebral................... 215 chronic verticalar.................. 215 rheumatic......................... 208 senile............................. 209 INDEX. 881 PAGE Meningitis, spinal.....................425 tubercular cerebral................ 245 Motor cells, inflammation of............ 502 Motor and trophic cells, inflammation of. 450 Multiple cerebral sclerosis............. 276 symptoms......................... 277 causes............................ 283 diagnosis......................... 284 morbid anatomy................... 285 pathology......................... 286 treatment......................... 289 Multiple cerebro-spinal sclerosis........ 772 symptoms......................... 772 causes............................. 781 diagnosis......................... 782 prognosis.......................... 782 morbid anatomy and pathology.....782 treatment......................... 782 Multiple spinal sclerosis............... 618 Muscular atrophy, progressive......... 519 Myelitis, acute general................. 441 acute.............................. 441 Nerves, tumors of..................... 810 Nervous system, toxic diseases of....... 838 Neural anaesthesia..................... 823 atrophy........................... 807 congestion......................... 802 hyperaesthesia..................... 827 sclerosis........................... 807 spasm............................. 820 paralysis.......................... 812 Neuralgia............................. 827 cervico-brachial.................... 831 symptoms......................... 831 causes............................. 831 diagnosis......................... 831 prognosis.......................... 831 Neuralgia, cervico-occipital............ 830 symptoms.........................830 diagnosis......................... 830 prognosis.......................... 830 Neuralgia, crural...................... 832 Neuralgia of fifth pair of nerves........ 828 symptoms......................... 828 causes............................. 829 diagnosis......................... 830 lumbo-abdominal.................. 832 sciatic............................. 832 treatment of....................... 833 Neuritis, acute........................ 804 chronic............................ 807 Non-inflammatory softening of the spinal cord............................ 629 symptoms......................... 629 causes............................. 632 diagnosis......................... 632 prognosis......................... 632 56 PAGE Non-inflammatory softening of the spinal cord, morbid anatomy and pathol- ogy............................. 633 treatment......................... 633 Obliteration of cerebral blood-vessels... 116 Organic infantile paralysis............. 454 Pachymeningitis....................... 114 cervical........................... 429 Paralysis agitans...................... 784 symptoms......................... 784 causes............................. 784 diagnosis......................... 785 prognosis.......................... 785 morbid anatomy and pathology..... 785 treatment......................... 786 Paralysis, anapeiratic.................. 786 facial............................. 812 general........................... 355 glosso-labio-laryngeal.............. 5*^2 neural............................ 812 of radial nerve.................... 819 pseudo-hypertrophic spinal... ___ 490 spinal, of adults................... 470 Paralysis, lead........................ 840 symptoms......................... 840 Paralysis of sixth nerve................ 819 Partial cerebral anaemia................ 116 Passive cerebral congestion............ 40 symptoms......................... 40 causes............................ 42 diagnosis.......................... 45 prognosis......................... 47 morbid anatomy................... 48 pathology......................... 49 treatment......................... 50 Perception............................ 312 Perceptional insanity.................. 325 Peripheral nervous system, diseases of.. 801 Pigment, embolism.................... 139 Plumbism............................. 838 symptoms......................... 838 Posterior root-zones, sclerosis of........ 585 Posterior tract of gray matter, inflamma- tion of.......................... 553 Primary symmetrical lateral sclerosis... 569 symptoms......................... 569 causes............................ 571 diagnosis......................... 571 prognosis.......................... 572 morbid anatomy and pathology..... 573 treatment......................... 573 Progressive facial atrophy.............. 543 causes............................ 547 diagnosis......................... 547 prognosis......................... 547 morbid anatomy and pathology..... 548 treatment......................... 552 882 INDEX. PAGE Progressive locomotor ataxia........... 585 symptoms......................... 585 causes............................ 595 diagnosis..........................595 prognosis......................... 596 morbid anatomy................... 596 pathology......................... 601 treatment......................... 612 Progressive muscular atrophy.......... 519 symptoms......................... 519 causes............................ 525 diagnosis......................... 533 prognosis......................... 534 morbid anatomy and pathology..... 534 treatment......................... 542 Pseudo-hypertrophic spinal paralysis... 490 symptoms......................... 491 causes............................ 496 diagnosis......................... 496 prognosis.........................497 morbid anatomy and pathology..... 497 treatment......................... 502 Radial nerve, paralysis of.............. 819 Rheumatic meningitis.................. 208 Sciatica............................... 832 symptoms......................... 832 causes............................ 832 diagnosis......................... 833 prognosis......................... 833 morbid anatomy and pathology..... 833 Sciatic neuralgia....................... 832 Sclerosis, amyotrophic, lateral spinal.... 574 Sclerosis, diffused cerebral............. 265 Sclerosis, multiple cerebral............. 276 Sclerosis, multiple cerebro-spinal....... 772 Sclerosis, multiple spinal.............. 618 Sclerosis, neural....................... 807 Sclerosis, primary symmetrical lateral.. 569 Sclerosis of posterior root-zones........ 585 Secondary degeneration of spinal cord.. 624 symptoms......................... 625 causes............................ 627 diagnosis......................... 627 prognosis......................... 627 morbid anatomy and pathology..... 627 treatment......................... 628 Senile meningitis...................... 209 Sixth nerve, paralysis of............... 819 Softening, cerebral.................... 145 Softening, non-inflammatory, of spinal cord............................ 629 Spasm, facial.......................... 820 neural............................ 820 Spinal anaemia........................ 585 Spinal congestion...................... 377 symptoms......................... 377 PAGE Spinal congestion, causes.............. 379 diagnosis......................... 381 prognosis......................... 382 morbid anatomy................... 382 pathology......................... 382 treatment......................... 383 Spinal cord, anaemia of posterior columns of.............................. 386 diseases of........................ 377 disseminated inflammation of...... 618 inflammation of...................441 non-inflammatory softening of...... 629 secondary degeneration of.......... 624 tumors of......................... 634 Spinal haemorrhage....................418 symptoms........................ 418 causes.............................419 diagnosis......................... 419 prognosis......................... 421 morbid anatomy and pathology.....423 treatment......................... 424 Spinal irritation....................... 386 history........................... 386 symptoms......................... 394 causes............................. 399 morbid anatomy and pathology.....400 diagnosis.........................402 prognosis.......................... 403 treatment........................404 Spinal meningitis..................... 425 Spinal paralysis, infantile..............451 of adults......................___470 symptoms......................... 472 causes............................. 480 diagnosis......................... 481 prognosis......................... 483 morbid anatomy and pathology.....483 treatment......................... 455 Suppurative encephalitis............... 253 symptoms......................... 253 causes............................. 256 diagnosis......................... 257 prognosis.......................... 257 morbid anatomy and pathology..... 258 treatment......................... 262 Tetanus............................... 555 symptoms......................... 555 causes............................. 558 diagnosis......................... 559 prognosis.......................... 560 morbid anatomy and pathology..... 560 treatment......................... 565 Third nerve, paralysis of............... 817 symptoms......................... 817 causes............................. 818 diagnosis......................... 818 prognosis.......................... 818 INDEX. 883 PAGE Third nerve, morbid anatomy and pa- thology......................... 819 treatment......................... 819 Thrombosis of cerebral arteries......... 116 Bymptoms......................... 117 causes............................. 120 diagnosis.........................121 prognosis.......................... 121 morbid anatomy and pathology..... 121 treatment......................... 125 cerebral veins and capillaries....... 138 cerebral capillaries................ 143 Thrombosis of cerebral veins and si- nuses ...........................133 symptoms......................... 133 causes............................. 137 prognosis......................... 137 morbid anatomy and pathology..... 138 Torticollis............................ 821 causes............................. 822 diagnosis.......................... 822 prognosis.......................... 822 morbid anatomy and pathology..... 822 treatment......................... 822 Toxic diseases of the nervous system___ 838 Tremor, convulsive.................... 696 Treatment of neuralgia................. 833 Trophic cells, inflammation of.......... 518 PAGE Tubercular cerebral meningitis......... 245 symptoms......................... 245 causes............................. 249 diagnosis......................... 250 prognosis.......................... 250 morbid anatomy and pathology..... 251 treatment......................... 252 Tumors of the brain................... 292 symptoms......................... 292 causes............................. 299 diagnosis.......................... 300 prognosis......................... 302 treatment......................... 307 Tumors of nerves...................... 810 Tumors of spinal cord.................. 634 symptoms......................... 634 causes............................. 639 diagnosis......................... 639 prognosis.......................... 640 morbid anatomy and pathology..... 640 treatment......................... 640 Tiirck, columns of..................... 568 Veins and sinuses cerebral, thrombosis of............................... 133 Volitional insanity..................... 342 Will................................... 313 THE END. 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With 188 Illustrations and a Plate of Spectra in Chromo- lithography. Price, $2.00. ANIMAL PARASITES AND MESSMATES. By Monsieur Van Beneden, Professor of the University of Louvain, Correspondent of the Institute of France. With 83 Illustrations. Prica $1.50. PROSPECTUS. D. Appleton & Co. have the pleasure of innounciug that they have made arrangements for publishing, and have recently omenced tne issue ol, a'Series of Populab Monographs, or small works, under the above title, which will embody the ults of recent inquiry in the most interesting departments of advancing science. The works will be issued simultaneously in New York, London, Paris, Leipsic, Milan, and St. Petersburg The International Scientific Series is entirely an American project, and was originated and organized by Dr E L Youmans who spent the greater part of a year in Europe, arranging with authors and publishers. The forthcoming volumes Prof. W. Kingdon Clifford, M. 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Saint-Claire Deville, An Introduction to General Chemistry. Prof. Wubtz, Atoms and the Atomic Theory. Prof. De Quatrefagbs, The Human Race. Prof. Lacaze-Duthiers, Zoology since Cuvier. Prof. Berthelot, Chemical Synthesis. Prof. C. A. Young, Ph. D. (of Dartmouth College), The Sun. Prof. Ogden N. Rood (Columbia College, New York), Mod- ern Chromatics and its Relations to Art and Industry. Dr. Eugene Lommel (University of Erlangen), The Nature of Prof. J. Rosenthal, General Phvsiology of Muscles and Nerves. Prof. James D. Dana, M. A., LL. D., On Cephalizalion; or, Head-Characters in the Gradation and Progress of Life. Prof. S. W. Johnson, M. A., On the Nutrition of Plants. Prof. Austin Flint, Jr., M. D., The Nervous System, and its Relation to the Bodily Functions. Prof. Bernstein (University of Halle), The Five Senses of Man. Prof. Ferdinand Cohn (Breslau University), Thallophytis (Alga, Lichens, Fungi). Prof. Hermann (University of Zurich), On Res/Oration. Prof. Leuckart (University of Leipsic), Outlines of Animal Organization. Prof. Liebreich (University of Berlin), Outlines of Toxicology. Prof. Kundt (Uniiersity of Strasburg), On Sound. Prof. Rkes (University of Erlangen), On Parasitic Plants. Prof. Stkinthal (University of Berlin), Outlines of the Science of Language. P. Bert (Professor of Physiology, Paris), Forms of Life and other Cosmical Conditions. E. Alglave (Professor of Constitutional and Administrative Law at Douai, and of Political Economy at Lille), The Primitive Elements of Political Constitutions. P. Lorain (Professor of Medicine, Paris), Modern Endemics. Prof. Schutzenberger (Director of the Chemical Laboratory at the Sorbonne), On Fermentations. Mons. Fkeidel, The Functions of Organic Chemistry. Mons. Dbbray, Precious Metals. Prof. Corfield, M. A, M. D. (Oxon), Air in its Relation to Health. Prof. A. Giard, General Embryology. D. APPLETON & CO., Mitotan, 549 & 551 Broadway, New York. DESCRIPTIVE CATALOGUE OF MEDICAL WORKS. I3STT3KX: OF SUBJB^OTS. PAGE Anatomy................................. 16 Anaesthesia............................... 26 Acne..................................... 4 Body and Mind........................... 18 Breath, and Diseases which give it a Fetid Odor................................. 16 Cerebral Convolutions..................... 1 Chemical Examination of the Urine in Dis- ease.................................. 8 Chemical Analysis....................... 14 " Technology.................. .. 81 Chemistry of Common Life............... 17 Clinical Electro-Therapeutics.............. 12 " Lectures and Essays............... 24 Comparative Anatomy.................... 6 Club-foot................................. 27 Diseases of the Nervous System.....10,12,13 " " " Bones..................... 20 u "Women................... 26,27 " "theChest..................... 26 " "Children.,................. 25,29 " " the Rectum................... 28 is » n Ovaries................... 81 Emergencies............................. 15 Electricity and Practical Medicine......... 19 Foods.................................... 27 Galvano-Therapeutics..................... 20 Hospitalism.............................. 26 Histology and Uisto-Chemistry of Man___ 8 Infancy.................................. 6 Insanity in its Relation to Crime.......... 12 Materia Medica and Therapeutics........ 5, 23 Medical Journal.......................... 32 Mental Physiology........................ 6 pags Midwifery........ ...................26, 27 Mineral Springs.......................... 80 Neuralgia........ ....................... 2 Nervous System....................... 12,13 Nursing................................ 22 Obstetrics........................8, 7,26,27 Ovarian Tumors.......................... 28 " Diagnosis and Treatment..........80 Paralysis from Brain-Disease............. 8 Physiology....................... 6,9,10,11 Physiology of Common Life.............. 17 Physiology and Pathology of the Mind..... 18 Physiological Effects of Severe Muscular Exercise............................. 12 Pulmonary Consumption.................. 4 Practical Medicine........................ 21 Physical Cause of the Death of Christ..... 26 Popular Science.......................... 82 Puerperal Diseases....................... 2 Reports................................. 24 Recollections of Past Life................. 15 " of the Army of the Potomac.. 17 Responsibility in Mental Diseases......... 18 Sea-Sickness............................. 2 Surgical Pathology........................ 4 " Diseases "of the Male Genito-Uri- nary Organs ......................... 28 Surgery, Conservative..................... 2 " Orthopedic...................... 25 Syphilis.................................. 28 Science.................................. 32 Skin-Diseases............................ 22 Therapeutics............................. 5 Uterine Therapeutics..................... 27 Winter and Spring........................ I D. APPLETON & CO, PUBLISHERS AND IMPORTERS, 549 & 551 BROADWAY, NEW YORK. 1877. 2 D. Appleton & Co.'s Medical Publications. ANSI IE. IN CUTcllg'lcl, and Diseases which resemble it. By FRANCIS E. ANSTIE, M. D., F. R. 0. P., Senior Assistant Physician to Westminster Hospital; Lecturer on Materia Medica In West- minster Hospital School; and Physician to the Belgrave Hospital for Children; Editor of "The Practitioner" (London), etc. 1 vol., 12mo. Cloth, $2.50. "It is a valuable contribution to scientific medicine."— The Lancet {London). BARKER The Puerperal Diseases, cunicai Lectures delivered at Bellevue Hospital. By FORDYCE BARKER, M. D., Clinical Professor of Midwifery and the Diseases of Women in the Bellevue Hospital Medical College; Obstetric Physician to Bellevue Hospital; Consulting Physician to the New York State Women's Hospital; Fellow of the New York Academy of Medicine: formerly Presi- dent of the Medical Society of the State of New York; Honorary Fellow of the Obstetrical Societies of London and Edinburgh; Honorary Fellow of the Royal Medical Society of Athens, Greece, etc., etc., etc. Third Edition. 1 vol., 8vo. Cloth. 526 pages. Price, $5; Sheep, $6. " For nearly twenty years it has been my duty, as well as my privilege, to give clinical lect- ures at Bellevue Hospital, on midwifery, the puerperal and the other diseases of women. This volume is made up substantially from phonographic reports of the lectures which I have given on the puerperal diseases. Having had rather exceptional opportunities for the study of these diseases, I have felt it to be an imperative duty to utilize, so fer as lay in my power, the advan- tages which I have enjoyed for the promotion of science, and, I hope, for the interests of human- ity. In many subjects, such as albuminuria, convulsions, thrombosis, and embolism, septicaemia, and pysemia, the advance of science has been so rapid as to make it necessary to teach something new every year. Those, therefore, who have formerly listened to my lectures on these subjects and who now do me the honor to read this volume, will not be surprised to find, in many par- ticulars, changes in pathological views, and often in therapeutical teaching, from doctrines before Inculcated. At the present day, for the first time in the history of the world, the obstetric depart- ment seems to be assuming its proper position, as the highest branch of medicine, if its rank be graded by its importance to society, or by the intellectual culture and ability required, as com- pared with that demanded of the physician or the surgeon. A man may become eminent as a physician, and yet know very little of obstetrics; or he may be a successful and distinguished surgeon, and be quite ignorant of even the rudiments of obstetrics. But no one can be a really able obstetrician unless he be both physician and surgeon. And, as the greater includes the less, obstetrics should rank as the highest department of our profession."—From Author's Preface. L/n oea-oickness. byfordyce barker, m. d. 1 vol., 16mo. 36 pp. Flexible Cloth, 75 cents. Reprinted from the New Yoek Medical Journal. By reason of the great demand for the number of that journal containing the paper, it is now presented in book-form, with such pre- scriptions added as the author has found useful in relieving the suffering from sea-sickness. BUCK Contributions to Reparative Surgery: Showing its Application to the Treatment of Deformi- ties, produced by Destructive Disease or Injury; Con- genital Defects from Arrest or Excess of Development ; and Cicatricial Contractions from Burns. By GURDON BUCK, M. D. Illustrated hy Numerous Engravings. 1 vol., 8vo. D. Appleton <& CoSs Medical Publications. 3 BARNES. Obstetric Operations, including the Treatment of Hemorrhage, and forming a Guide to the Management of Difficult Labor. By ROBERT BARNES, M. D., London, F. R. C. P., Obstetric Physician and Lecturer on Obstetrics and the Diseases of Women and Children to St George s Hospital; Examiner in Obstetrics to the Royal College of Physicians and the Royal College of Surgeons; President of the Metropolitan Branch of the British Medical Associa- tion ; late Examiner to the University of London; formerly Obstetric Physician to the Lon- don and to St. Thomas Hospitals; and late Physician to the Eastern Division of the Royal Maternity Charity. ' Third Edition. Revised and extended. 1 vol., 8vo. 606 pages. Cloth, $4.50. iv " fnch t work as Dr Barne8's was greatly needed. It is calculated to elevate the practice of the obstetric art in this country, and to be of great service to the practitioner."—Lancet. " TllT V0ok of Dr' Barnes ls noi* properly speaking, a dogmatic treatise on obstetric opera- tions. It is a series of original lectures, comprising, at one and the same time, a practical analysis of the serious accidents in parturition, the reasoned-out indications for, and the most judicious researches in the manner of operating, the method to choose, the instrument to prefer, and the details of the manoeuvres required to insure success. The clearness of the style is perfect. The order, without being altogether rigorous, is what it is able to be generally in a series of clinica! lectures. The description of the instruments, the application of the forceps, cephalotripsy, em- bryotomy, Cesarean section, the practical reflections on narrowing and malformation of the pel- vis, ruptures of the uterus, placenta praevia, haemorrhage, and, in fact, all the grand questions in obstetrics are treated with accurate good sense. At each instant, by some remark or other, is revealed a superior mind, ripened by having seen much and meditated much."—From Preface to the French Edition by Prof. Pajot. " BASTIAN. Paralysis from Brain Disease in its Common Forms. By H. CHARLTON BASTIAN, M.A., M.D., F.R.S., Fellow of the Royal College of Physicians; Professor of Pathological Anatomy in TJnhrerslty College, London; Physician to University College Hospital; and Senior Assistant Fhysiciaa to the National Hospital for the Paralyzed and Epileptic. With Illustrations. 1 vol., 12mo. Cloth. $1.75. PREFACE. These Lectures were delivered in University College Hospital last year, at a time when I was doing duty for one of the senior physicians, and during the same year—after they had been re- produced from very full notes taken by my friend Mr. John Tweedy—they appeared in the pages of The Lancet. They are now republished at the request of many friends, though only after having undergone a very careful revision, during which a considerable quantity of new matter has been added. It would have been easy to have very much increased the size of the book by the introduction of a larger number of illustrative cases, and by treatment of many of the subjects at greater length, but this the author has purposely abstained from doing, under the belief that in its present form it is likely to prove more acceptable to students, and also perhaps more useful to busy practi- tioners. Notwithstanding its defects and many shortcomings, the author is not without a hope that this little book may be considered in some measure to supply a deficiency which has long existed in medical literature. No department of medicine stands more in need of being represented in a text-book of moderate compass; so that, imperfect as it is, this small work may perhaps be of some service till it ls superseded by something better. In it the author has endeavored to treat the subject with more precision than has hitherto been customary, and, while the lectures contain some novelties in method and mode of exposition, he hopes they may also be found not unfaith- fully to embody the principal facts at present known concerning this very important class of diseases. 4 D. Appleton <& CoSs Medical Publications. BENNET. On the Treatment of Pulmonary Con- sumption, by Hygiene, Climate, and Medicine, in its Connection with Modern Doctrines. By JAMES HENRY BENNET, M. D., Member of the Royal College of Physicians, London ; Doctor of Medicine of the University of Parle, etc., eta. 1 vol., thin 8vo. Cloth, $1.50. An interesting and Instructive work, written in the strong, clear, and lucid manner which appears In all the con- tributions of Dr. Ben net to medical or general literature. '* We cordially commend this hook to the sttei.tlon of all, for Its practical common-sense views of the nature and treatment of the scourge of all temperate climates, pulmonary consumption."—Detroit Review of Medicine. Winter and Spring on the Shores of the Mediterranean; or, the Riviera, Mentone, Italy, Corsica, Sicily, Algeria, Spain, and Biarritz, as Win- ter Climates. This work embodies the experience often winters and springe passed by Dr. Bennet on the shores of the Mediter- ranean, and contains much valuable Information for physicians in relation to the health-restoring climate of the re- gions described. 1 vol., 12mo. 621 pp. Cloth, $3.50. " Exceedingly readable, apart from Its special purposes, and well illustrated."—Evening Commercial. " It has a more substantial value for the physician, perhaps, than for any other class or profession. . . . We com- mend this book to oar readers as a volume presenting two capital qualifications—it Is at once entertaining and Instruc- tive."—N. Y. Medical Journal. BILLROTH. General Surgical Pathology and The- rapeutics, in Fifty Ledums. A Text-book for Students and Physicians. By Dr. THE0D0R BILLROTH. Translated from the Fifth German Edition, with the special permission of the Author, by CHAIJLES E. HACKLEY, A.M., M. D., Surgeon to the New York Eye and Ear Infirmary : Physician u> the New York Hospital; Fellow of the New York Ai'Ademy <>f Medicine, etc. 1 vol., 8vo. 714 pp., and 152 Woodcuts. Cloth, $5.00; Sheep, $3.00. Profes-or Theodor Billroth, one ..f the most noleil authorities on Sunru-al I'athnlogT. fives m this volume a complete ritumr «l the existing stair of knowledge in Ihi. Iiram-h of medical science. The fart "of this iiuMiratl.ni going through (bur editions in '.eniiany, and having Wen translated into Kreuch, Italian. Russian, and Hunuanan. should be some guarantee lor tta standing. • ** The want of a Iwok In the Knirllsh language, presenting In a concise form the views of the liennan pathologists, has long been felt; and we venture to «av no hook could more perfectly supply that want tlian the |ir««ent volume. . . . We would flronglv recommend it to all who take any interest in the progress of thought aud observation In surgi- cal Mill.ology. and surgery. "— The hi«.H. * " We can a.sure our readers that they will consider neither money wasted in Its purchase, nor time In Us perusal." —The Medical Investigator. BULKLEY. Acne; its Pathology, Etiology, Prog- nose, and Treatment. Bt L. DUNCAN BULKLEY, A. M., M. D., New York Hospital. A monograph of about seventy pages, illustrated, founded on an analy- sis of two hundred cases of various forms of Acne. (In press.) I). Appleton T!f8eafeSi °n 'ft6 Mlnd and Nervous System, and of Clinical Medicine, In the Bellevue EMI ;£tU£1 C°i'?P; ViSe::President of the Academy of Mental Science*, National Institute of Letters, Arts, and Sciences; late Surgeon-General U. S. A., etc 1 vol., 8vo. 497 pp. Cloth, $4.50. " It is the duty of every physician to study the action of electricity, to become acquainted with its value in therapeutics, and to follow the improvements that are being made in the apparatus for its application in medicine, that he may be able to choose the one best adapted to the treatment of individual cases, and to test a remedy fairly and without prejudice, which already, especially in nervous diseases, has been used with the best results, and which promises to yield an abundant harvest in a still broader domain.'*—From Author's Preface. 8PBCQCEN OF ILLUSTRATIONS. Baxton-Etttnghansen Apparatus. "Those who do not read German are under great obligations to VTuTiaai A. Hammond, who has given them not only an excellent translation of a most ex- cellent work, but has given us much valuable information and many suggestions from his own personal experience."—Medical Record. " Dr. Moritz Meyer, of Berlin, has been for more than twenty years a laborious and conscientious student of the application of electricity to practical medicine, and the results of his labors are given in this volume. Dr. Hammond, in making a translation of the third German edition, has done a real service to the profession of this country and of Great Britain. Plainly and concisely written, and simply and clearly arranged, it contains just what the physician wants to know on the subject."—N. Y. Medical Journal. " It is destined to fill a want long felt by physicians in this country."—Journal of Obstetrics 20 D. Appleton & CoSs Medical Publications. MARKOE. A Treatise on Diseases of the Bones. Bt THOMAS M. MARKOE, M. D., Professor of Surgery In the College of Physicians and Surgeons, New York, etc. WITH NUMEROUS ILLUSTRATIONS. 1 vol., 8V0. Cloth, $4.50. This valuable work is a treatise on Diseases of the Bones, embracing their structural changes as affected by disease, their clinical history and treatment, in- cluding also an account of the various tumors which grow in or upon them. None of the injuries of bone are included in its scope, and no joint diseases, excepting where the condition of the bone is a prime factor in the problem of disease. As the work of an eminent surgeon of large and varied experience, it may be re- garded as the best on the subject, and a valuable contribution to medical litera- ture. " The book which I now offer to my professional brethren contains the substance of the lec- tures which I have delivered during the past twelve years at the college. ... I have followed the leadings of my own studies and observations, dwelling more on those branches where I had seen and studied most, and perhaps too much neglecting others where my own experience was more barren, and therefore to me less interesting. I have endeavored, however, to make np the deficiencies of my own knowledge by the free use of the materials scattered so richly through our periodical literature, which scattered leaves it is the right and the duty of the systematic writer to collect and to embody in any account he may offer of the state of a science at any given period."—Extract from Authofs Preface. NEFTEL. GalvanO-TherapeuticS. The Physiological and Therapeutical Action of the Galvanic Current upon the Acoustic, Optic, Sympathetic, and Pneumogastric Nerves. By WILLIAM B. NEFTEL. 1 vol., 12mo. 161 pp. Cloth, $1.50. This book has been republished at the request of several aural surgeons and other professional gentlemen, and is a valuable treatise on the subjects of which it treats. Its author, formerly visiting physician to the largest hospital of St. Petersburg, has had the very best facilities for investigation. " This little work shows, as far as it goes, full knowledge of what has been done on the subjects treated of, and the author's practical acquaintance with them."—New York Medical Journal. "Those who use electricity should get this work, and those who do not should peruse it to learn that there is one more therapeutical agent that they could and should possess."—The Medical Investigator. D. Appleton ne of the Physicians to the Bureau of Medical and Surgical Relief at Bellevue Hospital fat the Out-door Poor; Fellow of the New York Academy of Medicine, etc., and CHARLES E. HAOKLEY, M. D., One of the Physicians to the New York Hospital; one of the Surgeons to the New York Eye and Ear Infirmary; Fellow of the New York Academy of Medicine, etc Bevised Edition. 2 vols., 8vo. 1,528 pp. Cloth, $9.00; Sheep, $11.00, The author undertakes, first, to give a picture of disease which shall be as lifelike and faithful to nature as possible, instead of being a mere theoretical scheme; secondly, so to utilize the more recent advances of pathological anatomy, physiology, and physiological chemistry, as to furnish a clearer insight into the various processes of disease. The work has met with the most flattering reception and deserved success; has been adopted as a tffxt-book in many of the medical colleges both in this country and in Europe; and has received the very highest encomiums from the medical and secular press. "It is comprehensive and concise, and is characterized by clearness and originality."—Dublin Quarterly Journal of Medicine. " Its author is learned in medical literature; he has arranged his materials with care and judgment, and has thought over them."—The Lancet. " As a full, systematic, and thoroughly practical guide for the student and physician, it is not excelled by any similar treatise in any language."—Appletons' Tournal. " The author is an accomplished pathologist and practical physician; he is not only capable of appreciating the new discoveries, which during the last ten years have been unusually numerous and important in scientific and practical medicine, but, by his clinical experience, he can put these new views to a practical test, and give judgment regarding them."—Edinburgh Medical Journal. " From its general excellence, we are disposed to think that it will soon take its place among the recognized text-books."—American Quarterly Journal of Medical Sciences. " The first inquiry in this country regarding a German book generally is, ' la it a work of practical value ? " Without stopping to consider the justness of the American idea of the ' practical,' we can unhesitatingly answer, ' It is I' "—Neu York Medical Journal. " The author has the power of sifting the tares from the wheat—a matter of the greatest importance in a text-book for students."—British Medical Journal. " Whatever exalted opinion our countrymen may have of the author's talents of observation and his practical good sense, his text-book will not disappoint them, while those who are so unfortunate as to know him only by name, have in store a rich treat."—New York Medical Record 22 D. Appleton & CoJ's Medical Publications. NIGHTINGALE. NoteS On Nursing : What it is, and what it is not. By FLORENCE NIGHTINGALE. 1 vol., 12mo. 140 pp. Cloth, 75 cents. Every-day sanitary knowledge, or the knowledge of nursing, or, in other words, of how to put the constitution in such a state as that it will have no dis- ease or that it can recover from disease, takes a higher place. It is recognized as the knowledge which every one ought to have—distinct from medical knowl- edge, which only a profession can have. NEUMANN. Hand-Book of Skin Diseases. By Dr. ISIDOR NEUMANN, Lecturer on Skin Diseases in the Royal University of Vienna. Translated from advanced sheets of the second edition, furnished by the Author; with Notes, By LUCIUS D. BULKLEY, A. M., M. D., Burgeon to the New York Dispensary, Department of Venereal and Skin Diseases; Assist- ant to the Skin Clinic of the College of Physicians and Surgeons, New York; Mem- ber of the New York Dermatological Society, etc., etc. 1 vol., 8vo. About 450 pages and 66 Woodcuts. Cloth, $4.00. Prof. Neumann ranks second only to Hebra, whose assistant he was for many years and his work may be considered as a fair exponent of the German practice of Dermatolo- gy. The book is abundantly illustrated with plates of the histology and pathology of the skin. The translator has endeavored, by means of notes from French, English, and Ameri- can sources, to make the work valuable to the student as well as to the practitioner. "It Is a work which I shall heartily recommend to my class of students at the Univer- sity of Pennsylvania, and one which I feel sure will do much toward enlightening the pro- fession on this subject."—Louis A. Duhring. " I know it to be a good book, and I am sure that it is well translated; and it is inter- esting to find it illustrated by references to the views of co-laborers in the same field."— Erasmus Wilson. " So complete as to render It a most useful book of reference."—?'. McCall Anderson. " There certainly is no work extant which deals so thoroughly with the Pathological Anatomy of the Skin as does this hand-book."—N. Y. Medical Record. " The original notes by Dr. Bulkley are very practical, and are an important adjunct to the text. . . . I anticipate for it a wide circnlation."—Stfas Durkee. Boston. " I have already twice expressod my favorable opinion of the book in print, and am glad that it is given to the public at last"—James C. White, Boston. " More than two years ago we noticed Dr. Neumann's admirable work In Its original shape; and we are therefore absolved from the necessity of saying more than to repeat onr strong recommendation of it to English readers."—Practitioner. D. Appleton d> Co.'s Medical Publications. 23 PAGET. Clinical Lectures and Essays. By Sir JAMES PAGET, Bart., F. E. 8., D. C. L., Oxon., LL. D., Cantab.; Sergeant-Surgeon Extraordinary to her Majesty the Queen; Surgeon to H. E. H. the Prince of Wales; Consulting Surgeon to St. Bartholomew's Hospital EniTED by HOWARD MARSH, Assistant Surgeon to St. Bartholomew's Hospital, and to the Hospital for Sick Children. 1 vol., 8vo. Cloth. Price, $5.00. CONTENTS. The Various Rises of Operations—The Calamities of Surgery—Stam- mering with other Organs than those of Speech—Cases that Bone-Setters cure—Strangulated Hernia—Chronic Pyaemia—Nervous Mimicry—Treat- ment of Carbuncle—Sexual Hypochondriasis—Gouty Phlebitis—Residual Abscess—Dissection-Poisons—Quiet Necrosis—Senile Scrofula—Scarlet Fe- ver after Operations—Notes for the Study of some Constitutional Diseases —Notes—Index. PEASLEE. Ovarian TumOrS ; Their Pathology, Diagnosis, and Treatment, with Reference especially to Ovariotomy. By E. R. PEASLEE, M.D., Professor of Diseases of Women in Dartmouth College; one of the Consulting Physicans to the New York State Woman's Hospital; formerly Professor of Obstetrics and Diseases of Women in the New York Medical College; Corresponding Member of the Obstetrical Society of Berlin, etc. 1 vol., 8vo. Illustrated with many Woodcuts, and a Steel Engraving of Dr. E. McDowell, the " Father of Ovariotomy." Price, Cloth, $5.00. This valuable work, embracing the results of many years of successful experience in the de- partment of which it treats, will prove most acceptable to the entire profession; while the high standing of the author and his knowledge of the subject combine to make the book the best in the language. It is divided into two parts: the first treating of Ovarian Tumors, their anatomy, pathology, diagnosis, and treatment, except by extirpation; the second of Ovariotomy, its history and statistics, and of the operation. Fully illustrated, and abounding with information, the result of a prolonged study of the subject, the work should be in the hands of every physician in the country. The following are some of the opinions of the press, at home and abroad, of this great work, which has been justly styled, by an eminent critic, " the most complete medical monograph on a practical subject ever produced in this country." "His opinions upon what others have advised are clearly set forth, and are as interesting and Important as are the propositions he has himself to advance; while,there are a freshness, a vigor, an authority about his writing, which great practical knowledge alone can confer."— The Lancet. " Both Wells's and Peaslee's works will be received with the respect due to the great repu- tation and skill of their authors. Both exist not only as masters of their art, but as clear and graceful writers. In either work the student and practitioner will find the fruits of rich expe- rience of earnest thought, and of steady, well-balanced judgment. As England is proud of Wells, so may America well be proud of Peaslee, and the great world of science may be proud of both."—British Medical Journal. " This is an excellent work, and does great credit to the industry, ability, science, and learning of Dr Peaslee. Few works issue from the medical press so complete, so exhaustively learned, so imbued with a practical tone, without losing other substantial good qualities."—Edinburgh Medical Journal. ._ .. . . " In closing our review of this work, we cannot avoid again expressing our appreciation of the thorough study, the careful and honest statements, and candid spirit, which characterize it For the use of the student we should give the preference to Br. Peaslee's work, not only from Us completeness, but from its more methodical arrangemenV —American Journal of Medical Sciences. 24 D. Appleton c& CoSs Medical Publications. PEREIRA. Dr. Pereira's Elements of Materia Medica and Therapeutics. Abridged and adapted for the Use of Medical and Pharmaceutical Practitioners and Students, and comprising all the Medicines of the British Pharmacopoeia, with such others as are frequently ordered in Prescriptions, or required by the Physician. Edited by ROBERT BENTLEY and THEOPHILUS REDWOOD. New Edition. Brought down to 1872. 1 vol., Royal 8vo. Cloth, $7.00; Sheep, $8.00. i\.epOrtS. Bellevue and Charity Hospital Reports for 1870, containing Valuable Contributions from Isaac E. Taylor. M. D., Austin Flint, M. D., Lewis A. Saves, M. D., William A. Ham- mond, M. D., T. Gaillard Thomas, M. D., Frank H. Hamilton, M. D., and others. 1 vol., 8vo. Cloth, $4.00. "These institutions are the most Important, as regards accommodations for patients and variety of cases treated, of any on this continent, and are surpassed by but few in the world. The gentlemen connected with them are acknowledged to be among the first in their profession, and the volume is an important addition to the professional literature of this count- y."—Psycho- logical Journal. RICHARDSON. Diseases of Modern Life. By Dr. B. W. RICHARDSON, F. R. S. 1 vol., 12mo. $2.00. Paet the Ftrst.—PHENOMENA OF DISEASE, INCIDENTAL AND GENEBAL. Chap. I.—Natural Life to Natural Death. Euthanasia. II.—Phenomena of Disease, Classification and Distribution. " III.—Disease Antecedent to Birth. " IV.—External Origins and Causes of Disease. V.—Phenomena of Disease, from Causes External and Uncontrollable. " VI.—Phenomena of Disease, from Causes External and Communicable. " VII.—Phenomena of Disease, incidental to Old Age and Natural Decay. Paet the Second.—PHENOMENA OF DISEASE, INDUCED AND SPECIAL Chap. I.—Definition and Classification of Induced Diseases. II.—Disease from Worry and Mental Strain (Broken Heart). " III.—Disease from Worry and Mental Strain, continued (Paralysis). " IV.—Disease from Physical Strain. V.—Disease from Combined Physical and Mental Strain. " VI.—Disease from the Influence of the Passions. " VII.—Disease from Alcohol. Physiological Proem. " VIII.—Phenomena of Disease from Alcohol. The Functional Type. " IX.—Organic Disease from Alcohol. X.—Disease from Tobacco. Physiological Phenomena. " XI.—Disease from Tobacco, continued (of the Heart and Lungs). XII.—Disease from Tobacco, continued (of the Brain and Nervous System) XIII.—Disease from the Use of Narcotics (from Opium, Chloral, and Abslnthel " XIV.—Disease from Misuse of Foods. " XV.—Disease incident to some Occupations. " XVI.—Disease from Late Hours and Deficient Sleep. " XVII.—Disease from Imperfect Supply of Air. " XVIII.—Disease from Imitation and Moral Contagion. Pabt the Third.—SUMMAEY OF PP.ACT1CAL APPLICATIONS. D. Appleton & CoSs Medical Publications. 25 SAYRE. Lectures on Orthopedic Surgery, and Diseases of the Joints. Delivered at Bellevue Hospital Medical College during the Winter Session of 1874-1875. By LEWIS A. SAYRE, M. D., Professor of Orthopedic Surgery, Fractures and Dislocations, and Clinical Surgery, In Bellevue Hospital Medical College; Surgeon to Bellevue Hospital; Consulting Surgeon to Charity Hospital; Consulting Surgeon to St. Elizabeth's Hospital; Consulting Surgeon to North- western Dispensary; Member of the American Medical Association; Permanent Member of the New York State Medical Society; Fellow of the New York Academy of Medicine; Member of the New York County Medical Society, of the New York Pathological Society, of the Society of Neurology, of the Medico-Legal Society; Honorary Member of the New Brunswick Medical Society; Honorary Member of the Medical Society of Norway; Knight of the Order of Wasa, by His Majesty the King of Sweden, etc., etc. Illustrated by Numerous Wood-Engravings. 1 vol., 8vo. Cloth, $5.00; Sheep, These lectures are published at the request of medical gentlemen of the highest standing, in different sections of our country, as well as many abroad, who are anxious to have Dr. Sayre's peculiar views and extended experience in this specialty given to the profession in a plain and practical manner. The book contains the substance of his course of lectures delivered at Belle- vue Hospital Medical College, as well as many Important cases from his note-book, and from the hospital records. He has also added a number of cases before presented by him to the profes- sion in medical journals, or at the different medical societies, which are considered worthy of permanent record. The work is enriched by beautiful and excellent illustrations, engraved from original draw- ings and photographs prepared expressly therefor. The author having enjoyed exceptional op- portunities for the study and treatment of these diseases, the results of his labors cannot fail to be of Inestimable value to every student and practitioner, and of service to suffering humanity. STEINER. Compendium of Children's Diseases. A Hand-book for Practitioners and Students. By Dr. JOHANN STEINER, Professor of the Diseases of Children in the University of Prague, and Physician to the Francis- Joseph Hospital for Sick Children. Translated from the Second German Edition by Lawson Tait, F. R. 0. S., Surgeon to the Birmingham Hospital for Women; Consulting Surgeon to the West Bromwich Hospital; Lecturer on Physiology at the Midland Institute. 1 vol., 8vo. Cloth, $3.50. TRANSLATOR'S PREFACE. Dr. Steiner's book has met with such marked success in Germany that a second edition has already appeared, a circumstance which has delayed the appearance of its English form, in order that I might be able to give his additions and corrections. In Germany the use of the metric system has not yet entirely superseded the local measures; but it Is rapidly doing so, as in England. I have, therefore, rendered all thermometric observa- tions In the Centigrade scale, and all measurements in centi- and millimetres. I have added as an Appendix the " Rules for Management of Infants " which have been issued by the staff of the Birmingham Sick Children's Hospital, because I think that they have set an example by freely distributing these rules among the poor for which they cannot be sufficiently commended, and which it would be wise for other sick children's hospitals to follow. I have also added a few notes, chiefly, of course, relating to the surgical ailments of children. BraimroHAM, October, 18T4. LAWSON TATT. 2G D. Appleton & CoSs Medical Publications. STROUD. The Physical Cause of the Death of Christ, and its Relations to the Principles and Practice of Christianity. By WILLIAM STROUD, M. D. With a Letter on the Subject, by Sir James Y. Simpson, Bart., M. D. 1 vol., 12mo. 422 pp. Cloth, $2.00. This important and remarkable book is, in its own place, a masterpiece, and will be considered as a standard work for many years to come. " The principal point insisted on ls, that the death of Christ was caused by rupture or lacera- tion of the heart. Sir James Y. Simpson, who had read the author's treatise and various com- ments on it, expressed himself very positively in favor of the views maintained by Dr. Stroud." —Psychological Journal. SIMPSON. The Posthumous Works of Sir James Young Simpson, Bart., M. D. In Three Volumes. Volume I.—Selected Obstetrical and Oynmcological Works of Sir James Y. Simpson, Bart., M. D., D. C. L., late Professor of Midwifery in the University of Edinburgh. Contain- ing the substance of his Lectures on Midwifery. Edited by J. Watt Black, A. M., M. D., Member of the Royal College of Physicians, London; Physician-Accoucheur to Charing Cross Hospital, London; and Lecturer on Midwifery and Diseases of Women and Childrea In the Hospital School of Medicine. 1 vol., 8vo. 852 pp. Cloth, $3.00. This volume contains all the more important contributions of Sir James Y. Simpson to the study of obstetrics and diseases of Women, with the exception of his clinical lectures on the latter subject, which will shortly appear in a separate volume. This first volume contains many of the papers reprinted from his Obstetric Memoirs and Contributions, and also his Lecture Notes, now published for the first time, containing the substance of the practical part of his course of mid- wifery. It is a volume of great Interest to the profession, and a fitting memorial of its renowned and talented author. " To many of our readers, doubtless, the chief of the papers it contains are familiar. To others, although probably they may be aware that Sir James Simpson has written on the sub- jects, the papers themselves will be new and fresh. To the first class we would recommend this edition of Sir James Simpson's works, as a valuable volume of reference; to the latter, as a collec- tion of the works of a great master and improver of his art, the study of which cannot fail to make them better prepared to meet and overcome its difficulties."—Medical Times and Gazette. Volume II.—Anaesthesia, Hospitalism, etc. Edited by Sir Walter Simpson, Bart. 1 vol., 8vo. 560 pp. Cloth, $3.00. " We say of this, as of the first volume, that it should find a place on the table of every prac- titioner ; for, though it is patchwork, each piece may be picked out and studied with pleasure and profit."— The Lancet (.London). Volume III.—The Diseases of Women. Edited by Alex. Simpson, M. D., Professor of Midwifery In the University of Edinburgh. 1 vol., 8vo. Cloth, $3.00. One of the best works on the subject extant. Of Inestimable value to every physician. SWETT. A Treatise on the Diseases of the Chest. Being a Course of lectures delivered at the New York Hospital. By JOHN A. SWETT, M. D., Professor of the Institutes and Practice of Medicine in the New York University: Physician to the New York Hospital; Member of the New York Pathological Society. 1 vol., 8vo. 587 pp. $3.50. Embodied in this volume of lectures Is the experience of ten years in hospital ana pnvau practice. D. Appleton & Co.'s Medical Publications. 27 SAYRE. A Practical Manual on the Treatment of Club-Foot. By LEWIS A. SAYRE, M. D., Professor of Orthopedic Surgery in Bellevue Hospital Medical College; Surgeon to Bellevue and Charity Hospitals, etc. 1 vol, 12mo. New and Enlarged Edition. Cloth, $1.00. u The object of this work is to convey, in as concise a manner as possible, all the practical in- formation and instruction necessary to enable the general practitioner to apply that plan of treat- ment which has been so successful in my own hands."—Preface. "The book will very well satisfy the wants of the majority of general practitioners, for whose use, as stated, it is intended."—New York Medical Journal. SMITH. On Foods. By EDWARD SMITH, M. D., LL. B., F. R. S., Fellow of the Royal College of Physicians of London, etc., etc. 1 vol., 12mo. Cloth. Price, $1.75. " Since the issue of the author's work on " Practical Dietary," he has felt the want of another, which would embrace all the generally-known and less-known foods, and contain the latest scien- tific knowledge respecting them. The present volume is intended to meet this want, and will be found useful for reference, to both scientific and general readers. The author extends the ordi- nary view of foods, and includes water and air, since they are important both in their food and sanitary aspects. SCHROEDER. A Manual Of Midwifery. Including the Pa- thology of Pregnancy and the Puerperal State. By Dr. KARL SCHROEDER, Professor of Midwifery and Director of the Lying-in Institution in the University of Erlangen, TRANSLATED FROM TUB THIRD GERMAN EDITION By CHARLES H. CARTER, B. A., M. D., B. S. London, Member of the Royal College of Physicians, London, and Physician Accoucheur to St. George's, Hanover Square, Dispensary. With Twenty-six Engravings on Wood. 1 vol., 8vo. Cloth. u The translator feels that no apology is needed in offering to the profession a translation of Schroeder's Manual of Midwifery. The work is well known in Germany and extensively used as a text-book; it has already reached a third edition within the short space of two years, and it is hoped that the present translation will meet the want, long felt in this country, of a manual of midwifery embracing the latest scientific researches on the subject. TILT. A Hand-Book of Uterine Therapeu- tics and of Diseases of Women. By EDWARD JOHN TILT, M. D., Member of the Royal College of Physicians; Consulting Physician to the Farringdon General Dispensary; Fellow of the Royal Medical and Chirurgical Society, and of several British md foreign societies. 1 vol., 8vo. 345 pp. Cloth, $3.50. Second American edition, thoroughly revised and amended. " In giving the result of his labors to the profession the author has dene a great work. Ou: readers will find its pages very interesting, and, at the end of their task, will feel grateful to the author for many very valuable suggestions as to the treatment of uterine diseases."— The Lancet. " Dr. Tilt's 'Hand-Book of Uterine Therapeutics' supplies a want which has often been felt. It may, therefore, be read not only with pleasure and instruction, but will also be found very useful as a book of reference."— The Medical Mirror. " Second to none on the therapeutics of uterine disease.' —Journal of Obstetrics. 28 D. Appleton & Co?s Medical Publications. VAN BUREN AND KEYES A Practical Treatise on the Surgical Diseases of the Genito- Urinary Organs, including Syphi- lis. Designed as a Manual for Students and Practition ers. With Engravings and Cases. By W. H. VAN BUREN, A. M\, M. D., Professor of Principles of Surgery, with Diseases of the Genito-Urinary System and Clinical Surgery, in Bellevue Hospital Medical College; Consulting Surgeon to the New York Hos- pital, the Charity Hospital, etc; and ' E. L. KEYES, A. M., M. D., Professor of Dermatology In Bellevue Hospital Medical College; Surgeon to the Charity Hos- pital, Venereal Diseases; Consulting Dermatologist to the Bureau of Out-Door Relief, Belle- vue Hospital, etc. 1 vol., 8vo. Cloth, $5.00; Sheep, $6.00. This work is really a compendium of, and a book of reference to, all modern works treating in any way of the Burgical diseases of the genito-nrinary organs. At the same time, no other single book contains so large an array of original facts con- cerning the class of diseases with which it deals. These facts are largely drawn from the extensive and varied experience of the authors. Many important branches of genito-urinary diseases, as the cutaneous maladiei of the penis and scrotum, receive a thorough and exhaustive treatment that the pro- fessional reader will search for elsewhere in vain. The work is elegantly and profusely illustrated, and enriched by fifty-five original cases, setting forth obscure and difficult points in diagnosis and treatment "The first part Is devoted to the Surgical Diseases of the Genito-Urinary Organs; and part second treats of Chancroid and Syphilis. The authors ' appear to have succeeded admirably in giving to the world an exhaustive and reliable treatise on this important class of diseases.1 "— Northwestern Medical and Surgical Journal. " It is a most complete digest of what has long been known, and of what has been more re- cently discovered, in the field of syphilitic and genito-urinary disorders. It ls perhaps not an exaggeration to say that no single work upon the same subject has yet appeared, in this or any foreign language, which is superior to it."— Chicago Medical Examiner. "The commanding reputation of Dr. Van Buren in this specialty and of the great school and hospital from which he has drawn his clinical materials, together with the general interest which attaches to the subject-matter itself, will, we trust, lead very many of those for whom it Is our office to cater, to possess themselves at once of the volume and form their own opinions' of its merit."—Atlanta Medical and Surgical Journal. Lectures upon Diseases of the Rectum. Delivered at the Bellevue Hospital Medical College. Session of 1869-'70. By W. H. VAN BUREN, M. D., 1 vol., 12mo. 164 pages. Cloth, $1.50. " It seems hardly necessary to more than mention the name of the author of this admirable little volume in order to insure the character of his book. No one In this country has enjoyed greater advantages, and had a more extensive field of observation in this specialty, than Dr. Van Buren, and no one has paid the same amount of attention to the subject . . . Here is the experience of years summed up and given to the professional world in a plain and practical man- ner."— Psychological Journal. D. Appleton & Co.'s Medical Publications. 29 VOGEL. A Practical Treatise on the Diseases of Children. Second American from the Fourth German Edition. Illustrated by Six Lithographic Plates. By ALFEED VOGEL, M. D., Professor of Clinical Medicine in the University of Dorpat, RumIs. TRANSLATED AND EDITED BY H. RAPHAEL, M. D., Late Hous6 Surgeon to Bellevue Hospital; Physician to the Eastern Dispensary for the Disease? of Children, etc., etc. 1 vol., 8vo. 611 pp. Cloth, $4.50. The work is well up to the present state of pathological knowledge; complete without unnecessary prolixity; its symptomatology accurate, evidently the result of careful observation of a competent and experi- enced clinical practitioner. The diagnosis and differential relations of diseases to each other are accurately described, and the therapeutics judicious and discriminating. All polypharmacy is discarded, and only the remedies which appeared useful to the author commended. It contains much that must gain for it the merited praise of all im- partial judges, and prove it to be an invaluable text-book for the stu- dent and practitioner, and a safe and useful guide in the difficult but all- important department of Psediatrica. " Rapidly passing to a fourth edition in Germany, and translated into three other languages, America now has the credit of presenting the first English ver- sion of a book which must take a prominent, if not the leading, position among works devoted to this class of disease."—N. Y. Medical Journal. " The profession of this country are under many obligations to Dr. Raphael for bringing, as he has dona, this truly valuable work to their notice."—Medical Record. "The translator has been more than ordinarily successful, and his labors have resulted in what, in every sense, is a valuable contribution to medica, science."—Psychological Journal. "We do not know of a compact text-book on the diseases of children more eomplete, more comprehensive, more replete with practical remarks and scientific Ss more in keeping with the development of modern medicine and more worthy of the attention of the profession, than that which has been the subjec* of our remarks."—Journal of Obstetrics. 30 D. Appleton