(Snrnpll ICaw i>rl|nol Slibtary Cornell University Library RC 360.A46 Diseases of the nervous system their pre 3 1924 017 521 851 The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924017521851 DISEASES OF THE NEEVOUS SYSTEM DISEASES OF THE NERVOUS SYSTEM THEIR PREVALENCE AND PATHOLOGY JULIUS ALTHAUS, M.D., M.RC.P. Lond. SENIOR PHTSIOIAlf TO THE HOSPITAL FOB EPILEPSt'aSD PARALYSIS, REGENT'S PARK; FELLOW OP THE ROYAL MEDICAL AND CHIKtTRGIOAI. SOCIETr, OF THE STATISTICAL SOCIETY, AND OF THE MEDICAL SOCIETY OF LONDON ; MEMEER OF THE CLINICAL SOCIETY; CORRESPONDING MEMBER OF THE SOClfeTfe D'HYDROLOGm MSdIOALE DE PARIS, OF THE ELECTRO- THERAPECTICAL SOCIETY OF NEW YORK, ETC. ETC. ETC. NEW YOEK G. P. PUTNAM'S SONS 182 FIFTH AVENUE 1878 TO THE MEMORY OF THE LATE PEOFESSOE EOMBEEG op BEELIN THIS VOLUME IS INSCRIBED IN GEATEFUL RECOLLECTION OP HIS TEACHING AND HIS FRIENDSHIP BY THE ATTTHOE PEEFAGE. Ik this volume I have endeavoured to elucidate the part played by diseases of the Nervous System in national pathology, and to show the laws to which their occur- rence and fatality are subject. I have also fully entered into the special pathology of the several diseases of the nervous centres, which, although much remains to be done, has made gigantic strides in our time. The pathology of peripheral nerve-diseases, and the diagnosis, prognosis, and treatment of the entire class of these maladies, will be considered in a subsequent volume. 18 Bbyanston Street, Pobthan SauAEBT. September 1877- CONTENTS. PAGE PREFACE vii CHAPTER I. Introduction — Problems of Investigation — Nervous Diseases subject to a Definite Law^Are surpassed in Fatality only by Zymotic, Tuber- cular, and Respiratory Diseases — Are less numerous in large Towns than in the Country — More frequent in the Celtic than the Anglo- Saxon Race — Influence of Sex — Males are more liable to them than Females — Influence of Age — Infants and the Aged particularly liable ........ 1 Glassification of Nervous Diseases. By the Registrar-General — The Royal College of Physicians — The Author — ^Physiological Pathology of the Nervous Centres . . 18 1. The Spinal Gord. Functions of the White Columns and the Grey Matter in the Centre — The Latter is Kinesodic and ^thesodic — Section develops Epileptic Tendency — Dr. Brovp^n-S^quard's Guinea-pigs — ^Reflex Action — TJnterschenkel-Phaenomen — Inhibitory Influence — Co-ordina- tion of Movements — Influence of the Cord on the Viscera — The Bladder — The Kectum — The Sexual Organs — Priapism — The Womb — Digestive Organs — Vaso-motor Centre — Centre for the Regulation of Body-heat— Oilio-spinal Centre— The Iris — Trophic Disturbances — Respiration and the Heart's Action — Secretions — Vicarious Interchange of Functions . . . • .24 2. The Meckdla Oblongata. Centre for the Respiratory Movements — JVcmd Vital— The Heart's Action — The Vaso-motor Centre — Deglutition — Articulate Speech . 37 CONTENTS. 3. The Brain. The OerelieUum and Pons Varolii — Corpora Quadrigemina— Thalamus Opticus— Internal Capsule— Corpus Striatum— The Cortex— Loca- lisation of the Cerebral Faculties— Researches of Fritsch, Hitzig, and Farrier- Histological Peculiarities of the Cortex— Comparative Anatomy — Circumscribed Destruction of Convolutions — Broad- bent's Hypothesis— Anaesthesia and Paresis — Aphasia — The Occi- pital Lobes — ^Trephining in the Line of Rolando . • .40 CHAPTER II. CONTTJLSIONS. Mortality from them — Influence of Sex and Age — Direct, Reflex, and Central Convulsions — The Neuropathic Constitution — Cerebral Anaemia — Researches of Kussmaul and Tenner — Hydrencephaloid — ^Vaso-motor Anssmia — Nervous Apoplexy . . .55 1. Infantile Eclampsia. Description of Attack — Causes of it — Excessive Heat and Cold . 71 2. Puerperal Uclampsia. Its Connection with Nephritis — Mode of Occurrence of the Disease — Increase of Temperature ■ . . . . .76 3. Eclampsia from Poisoning. Saturnine Epilepsy — ^Experiments on Dogs fed with Lead — Fits caused by other Poisons . . . . . . .80 CHAPTER III. APOPLEXY. Mortality from it — Influence of Sex and Age — Dr. Lidell's Reports on Apoplexy in New York . . . . . .82 CONTENTS. 1. Cerebral Hoemorrhage. Its Causes — Rupture of Aneurisms — Of Capillary Vessels — Contracted Granular Kidney — Intemperance leading to Apoplexy — Heart Dis- ease does not generally produce it — Miliary Aneurisms — Exciting Causes — Cold — Apoplectic Habit — Anatomical Features of Corpus Striatum Hsemorrliage — ^Necro-biosis subsequent to it — The Apo- plectic Cyst — ' Apoplexie Foudroyante ' — Premonitory Symptoms — Nose-bleeding — Apoplexy of the Retina — Symptoms of the Fit it- self — Loss of Consciousness — Paralysis — Conjoint Lateral Deviation of the Head and Eyes — Temperature — Cerebral Fever — Cerebral Macula — Motor Paralysis after the Attack — ^Paralysis of the Face and Deviajiion of the Tongue — ^The Arm and Leg — Recovery — Subsequent Sclerosis of the Lateral Columns of the Spinal Cord — Trophic Disturbances — Late Rigidity of the Muscles — Oonvulsibility and ExhaustibUity — Mental Fimctions — Hemiansesthesia — Tempe- rature — -The Pulse ....... 2. Meningeal Scemorrha^e. Its Occurrence in Infants from Forceps Delivery — Greater Mortality of Boys than Girls — Influence of Alcohol on its Occurrence in Adults 121 3. Cerebral Hypercemia. Active and Passive Hypersemia — Their Causes and Pathology — The Symptoms multiple — Apoplexy ..... 124 4. Embolism of Cerebral Arteries . . 132 5. Aoute Alcoholic Intoxication. The various Degrees and Stages of Drunkenness . . . 132 6. Acute Intoxication by Opium Mid other Narcotic Poisons. Opium and Morphia — Hydrocyanic Acid .... 134 137 7. Two Forms of the Disease— Cardiac and Apoplectic— Their Patho- log-y CONTENTS. CHAPTER IV. PABALTSIS. PAOE Paralysis has increased during tlie last Decennia — Influence of Sex and Age — Cerebral Palsy — Sclerosis— Tumours — Softening of the Brain — Embolism and Thrombosis of Cerebral Arteries — Thi'ombosis of Veins and Sinuses of Dura Mater — Red, Yellow, and White Sof- tening — Researches of Virchow and Cohnheim by the Aid of Vivi- section — ^Embolism of the Mid-cerebral Artery — ^Marantic Throm- bosis — Otitis ....... 140 1. Aphasia. History of the Localisation of Intelligent Language — Researches of GaU and Spurzheim, BouiUaud, Dax, and Broca — The third left Prontal Convolution — Mistakes in Diagnosis — ^Amnemonic and Atactic Aphasia^Lordat's Case — Agraphia — Amimia — Verbal Deafness and Blindness — Paraphasia — Paragraphia and Paramimia — Functional Aphasia — Case related by Herodotus . . 155 2. General Paralysis of the Lisane. Its Pathology and Symptoms — Ambitious Delusions — -Imbecility . 164 3. Paralysis Agitcms, Shaking Palsy. Tremor and Paralysis — Deformity of the Body — Tendency to forced Movements ........ 168 4. Lahio-glosso-pharyngeal Paralysis. Difficulties of Deglutition and Articulation— Pathology of the Disease — Alaha— Anarthria — Aphonia— Dysarthria . . .171 5. Diphtheritic Paralysis. Two Forms of the Disease — The Soft Palate and Motor Nerves of the Eyes chiefly affected — Migrating Neuritis ■ . . , 178 CONTENTS. CHAPTER Y. CEPHALITIS. PAGE Influence of Sex and Age on its Occurrence — Arachnitis no longer a special Disease ....... 182 1. External Cerebral Pachy-ineningitis. A Purulent and Non-purulent Form — Occurs in the Aged . . 185 2. Internal Scemorrhagic Pachy-meningitis, Hcematoma Durce Matris. Virchow's and Huguenin's researches — Occurs in Decrepit Persons — Influence of Alcohol — Three Stages of the Disease . . 186 3. External Spinal F achy -meningitis . . 190 4. Internal Spinal Pachy-meningitis. The Hypertrophic and Hsemorrhagic Form — Their different Stages . 191 6. Lepto-meningitis Cerehralis. Acute and Chronic Form — Its Occurrence in Infants and Adults . 193 6. Lepto-meningitis Spinalis. Acute and Chronic Form — Cervical, Dorsal, and Lumbar Meningitis . 196 7. Encephalitis, Inflammation of the Brain. Recent Changes in our Pathological Views — Influence of Injury — Ana- tomical Lesions — Abscess of the Brain — Pysemia — Otitis . . 201 8. Myelitis. Acute and Chronic Form— Bed, Yellow, and Grey Softening— Myeli- tis from Pressm-e — Spontaneous Form of the Disease — Brachial Diplegia— Cervical Paraplegia— Hemi-paraplegia— Spinal hemi- plegia — Spinal Epilepsy— Descending Neuritis and Myositis— Para- CONTENTS. PAGE lysis of the Sphinctei-s— Cystitis— Decubitus— Chronic and Acute Bed-sores— Other Trophic Disturbances— Priapism— Progress of the Disease .....••• ^"° CHAPTER VI. EPILEPSY, HYSTERIA, AND CATALEPSY. 1. Epilepsy. Influence of Sex and Age — Symptomatic, Idiopathic, Centric, Eccen- tric, Sympathetic, Vaso-motor, and Spinal Epilepsy — Pons and Medulla the Principal Seat of the Disease — Peculiar Shape of Skull in Epileptics — Pathological Alterations in the Brain . 222 (a.) The Epileptic Fit. Three Periods— Aura — Symptoms of the Fit — Simulated Epilepsy — The Sphygmograph — Mode of Occurrence of Attacks — Epilepticism 232 (b.) The Lesser Hvil, Petit Mai — Epilepsia Mitior . . . . . .241 (c.) Epileptic Vertigo. Automatic Acts — Are such Patients responsible ? — Oases— Epileptic Mania — Epileptoid ....... 242 Mental Condition of Epileptics — Influence of Hereditary Tendency and Alcohol ....... 246 2. Hysteria. The Uterine Theory of the Complaint erroneous — Influence of the Emotions — Of Sex and Age — Of Education — Description of Symp- toms—Hysterical Fits— Acute Hysteria— Mental Peculiarities- Cures by Faith — Paralysis — ^Neiuo-ansesthesia— Ovarian Hyper- esthesia— Hystero-epilepsy—Stigmatisation— Louise Lateau . 248 3. Catalepsy. Its Occurrence in Children — Flexibilitas Cerea — Influence of Faradisa- tion ••■•••.. 264 CONTENTS. CHAPTER VII. INSANITY. PA&E Influence of Sex and Age— Increase of Insanity — The Living Lunatic Population ........ 267 CHAPTER VIII. DELIRIUM TEEMENS. Influence of Sex and Age — The Disease particularly frequent in Eng- lish Females — Its Occurrence in London and all the diiferent Counties of England and "Wales — Symptoms and Anatomical Changes ........ 273 CHAPTER IX. TETANUS. ' Influence of Sex and Age — Traumatic, Toxic, Rheumatic, and Idio- pathic Tetanus — Trismus — Opisthotonus — Pleiirosthotonus — Or? thotonus — Emprosthotonus — Muscular Rigidity — Spasmodic Fits . 280 CHAPTER X. CHOEEA. Influence of Sex and Age — Symptoms — Hemichorea — Its Causes — Pathological Anatomy — Relations of Chorea, Rheiunatism and Endocarditis 293 CHAPTER XI. OTHBE STETICTUEAL DISEASES OF THE NBEYOUS CENTEES. Influence of Sex and Age 305 I. Progressive Locomotor Ataxy. Tahes Dorsalis — Co-ordination of Movements — Anatomical Lesions- Stages of the Disease 307 CONTENTS. 2. Progressive Muscular Atrophy. Lesions in the Muscles and the Nerve-centres— Chronic Polymyositis— Diffuse Lipomatosis— Atrophy of the Anterior Horns— Symptoms . 820 3. Pseudo-hypertrophy of the Muscles. False and real Hypertrophy of the Muscular Tissue . . . • o-^i 4. Disseminated Insular Sclerosis, Charcot's Disease. Peripheral, Transition and Central Zone of Lesion — Stages of the Com- plaint — Influence of Age— Tremor, Vei-tigo, and Spinal Epilepsy . 330 5. Hypertrophy of the Brain. Heavy and Hypertrophied Brain . ... 335 6. Atrophy of the Brain. Idiocy in Children- Second Childhood of the Aged — Hydrocephalus Senilis 337 7. Tumours of the Brain. Glioma — Psammoma — Melanoma — Neuroma — Cholesteatoma — Cancer — Fungus Durse Matris^-Tubercle — Symptoms — Optic Neuritis — Choked Disc — Aneurisms of the Mid-cerebral, Basilar and Posterior Communicating Arteries ........ 340 8. Syphilitic Affections of the Nervous System . . 348 a. Syphilis of the Brain and Cranial Nerves 350 a. Congestive Form. 0. Syphiloma, Gummatous Tumour. y. Disease of the Arteries. 6. Syphilis of the Spinal Cord ... .... 858 INDEX 361 DISEASES OF THE NEEYOUS SYSTEM. CHAPTEE I. INTEODUCTION CLASSIFICATION PATHOLOeiCAL PHTSIOLO&T OF THE NEBTOtrS CENTRES. Onlt vague notions are at the present time entertained by the profession on the prevalence and fatality of nervous diseases ; for although some able investigations into the causation of a few special affections of the nervous system have been made, and in this country more particularly by Sir George Burrows, Dr. Eussell Eeynolds, and Dr. Sieveking, who have endeavoured to elucidate the causes of apoplexy and epilepsy, yet nothing comprehensive has as yet been established with regard to the ■ etiology of the entire class of these maladies. The frequency with which they occur, the place they occupy in the general mortality of the nation, the age at which they are most mur- derous, and the peculiar influence of sex upon their development are, as yet, quite unknown. Amongst the general public and a portion of the profession a notion is prevalent that nervous diseases, and more particularly paralysis and insanity, are, and have been for some time past, on the increase ; that, inasmuch as the struggle of life is keener, the competition more intense, the work heavier, and the anxiety more absorbing, than used to be the case in previous periods of the history of mankind, B 2 DISEASES OF THE NERVOUS SYSTEM. more especially in the large centres of population, the nervous system is more liable to break down by exhaustion and disease than was the case in former times. It should, however, be understood that such notions and assertions have at present no scientific base at all ; but that they are made at random, and^ often only in order to prove or to illustrate some preconceivec^ ideas of those who propound them. Do nervous diseases occur in a certain definite proportion, or do they vary perceptibly from time to time ? Are paralysis and insanity really more frequent nowadays than formerly ? Are large towns more suit- able for their development than the country ? Is the Anglo- Saxon race more liable to their invasion than other races? These, and a number of similar questions, still await solution, and they are not only medically, but socially speaking, of the highest importance. That there should be so much uncertainty concerning these interesting subjects is unquestionably, to a great extent, owing to the fact that the few observers who have occupied themselves with the study of these problems have deduced their conclusions almost entirely from their own private and hospital practice ; and their statements must, on account of the smallness of the numbers from which they have been derived, appear unsatis- factory and unconvincing. Even where such researches have extended over a series of years, erroneous conclusions have been arrived at. Thus M. Falret, for many years physician to La Salpetriere, ascertained that of 2,297 cases of apoplexy, 1,660 occurred in males, and only 637 in females ; and Dr. Hammond, of New York, found the proportion to be 153 male, and 76 female cases in a total of 229. These numbers have led those authors to confidently express the opinion that apoplexy or cerebial haemorrhage is more common amongst men than amongst women ; and yet it is shown by my researches, which comprise not 229 as Dr. Hammond's, or 2,000 like M. Falret's, but nearly a quarter of a million cases, that women, in England at least, are rather more liable to die of apoplexy than men, and this not only for a year or two, but absolutely in the whole period over which the investigation extends. Unless we, there- fore, assume that deaths from apoplexy occur in France and in the United States in a very different proportion from what they THEIR CAUSATION AND PREVALENCE. 3 do in England, we are led to the conclusion that the two physi- cians just named accidentally happened to come across more cases of males than females in the limited field of observation which was at their disposal ; and that their deductions must therefore be devoid of value. In order to arrive at truly reliable and definite results, I have addressed myself to that large storehouse of facts — the Annual Eeports of the Eegistrar-Greneral on disease and death in England and "Wales. Dry and repulsive as large volumes filled with numbers are to the uninitiated, their contents become of surpassing interest to those who wish to recognise some general law to account for the apparently unconnected and accidental facts which come under our observation in daily life, and to perceive something fixed and stable where without such research there would appear to be nothing but chance. The only regret I have experienced in studying these volumes, which have been compiled with so much industry and care, was that they are not more complete and comprehensive, and that certain important omissions from the data placed at the disposal of the Eegistrar- General prevent us from gaining such a complete insight into the more hidden springs of morbid action as we would desire to obtain. But, taken as they are, they were to me of the very greatest value, as they enabled me to deal, not with hun- dreds or thousands, but with hundreds of thousands of cases, ex- tending not only over a few years, but over a considerable period in the life of the nation. Before attempting to utilise these reports, I had carefully to consider what reliance could be placed upon reports which are compiled from the certificates of death filled up by the entire body of the medical practitioners of the kingdom. It is certain that the entries of recent date are more correct than those which were made forty years ago ; and the first period of five years which is included in my investigations differs in such striking respects from the subsequent ones as to create sus- picions of incorrect registration. This is not surprising if we consider that the diagnosis of disease is at present not only altogether more advanced, but also much more universally disseminated amongst the general body of practitioners than formerly. Amongst many proofs for this I will only mention B 2 4 DISEASES OF THE NERVOUS SYSTEM. that the entries of old age as a cause of death have gradually diminished from ten per cent, of the entire mortality in 1838 to five per cent, in 1872. Now it seems impossible to assume that thirty-five years ago twice as many people should reaUy, have died of old age simply, without disease, than is now the case ; for this would show a great deterioration in the public health, which we know from other sources to have improved rather than become worse ; and to my mind these numbers simply prove that formerly old age was more frequently and indiscriminately put down as a cause of death than now, when the search for disease is keener, and consequently more suc- cessful. Fortunately, however, the groups of nervous diseases which appear in the Eegistrar-General's reports have such striking and characteristic features that, on the whole, the errors under this head cannot amount to anything very con- siderable, with the exception of the first few years. The general results of my researches on the entire class of nervous diseases may be summed up as follows : — FiKST Pkoposition. The rate at which diseases of the nervous system prove fatal to the papulation of this country is a steady one, and subject to a definite law, to which there are not any or only apparent exceptions. This rate does not appear to vary perceptibly from time to tvrne, and amounts to about twelve per cent, of the entire mortality from all causes. This proportion is proved by the facts given in the annexed table, which shows at a glance the deaths that have been re- gistered in England and Wales from 1838 to 1871, with the exception of the four years from 1843 to 1846, for which there is no information. The number of years actually noted amounts therefore to thirty, which I have tabulated, not singly, which might have been confusing, but by periods of five years, or lustra, which affords a clearer and easier survey over the whole. Side by side with the numbers of deaths which took place from nervous diseases during these six lustra, I have placed the numbers of THEIR CAUSATION AND FREVAZENCB. o M o o W n a Hi < H O 3 O » M Q 03 P O O CS ft o W o o pH : 00 to J3 CO iH li -5^ CO : 00 o in" 00 od~ to r- 1 (n" CO 1~-" CO «" 00 O m~ O) U3 CO «? CO oo" 00 t^ 00 co" to 00 co" o o (N to in" CO IN o~ 1-4 EC II 1 o 00 00 IN oo" ■o (N (N «3 1—1 co" IN o o OS oo" o 50 C3 CO CO GO rH CD eb 00 00 CO 1 2 I> lO CO iH CO 9 CO 2 l> 00 (0 C3 a o 0) a 6 DISEASES OF THE NERVOUS SYSTEM. the population of the kingdom, and the general mortality from all causes during the same period' ; for if only the deaths from nervous maladies had been tabulated, an erroneous impression that they had considerably increased might have been con- veyed. Indeed, the table shows that in the first lustrum above 200,000, and in the last above 300,000, deaths occurred from these diseases ; and that during the intervening lustra a steady and gradual rise in the numbers had taken place. But an actual increase of such mortality could only be taken as proved thereby if the population of the country had remained stationary during that period. It is well known that the population of France has remained more or less stationary for a number of years past; but in this country the number of inhabitants has steadily risen, and there were in 1871 seven millions more people than there were in 1838. It was therefore necessary to calculate the death-rate for nervous diseases according to the number of inhabitants; and Table I. shows that this has varied from 26 to 28 for 10,000 people during six lustra, which gives a tolerably steady rate at wMch nervous diseases prove fatal to the English nation. Such a mode of calculation, however, does not give quite as accurate results as may be obtained on comparing the mortality' from nervous diseases with the general mortality from all causes, as is done in the further portions of the table. A census takes place only once in every ten years, and the population of the intervening years has therefore to be found by computation, which can never be absolutely correct. Com- putation cannot, for instance, take into proper account the incidental agencies of emigration and immigration, which we know to be liable to considerable fluctuations, as they are greatly dependent upon certain political and social circum- stances, which, in the nature of things, are constantly changing. If, on the contrary, we compare the deaths from nervous diseases with the deaths from all causes, we deal only with a number of separate facts, each of which has been definitely" ascertained, and from which computation is altogether ex- cluded. It is therefore evident that this latter mode of calcu- lation offers considerable advantages over the former one. Now, the percentages registered on Table I. are seen to be THEIR CAUSATION AND PMEVALENCE. 7 remarkably steady and uniform, the mean average for thirty years being 12'26, and the greatest discrepancy from the mean being 0*42 — that is, less than one-half per cent, for six lustra. These numbers show that the proportion in -which nervous diseases prove destructive of human life is a very definite one, and subject to a certain law from which there are not any, or only apparent, deviations. Admitting that there is such a law, we could not expect that the numbers of deaths ■ from these complaints should be absolutely identical from one lustrum to another in twenty millions of people, because there is always a variety of modifyiag influences at work which have to be taken into consideration. In a nation which peoples almost all the habitable regions of the globe, and is, as it were, con- stantly on the move, both outward and homeward, the habitual operation of such a law must always to some slight extent be interfered with. ThuSy men suffering from nervous diseases come home from the colonies either for medical advice or from a wish to die in their native land ; or they leave this country in search of health abroad, where perhaps they find a grave. Again, zymotic diseases, which occur not at a steady rate, but in waves, interfere with the operation of this law, inasmuch as they carry off persons who might, but for their intercession, have died of nervous afifections ; and, according to the degree of intensity which they assume, these diseases either swell or reduce the entire mortality of the period. A remarkable instance of this is given by the cholera epidemic of 1849, which altered for that year the habitual death-rate of all other diseases, and particularly that of nervous maladies. In that year the habitual death-rate from these complaints reached an absolute minimum of 10-80, while it was 11-64 in the year before, and 12-88 in the year after. This interference of Asiatic cholera in 1849 caused the death-rate of the second lustrum of the table to be the lowest of all : and but for this accidental dis- turbance the mortality from nervous diseases would have shown even greater uniformity than is actually the case ; for if we leave out the second lustrum as an abnormal one, the mean average for the remaining five becomes 12-35, and the greatest discrepancy from the mean is reduced from 0-42 to 0-25 per cent. 8 JDISEASBS OF THE NERVOUS SYSTEM. A final reason why the proportion of deaths from nervous diseases must vary to a slight extent is found in the vicissitudes of registration. Even if we allow for a high degree of skilled diagnosis and conscientiousness in filling up the certificates on the part of the medical practitioners of the country, there may, in a nmnber of cases, be different views as to the complaint which actually gave rise to death. Thus, paralysis is not un- frequently complicated with Bright's disease and dropsy ; and one practitioner might register the former, while another would register the latter, as the cause of death. Bronchitis will some- times carry off persons after an attack of cerebral haemorrhage, and either one or the other of these complaints may then be registered. There is reason to believe that during the first few years in which registration of the causes of death took place, such vicissitudes have been particularly active ; and it is an interesting circumstance that if we leave out not only the second lustrum on accoimt of its having been disturbed by cholera, but also the first for faults in registration, the death- rate for nervous diseases becomes still more uniform, as for the twenty years from 1852 to 1871 the greatest discrepancy is found to be only 0"18, instead of 0*25 for five, and 0*42 for the six lustra. After taking into account the influence of these and other circumstances combined, it becomes quite evident that slight variations in the registered mortality from nervous affections cannot alter the general law, which decrees that a certain definite proportion of the population of the kingdom — viz., about 12 per cent, of those who die — is annually cut off by nervous diseases. The common assertion, that nervous diseases have consider- ably increased during the last decennia, is therefore shown to be incorrect. Second Pkoposition. Diseases of the nervous system occupy the fourth rank amongst the maladies destructive of human life, hevng only surpassed in fatality by zymotic, tubercular, and respiratory diseases. This proposition is derived from the annexed table, which THEIR CAUSATION AND PREVALENCE. 1-1 P O > « ■< P rt w n P Eri o E-i -< C_i CO o Ph ^ Pi o O H O l-H o a EC! 00 o w Ah iH U5 i-l Oi in 1—1 05 n CO in l-H o o CO 1 li 00 oo" i-H O co" CO o IN o 1- co" t-H CO ■N IN r-" >o CO CO CO 1 60 o iH : 00 o iH n CO iH CO CO 53 CO O 1— ( 00 00 oT CO r— 1 (M oo" to C<1 IN CO IN o o oo" o CO a Ph pi o 00 o o o ia i-H o CO a lb iH l-H in iH CO iH 3 OS »n s i 00 CO 1^ ^-^ CO co"" CO CO CO QO .— I l-H CO CO CO CO OS »— 1 t^ o" CO h eg O o 6 05 CO o 00 CD CO «) IN CVl pa U 03 tsfl 00 CO CD o C3 > CO cc' CO CD 00 o o" CO 00 in" CD O ID • ^• o n ^^ ID <* 00 CO 00 iH CO n 00 I-l 00 CO Ui 1 CI ta 00 iH CD 00 rH CO CD pa CO 00 CO 00 10 DISEASHS OF THE NERVOUS SYSTEM. shows the numbers of the population that have been earned off during six lustra by the four most important classes of maladies which appear in the Eegistrar-General's Eeports, viz., zymotic, tubercular, nervous, and respiratory diseases. All the other classes— viz., old age, diseases of the organs of digestion, circulation, locomotion, and integumentary system, child-birth, premature birth and debility, atrophy, diseases of the genito -urinary organs, and external causes — furnish much lower quota to the genei'al mortality, and it therefore did not appear to me worth while to include them in the list. It is seen from this table that zymotic diseases, under which head the Eegistrar-General comprises the eruptive fevers, whooping-cough, croup, thrush, diarrhoea and dysentery, cholera, influenza, purpura and scurvy, ague, remittent and infantile fevers,typhus, typhoid, puerperal, and' rheumatic fevers, erysipelas, syphilis, noma, and hydrophobia, rank first amongst the agencies destructive of human life, and that their fatality is subject to considerable fluctuations. The highest point was reached in 1849, when Asiatic cholera ravaged these shores. The number of deaths from these diseases amounted to 137,769 in that year, and they contributed not less than 30 per cent, to the general mortality. The mortality of the entire second lustrum amounted to 24*63, and this proportion has never again been attained. The mean average of the mortality from zymotic diseases for six lustra is seen to be 22*90 — that is, more than 10 per cent, higher than that for nervous diseases. The next great class — viz., tubercular affectiovis — comprise in the Eegistrar-General's Eeports scrofula, tabes mesenterica, phthisis, and hydrocephalus. The mortality from these distempers has not been nearly so steady as that from nervous diseases, for they are seen to have considerably diminished of late years. The difference between the first and second lustrum is indeed so great that we are led to suspect errors of registration, certain affections of the respiratory organs having probably, when registration was first commenced, been put down as tubercular, while they were later on registered under the heading of respi- ratory diseases. This supposition derives considerable support from the circumstance that a rise, almost approaching in sudden- THEIR CAUSATION AND PREVALENCE. ]1 ness to the fall of tubercular diseases, is seen to have taken place from the first to the second lustrum in the class of respi- ratory diseases. Nevertheless, it is quite evident from the table that tubercular affections have steadily decreased of late years ; and this is probably in a great measure owing to the increased prosperity of the nation, and perhaps also to some extent to improved modes of treating these diseases. Tubercular affections are less destructive than the zymotic, the mean being lo*94 against 22*90; but more so than nervous diseases, the mean of which is 12*26. Diseases of the respiratory organs are seen to be decidedly on the increase, even if we allow a certain margin for errors in registration ; and as amongst these diseases bronchitis has particularly increased, the great rise of the manufacturing industry in the country has probably been the cause of it. Bronchitis is chiefly produced by the inhalation of mechanical irritants contained in the atmosphere ; and while new manu- factures are constantly springing up, only little has been done to remedy the evils of smoky towns, dusty workshops, and badly-ventilated mines. Thus it has come to pass that, while in the first lustrum respiratory diseases occupied the fourth place amongst destructive distempers, they have in the present time risen to the second rank, the percentage of the last lustrum being 15-33, against 14-16 for tubercular, and 12-48 for nervous affections. Diseases of the nervous system are therefore seen to occupy the fourth rank amongst the maladies destructive of human life. Thied Pkoposition. Nervous diseases are not, as is commonly asserted, more frequent, but, on the contrary, less numerous, in large toiuns than in the country, and it is probable that their occurrence is powerfully influenced by race. This proposition is derived from the annexed table, in which I have collected and compared the deaths from these diseases as they occurred respectively in London, the South-Western Counties, and Wales for a quarter of a century. The commonly 12 DISEASES OF THE NERVOUS SYSTEM. H is; P o O o p <( H ft = p o "A O H Fh in H o OB 1-1 1 bo 3 o 00 io iH p-l 00 CO uo CO CO CO CD__ oo" CO o CD o" U3 00 o CO cd" o o 00 1-H CO (M 00 00 1— < oq o CO co" o co" od H 12; t= o o H in H t) O CO 6 iH s s o 0) o a § 1- 00 T— 1 CO CO of 00 CO 05 cn oo" crj 00 IM ^_ 00 I-H a „ . PI O otT i-H 00 o CO o" O CO I— 1 1^ eq" 1^' O « !2; o ID 1 6B !D O 6 O pH 6 lO o CD 6 iH s s CO CO 2 1i CO o o oq CO o CO CO CD cm" CO CO CO CO 00 to 00 o~ 00 CO «H : o cd Q '^ CO CO »— ( CO C5 CO CO 00 CO o_ eo~ CO JO Ol co__ oo" CO CO im" iH in 00 CO N in 00 CD t> W 00 1-1 CO CO N CO 00 iH l> I> CO 00 l-t THEIR CAUSATION AND PREVALENCE. 13 received notion that diseases of the nervous system are more prevalent and fatal in the great centres of social, professional, and commercial life than in rural districts is thereby proved to be fallacious, for it appears that the death-rate is lowest in London — viz., 10"66 per cent, of the mortality from all causes for the five lustra ; that in the South-Western Counties it is higher than in London, amounting in the average to 11 "20; and that it is very much higher in Wales — viz., 15*38 — that is, nearly 5 per cent, more than in London. These facts, which stand out with great clearness from Table III., appear to me eminently suggestive. That the nervous system should be more liable to break down in the fine and wholesome atmosphere of agricultural districts than in the close and foul air of the courts and alleys which abound in great cities, seems to show that excess of manual labour is more exhaustive to the nervous system than excess of Tnental labour, and that the more nourishing and substantial food which is enjoyed by even the poorest classes in London, as compared with their brethren in the country, more than compensates them in this respect for the advantages the country affords, as far as air and climate and the supposed wholesomeness of rural pursuits are concerned. The liability to nervous diseases would seem to diminish pari passu with the increased density of the population. In the years from 1841 to 1860 the density of population in London was 0*35 acres to a person; in the South- Western Counties 2*78 acres ; and in Monmouthshire and Wales 4*40 acres to a person. Eespiratory diseases are in this respect alto- gether different, being proportionately much more numerous in London than in country districts, and particularly in Wales. I do not, however, consider that a lesser density of popula- tion explains altogether the extraordinary difference in the mortality from nervous diseases which is shown to exist between London and the South-Western Coimties on one, and Wales on the other side ; for I have found that Wales exceeds all English counties so strikingly in this respect, that neither density of population, nor climate, nor difference of occupation will account for that circumstance. I am therefore inclined to attribute this difference to another influence which distinguishes 14 DISEASES OF THE NERVOUS SYSTEM. Wales fundamentally from all other English counties, and that is — difference of race. I think we may fairly conclude, from the facts which I have brought forward, that the nervous system of the Anglo-Saxon race has greater powers of endurance and resist- ance to unfavourable influences than that of the Celtic race, and is better able to bear rude shocks, as well as the ordinary wear and tear of life, with impunity. If this were definitely proved by further researches, more especially concerning the French, Italians, and Spaniards, as opposed to the English, Americans, and Germans, an interesting clue would be furnished to the problem why it is that the Anglo-Saxon race appears destined to rule the world. Fourth Proposition. Sex has a ^powerful influence on the production of nervous diseases; for although in this country the population of females exceeds that of males, the deaths of males from nervous affections preponderate constantly over those of females, the male death-rate being 12'94 and the female 11*62 per cent. This proposition is deduced from the annexed Table IV., which shows that the percentages for the deaths of males and females have been very uniform during the last twenty-five years. For males the highest point was 13-08, and this number actually occurs twice — viz., in the third and fifth lustra. The lowest point is 12"62, and the mean average 12-94. The highest dis- crepancy from the mean is 0"32 ; but if we exclude the first lustrum, in which the influence of cholera disturbed the ordinary death-rate, the mean average becomes 13'02, and the greatest discrepancy is reduced to 0'12. For females the numbers are seen to be constantly lower than for males, but likewise very uniform. The highest point reached was 11-90, the lowest 11-07, and the mean average for the five lustra amounted to 11-62. The greatest discrepancy amounted to 0-55 ; but if we exclude the first lustrum for the reason stated above, the mean average becomes 11-76 and the greatest discrepancy falls to 0-14. It is therefore proved that males are constantly more liable THEIR CAUSATION AND PREVALENCE. 15 w W E-i o o l« ^ fH J.1 p ^ K <:! » o (-, ^ CD 00 CO CO iH o OS S3 iH i «J _ 11 ^ a o o" O o o 1—) to CD »— 1 00 CO rr' o" 03 CO o CN I-H r 00 o" i-H 00 CO 00 CO to" r-t to" CO 05 O oo (n" 09 < CO ■H (N ' o M iH 00 o m o 9 iH 00 O 03 C» Is a !0 o> CM O I— ( -J2 to O CO o" o I— 1 I— 1 CD o_ IM l-H o lo" t-H tM : O ffl : li III to CO 00 oo" M l-H CO ^_ lo" O CO o_ oo" I-H l-H •in CD iH 1 C0 00 1 I> s CD CO W CO s s 00 iH 16 DISEASES OF THE NERVOUS SYSTEM. to die of nervous diseases than females, and that the average preponderance of the stronger over the weaker sex amounts in this respect to nearly l^ per cent, of the entire mortality from all causes. Fifth Peoposition. Age has even a more -powerful imfiuence on the 'production of nervous diseases than sex ; for these maladies attain an immense Tnaximum, in the first year of life, owing to the great prevalence of infantile convulsions. They are much less fre- quent in youth and middle age, and attain a second maxi- mum in old age — that is, after seventy, owing to the prevalence of apoplexy and paralysis ; hut the second maximum amounts to only about the tenth part of the first vnaximum attained during infant life. The information given on this point by the Eegistrar- Greneral applies, as a rule, only to London ; and in the earlier volumes is given for twenty-six, and in the later for seventeen different periods of life. For the year 1847, however, the ages of all persons who died in the whole of England have been detailed ; and I have thought it best to take the information given for that year as the base for my diagrams, as I consider it more illustrative of this matter than taking only the ages of people who died in London, although for a series of years. Diagram A shows the influence of age on the mortality from nervous diseases altogether ; and we may see at a glance that this influence is far greater than that of sex. The periods of life are stated at the top, and the number of deaths which occurred at the side. The first five years of life are given each one singly, and then there is an entry comprising all the deaths which have taken place under five years of age. This period is separated from the other periods by a thick stroke. All the other squares contain periods of five years up to ninety-five ; after which there is one with a mark of interro- gation, containing any in which the age has not been ascer- tained. The ciu-ve which shows the number of deaths in all these THEIR CAUSATION AND PREVALENCE. 17 1 D I A G R A M A. 5tevifin{ *« influence of iCtm the Mortility from OisMtM of Ihs Nervous System, in EnJIafld & Wales In 1847 9N* 1 1 2 3 4 ► "s'l 5 10 15 20 25 30 35 40 45 50 [55 60 65 70 75 80 85 90 95 ? ZSOOO 30.DOO 15,000 loboo 5^000 {Sen 2*00 J3S0 2300 2J50 2200 2150 2100 2050 .2000 I9S0 1900 l«50 1600 I7M 1700 B 1660 R 1600 (550 ISOO 14,50 1400 1350 1300 1260 1200 11 BO 1100 issa 1000 690 800 650 BOO 750 700 650 r* \ itg ^jL ^ «A ^ . / \ jL iTI^ ^2 01 i 1 . I I I 1 } , ^ / I Ai-\ IS / /Uts JEa-T" ^ II B,^« -Ti^s i ^ V . 1 fiO 1 1 \ \ 1 \ / V' L g4 / 1 \ ^ ■7^ -^m \ V \ 600 660 500 450 4^)o 1 ■ \ \ ^ \ 1 r \ 300 260 200 ISO 100 60 \ — — — — — — — — — — — ~ -^ ^ d The top line of Domben deDoUs the periods of age at which the denthe bave tabeo place. The aide lino of nomben UdlcaUe the qumbcn of dM^tbs at tbe dlffereot D«rlods of Ufc 18 DlSJEASi:S OF THE NERVOUS SYSTEBl. different periods is, in Diagram A, seen to attain an immense maximum in the first year of life ; it descends suddenly after tliat nntil four years of age ; and the further rise assumed by it only sums up, as it were, the results of the first five years. This curve shows that the number of deaths from nervous diseases during the first lustrum of life is greater than that at all the succeeding ages taken together— viz., in round num- bers, 25,000 out of a total of 48,000. From five the curve continues at a low ebb until thirty. At thirty-five a rise is perceptible, which becomes large at sixty, and reaches its maximum at seventy; but this second maximum amounts only to about the tenth part of the first maximum attained in the first period, the numbers being about 2,500 against 25,000. The first maximum is chiefly owing to the mortality from con- vulsions, and the second maximum to that from apoplexy and paralysis. A moot point in our subject which still remains unsettled is the classification of nervous diseases. The most simple, and in a certain way admirable nomenclature, is that which was adopted in 1838 by the Eegistrar-General in his statistical reports, and which is as follows-: — 1 . Cephalitis, Under this heading are included inflamma- tion of the brain and spinal cord and their membranes — that is, encephalitis, meningitis, myelitis, and spinal meningitis. 2. Hydrocephalus, or dropsy of the brain. This disease, which is now generally called meningitis tuberculosa, only remained in our class until 1842, when it was expunged from it, and transferred to the class of tubercular diseases. This being the more suitable pathological place for the affection, I have not tabulated the cases of hydrocephalus for those years ^ in which it appeared amongst nervous diseases, but deducted them from the sum total of deaths, so as to insure, as far as possible, uniformity in my tables. 3. Convulsions, spasms, or fits. This entry is more parti- cularly intended for infantile convulsions or eclampsia, which constitute by far the largest cause of mortality from diseases of the nervous system altogether. 4. Apoplexy, the apoplectic fit. Apoplexy being merely a symptom, and not a disease, this entry includes not only cases CLASSIFICATION. 19 of severe cerebral hypersemia and cerebral hemorrhage, but also sunstroke, and acute intoxication by opium, alcohol, and other narcotic poisons. On the whole, however, fatal cases of cerebral haemorrhage must, in the nature of things, form the large majority of cases classed under this heading. 5. Paralysis, palsy, the paralytic fit, hemiplegia, and paraplegia. This rubric contains chiefly cases of softening of the brain giving rise to hemiplegia, but also of paralysis owing to cerebral haemorrhage which has not immediately proved fatal, chronic spinal disease, progressive locomotor ataxy (which generally ends in paralysis), infantile paralysis, and shaking palsy. 6. Delirium trem,ens, or potatorum, was, until the year 1858, included in the class of Nervous Diseases, but was then transferred into Order 3 of Class I. (zymotic diseases), and registered, together with intemperance, under the heading of Alcoholism. I have, however, continued to tabulate the cases of delirium tremens until 1871, in order to gain as extensive a survey as possible of the fatality of this complaint, which I look upon much more as a nervous than as a zymotic disease. 7. Tetanus, trismus, locked-jaw, 8. Chorea, St. Vitus's dance. 9. Epilepsy, the falling sickness, includes in these Reports catalepsy and hysteria; but as hysteria is hardly ever fatal, and catalepsy extremely rare, it appears probable that almost all cases which have been registered were such of true epilepsy. 10. Insanity, including monomania, dementia, and idiocy. 11. Disease, a general term which is made to include softening without paralysis, abscess, tumour, atrophy of the brain and spinal cord, and diseases of the eyes and ears. This rubric forms a kind of lumber-room into which everything is thrown which cannot be registered imder any of the foregoing headings. The nomenclature of Nervous Diseases which has been adopted by the Royal College of Physicians of London is to my mind unfortunate, as it is neither so simple and practical as the one of the Eegistrar-General, which I have just mentioned, nor does it fully satisfy scientific requirements. To give only a few instances : we find that tetanus, shaking palsy, and chorea c 2 20 DISH ASUS OF THE NERVOUS SYSTEM. are put down amongst the functional diseases of the nervous system. Again, 'paralysis' is described as a disease of the nerves, apart from diseases of the brain and spinal cord ; and in the Annual Eeport for 1874, where the nomenclature of the College of Physicians has been used in addition to the old classification, this ' disease of the nerves ' is stated to have carried off not less than 12,503 persons in that one year! Now if any fact is well established in the pathology of the nervous system, it is this, that paralysis from disease of the peripheral nerves is not only very rare, except in time of war, but also hardly ever fatal ; and it is much more probable that no death at all occurred in 1874 from paralysis of the peripheral nerves than that 12,503 should have been caused by it. A statement scarcely less surprising is that during the entire year one person in all England and Wales should have died of tabes dorsalis ! The following is the classification of Diseases of the Nervous System which I am in the habit of using in the registration of the cases which come under my care at the Eegent's Park Hospital for Epilepsy and Paralysis : — I. General Neuroses. 1. Nervosity, nevrosismus, general hypersesthesia and con- vulsibility. 2. Eclampsia. 3. Epilepsy. 4. Catalepsy. 5. Hysteria. 6. Hypochondriasis. 7. Chorea. 8. Tetanus. 9. Vertigo. 10. Insomnia. 11. Tremor. 12. Athetosis. II. Diseases of the Brain and its Membranes. 1. Hypersemia. 2. Anaemia. CLASSIFICATION. 21 3. Apoplexy (cerebral haemorrhage), 4. Thrombosis 1 ^l ■ i- j.i. i. • , -r^ , 1. ~ , , , . !■ softening 01 the brain. 5. Jimbolism oi cerebral arteries J 6. Aphasia. 7. Meningitis. a. External pachy-meningitis. 6. Internal pachy-meningitis (hsematoma of the dura mater). c. Lepto-meningitis. d. Tubercular meningitis. 8. Encephalitis. 9. Chronic abscess of the brain. 10. Sclerosis. 11. Hypertrophy. 12. Atrophy. 13. Tubercle. 14. Tumours. 15. Syphilitic affections of the brain. III. Diseases of the Spinal Cord and its Membranes. 1. Hypersemia. 2. Anaemia. 3. Haemorrhage into the spinal membranes. 4. Haemorrhage into the spinal cord. 5* Spinal irritation. 6. Spinal exhaustion. 7. Spinal meningitis. a. Pachy-meningitis. b. Lepto-meningitis. 8. Myelitis. a. Acute. b. Chronic. 9. Progressive locomotor ataxy. 10. Hypertrophy. 11. TubeMe. 12. Tumours. 1 3. Syphilitic disease of the spinal cord. 22 DISEASES OF THE JVERVOUS SYSTEM. IV. Diseases of the Cerebrospinal Nerves. 1 . Peripheral paralysis. a. Paralysis of the third nerve. b. „ of the fourth nerve. c. „ of the minor portion of the fifth nerve. d. „ of the sixth nerve. e. „ of the portio dura, facial palsy. /. „ of the spinal accessory nerve. g. „ of the hypoglossus nerve, glossoplegia. h. „ of the vocal cords, aphonia. i. „ of the cervical and dorsal nerves. a. Paralysis of the serratus anticus muscle. j3. „ of the dorsal muscles. 7. „ of the abdominal muscles. j. Paralysis of the phrenic nerve. k. „ of the radial nerve. I. „ of the median nerve, m. „ of the ulnar nerve. n. „ of the lumbar and sacral nerves. 2. Peripheral spasm. a. Trismus. b. Blepharo-spasm. c. Unilateral facial spasm. d. Spasm in the hypoglossus nerve. e. Spasm in the spinal accessory nerve. a. clonic torticollis. /8. tonic torticollis. /. Spasms of the nerves and muscles of the upper extremity. g. spasms of the respiratory muscles. a. Singultus. 0. Tonic spasm of the diaphragm. h. Sternutatio convulsiva, convulsive sneezing. i. Spasm in the lumbar and sacral plexus of nerves. Jc. Tetany. I. Permanent muscular contractions. 3. Peripheral ancesthesia. a. Anosmia, loss of smell. CLASSIFICATION. 23 h. Amblyopia and amaurosis (optic neuritis). c. Loss of taste. d. Nervous deafness. e. Anaesthesia of the fifth nerve. 4, Peripheral hypercesthesia. a. Headache. b. Spinal neuralgia. c. Tic douloureux. d. Olfactory hyperaesthesia. e. Auditory vertigo, Meniere's disease. /. Cervico-occipital neuralgia. g. Cervico-brachial neuralgia. h. Ulnar neuralgia. i. Intercostal neuralgia. k. Mastodynia. I. Neuralgia of the lumbar plexus. in. Sciatica. n. Neuralgia of the coccygeal plexus. o. Neuralgia of the joints. p. Visceral neuralgia. 5. Neuroma. V. Special forms of Paralysis. 1. General paralysis of the insane (dementia paralytica).^ 2. Paralysis agitans (shaking palsy). 3. Labio-glosso-pharyngeal paralysis. 4. Hysterical paralysis. 5. Lead palsy. 6. Eheumatic paralysis. 7. Eeflex paralysis. 8. Peripheral paralysis from injury to nerves. 9. Infantile paralysis. 10. Paralysis after acute diseases. 11. Diphtheritic paralysis. 12. Scrivener's palsy. 13. Paralysis of the bladder. 1 Only patients sufEering from the first stage of this disease are admittecii into the Institution. 24 DISEASES OF THE NERVOUS SYSTEM. VI. Special forms of Anaesthesia. 1. Cerebral anjesthesia. 2. Spinal „ 3. Hysterical „ 4. Toxic „ 5. Muscular „ VII. Affections of the Vaso-motor Nerves. 1. Megrim, sick headache. 2. Angina pectoris. 3. Graves's or Basedow's disease, exophthalmic goitre. 4. Unilateral atrophy of the face. 5. Progressive muscular atrophy. 6. Progressive muscular hypertrophy. I now proceed to give a rapid survey of the present state of the pathological physiology of the nervous centres, as far as it is of importance for my present purpose. I. The Spinal Cord. The physiology of the spinal cord is only very partially known at present, and recent investigations into it, instead of simplifying the subject, appear to have rendered it rather more complicated than it was previously. Division of the entire transverse section of the spinal cord causes complete paralysis and anaesthesia in all parts below the lesion ; while section of one lateral half causes paralysis of motion in all parts below the section on the same side, and anaesthesia in all parts below the section on the opposite side of the body. This shows that the motor impulses run down the cord on the same side from which the motor roots emerge, while the sensory impressions run up to the brain in the oppo- site side of the cord. Complete paralysis of motion is also caused by dividing the antero-lateral columns and the grey matter in the centre of the cord; while section of the posterior columns and the grey matter in the centre does not lead to this result. From this it has been concluded that the antero-lateral columns are the THE SPINAL CORD. 25 motor paths in the cord ; this view, however, is controverted by the fact that section of the antero-lateral columns alone only diminishes voluntary motion for a very short time, but does not destroy it, and that this becomes very speedily re-established, if the grey matter in the centre remains uninjured. The function of the anterior columns alone, which were formerly believed to be the true centres of motion, is still absolutely in the dark. They respond freely to stimulation, but conveyance of motor impulses is possible through the grey matter alone, and even through small portions of its transverse section. This substance, while it freely conducts motor impulses, is itself un- exeitable to any stimuli of whatever nature, and Schiff has therefore termed it ' Jdnesodic.'' With regard to sensation we find that the paths for the senses of touch, pressure, temperature, and tickling are situated in the posterior columns. Section of these destroys the sense of touch in all parts below the lesion, but it does not destroy all sensation, inasmuch as hypersesthesia, especially to painful im- pressions, is the result of this operation. The sensation of pain is not conducted through the posterior columns, but through the grey substance ; and division of the latter causes analgesm or loss of the sensation of pain, while if the posterior columns at the same time remain uninjured, the sense of touch is pre- served. The entire transverse section or any portion of the grey matter may still convey sensations after the antero-lateral as well as the posterior columns have been divided ; and as this substance is at the same time not excitable to stimulation, it appears to be not only kinesodic, but also CEsthesodic (Schiff). Eecent experiments of the lumbar cord of rabbits by Woros- chilofif have, however, rendered it probable that the lateral columns also play an important part in the conduction of sensations. While, therefore, motor impressions run down the same side and sensory impressions in general run up in the opposite side, more especially of the dorsal and cervical portion of the cord, it is not yet settled whether the paths of all kinds of sensations are crossed, as it would appear that the paths for the sense of touch and the muscular sense run up the same side of the organ. A singular consequence of section of one lateral half of the 26 DISEASES OF THE NERVOUS SYSTEM. cord, was first observed by Dr. Brown-Sequard, who found that, if guinea-pigs were kept alive after such an operation, they became within about three weeks subject to epileptic attacks, with loss of consciousness. After this condition had once be- come developed, fits could be produced at any time by irritating a certain area of the skin of the face and neck termed the ' epileptogenic zone.' This zone comprises a region defined by a line proceeding from the eye to the ear, then turning of from the ear to the centre of the lower jaw, branching off from there to the neck, and returning by a semi-circle to the ear. In this zone there is incomplete anassthesia of the skin, and slight irri- tation, such as blowing iipon it or pulling the hair growing on it, will give rise to epileptic fits. After a time such attacks come on spontaneously, and may occur in rapid succession ; but ' ultimately the epileptic condition and the anaesthesia of the epileptogenic zone is found to vanish. The young of guinea- pigs, born while the condition existed in the parent, inherit the tendency, without having undergone any operation for its production. The same phenomena have been produced by division of the posterior columns, posterior cornua, lateral columns, the pos- terior roots of the nerves for the lower extremities, of one or both sciatic and popliteal nerves ; also by complete section and by simple puncture of the cord, more especially between the eighth dorsal and second lumbar vertebra. Injury to the medulla oblongata, the pedunculi cerebri, and the corpora quad- rigemina, have given rise to the same results ; and it appeared that when the cord or the peripheral nerves were divided, the epileptogenic zone was on the side of the lesion, while if the cerebral parts mentioned were injured, it was present on the opposite side. It cannot therefore be concluded from these facts that the spinal cord has any special relation to the production of epilepsy. Westphal found that guinea-pigs were seized by general convul- sions on receiving a light tap on the head. After that the animals continued apparently quite well, but some weeks after the tap had been inflicted, became subject to epilepsy, which lasted from six weeks to six months. The autopsy showed small areas of haemorrhage in the medulla oblongata and cervical portion of THE SPINAL COED. 27 the cord. Hitzig produced epileptic convulsions by destroying the cortical centre for the anterior extremity in dogs ; and it follows from these researches that destruction of the most various portions of the nervous system may give rise to the development of the epileptic condition. One of the most important functions of the spinal cord is its reflex action, which since its discovery by Marshall Hall and Johannes Miiller, has been a favourite subject of study for physiologists. This faculty resides in the ganglion cells of the grey substance in the centre of the cord, where sentient im- pressions are conveyed from the posterior roots to motor paths in the anterior roots, without any simultaneous action of the will. The course of reflex action is probably extremely complicated, and Helmholtz has found that the time required for its occurrence is about twelve times as long as that which is necessary for simple motor conduction. The intensity of reflex action corresponds directly to the intensity of the stimulus, and inversely to the resistance to passage which is encountered. It may, therefore, be increased by increase of stimulus as well as by diminished resistance to passage. Pfliiger has shown that a stimulus of feeble intensity is only conveyed from a sentient fibre to a motive fibre of the same side and at the same level of the cord ; while if the in- tensity be increased, the stimulus is propagated to the corre- sponding fibres of the opposite side. Further increases cause propagation to the upper, and then to the lower portions of the cord, while ultimately all the muscles of the body may be thrown into reflex contractions. Eeflex action is generally caused by stimulation of the skin ; but Erb and Westphal have lately found that it may also be produced from tendons by giving them a light tap with the finger. This is most easily seen on the tendon of the rectus femoris, at the ligamentum patellae (Westphal's Unterschenkel- phaenomen), but may also be produced on the tendon Achillis, and that of the triceps muscle of the arm. The muscular con- traction which answers to the tap, takes place only in the muscles or set of muscles which are connected with the tendon, and is not owing to mechanical concussion of the muscular substance, as Westphal at first believed, but to real reflex action, the 28 DISEASES OF THE NERVOUS SYSTEM. centre for which is ia the lower portion of the spinal cord. The skin does not participate at all in this process. Where reflex excitability is unduly exalted, a similar effect may be produced by giving a tap on the periosteum of certain bones, as also fasciae and articular ligaments. Similar reflex actions may be caused from sentient nerves of the muscles, and from the nerves of the viscera, such as the stomach, intestines, bladder, rectum, &c. Keflex action may be inhibited partly by cerebral influence, as we shall see presently when the function of the corpora quadrigemina comes under discussion; and partly through irritation of the sentient nerves of the skin, or of the sensory nerve-trunks, or the sensory nerves of the muscles and viscera ; all of which may cause diminution, postponement, and even total abolition of reflex activity. The spinal cord has likewise great influence upon the co- ordvnation of Tnovements, by which certain muscles or sets of muscles are made to carry out complex actions which have a certain purpose. Co-ordination is composed of two several kinds of action, viz. of automatic or voluntary associations of muscles for a certain end, and of a state of equilibrium be- tween the antagonists. Most movements which occur in daily life are devoid of certainty and precision without co-operation of antagonists ; so that one set of muscles produces, and the other regulates and tempers, the movements. Complex muscu- lar movements are learned in early life by daily, nay, hourly practice. Immediately after birth the only co-ordinated movements are those of sucking, swallowing, and breathing; all other movements of this kind are only acquired by constant training. The baby that first begins to walk, may be said to suffer from want of co-ordination of the muscles of the legs (locomotor ataxy), and does not learn to walk or stand with- out having often fallen down, and thus received many prac- tical lessons of the importance of a judicious association' of muscles. In the same manner, speaking, writing, sewing, playing on musical instruments, and other complex movements have to be laboriously acquired, until at last the most intricate muscular actions maybe performed instinctively or automatically, without much, if any, effort of volition. Even, however, after THE SPINAL CORD. 29 perfection has been attained, the attention of the mind is still requisite, and unless this be given, the most perfect talker, writer, and player will have slips of the tongue and pen, or play wrong notes. We have to assume that the centres for the co-ordination of movements are formed in the embryo, and are capable of development, but that their full faculties are only acquired by years of practice. This appears to diminish the resistance to the passage of the influence of volition to these centres, which from being at first considerable, like that of a country road full of impediments to the driving of a coal waggon, becomes finally as slight as that which is experienced by a well-made brougham on a noiseless London pavement. The centres of co-ordination are however not actually situated in the spinal cord itself : on the contrary, their seat is in the brain ; which is not only shown by the fact that attention is required, even late in life, for carrying out the most complex movements in the most perfect manner, but also by direct physiological experiments, which go far to prove that the seat of these co-ordinating centres is in the cerebellum, the corpora quadrigemina, and the thalamus opticus. Nevertheless the spinal cord plays an important part in co- ordination, inasmuch as it conducts the impulses for it from the brain to the anterior roots of the spinal nerves. The exact locality of these co-ordinating paths has not yet been ascertained. Pathological facts, more especially such as are observed in pro- gressive locomotor ataxy, render it probable that they are situated in the posterior columns of the cord ; while physio- logical experiments appear to locate them in the middle third of the lateral columns, between the anterior and posterior ones. The spinal cord also contains centres and paths for the con- veyance of nervous impulses to the viscera. Those viscera which are under the most immediate influence of this organ, are the bladder, rectum, and the male and female organs of generation. The influence of the cord upon the movements of the bladder has been chiefly investigated by Budge and Goltz. It appears that as urine accumulates in the bladder, the coats of the viscus are stimulated by distension and pressure ; this causes reflectory contraction of the detrusor urinse, the path for it being through 30 BISWASES OF THE NERVOUS SYSTEM. a centre in the lumbar portion of the cord. The desire to pass water is now consciously perceived, and the urine may then either be passed voluntarily by the impulse for the contraction of the detrusor and the relaxation of the sphincter arriving from.J the brain through the cord in the nerves of the bladder ; or the desire may be resisted by voluntary contraction of the sphincter, until the detrusor becomes fatigued or accustomed to pressure, and the desire to empty the bladder passes off. As, however, the urine continues to accumulate, fresh contractions of the detrusor are caused, until the sphincter is relaxed either by the orders of volition, or by the preponderating contraction of the detrusor, and the bladder is emptied. Pressure by the abdominal muscles, either voluntary or reflectory, may considerably pro- mote the evacuation of the viscus. The centre for the movements of the bladder being situated in the lumbar cord, the viscus may still be emptied even after the dorsal portion of the cord has been divided, as soon as the bladder is sufficiently full or its coat stimulated in any way. Nevertheless the bladder generally appears paralysed in the first few days after the operation, which i? owing to shock to the lumbar cord, resulting from the operative proceeding. As soon, however, as the effects of shock have passed off, the function is re-established. While stimulation of the coats of the bladder itself is the most effective mode of causing the viscus to be emptied, stimu- lation of the anus and rectum may also conduce to this ; and a therapeutical illustration of this physiological fact is, that in obstinate cases of retention of urine, relief may be given by filling the rectum with ice, after all other treatment has failed. The centre for the bladder in the lumbar portion of the cord is, however, not the only one for it, since Faradisation of the restiform bodies and the pedunculi cerebri likewise cause contraction of the detrusor and evacuation of the viscus. Fibres ' proceed from the parts mentioned through the anterior columns of the cord to the anterior roots of the third and fourth sacral nerves, and their function may be excited apparently by cerebral - influence as well as reflex action, the paths for this being in the posterior roots of the sacral nerves. In spite of the existence of this cerebral centre, Goltz THE SPINAL CORB. 31 inclines to the opinion that volition has no direct influence upon the contraction of the detrusor ; and that, if we are able to empty the bladder voluntarily without there being any desire to do so, this is effected partly by relaxation of the sphincter, and partly by powerful pressure of the abdominal muscles upon the coats of the viscus, which in its turn causes reflectory con- traction of the detrusor. The same reflectory centre in the lumbar cord which regulates the movements of the bladder, also serves for those of the rectum, as shown by the effects of Faradisation. The f^ces on arriving in the rectum cause peristaltic action reflexly ; but their evacuation is at first prevented by increased contraction of the sphincter. At the same time the conscious cerebral cortex is informed by the sentient fibres of the rectum that evacuation is approaching ; and this latter may then either take place, by the sphincter being voluntarily relaxed, and the reflex stimulus increased through simultaneous voluntary contraction of the abdominal muscles ; or it may be prevented for some time by voluntarily increasing the contraction of the sphincter. Ulti- mately, however, the tone of the latter will be unable to resist the constantly increasing peristaltic motion of the muscular coat of the rectum. As the faeces pass through the anus, reflectory rhythmical contractions of the sphincter ani are produced, by means of which the rectum is again closed up. Eelaxation of the sphincter of the bladder commonly takes place without relaxation of the sphincter ani, while the latter cannot, as a rule, be relaxed without simultaneous relaxation of the former. When, however, the reflex irritation preceding the evacuation of the faeces has reached a high degree, and is at the same time resisted, a simultaneous desire to empty the bladder has likewise to be repressed, unless on relaxing the sphincter of the urethra, that of the anus may follow. Another illustration of these physiological relations is, that spasmodic retention of the urine is best treated with an effective purge ; for when the sphincter ani relaxes, the spasm of the urethral sphincter cannot persist. Both sphincters may be paralysed together, without implication of any other part, as is found for instance in certain cases of spina bifida. The same reflectory centre in the lumbar cord which rules 32 BISJEASUS OF THE NERVOUS SYSTEM. over the movements of the bladder and rectum, excites the processes of erection and ejaculation. Stimulation of the erectile nerves v?hich arise from the sacral plexus and proceed to the corpora cavernosa, causes an inhibitory influence upon the ganglionic masses of the bloodvessels of the penis, whereby vascular tone is diminished, and the corpora cavernosa filled with blood to excess. That the erectile nerves are excited by the centre in the lumbar medulla, is shown by the fact that destruction of this centre renders erection impossible, while after the dorsal cord has been divided, erection may still be caused reflexly. There is no direct influence of volition over erection, which cannot be produced at pleasure ; but it is gener- ally owing to peripheral irritation in the neighbourhood of the organs, or to stimulation of the imagination. The seat of the sexual desire is in the cortex of the brain, and the reflex centre in the lumbar cord receives its stimulation from there, the path for the latter being through the spinal cord. Faradisation of the upper portion of the cord, the pons, and crura cerebri likewise produce erection. Ejaculation is under the influence of the same lumbar centre, but a more powerful irritation of this latter is required for ejaculation than for erection. In crushing of the spinal cord from fracture of the vertebra we generally observe priapism, which is paralytic and passive. The erectile tissue of the corpora cavernosa of the penis being unable to contract, blood is pumped into them to excess. There is, however, rarely complete erection, for the organ, although turgid, generally remains flexible. Priapism is greater in crushing of the upper dorsal than of the cervical spine, and is more marked and lasts longer in the young than in the aged. The reflex lumbar centre likewise regulates the contractions of the womb during labour ; and parturition may therefore still take place after destruction of the dorsal cord. There are other centres for the uterus in the upper portions of the spiual cord and the medulla oblongata, but none of them are of such essential importance for the induction of uterine contractions as the lumbar centre. The influence of the spinal cord upon the digestive organs has not yet been thoroughly ascertained, but Groltz has rendered it probable that the peristaltic movements of the stomach and THE SPINAL COBB. 33 intestines are under the influence of it, inasmuch as after the destruction of the cord powerful peristaltic contractions and diarrhoea take place. The cord also seems to contain inhibitory centres for the oesophagus and stomach. The chief vaso-motor centre is situated in the medulla oblongata, but there are minor centres for the bloodvessels throughout the entire length of the spinal cord. Faradisation of this organ causes constriction of all arteries below the seat of irritation, while destruction of it produces dilatation of the same arteries, likewise below the seat of the lesion. These vaso-motor centres appear to be situated in the anterior comua of the grey substance of the cord, and the vaso-motor nerves coming from them proceed from the lateral columns through the anterior roots of the spinal nerves to the periphery. That such centres exist all the way down in the cord is shown by the following phenomena : after the arteries have for some time remained distended from section of the cord, they contract again so as to resume their normal diameter, when the effects of shock, and consequent paralysis of the lower centres, have passed off. Every further section of the cord lower dowi causes the same phenomena, viz., at first dilatation, and after- wards contraction, of the arteries. Even after destruction of the lumbar cord, the bloodvessels of the hind parts do not remain permanently or completely paralysed ; and we are therefore led to the conclusion that, independently of the vaso-motor centres in the medulla oblongata and the spinal cord, there are local ganglionic centres in the vessels themselves, analogous to the motor ganglia of the heart, which still cause rhythmic contrac- tions of that organ, after it has been severed from its centre in the medulla oblongata, as well as from the sympathetic and pneumogastric nerve. After destruction of the higher centres, the lower, and also the peripheral centres, seem to gain in power, through the increased quantity of blood contained in the vessels after such operations. The cervical portion of the cord also contains a centre which regulates the production of the hodyr-heat, and corre- sponds in its situation to the sympathetic fibres which pass from the medulla oblongata through the spinal cord to the cervical ganglia of the sympathetic nerve. In fracture of the spine and 34 DISEASES OF THE NERVOUS SYSTEM. crushing of the cervical cord, there is, as a rule, greatly in- creased temperature, owing to, or at least connected with, paralytic dilatation of the bloodvessels. In the earliest stages of such an injury there may be coldness owing to shock, but in a short time the thermometer runs up to 104°, and often shows 110° shortly after death. In exceptional cases the temperature is lowered, so that with the bulb in the urethra or rectum, we only find 93° or 94°. In such cases we must assume that either the effects of shock predominate largely, or that the heat-regulating centre may have escaped the injury. If the patient survives, the temperature is ultimately again lowered in all cases. This is seen eventually after all nerve- lesions, whether motor, sensory, mixed or vasomotor, and is no doubt connected with a reduction of the cellular changes to which the temperature of living tissues is due. If the injury to the spine is confined to one side of it, the increase of tem- perature is likewise limited to that side ; and this is also the case where the brachial plexus is torn across. The cervical cord is the only organ in the body, mechanical injury of which has the effect of inducing hyper-pyrexia. The centre for the regulation of the body -heat loses its power in lessening combustion also under the influence of certain morbid poisons, such as those of typhoid and rheumatic fever, and of excessive external heat. Such loss of control does indeed appear to be the essence of fever; and as the power of the centre is at the lowest ebb at the time of death, the post- mortem increase of temperature in certain pathological con- ditions affecting it, is more easily explained with reference to this than could be done in any other manner. Crushing of the cervical and upper portion of the dorsal cord is likewise followed by contraction of the pupil. That the movements of the iris are partly under the in- fluence of the spinal cord, was already known to Budge, who has described the cilio-spinal centre as situated between the seventh cervical and sixth dorsal vertebrae. Faradisation of this region causes the pupil to become dilated, the stimulus being conveyed to the cervical sympathetic nerve, which animates the radiating fibres of the iris (musculus dilatator). After section of the sympathetic nerve the pupil becomes con- THE SPINAL COjRD. 35 stricted, since the circular fibres of the iris now obtain full power over that membrane. Salkowski has located this centre higher up, in the medulla oblongata, and finds that the motor fibres emanating from it run down in the cervical cord without crossing over, and proceed through the anterior roots of the lower cervical and upper dorsal nerves into the cervical sympathetic, from whence they proceed to the eye. Section of these fibres causes constriction of the pupil, as above. Trophic disturbances of peripheral parts, after their con- nection with the spinal cord has been destroyed, are so common that we are obliged to assume the existence of trophic centres in that organ ; but nothing definite is known regarding their position and connections. The existence of a special set of trophic nerves, which had been asserted by Samuel, has not been confirmed. It is, however, probable that the trophic centres for the sentient nerves are situated in the spinal ganglia, and that those for the motor nerves and muscles, the joints and bones, lie in the anterior cornua of the grey substance ; while the cord itself contains its own centres for its nutrition and preservation. Respiration and the heart's action are more directly imder the influence of the medulla oblongata than that of the spinal cord; yet the cord unquestionably participates in regulating these movements. Eokitansky the younger has been led to assume the existence of respiratory centres in the cervicEfl portion of the cord, the function of which is said to become more marked after separation from the medulla oblongata. The paths by which the respiratory impulses travel from their centres to the respiratory muscles, appear to be situated in the lateral columns of the cervical and upper portion of the dorsal cord. Some physiologists are inclined to put the exciting centre of the heart's action into the cervical spine, from where the impulses would travel down to the sympathetic nerve and the heart ; but further observations appear necessary for decid- ing this question. Accidental crushing of the lumbar and dorsal spine in man, from fracture of the vertebrae, appears to have no influence on the heart's action. Where, however, the cervical spine is injured, the pulsations are diminished, from paralysis of the D 2 30 i)isi:ases of the nervous system. sympathetic fibres coursing in that regi&n. The pulse is there- fore full and large, and uncommonly slow, as it may sink to thirty-five beats in the minute. This is owing to loss of balance between the several systems of cardiac nerves, and preponderance of the inhibitory, which is represented by the pneumogastric nerve, over the exciting or accelerating nerves, represented by the sympathetic system. It forms a striking contrast to see symptoms of the utmost excitement, distress, and suffering from spinal injury associated in this manner with a slow and steady pulse. "VMaether the spinal cord has any direct influence upon the secretions remains Still unsettled. Eckhard has observed that section of thccervicAl cord causes an arrest of urinary secretion, and thinks that there is a centre for exciting urinary secretion in the rhomboid 'fossa. The altered condition of the urine in myelitis and other diseases of the spinal cord was formerly ascribed to a special influence of that organ upon urinary secretion, but is now generally acknowledged to be owing to cystitis from accumulation of urine in the bladder. Finally we must allude to the law of substitution, or vicarious interchange of functions, which Schiff has endeavoured to establish 'for 'the several portions of the spinal cord. He has found that after injury to this organ function may return with- out the anatomical lesion having been repaired ; and explains this by assuming that other portions of the cord, which have remained in their normal condition, undertake the duties of the injured portions in their turn. The only exception to this rule is found in the posterior columns, injury of which will per- manently destroy the sense of touch, without the possibility of recovery. Whether severe anatomical lesions, such as inflam- mation, sclerosis, hsemorrhage, etc., are capable of being thoroughly repaired, remains however very doubtful. It is true that excised portions of the cord may be regenerated, in frogs, as shown by Brown-Sequard, Masius, and Vaulair ; but such does not appear to be the case in the higher mammalia and man, for Eichhorn and Naunyn could not discover any regeneration of destroyed ganglion cells in dogs. If the lower portion of the dorsal cord was divided, there was complete degeneration of the parts operated upon ; afterwards an inter- THE. MED ULLA . OBL ONGA TA. 37 mediate substance of cellular tissue, resembling the neuroglia, was formed, in the centre of which there was a cavity ; and in the course of many months a scanty number of nerve-fibres were re-formed in this substance. In accordance with these anato- mical lesions, partial recovery of motion and sensation took place ; but the animals nevertheless perished ultimately in consequence of the injury they had received. Groltz and Freusberg, on the other hand, have never been able to see either regeneration of tissue or recavery of function in dogs which had been treated in this manner ; and this latter result would agree with our clinical experience, which shows that recovery from pathological, lesions of this sort in man is extremely rare, and that even where it occurs, it is very im- perfect. II. The Medulla Oblongata. This organ, which connects the spinal cord with the great ganglia of the brain, and allows decussation of the motor con- ductors of the cord in the anterior pyramids, so as to connect each half of the brain with the opposite half; of the body, is a centre of reflex co-ordination endowed with the most various and important functions. The principal one of these is to guide and direct the respiratory rnovements-. When the entire brain above the medulla oblongata has been removed, respiration will still continue, while if the medulla, be destroyed in a warm-blooded animal, this will instantly cease breathing and die. The exact seat of the respiratory centre is in the apex of the fourth ventricle, on the beak of the calamus scriptorius, and has by Flourens been termed the vital knot {nceud-vital). Faradisation of this «pot causes sudden rigidity of the respiratory muscles of the neck chest-walls, and diaphragm ; and morbid stimulation of it has the same effect. The access of air to the windpipe and the bronchial tubes is prevented, and respiration suddenly arrested, by convulsions proceeding from the medulla oblongata. The brain is consequently all at once deprived of oxygen, and death from asphyxia must ensue unless the convulsion quickly subsides. When this tonic rigidity of the respiratory muscles continues beyond a minute or two, a fatal result is certain ; but in many attacks of eclampsia it is followed by clonic convulsions : we 38 DISEASES OF THE NERVOUS SYSTEM. perceive jerking movements of the chestwalls, from alternate rigidity and relaxation of the respiratory muscles, whereby a small quantity of air is allowed to enter the lungs. This at once cuts short the asphyxia, since even a slight supply of oxygen is sufficient to keep up life for a time. The clonic convulsions at first succeed each other rapidly, and then at longer intervals, the contractions becoming less frequent, and the relaxation more prolonged, until at last the rigidity ceases altogether; respiration becomes regular, the attack is over, and the patient's life saved — at least for a time. The relation of the medulla to respiration explains the curious phenomenon of the cry or scream, which so often ushers in epileptic and other convulsions. This is not, as commonly' believed, a sign of pain, but simply a convulsive expiration, owing to sudden irritation of the co-ordinating centre of the respiratory movements. The medulla oblongata'has also an important influence upon the hearts action. It does not of itself cause the I'hythmical contractions of that organ, which are under the influence of Wie motor ganglia, situated in the cardiac substance itself. The heart, therefore, may continue to beat rhythmically after all the nerves which connect it with the brain and spinal cord have been divided. The nerves proceeding from the medulla oblongata to the heart have a twofold influence, viz. to accele- rate and to .restrain its rhythmical action. The restraining or inhibitory influence is exercised by the pneumogastric nerve, section of which causes the pulsations to become so quick that they can no longer be counted ; while Faradisation of it, by putting into full force its inhibitory influence, causes the hear to stand still during diastole. On the other hand, the sympa- thetic fibres which pass from the medulla oblongata down the spinal cord, and reach the heart through the lower cervical and first dorsal ganglia of the sympathetic nerve, accelerate the heart's action. Convulsions proceeding from the inhibitory centre of the heart's action cause an immediate arrest of the cardiac movements, and may thereby produce death by syncope. The medulla oblongata contains likewise the vaso-motor centre, which regulates the innervation of the bloodvessels, and appears to be situated on, each side of the median line of the THE MEDULLA OBLONGATA. 39 floor of the fourth ventricle. Section of this centre causes paralysis of the bloodvessels, while Faradisation of it causes their contraction. Convulsion implicaJting this portion of the medulla causes instantaneous anaemia (or rather ischsemia) of the brain, with the symptoms of vertigo, general convulsions, and apoplectic coma. The medulla oblongata is further the co-ordinating centre of the movements of deglutition, for which it associates the action of the muscles of the lips, tongue, palate, and pharynx. Section of the medulla renders swallowing impossible. Con- vulsive movements of deglutition are not unfrequently observed together with general convulsions, and then point to irritation of this particular centre. The medulla is likewise the centre for the reflex co-ordination of actions in the sphere of the portio dura, causing reflex emotional expression of the face. Facial spasm in its most horrible forms is often combined with convul- sions arising from irritation of this portion of the nervous system. The medulla oblongata is finally the co-ordinating centre of articulate speech. It contains the nuclei of the pneumogastric and accessory nerve, that is, the sensory-motor nuclei for respi- ration and the voice, which are indispensable for speaking ; and the motor nuclei of the hypoglossus and portio dura, which organise articulation. The nuclei of these nerves are situated close together, in pairs, at both sides of the raphe ; and in con- sequence of this arrangement, aided by commissural fibres pro- ceeding from one side to the other, a simultaneous contraction of the corresponding muscles of the tongue, lips, and palate may be caused, even when the motor impulse proceeds from one side only. These anatomical facts are of great importance in the con- sideration of that form of paralysis which is known as progressive bulbar paralysis, and in degeneration of the grey substance of the spinal cord which has the tendency to ascend to the medulla oblongata. The integrity of pronunciation of letters is bound to the integrity of the motor nuclei in the medulla which have just been mentioned. As in the diseases just alluded to, one ganglion cell after another perishes, pronunciation of one con- sonant and vowel after another becomes impossible, and the 40 DISEASES OF THE' NEHVOUS SYSTEM. ■words indistinct and unintelligible. In such cases there is no affection of the intellect, nor any loss of intelligent languagfe (aphasia), but simply anftihilation of speech from impossibility of pronouncing letters. Aphasia is generally associated with agraphia, or loss of the power of intelligent writing ; white in progressive bulbar paralysis, the patient is able to write and thereby to communicate his thoughts and sensations, provided the paralysis does. not affect the arms and hands likewise. III. The Brain. Lesions of the cerebellum cause disorders of movement resembling those observed in the various degrees of alcoholic intoxication, so that the proper equilibration of the body is interfered with. Faradisation of this organ produces move- ments of the eyes in different directions, according to the parts of the cerebellum which are acted upon, and also certain move- ments of the head and limbs, together with contraction of the pupils. These movements are intended to maintain the equi- librium of the body, so that if there be a tendency to dis- placement, a compensatory action is excited, preventing or' neutralising the same. Thus, destruction of the anterior part of the middle lobe of the cerebellum causes a tendency to fall forward, while Faradisation or pathological irritation of the same induces such muscular movements as would counteract that tendency. Destruction of the ^posterior part of the middle lobe creates a tendency to fall backwards, and of the lateral lobes to fall sideways, while Faradisation of those parts appears to call into play those muscular actions which are intended to prevent the tendency to fall backwards or sideways. Patho- logical lesions which destroy the harmony of the different parts concerned in the maintenance of equilibrium, cause the feeling of vertigo. These functions of the cerebellum cannot, however, be quite detached from those of the optic lobes and pons Varolii, and these three parts seem to form a conjoint mechanism incapable of being disjoined without causing a general dis- order of function (Ferrier). There appears to be no distinct relation between the cerebellum and the sexual appetite. No doubt priapism has occasionally been observed in haemorrhage THE BRAIN. 41 of the middle lobe of the cerebellum, but sueh an effect is most likely owing to the pressure of the clot upon the posterior surface of the medulla and the pons. Injury of the pons Varolii causes complete facial paralysis on the same side, and paralysis of the arm and leg on the opposite side. The pons has also an important influence on articulation, as it is found that in disease of it, although in- telligent language does not suffer, yet the pronunciation of words is so clumsy that the patients are nearly or quite un- intelligible. Meynert has divided the- ganglia of the brain in two great parts, viz., the ganglia of the tegmentum pedunculi, which comprise the corpora quadrigemina and the thalamus opticus ; and the ganglia of the pes pedunculi, which comprise the corpus striatum and the cortex of the brain. The tegmentum and pes are again connected with one another by a special system of commissural fibres. The functions of the corpora quadrigemina, or optic lobes, are of a complex character. When tkey are destroyed, vision is completely abolished, and the pupils do no longer contract when a light is appioached to the eyes. They have also a decided influence on the expression of the emotions, such as fear, terror, pleasure, etc. Faradisation of these bodies causes complex movements of all the muscles of the body, and espe- cially of those which are concerned in the maintenance of the normal attitude, and for purposes of progression. It is also found that the animals in which these parts are faradised, utter peculiar cries or moans ; and we may assume with a great degree of probability that the long-continued moaning which is some- times heard during epileptic attacks, is owing to morbid irri- tation of the corpora quadrigemina, just as the sharp initial cry of the convulsive seizure appears to arise from irritation of the medulla oblongata. We have seen that the spinal cord is the centre of reflex action, but it is in this respect subject to a restraining or in- hibitory influence on the part of the brain. It is probable that the corpora quadrigemina are the precise part of the brain endowed with this important function ; for Setschenow has shown that chemical irritation of these lobes causes a long 43 DISEASES OF. THE NERVOUS SYSTEM. interval to elapse between an impression and the reflex move- ment following it, while otherwise both are almost simultaneous. Powerful irritation of the parts abolishes reflex action alto- gether ; and this is in consonance with the experience of daily life that we are able by strong efforts of the will to prevent, or at least to diminish and postpone, reflex movements. Disease or injury of the inhibitory centre of reflex action increases convulsibility to a very great extent, by the removal of the check physiologically laid upon the reflex function. In de- capitated frogs we therefore find reflex excitability enormously increased. The paths for the conduction of reflex inhibition are believed to lie in the anterior columns of the spinal cord. The thalamus opticus, which constitutes the second part of Meynert's ganglia of the tegmentum pedunculi, is insensible to Faradisation. Destruction of it in animals does not cause paralysis or anaesthesia of the skin, but certain motor dis- turbances which appear to indicate a weakening of the muscular sense. Haemorrhage into the posterior portion of the thalamus may cause hemiplegia, crossed amblyopia, hemi-ansesthesia, and impaired articulation; these symptoms, however, are not a direct consequence of the lesion of the thalamus, but are owing to the pressure which the clot exercises upon the neighbouring internal capsiile of the nucleus lentiformis. The internal capsule, which separates the nucleus from the corpus striatum, contains in its posterior third mixed motor and sensory fibres, which in their further progress towards the hemispheres separate, the motor fibres going forwards, and the sensory going backwards. Charcot and Veyssiere have shown that lesions of the anterior portion of the internal capsule cause simple motor hemiplegia, while lesions of its posterior portion cause hemiplegia combined with hemi-ansesthesia. The an- terior central hemispheral area, which is purely motor, is called the sphere of the lenticulo-striated arteries ; and the posterior central hemispheral area is called the sphere of the lenticulo- optic arteries. Central softening of, or haamorrhage into, these parts likewise interfere with articulation. Meynert's ' ganglia of the pes ' consist of the corpus striatum and the cortex of the hemispheres, and appear to determine those movements which are caused by the will and intellect. THE BBAIN. 43 Faradisation of the corpus striatum causes unilateral tonio con- tractions of the muscles of the face, neck, trunk, and limbs, a condition of pleurosthotonus, in which the body is bent to the opposite side with predominance of the flexors over the extensor muscles. It serves as a centre for combined movements, such as running, jumping, etc, which at first require conscious efforts and long-continued training, but ultimately become so easy that they can be performed without much or any attention. The corpus striatum may therefore be looked upon as an aux- iliary motor instrument of the will, intended for relieving the cortical centres of voluntary effort and conscious discrimination, of a large portion of the work which would otherwise have to be done by them. Lesions of the left corpus striatum interfere more with ar- ticulate speech than lesions of the right. They may destroy articulation entirely, or cause such difficulty in speaking as to render what is said unintelligible. Loss of articulate speech is therefore generally combined with right hemiplegia ; where it co-exists with left hemiplegia, it is generally only temporary and owing to shock. The corpus striatum is the uppermost limit where lesions of the brain cause simply impaired or im- possible articulation. Persons who have suffered from hemi- plegia and loss of speech from haemorrhage into this central portion, may still write and express their thoughts intelligently with the non-paralysed hand, provided the cortex of the brain is in a state of integrity, while real aphasia, or loss of intelligent language, is always owing to lesions of the cortical substance of the brain. The highest development of the brain is produced in the cortical substance of the hemispheres. The convolutions of the cerebral hemispheres which surround the corpora striata are the centres of conscious motor activity, and as such in intimate connection with all inferior centres. It was formerly believed that the cerebral hemispheres were insensible to any form of stimulation applied to them, whether mechanical, chemical, thermic, or electrical ; and Flourens, who was the pioneer in the physiological investigation of the functions of the brain, laid it down as a general principle that all portions of the hemispheres were capable of fulfilling the same functions, 44 visi:asi:s of the- nervous system. aud might supplement each other in case- one or several of them were destroyed. This law of substitution or vicarious interchange of functions, which was for a long time accepted by physiologists and physicians, may now however be looked upon as repealed by the efforts of numerous observers, who, although they differ somewhat in detail, agree in the main as to the fact that certain cerebral functions are bound to certain cerebral areas. The only physiologist of note who is still opposed to this principle is Dr. Brown-Sequard ; and we cannot help indulging^; a hope that he may, as evidence accumulates more and moBe, likewise become converted to the true doc- trine. The Localisation of Cerebral Faculties is at the present time the favourite study of the most advanced observers of all countries, and can only be briefly touched upon in this place ; more especially as our knowledge of it is still in its infancy, and present conclusions and theories will unques- tionably have to undergo extensive modifications before they may be looked upon as settled. It is the merit of Fritsch.and Hitzig' to have shown by physiological' experiments that there are' true motor centres in the cortex of the brain ; that motor and sensorial centres are differently located; that there are definite areas ruling the movements of the front and hiiid legs, the jaw and the tongue in animals, and that supplementary or vicarious action is only possible within these areas, but not outside them. This they were able to prove by applying electricity to different portions of the cerebral convolutions of living animals. Their experi- ments made it evident that grey matter could be directly stimulated, and that, according to the locality where the electrodes were applied, movements of individual sets of muscles took place, while areas in close contact with each other reacted in a totally different manner. Soon after the investigations of the Grerman observers had been made known. Dr. Ferrier *' commenced a series of experi- ' Fritsch and Hitzig in Beichert and Du Bois-Reymond's Aicbiv., 1870 ; and especially, Hitzig, ' Untersuchnngen fiber das Gehim.' Berlin, 1871. ' ' The funetions of the Brain.' London, 1876. THE BRAIN. 45 ments on the same subject, the results of which have been recently embodied in a most able and suggestive volume, and which have greatly advanced our knowledge of the functions of the brain. The results obtained by Hitzig and Ferrier are found to harmonise in many instances with the clinical observa- tions of Dr. H. Jackson, who has for years past endeavoured to trace localised unilateral convulsive movements to morbid irritation of certain portions of the cortex of the brain, pro- ducing what he calls ' discharging lesions.' The objection which was at first raised to Hitzig's and Ferrier's experiments, viz., that the movements observed were not owing to the stimulation of the cortex, but to the diffusion of the electric current to the true motor centres lower down, has been thoroughly disproved. It is now well established that a current of very low intensity, if applied at the proper point, causes certain movements, while a more powerful one, applied at the wrong point, does not produce any such move- ments. Moreover, if the centre be destroyed, and a current applied a few days afterwards to the raw surface, no effect is produced, although the transmission of the current is promoted rather than impeded by the injury. Nevertheless no complete unanimity has as yet been bj'ought about amongst those who are best able to judge of these conditions. Thus Schiff, Eckhard, and Hermann deny that the cortex is electrically excitable, and contend that the effect observed is in reality owing to stimulation of the medullary fibres proceeding from the cineritious substance to the central ganglia ; and Eckhard has traced one of these excitable medul- lary fibres for the front leg down to the corpus striatum. Messrs. Lussana and Lemoigne ' likewise deny that the cortical centres of Hitzig and Ferrier are motor centres in the ordinary sense of the word. They point to the fact that mechanical stimulation does not excite them, and that Faradis- ation and galvanisation are generally ineffectual when the animal is anaesthetised, or immediately after death. In all these points the cortical centres differ very much from the spinal cord, the medulla oblongata, and other centres of motion. ' 'AjoMves de Physiologie.' Paris, 1877. '46 DISEASES OF THE NERVOUS SYSTEM. In very young animals the existence of these centres cannot be shown, although reflex action is highly developed in them; and in some adult animals it is likewise impossible to make the cortical centres respond to electrical stimulation. The same observers also point to the fact, which has already been dwelt upon by Goltz, that the motor paralysis which is observed after destruction of these centres, is not complete nor persistent, while after destruction of the lower motor centres there is complete and permanent paralysis. They have therefore arrived at the conclusion that the centres in the cortex are the organs of volition and instinctive faculties; and that if they are destroyed, the movements may still be executed, although without an intelligent purpose. It appears to us that this question cannot be entirely decided by electrical investigations alone, but that histology, compara- tive anatomy, and pathology will have to furnish contributions towards the elucidation of it before we can expect to arrive at the truth. Unfortunately, very little has as yet been done as far as the two first-named auxiliary sciences are concerned. We must, however, give a due meed of praise to the researches of Betz of Kiew,' who has shown that the surface of the hemispheres is, by the fissure of Rolando, divided into two halves, in the anterior one of which, which corresponds to Hitzig's centres, the micro- scope reveals colossal pyramidal cells, while in the posterior one, which is not excitable, layers of nuclei predominate. Betz has found that his ' giant-pyramids,' which are found in Hitzig's excitable zone, occur nowhere else ; and what is even more important, that they only become properly developed after birth. We have in this distribution of nervous elements, there- fore, an analogy with the anterior motor and the posterior , sensitive sphere in the grey centre of the spinal cord. A valuable contribution to the same subject has been made by Dr. Herbert C. Major,^ who has investigated the structure of the island of Eeil in apes, and has foimd the pyramidal cells in it much smaller than in the human insula. > ' Anatomisoher Nachweis zweier Gehirncentren.' Centralhlatt. 1874, p. 578. 2 'The Structure of the Island of Reil in Apes.' The Lancet, July li, 1877. THE BRAIN. 47 Von Grudden ' has discovered that in the inexhaustible squirrel, the frontal or motor portion of the cortical substance is much more developed than in the tranquil, lazy rabbit; showing that motor impulses vary according to the develop- ment of the anatomical organs provided for them, A most important fact first brought forward by Hitzig is that, after the electrical stimulation of the grey motor centres has ceased, the movements which were produced under the immediate influence of the galvanic current have a tendency to reproduce themselves either partly or entirely, without further stimulation, but as an after-effect of the same ; and that such spontaneous convulsive movements may ultimately develope into epileptiform convulsions of the entire body. This is an important physiological foundation for what has been called ' cortical epilepsy,' and finds its analogy in the convulsive seizures which are observed in patients as a consequence of circumscribed irritation of the cortex by inflammation, tumours, and parasites. Such convulsions are at first partial, and become gradually transformed into true epileptic fits with loss of consciousness. Important crucial evidence as to cerebral localisation is furnished by circumscribed destruction of motor centres, which appears to cause either temporary or permanent paralysis of those sets of muscles which are ruled by the cortical centres. The principal methods for this investigation are those of Nothnagel, who cauterises small portions of the cineritious substance with chromic acid ; of Goltz, who washes cerebral matter out from an opening made by a trephine, by means of a stream of water ; and of Ferrier, who destroys brain matter with the actual cautery. The time which has elapsed since these investigations were undertaken is not sufficient to enable us to judge positively about their results. Yet there is no doubt that in some cases the loss of power is merely temporary; and some difficulty seems to arise as to a satisfactory explanation of this fact. Does Flourens's law of supplementary or vicarious action find an application in this instance ? If function reappears after the destruction of the corresponding centre, we may assume ' Kussmaul, ' Die Storungen der Spraclie.' Leipzig, 1877. 48 DISH ASUS OF THE NERVOUS SYSTEM. that the destroyed portion of the cortex is supplemented, either in the same or the opposite hemisphere, by another portion which had already been trained previous to, or is only being trained after, the reception of the injury. If the destruction be small, we may assume vicarious action in the same hemisphere ; but if it be extensive, it would be necessary to look to the corresponding centre in the opposite hemisphere as a substitute. Dr. Broadbent' has proposed a theory of bilateral action of the hemispheres, which at first sight would seem applicable to this case. According to him, in hemiplegia from corpus striatum haemorrhage, only those parts are really found devoid of motor power which have the faculty of acting singly, and independently of the corresponding parts of the opposite side. These parts are the arms, which are habitually engaged in totally different motions, and the legs, one of which in walking supports the body, while the other is thrown forward. On the other hand, the muscles which escape the paralysis are those which act only bilaterally, or in concert with the corresponding muscles of the opposite side. Thus it is impossible to expand one side of the chest or abdomen, or to move one eye, without the other. The anatomical explanation of these phenomena is, according to Dr. Broadbent, as follows : When muscles habitually act together, the nuclei of their nerves are usually connected by com- missures, and form, as it were, a single nucleus. This latter receives a set of fibres from each corpus striatum, and is usually called into action by both, but will be capable of being excited by either singly, and that more or less completely, according as the commissural connection between the two halves is more or less perfect. If, therefore, the centre of volitional action is destroyed on one side, the other will transmit an impulse to the common centre, and this will be communicated to the nerves of both sides ; equally, if the fusion of the two nuclei is complete, and in this case there will be no paralysis at all ; and more or less imperfectly to the nerve of the affected side, where ' - o 0> - ^ in 00 > . o 00 , -rs 5 o g 1 CO o. o o m CO £i R A M rom CONVULSI o in c 1? = o 7 lO 3 O S 0^ in CM t I A Mortal! o in ^1 o i in § _ k- _ to / UJ < o im __ — ' ft ^ - ^ "" - - r o c: o » X > Cvl eo / X — a ^ y . i~ - c= ■| .JC C/3 o o o o O CM « CS o o § o 3; C3 CS o CM s o. o o o. O o o o (0 o o JS o o o o 1J> o o o o o o CM o o o JS 1 a S a i1 a) ^ ll 68 DISEASES OF THE NERVOUS SYSTEM. The first period of five years shows altogether a mortality of 23,347, and convulsions are thus seen to be, without exception, the most fruitful source of infant mortality. No other disease equals it in severity, for even ' atrophy and debility,' which comprises the ultimate issue of a number of different diseases, is less fatal than convulsions. The following is a synopsis of the deaths which the most fatal diseases of infantile life from birth to the fifth year of age caused in 1874 : — Convulsions . Atrophy and debility Bronchitis . Scarlet fever Pneumonia . Measles Whooping-cough Hydrocephalus Teething Croup . Diphtheria . Small-pox . 26,534 26,514 21,147 16,712 13,638 11,318 10,012 5,991 4,316 4,220 1,713 543 The entire infantile mortality (under five years) having been 213,799 in the year 1874, we find that convulsions caused 12-42 per cent, of the entire mortality during that period of life. After the fifth year the curve in the diagram descends with unparalleled precipitation, never to rise again. The numbers for the different periods of life are as follows : — Under 5 years of age From 5 to 9 55 » 10 „ 14 55 „ 15 „ 19 55 „ 20 „ 24 55 „ 25 „ 29 55 „ 30 „ 34 55 „ 35 „ 39 55 „ 40 „ 44 55 23,347 deaths 320 55 61 55 29 55 31 35 22 55 16 55 21 55 18 55 CONVULSIONS. From 45 to 49 years of age „ 60 „ 54 „ 79 85 „ 89 „ 90 „ „ 95 » 55 „ 59 „ 60 „ 64 „ „ 65 „ 69 „ „ 70 „ 74 „ „ 75 80 „ 84 „ 94 „ 55 59 ] 3 deaths 13 12 10 9 12 9 4 6 1 1 The disease therefore ceases to be important after ten years of age. So much for the influence of age in the production of con- vulsions. With regard to the influence of sex, opinions differ considerably am^ongst the ablest physicians, some considering that sex has no influence at all, while others assert that the male or female sex are more predisposed to this disease. This question is, however, absolutely set at rest, at least as far as this country is concerned, by the following table, which shows at a glance the influence of sex on the mortality from this disease in England and Wales. Convulsions are seen to be much more fatal to hoys than to girls, the mean percentage being 25 for the former, and only 20 for the latter. Influence of Sex on Convulsions. Periods of five years Males Percentage Females Percentage ] 847-61 1852-56 1867-61 1862-66 1867-71 66,280 69,070 71,132 73,966 72,784 27-72 26-80 26-17 25-25 23-58 51,711 53,726 55,470 57,863 57,223 21-59 20-74 20-40 19-76 18-56 Mean percentage for 26 "1 years . . . J 25-77 20-28 This table shows throughout the entire period over which 60 mSHASJSS OF THE NERVOUS SYSTEM. the investigation extends, a decided excess of male over feniale mortality. Although more boys are born than girls (in the proportion of 104 to 100), yet there is an excess of females^ over males living. In 1874, for instance, in round numbers, 435,000 boys, and 420,000 girls were born ; but the male death-rate was 23-6 per 1,000, and the female 21-0 per 1,000, and the population was estimated in round numbers at 1 1,5 1 2,000 males, and 12,135,000 females, showing an excess of 623,000 females. This excess of females over males is partly owing to the greater fatality of convulsions in boys as compared with girls ; other important factors are diseases of the respiratory organs, and deaths from accidents or negligence, which are likewise much more numerous in males than in females. The fonowini>' numbers show the excess of male over female mortality from convulsions : — 1847-51 6-13 1852-56 6-06 1857-61 5-77 1862-66 5-49 1867-71 5-03 The difference between the first and last lustrum amounts to 1"10; and as the excess in percentages has become uninter- ruptedly smaller, we are allowed to draw the concltisioh that the influence of sex on the mortality from convulsions, although still considerable, is in process of being diminished. The term ' convulsions ' being an exceedingly indefinite oile, I now proceed to show to what class of diseases the term used by the Eegistrar-General should be applied. Convulsion means a morbid excess of muscular motion, taking place independently of the will, in the striped or volun- tary muscles which are animated by the cerebro-spinal nerves ; while by the term spasm we understand a morbid excess of motion in the unstriped contractile fibres, which are animated by ganglionic or sympathetic nerves. But not all convulsions occurring in the striped or voluntary muscles can be compre- hended in this section ; for we have to exclude from them a number of convulsive diseases with special features of their own, CONVULSIONS. 61 that distinguish them from eclampsia. These diseases are epilepsy, hysteria, tetanus, chorea and hydrophobia. All convulsions are of nervous origin; for although the principal symptoms are shown in the sphere of the striped muscles, which are thrown into a more violent, prolonged, and frequent action than is seen in health, when acting under the influence of the will, yet the inherent property of the muscles to contract, which is known as Hallerian irritability, is of no influence whatever in the production of convulsions. The muscles are nothing but passive instruments, which are put into morbid play through undue excitability of the nervous system that animates them. It is true that inherent muscular convulsions may be caused artificially by the influence of the poison of veratria, which will unduly excite the action of the muscles without the intervention of the nervous system ; but this is a form of convulsion which does not occur in practice, and has only been discovered by physiological experiments. Convulsions in general may be most conveniently classified as direct, reflex, and central. Direct convulsions are those which are owing to increased excitability of a motor or efferent nerve ; reflex convulsions are those produced by an irritation of sentient or afferent nerves which is transmitted to the spinal cord ; and central convulsions those which are caused by irri- tation of the cerebro-spinal motor centres themselves. Direct or local convulsions are owing to an excited state of a motor or efferent nerve at some point of its course between the brain and spinal cord on the one hand, and of the peri- phery of the body on the other hand. Such convulsions are localised in the muscles which are animated by the nerves in question, and do not extend beyond their sphere unless other portions of the nervous system should suffer at the same time. An instance of this kind of convulsion is convulsive tic of the face, as produced by direct irritation of the facial nerve through I'heumatic effusions, or disease of the osseous canals through -which the nerve is passing in its way from the base of the brain to the muscles of the face. Convulsions of this kind, although sufficiently troublesome to the patient affected by them, are never fatal, and are therefore not included in the present class. 62 DISHASES OF THE NERVOUS SYSTEM. Reflex convulsions are produced by irritation of the sen- tient or afferent nerves at some point of their course being' transmitted to the spinal cord. Ordinary impressions of this kind will produce physiological reflex movements, such as coughing, yawning, sneezing, laughing, etc. ; but if the im- pression is unduly powerful, convulsion may be the result. Stnictural alterations of the sentient nerves, such as inflam- mation ; caries of the teeth ; or foreign bodies and tumours pressing upon the tissue of the nerves ; injury, either accidental or from surgical operations ; excessive heat or cold, may, especially when acting on the terminations of the sentient nerves, transmit to the spinal cord an exaggerated impression, which may be followed by equally exaggerated muscular move- ments. In health a moderate stimulation will excite reflex action only on that side to which the stimulus is applied. Thus, gentle tickling of the sole of a foot will cause withdrawal of that leg ; but if the irritation is more intense it is transmitted to the opposite side of the cord, and the muscular contractions will ultimately occur in all four extremities of the body. We have seen in the first chapter that this transmission takes place through the ganglionic cells of the grey matter of the spinal cord. The pathological phenomena resemble in this respect the physiological ones very closely. Exaggerated muscular movements produced by unduly powerful stimulation are at first generally localised in the muscles of that region from where the over-stimulation proceeds. Where, however, the over-stimulation continues, or where the centre itself is habitually unduly excitable, the reflex convulsions may gra- dually spread from the local seat of the injury to distant parts, affecting first the corresponding side, but ultimately the whole of the spinal cord, and giving rise to general convulsions of the extremities. When such a state of general convulsibility of the spinal cord has been attained, it is no longer necessary that the original lesion which gave rise to it should continue ; for any impression which may then be received^ either by the sentient nerves or by the brain, may lead to fresh convulsive attacks. Yet it is found as a rule that even then the con- vulsions will habitually start from the seat of the original CONVULSIONS. 63 injury, and only gradually become generalised. As soon as the medulla oblongata has become implicated, the convulsions appear co-ordinated and bilateral, owing to the numerous nervous anastomoses which exist in that organ, and to the different nuclei of innervation being united with each other by commissural fibres. Exaggerated impressions transmitted to the spinal cord by sympathetic nerve-fibres may have a similar effect. It is in this way that worms, certain forms of indigestion, renal and biliary calculi, will occasionally give rise to convulsions. Finally, there are cerebrospinal or central convulsions, caused by morbid irritation of the great nervous centre of motor power itself, which, as we have seen, extends from the spinal cord to the cerebral hemispheres. Convulsibility of the motor centre may be produced by disease or injury at any portion of its course ; and the con- vulsions are in this case generally confined to those parts which are under the immediate influence of the affected portion of the motor centre. A faulty constitution of the blood is the next cause, and where this is encountered the convulsions are liable to be general. Anaemia in children has a most powerful influence in producing general convulsions ; the retention of excrementitious matters in the blood, such as urea, bile, and carbonic acid, leading to uraemia, cholsemia, and asphyxia, acts in a similar manner ; and so does the introduction into the system of certain vegetable and mineral poisons, more par- ticularly sti-ychnia, brucia, picrotoxia, and lead. Elevation of the temperature of the blood in some febrile diseases, especially scarlatina, quinsey, and erysipelas, may also act as an exciting cause, provided there is a neuropathic tendency in the system. There may finally be a habitual constitutional state of undue excitability of the motor centre : the neuropathic constitution, which is either hereditary or acquired, may exist without struc- tural lesions perceptible to our senses, and may, without any apparent cause, give rise to convulsions. This convulsibility of the motor centre is frequently in- herited from one or both parents ; and it is not indispensable for this that there should have been convulsions in either of the parents, but simply a definite nervous affection of some 64 DISEASES OF THE NERVOUS SYSTEM. kind. Hysteria of the mother, and epilepsy and drunkenness of the father, are probably amongst the most potent and fre- quent causes of convulsions in infants. Drunkenness of one or both parents at the moment of conception is believed power- fully to predispose the offspring to convulsibility. The entire period of intra-uterine life is likewise influential ; sudden shocks, painful emotions, grief, anxiety, privations, and fatigues of the mother, disturb the nutrition of the nervous system of the foetus, and lead to convulsibility, imbecility, and epilepsy of the infant. Tubercular consumption of either of the parents is likewise an efificient cause, as such children are ill-nourished, flabby, feeble, and unduly timid and excitable. Given a state of convulsibility of the motor centre, any impression, partaking of the nature of a moral or physical shock to special or general sensibility, whether perceived or not perceived, may give rise to a discharge of nervous force, or a nerve-storm, vrhich may be local or general ; and when the convulsibility has reached a high degree, such a storm may even break out without any apparent exciting cause at all. The nervous centre may then be aptly compared to a storm- cloud, from which lightning may be drawn forth either through external collision or an excessive internal charge. The emotional centres of the brain are likewise of influence in the production of convulsions ; fright, terror, prolonged grief and anxiety, a sudden impression on the imagination or memory, may produce a seizure. In such cases, however, we find as a rule that the convulsions affect more the sphere of the cerebral than of the spinal nerves, and that the parts chiefly affected are the face, eyes, and larynx. As the most intimate connection exists between convulsions and a bloodless condition of the brain, I shall now proceed to consider this latter subject in its various bearings. Cerebral Ancemia. That the quantity of blood in the brain and its membranes is subject to considerable variations, is no longer doubtful at the present time. Two Scotch physicians, Kellie and Monro, have denied that such could be the case, provided the brain CEREBRAZ ANJEMIA. 65 and its membranes were in their normal condition. They thought the brain incompressible through being enclosed in rigid walls, and only liable to congestion or ansemia if there was previous wasting or hypertrophy of the organ. We now know that the brain is not only somewhat compressible, but that variations in the quantity of blood are also rendered pos- sible by the vascular connection between the inner and the outer surface of the skull, and more particularly by means of the cerebro-spinal liquid, the quantity of which is in inverse ratio to the empty or loaded state of the- cerebro-spinal blood- vessels. Thus we find this liquid largely increased in hydro- cephalus where the brain is anaemic, while it is almost entirely absent in cerebral hypersemia or determination of blood to the head. Most important of all. Bonders has directly ob- served cerebral circulation through an opening in the skullcap of animals, which he closed by means of a watchglass ; and seen considerable variations in the diameter of the bloodvessels of the pia mater, which he noticed to become dilated during ex- piration. It is reasonable to assume that in children, where the bones of the skull are not yet completely ossified, and the sutures open, congestion or ansemia may even be more readily brought about than in adults. Sir Astley Cooper and Marshall Hall had already been struck by the resemblance of the phenomena observed after sudden and abundant haemorrhage, with the fits of epilepsy and eclampsia; but it was Kussmaul and Tenner' who, by a masterly experimental investigation of this subject, showed that such attacks are invariably caused by rapidly induced cerebral ansemia. They employed vigorous, non-anaesthetised cats, dogs, and rab- bits, and caused anaemia of the brain either by bleeding them to death, or by ligaturing both carotid and subclavian arteries — the latter, because the vertebral arteries arise from the sub- clavian. The invariable result was loss of consciousness and general epileptic convulsions, with involuntary evacuation of the urine and fseces. There was at first tonic rigidity, which was soon followed by clonic convulsions ; and these were oc- casionally so violent as to throw the animal over the shoulders > ' Untersucliimgen fiber TJrsprimg und Wesen der fallsiiclitigen Zuckim- gen, Molesohott's Untersuchmigen,' vol. iii. 1857, F 66 niS^ASJSS OF THE NERVOUS SYSTEM. of the operator. Where the ligature was used, the raost violent convulsive fit could at once be arrested by removing the same from only one carotid. It was also found in these experiments that the functions of the spinal cord and medulla oblongata continued for some time after that of the brain had been an- nihilated; for respiration and reflex excitability persisted during the coma, and the animal could be restored to life as long as the heart's action was not entirely suppressed. That there was true cerebral ansemia in these cases was also shown by Donders's watch-glass experiment. If cerebral ansemia was only partial, by leaving one carotid or vertebral artery open, the animal became drowsy, feeble, and delirious, but was not convulsed. Compression of the carotid arteries in men had nearly the same effect as ligature of the same in animals. Kussmaul and Tenner also showed that hypersemia of the brain does not cause any convulsions. In order to prove this they first divided the cervical sympathetic in rabbits, and afterwards tied both the external and internal jugular veins, with the result that no convulsions appeared. A cross experiment which was intended to produce cerebral ansemia and convulsions by Faradisation of the cervical sympathetic, succeeded only once, in a rabbit. They first tied one carotid and both subclavian arteries, and then faradised the sympathetic of that side where the carotid had not been tied. The fundus of the eye became suddenly pale, the pupil dilated so much that the iris disappeared, the neck was drawn back, and violent convulsions were produced. On discontinuing the Faradisation, the fundus of the eye became red, the convulsions ceased, and the pupil contracted. That these phenomena should not have been produced in other experiments is ex- plained by the circumstance that only a portion of the vaso- motor nerves of the brain courses through the cervical sympathetic. Nothnagel has succeeded in causing epileptiform seizures in animals by irritation of the peripheral nerves. In this way contractions of the cerebral arterioles and consequent ansemia was caused by reflex action. Ansemia of the spinal cord does not cause convulsions. The CEREBRAZ ANJSMIA. 67 cord therefore serves only as conductor, and the origin of the convulsions is in the pons and the medulla oblongata. Cerebral anaemia may be produced by injury of a large artery, the rupture of an aneurism, flooding after childbirth, and ligature of the carotid artery, which has been performed for the cure of aneurism and of tic douloureux. In the few cases in which both carotids have been tied, the patients have died soon afterwards from cerebral ansemia. This is also induced, not only when the brain receives too little blood, but also when its composition is altered, and more particularly so when the number of red corpuscles is considerably diminished. Intersti- tial nutrition of the brain must be energetic from one instant to another, in order to allow a proper function of the organ to be carried on; for no tissue is more easily vulnerable than cerebral tissue. Without a continuous supply of oxygen such interstitial nutrition is impossible ; and as the red corpuscles are the carriers of oxygen, any considerable decrease in their number must have an unfavourable influence on the condition of the brain. Instances of this are seen in starvation, where the quantity of the blood altogether is diminished ; in ansemia, where the number of red corpuscles is diminished; and in ischsemia, where some impediment to circulation prevents the cerebral arterioles from receiving a proper supply of blood. It is by this latter that sudden death from cerebral ansemia may be caused in convalescents from acute diseases, such as yellow fever. In cases of this kind the blood accumulates in the lower extremities and the abdomen, when the patient, who has been reclining for a long time, suddenly gets into the erect position. The collapse on tapping for ascites, or an ovarian cyst, has to be similarly explained. By removing a large quantity of liquid the intra-abdominal pressure is suddenly reduced; the veins thus receive an unusually large supply of blood, and as they are enfeebled by long-continued compression, it accumulates in them ; the arteries therefore receive too little blood, and cerebral ansemia is the result, the vis a tergo being insufficient to deter- mine a proper supply of arterial blood to the head. A similar result is caused when other organs suddenly receive an unusually large quantity of blood, as the leg during the application of Junod's cupping-boot. In certain exhaustive diseases, such as V 2 68 DISHASHS OF THE NERVOUS SYSTEM. dysentery, chronic nephritis, cancer, phthisis, saturnine and mercurial poisoning; in protracted suppuration; in typhoid fever and small-pox, where the intestinal ulceration and the pustules of the skin impoverish the blood ; in women who have home a number of children in rapid succession and suckled them all ; and where the intracranial space is much reduced by the effusion of serum, the extravasation of blood, or tumoiurs, the like result may be brought about. Certain drugs, such as ergot and quinine, are believed to have a similar effect ; what is less doubtful is that some diseases of the heart have the tendency to cause cerebral anaemia. Thus we find that in fatty degenera- tion of the heart and myocarditis, there is not sufficient pressure exerted by the muscular substance of the organ to carry suffi- cient blood into the carotids; also where the aortic ostium is narrowed and the valves do not close ; and compression of the umbilical cord during labour has the same effect on the foetus. Cerebral anaemia is on the whole most frequent in infancy and old age. In the aged it is habitually caused by atheromatous degeneration of the cerebral arteries. These are reduced in diameter by the deposit, and the circulation in the brain is thereby impeded. This is still further aided by the rigidity of the arterial coat, for Marey has shown that liquids are propelled more slowly in rigid than in elastic tubes"; and by the insuffi- cient strength of the heart's action, which is the rule in the aged. In infants and children, whose more yielding skull adapts itself more readily to changes in the quantity of blood, the most potent cause of cerebral anaemia is improper feeding. In foundlings and the children of the poor this is habitual, and generally leads to diarrhoea, which in a short time causes general and cerebral anaemia. Treatment by depressant medi- cines may have the same effect. The symptoms which are observed under these circumstances strongly resemble those of acute hydrocephalus or tubercular meningitis; and Marshall Hall has therefore proposed the term ' hydrencephaloid ' for these cases. There is a stage of excitement followed by stupor. The children are restless and frightened, scream, moan, and sob, are unduly sensitive to light, noise, and touch, and in a general state of convulsibiUty. The skin is hot, the face red, the pulse CEREBRAL ANEMIA. 69 frequent, and the pupil constricted. This stage is more or less rapidly followed by prostration, pallor of the face, insensibility, dilatation and immobility of the pupils, and anaesthesia of the nerves of special sense. The respiration becomes difficult an 4th „ „ 13 „ 55 5th „ „ The entire number of deaths for the first period of five years is therefore 229, and this considerably exceeds that of the imme- diately succeeding periods up to 35 years of age, when the disease again becomes more largely fatal. The minimum is reached at ten; after that there is a rise which is at first slow, but gradually becomes more rapid. The maximum is reached at seventy, and then there is another fall, but at no time of life is there any actual cessation. The following are the exact numbers : — Under 5 years of age . 229 deaths From 5 to 9 years of age 70 „ „ 10 „ 14 59 „ ,5 15 „ 19 129 „ 55 20 „ 24 152 „ ' A Treatise on Apoplexy.' New York, 1873. P. 30. G 2 84 DISEASES OF THE NERVOUS SYSTEM. D I AGRA M C , innufence of AGE onUie Mortality From APO P LEXY in England and Wales in 1847. - <». . 6« 7 o K ^? 00 « «<• ^ > ^ o 00 o CO i ^ s o rO •v CM ? o KV >o vl O > lO ^ s/ |>0 ■k * fO II <\ « 1 °> ■s - ,Js 1 bJD CO =• 7* L i o o o o o <» o 00 o o o o o o o o o <*• o If) o o a CM o o CM o C3 O S o ■a 1 u B n il e i II APOPLUXi ' From 25 to 29 years of age 183 deaths 30 34 195 5) 35 39 308 53 40 44 370 >J 45 49 472 5> 50 54 564 5J 55 59 710 5) 60 64 926 5) 65 69 979 5J 70 74 1,017 J5 75 79 852 ?5 80 84 438 55 85 89 177 55 90 95 22 55 Over 95 6 55 ? 17 55 85 Considering how few people are alive after 74, the mortality from apoplexy appears very large indeed in the latest periods of life. This is no matter of surprise if we consider that apoplexy in its most frequent form, viz., that which is produced by cerebral haamorrhage, is essentially a disease of vascular decay, which is most largely encountered in advanced age. Deaths from this form of apoplexy are rare before forty years of age ; and it is therefore fair to assume that those deaths which occur previous to that period are chiefly induced by meningeal hae- morrhage, cerebral hypersemia, encephalitis, acute alcoholic intoxication, and embolism of cerebral arteries. In the later periods of existence, apoplexy is mostly owing, besides to cere- bral haemorrhage, to that form of meningeal haemorrhage which is connected with pachymeningitis (haematoma of the dura mater). Dr. Lidell's tables of apoplexy in the city of New York show on the whole the same proportion of the different periods of life. In order to facilitate a comparison between the mortality from the same disease in New York and in England, I have put the figures side by side in the following table : — DISEASES OF THE NERVOUS SYSTEM. Deaths from Apoplexy New York, 1867-69 England and Wales in 1847 Under 10 years of age 68 deaths 299 From 10 to 19 years of age 15 , 188 „ 20 „ 29 60 , 335 „ 30 „ 39 146 , 603 „ 40 „ 49 177 , 842 „ 60„59 187 , 1,274 „ 60 „ 69 209 ; 1,905 „ 70 „ 79 142 , 1,869 „ 80 „ 89 32 , 615 Over 90 years of age 2 , 45 These figures show a very close analogy, and go far to prove that the production of apoplexy in America obeys, as far as age is concerned, the same laws which obtain in this country. .The first period of life is in both countries more fatal than the second ; after the second period, an uninterrupted rise takes place until the decade from sixty to seventy ; and after that there is an uninterrupted fall to the end. It is however to be remarked that, while for New York the difference between the seventh and eighth decennium of life is considerable, it is very slight for England and Wales, which probably means that longevity is greater in England than in the States. While, therefore, age is found to have a most powerful influence in the production of apoplexy, my researches tend to show that sex has, at least as far as this country is concerned, only little influence upon it. Up to the present time it has been generally assumed that males are greatly more liable to die from this disease than females ; but it will be seen from the following Mortality of Males and Females from Apoplexy in England and Wales. 1847-51 1852-56 1857-61 1862-66 1867-71 Males Percentage Females Percentage 19,800 20,766 21,508 24,704 27,665 8-26 8-06 7-93 8-47 8-92 19,521 20,925 22,106 24,987 27,593 8-21 8 06 8-13 8'67 9-00 Average of 25 years . 8-33 — 8-40 APOPLEXY. 87 table that in England and Wales the sexes die in nearly equal proportion of apoplexy, and that the slight excess which is found to exist is not on the side of males, but on that of fe- males. These numbers have to be considered in connection with the circumstance that the female population of England and Wales constantly exceeds the male by more than half a million, and that the mortality of males constantly exceeds that of females by nearly 20,000. Thus, in 1874, matters stood as follows : — Population living Males Females Excess of females 11,512,956 12,135,653 622,697 Deaths from Apo- plexy . 6,420 6,428 — General mortality 272,178 254,454 — Percentage of mor- tality from Apo- plexy to general mortality 2-36 2-53 — It therefore appears that apoplexy is more fatal to females than to 'males, to the extent of -17 of the entire mortality from all causes. Dr. Lidell's tables show a preponderance of the male over the female sex in New York as far as mortality from apoplexy is concerned ; but his cases amount altogether only to 1 ,038, and extend over three years only, while mine are infinitely more numerous, and extend over twenty-five years ; so that my evi- dence, at least as far as England and Wales are concerned, must be considered irresistible. The general agreement of continental authors as to the greater prevalence of apoplexy in men may possibly have its foundation in the different habits of English and continental women. I shall have to show in a subsequent chapter that delirium tremens is much more frequent in the female sex in England than elsewhere ; and as some forms of apoplexy are unquestionably owing to intemperance, it may be assumed that the greater addiction to drink of females of the lower classes in this country compared to others increases their liability to 88 DISEASES OF THE NERVOUS SYSTEM. apoplexy. In no other capital of Europe are drunken women as frequently seen as in London ; and if the excesses publicly committed by them on Bank Holidays correspond to what takes place more privately in ordinary times, their great liability to apoplexy is easily accounted for. I now proceed to analyse the pathological conditions which give rise to death from apoplexy. Apoplexy ' means in general medical parlance the condition in which a person has more or less suddenly lost his consciousness, sensibility, and motility while respiration and the heart's action continue. It is thereby distinguished from syncope, in which the heart's action is suspended, and from asphyxia, in which respiration has been arrested. Apoplexy was formerly believed to be a disease of itself, but modern investigations have shown that it is merely a symptom of disease, and that it may be produced by the following pathological conditions : — 1. Haemorrhage into the brain. 2. Hgemorrhage into the membranes of the brain. 3. Hypersemia of the brain, or determination of blood to the head. 4. Embolism of cerebral arteries. 5. Acute alcoholic intoxication. 6. Acute intoxication by opium and other narcotic poisons. 7. Sunstroke. In the following I shall analyse these diseases in their connection with ap9plexy, and begin with the most important of them, viz. haemorrhage into the brain. 1 . Cerebral HceTnorrhage. This is by far the most frequent cause of apoplexy ; but in spite of its great importance its anatomical and clinical features have only of late been more accurately ascertained. The old ideas about its being due to the rupture of an atheromatous bloodvessel are still found in the text-books ; and many highly significant symptoms, which are not only of great pathological interest, but also of considerable value for determining the prognosis of the affection, are not yet familiar to practitioners, ' From airh and irKiiiTaa, or itA^ktoi, to strike, to knock down. APOPLEXY. 89 from attention not having been sufficiently directed to their occurrence and meaning. Cerebral haemorrhage is produced — 1. By rupture of the large cerebral arteries, such as the middle cerebral and basilar, after these vessels have undergone ordinary aneurismal dilatation. ( Vide Chapter XI.) 2. By rupture of the capillary vessels, which is generally caused by injury to the head, either direct or by contre-coup. Such effusions may be minute or considerable. Where they are minute, they occur mostly in a circumscribed form, more especially at the base of the brain, and more in the anterior and middle than in the posterior lobes. This is owing to the anatomical peculiarities of the inner surface of the skull, as at the base of it there are far greater irregularities in the shape of the bones than at the upper surface ; and the anterior and middle lobes are more liable to be bruised on account of the numerous projections of bones with which they are in contact, while the posterior lobes are situated on a soft cushion, the tentorium cerebelli. Where these effusions are minute, the symptoms are those of encephalitis ; while where they are large, the signs are those of cerebral haemorrhage from other causes, as will be presently described. Eupture of the capillary vessels of the brain also occurs in the course of that chronic inflammation of the grey matter which is found in some forms of insanity ; and may be consequent upon embolism, and tumours which grow in the substance of the brain, and corrode the coats of the bloodvessels. It is also occasionally observed in leukaemia, where it is owing to accumu- lation of white corpuscles in the capillary vessels, which thus gradually become distended, blocked up, and ruptured. As a rule, however, alterations in the quality of the blood, which were formerly believed to be important factors in the production of cerebral haemorrhage, have only little influence in this respect. In scurvy and haemophilia, for instance, a clot is rarely found, while ecchymosis, or infiltration of blood into the elements of the tissues, is more frequently observed. 3. In consequence of contracted granular kidmey, which leads to blood-poisoning, and consequent overaction and hyper- trophy of the coats of the arterioles, and hypertrophy of the left 90 SISHASUS OF THE NERVOUS SYSTEM. ventricle. This connection was first pointed out by the late Dr. Kirkes, who traced, in a number of cases, kidney disease as the primary affection, and cerebral haemorrhage as the last link in the chain of pathological events. Thus inteTuperance will lead to apoplexy. Alcohol, more particularly when taken in a concentrated form, as ' spirits and water,' and in habitually large quantities, gradually cauterises the glandular cells of the kidneys by which the drink has to be removed from the system. In proportion as these secreting cells are destroyed, the smallest renal arteries, which regulate the blood supply to the kidney, resist the entrance of blood, and become hypertrophied in their persistent endeavours to do so. Then as the surface of the kidney diminishes, the blood becomes poisoned with effete matters, a state which sets all the arteries throughout the system to contract in an excessive manner. In order to over- come the effect of this, the left ventricle increases in size and power, without there being any valvular disease to account for this. Dr. George Johnson explains these conditions by his theory of the ' stop-cock action ' of the muscular coat of the arterioles. Long-continued over-action leads to hypertrophy of muscular tissue ; and it is found that the inner longitudinal layer of fibres becomes equal in thickness to the outer circular layer. Thus, the onward movement of the blood is impeded ; and the heart, resenting this resistance, has to act with increased vigour to overcome it, and carry on the circulation. Upon this, the arterioles contract more energetically still; and in this struggle between the two forces, the left ventricle becomes hypertrophied, and thus the pressure upon the arterial walls is increased. Thus there is considerable risk of hseniorrhage in those arterioles, the tissue of which does not become propor- tionally hypertrophied. In some cases it is found that the small subcutaneous arteries increase largely in size, while those of the brain do not do so in the same proportion ; and wherever the excessive impelling force of the left ventricle is not exactly counterbalanced by corresponding hypertrophy of cerebral arterioles, an attack of cerebral haemorrhage may be feared, simply from increase of vascular pressure. The heart under these circumstances reaches sometimes an enormous size, and APOPLEXY. 91 Dr. Broadbent ' has recorded a case in which it weighed nine- teen ounces. Ordinary hypertrophy of the left ventricle from disease of the aortic valves does not lead to cerebral haemorrhage. For many years. heart disease use to be considered one of the chief causes of cerebral hgemorrhage, but it is probable that there has been confusion between rupture of cerebral bloodvessels, and embolism of cerebral arteries. The latter generally arises from previous endocarditis, and may occur with all the symptoms of apoplexy, rendering the diagnosis in some cases extremely difiScult. But heart disease by itself does not produce cerebral hcemorrhage. Hypertrophy of the heart often acts only as a compensation for imperfect closing of the valves, and enables the circulation to be efficiently carried on, while without such hypertrophy circulation must be very much impeded. A large munber of young and middle-aged persons are subject to various forms of heart disease, without becoming thereby liable to ruptiue of cerebral bloodvessels. Patients with emphysema and great dilatation of the right side of the heart, are often subject to giddiness, drowsiness, and other cerebral symptoms, owing to the brain being supplied with imperfectly aerated blood, and slow poisoning with carbonic acid ; but cerebral hsemorrhage is quite exceptional in such cases, and occurs only when there is some peripheral obstacle to circulation, such as renal disease, which leads to increased tension in the blood- vessels of the brain. 4. By far the most important form of cerebral hsemorrhage, however, is that which occurs by rupture of the cerebral arterioles, after they have undergone the change known as miliary aneurismal dilatation. Miliary aneurisms are found in the large majority of cases of what is commonly called apoplexy, and constitute a disease of itself, which has special clinical and pathological features. These little aneurisms were first described by Virchow, but their pathological significance, and their constant relation to the common form of cerebral hsemorrhage, was only pointed out by Charcot and Bouchard, who called them ' miliary ' from their resemblance to a millet seed. They are owing to a sclerous condition of the cerebral > ' The Lancet,' Jan. 27, 1872. 92 DISEASES OF THE NERVOUS SYSTEM. arterioles, the middle coat of -which is atrophied, while the connective tissue of the adventitia is hypertrophied. The vessel owes its power of resistance to the current of blood chiefly to the middle coat, and when the influence of this is removed, fusiform, cylindrical, or sacculated dilatations take place. The dilated adventitia adheres to the peri-vascular sheath ; and various accidental causes which produce a tempo- rary increase of pressure, may determine its rupture. These little aneurisms may, however, heal spontaneously by the form- ation of a clot in them, which then undergoes pigmentary degeneration. Miliary aneurisms are slowly developed, and generally found to exist in considerable numbers. The catise of their formation is at present unknown, but it is probably a general one, for they have been discovered not only in the brain, but also in the oesophagus, on the visceral layer of the peri- cardium, the branches of the splenic artery, and the central artery of the retina. In the brain they are found in the fissures between the convolutions ; in the corpus striatum and optic tha- lamus; in the white matter of the hemispheres, the cerebellum, and the pons Varolii. Their size varies from that of a millet grain to that of a large pin's head, and they are visible to the naked eye as dark red granulations. In my opinion the cause of the formation of miliary aneurisms has to be sought, first, in the tendency to vascular decay inherent to old age ; second, in intemperance, combined with anxiety and hard work ; and third, in hereditary predisposition. When miliary aneurisms have become fully developed, com- paratively slight causes may bring about their rupture. Thus we find that cold has a decided influence as an exciting cause of this form of cerebral haemorrhage. It produces contraction of the bloodvessels of the skin, and thereby increases the tension in the cerebral arteries, while by stimulating the vaso-motor nerves, a dilatation of the cerebral arterioles is effected ; under these circumstances a rupture of one or several miliary aneurisms is easily brought about. This explains why elderly persons are not unfrequently struck down with apoplexy in a cold bath, or immediately after taking one. Attacks of cerebral hasmorrha^e aire also more frequent during a severe winter than at other APOPLEXY. 93 seasons. Sudden changes in the temperature and the baro- metric pressure ; staying in high elevations where the atmo- spheric pressure is feeble ; and mental emotions which augment the activity of the cerebral circulation, also act as exciting causes of the attack. The same influence may be exercised by anything which increases the tension in the arterial system for a time, by impeding the return of the blood from the brain through the jugular vein. It is in this way that great muscular efforts, lifting heavy loads, violent coughing, sneezing, or vomiting, seem to bring on a stroke. Thrombosis of the sinuses of the dura mater, compression of the jugular veins or the superior cava by tumours, and finally lesions of the right heart, and the pulmonary artery, may lead to a similar result. In this place I must say a few words about the so-called apoplectic habit. Where the body is stout, the neck short, the shoulders broad, the chest well or powerfully developed, the abdomen large, the flesh abundant, and there is general and chiefly abdominal plethora, both doctor and patient used to feel great apprehension of an approaching attack of paralysis. But the influence of the fall habit of body has been very much exaggerated; it certainly predisposes to attacks of cerebral congestion, but not of haemorrhage, to which latter lean and ansemic people are quite as much exposed as those of an opposite habit. The quantity of blood which escapes in consequence of the rupture of one or several miliary aneurisms, varies from a few drops to about sixteen ounces. This effused blood tears up the brain-tissue, and produces a cavity which may occupy the better portion of an entire hemisphere. There is generally only one clot, which occupies some portions of the grey matter. Most cases of cerebral haemorrhage resalt from rupture of those arterioles which arise from the mid-cerebral artery, and proceed through the substantia perforata lateralis to the corpus striatum. The blood penetrates to the centre of Vieussens, pushes the thalamus opticus inwards, and raises and finally ruptures the corpus striatum. It will then invade the lateral ventricles, and through Monro's foramen, break into the third; it may also break through the island of Keil, and following the fissure of Sylvius, fill up the fourth ventricle, or tear up the lower 94 DISH ASUS OF THE NERVOUS SYSTEM. portion of the infundibulum, and spread to the base of the brain. Next in frequency to the corpus striatum comes the thalamus opticus. Andral has collected the autopsies of 392 cases, in 202 of which both corpus striatum and thalamus opticus were simultaneously affected ; in 61 the corpus striatum alone, and in 35 the optic thalamus alone : in 27 that portion of the hemisphere which is above the centrum ovale of Vieussens; in 16 the lateral lobes of the cerebellum ; in 10 that portion of the brain which is in front of the corpus striatum; in 9 the corpus callosum ; in 7 the posterior lobes of the brain ; in 5 the middle lobes ; in 3 the peduncles of the brain ; in 1 the cms cerebelli ; in 1 the corpora olivaria, and in 1 the petuitary body. In the majority of cases there is only one clot, which, however, may be owing to the rupture of a number of small aneurisms ; but Dr. J. Ogle has recorded a case in which separate clots were discovered in the right corpus striatum, the left thalamus opticus, and the pons Varolii. There is, indeed, no portion of the brain which may not become subject to haemorrhage. After death the convolutions of the suffering hemisphere are found flattened and anaemic, from pressure of the clot upon the cerebral arterioles which thereby become empty ; the veins of the pia mater are also empty. The effused blood coagulates rapidly ; it looks like currant jelly, and is mixed with debris of the cerebral matter, which are plainly seen when a jet of water is made to play upon the parts and washes the blood away. The parts surrounding the clot are softened. Where the patient does not succumb to the stroke, a necro-biotic process of absorption sets in after the haemorrhage is arrested. The blood-corpuscles and nerve-fibres undergo fatty degeneration; the serum is absorbed ; granular bodies are formed out of the debris ; and pigmentary granulations and crystals of haematine, haematoidine, and amorphous granulations of haematosine, form a semi-liquid mass, which is at first black, and afterwards assumes an ochrous appearance. At the same time a subacute inflammation takes place in the neuroglia, or cementing connective tissue of the brain- matter, which is in many cases of a healing kind, but occa- APOPLEXY. 95 sionally assumes a hyper-acute character, and runs a short and fatal course. The yacuum which is caused by the contraction of the clot, is filled up by the effusion of a liquid, which is at first homogeneous, but gradually assumes the characters of connective tissue, which is deposited in concentric layers, and ultimately forms a capsule, which encloses the remains of the clot. This limiting membrane secretes serum, which, by imbibing the decayed matters of the cavity, facilitates their absorption. The liquid is either colourless or has a yellowish tinge. The size of the cyst varies from that of a pea or cherrystone to that of a small apple ; but sometimes the inflam- mation extends to a considerable distance from the original lesion, and leads to sclerosis. When the clot has been large, a considerable loss of substance must be the result ; iae mem- branes are depressed, and only separated from the ventricles by a thin layer of tissue. As time goes on the cyst-wall becomes hardened, and completely separates anything yet remaining of the clot from the surrounding cerebral matter in which it lies imbedded. Apoplectic cysts are not found in the cortical substance, but only in the interior of the hemispheres, which is owing to the circumstance that the vacuum which is caused by haemorrhage in the cortical substance is filled up by the effusion of a corresponding quantity of meningeal serum, while in the hemispheres it is filled up by the cystic liquid just described. In the cerebral convolutions where such an effusion has taken place, an accumulation of yellow or brownish pigment, which is intimately connected with the pia mater, is sometimes the only remnant of the clot. These changes vary considerably, according to the constitu- tional powers of the patient; and a small clot in an aged person with enfeebled systemic energy, where the healing process is slow, may cause more loss of function than a clot considerably larger in a comparatively young man of otherwise unimpaired vigour. In old, decrepit, exhausted, and badly- nourished persons, there is less contraction of the clot, and more liability to inflammatory irritation with its well-known consequences. In some cases, a subacute inflammation goes on for a long time in the neighbourhood of the original lesion, 96 DISEASES OF THE NERVOUS SYSTEM. and this is indicated by rigidity and contraction of the paralysed muscles, with spasms and general irritability, which is sooner or later followed by exhaustion and collapse. The absorption of the clot generally commences in about four to eight days after the seizure ; the formation of the cyst commences about three weeks afterwards, and is generally finished in three months. If much liquid accumulates in the cyst, a great amount of wasting may take place in the cerebral matter, and which in no way differs from ordinary senile atrophy. It is not at all proportionate to the size of the original effusion, but may be very extensive where the clot has been very small. Cerebral hasmorrhage never kills with the same rapidity as some forms of heart disease ; and what French authors call ' apoplexie foudroyante ' does not really deserve to be compared with the rapidity of a lightning stroke, for even in those cases which are most rapidly fatal — viz., where the bleeding takes place from the rupture of an ordinary aneurism of one of the basilar arteries, the least interval between the commencement of the symptoms and the fatal issue has been seven minutes, and it will commonly take from ^fteen to thirty minutes. Syncope, indeed, may kill as quickly as lightning, but the term ' apoplexie foudroyante ' is a misnomer. In the large majority of fatal cases from six to twelve hours elapse between the beginning of the illness and its end ; and that this should be so is easily accounted for by the circum- stance that the size of the miliary aneurisms is too small to allow the rapid escape of a quantity of blood sufficient to kill. It is well known that the brain is able to bear the presence of a small quantity of blood in some of its parts without resenting it violently ; and the anaemia of the organ which is caused by the haemorrhage, and the shock to the brain which accompanies the effusion, must have reached a considerable degree before they prove to be incompatible with life. Premonitory Symptoms. Some observers have denied that cerebral hsemorrhage is preceded by any symptoms showing that the brain is becoming APOPLEXY. 97 liable to an attack of apoplexy ; and there can be no doubt that a number of symptoms which were previously put down as such are in reality owing to incipient softening of the brain. These are loss of memory, embarrassed speech, inability to write or spell correctly, loss of the capability of carrying out certain finer movements, such as threading a needle, buttoning a shirt-sleeve, etc., and impaired intellect. There are, however, other signs which plainly belong to the disease which we are now considering, and which cannot be reasoned away by any specious argumentation ; although it is quite true that occa- sionally the patient is struck down in apparently excellent health. An important premonitory symptom is bleeding at the nose, which, unimportant in children, becomes of grave signifi- cance in elderly persons. It may precede an attack of apoplexy by a few months, or even several years. Mydriasis and paralysis of the rectus externus muscle likewise occur, and are then probably owing to minute bleeding in the neighbourhood of the nuclei or roots of the third and sixth nerve. Apoplexy of the retina occurs from various causes, such as impeded general circulation from disease of the heart, liver, kidneys, and womb ; or where there is an obstacle to local circulation, as when a tumour presses upon the optic nerve, either in the orbit or within the skull. It is, however, frequently connected with general vascular decay, and may, if recognised by an examination with the ophthalmoscope, lead us to suspect similar changes in the cerebral bloodvessels. Sometimes the hsemorrhage occurs just in the yellow spot, and the patient then becomes blind in a few minutes ; while where the effusion takes place nearer the periphery, and is not very large, the sight may be very little affected. The ophthalmoscope in such cases, however, always shows that we have to do with a grave lesion, which, even if the other symptoms are slight, will pro- bably sooner or later cause incurable blindness ; for the disease is extremely liable to relapses, and repeated effusions of blood must eventually lead to atrophy of the optic nerve and retina. Apoplexy of the retina generally occurs in advanced life, that is, after fifty years of age, and has been more frequently seen in men than in women. It is probably always, sooner or H 98 DISSASJES OF THE NERVOVS SYSTEM. later, followed by cerebral hsemorrhage. Dr. Berthold' has recorded the case of a woman aged 40, who came to consult him for well-marked hsemorrhage into the macula lutea, and who, while under examination, was seized with an attack of cerebral heemorrhage which proved fatal. The ophthalmoscopic appearances vary somewhat in cases of this class. There is either a number of small round circum- scribed spots -of blood ; or there are longitudinal streaks or brush-like bands, when the blood has been effused within the nerve-fibre layer ; or there are large irregular patches in the neighbourhood of the veins, which are dark and greatly dilated and tortuous, while the arteries appear small and ansemic. The disc is Idurred and has an indistinct outline, or it appears very dark from hypersemia of the veins. The effusion has more tendency to spread into the choroid than into the vitreous body, but if it breaks into the latter it causes dense opacities. The blood ultimately undergoes pigmentary degeneration. Other symptoms which I have known to precede an attack of cerebral hsemorrbage, are a feeling of malaise about the head, which is chiefly experienced on rising in the morning, but goes off as the day advances. Emotions, annoyance, and indi- gestion are apt to bring it on again at any time of the day. Drowsiness, which can be shaken off by an effort, and disinclina- tion to work, are likewise experienced. Giddiness on stooping, or on quickly turning the head ; severe paroxysmal headache ; attacks of glimmering, so that the patient sees stars, sparks, and other luminous appearances in a vibratory or wave-like ■motion ; neuralgic pains in the sphere of the brachial plexus, sometimes singling out the little finger with particular vehe- mence; flushings of the face, with hot ears and cold hands and feet — all these symptoms may come on separately or conjointly, ^nd point to impaired cerebral circulation from sclerosis of the arterioles, being due to anaemia rather than to hypersemia. The aittack of cerebral hsemorrhage generally commences with giddiness, specks before the eyes, noises in the head, and tingling in the limbs ; the patient speaks thickly, staggers, falls, and suddenly loses his consciousness ; if taken up, he falls back, an inert mass. He is now insensible to stimulation, ' ' Klinische Monatsblatter fur Augenheilkiinde,' April, 1874. APOPLEXY. 99 while the automatic movements of respiration and the heart's action continue. This is the ordinary sequence of events in corpus striatum and thalamus opticus haemorrhage. Where the blood breaks into the meninges or the lateral ventricles, the limbs of one side of the body are contracted and convulsed ; while if there is hemiplegia without loss of consciousness, the haemorrhage has most probably taken place into the cerebellum. It is not easy to account for the loss of consciousness where the effusion in the central ganglia is small. This cannot be attributed to ' congestion ' as was formerly done ; for there is no congestion. Nor is the anaemia of the brain produced by the bleeding sufficient to account for the coma, as in some cases the effusion is very small, and nevertheless causes insensibility. It is also well known that cerebral anaemia does not invariably lead to unconsciousness. There is, for instance, great cerebral anaemia in cholera, but no unconsciousness ; and on the other hand, in cysts and abscess of the brain, a great deal of pressure may exist without producing insensibility. Much, no doubt, depends upon the suddenness with which the symptoms are produced : and a rapidly-occurring injury is more likely to cause unconsciousness than one which takes place so slowly as to allow the brain to become accustomed to the pressure. A patient may live for a considerable time with cerebral abscess, and then suddenly die comatose, when the abscess bursts, and the lateral ventricles become flooded with pus. In such a case there is no actual increase of intracranial pressure, but merely a transfer of pus from one portion of the brain to another, which latter is less able to bear it than the former. Pagen- stecher's experiments on dogs have shown that an injection of about twenty-three fluid ounces into the cavity of the skull is required to produce symptoms of compression ; and the average weight of the clot is from four to six ounces only. Apart from the slowness or suddenness with which the pressure is produced, we find that when certam portions of the brain are affected by haemorrhage, loss of consciousness is more apt to come on than when others suffer ; and it is chiefly the central ganglia which resent the irruption of blood in this manner. We are therefore obliged, for want of a better expla- nation, to assume shock of the brain by the sudden invasion of . 100 JDISUASJSS OF THE NERVOUS SYSTEM. blood into the structure of the central ganglia, in order to account for the loss of consciousness. This shock is transmitted from the corpus striatum or thalamus opticus to the correspond- ing hemisphere, and from there, by the numerous commissural fibres which connect the two halves of the brain, to the opposite hemisphere. It may even be propagated to the spinal cord, which is shown by the abolition of reflex movements. In most cases, however, reflex excitability is increased, by removal of the inhibitory action exerted by the brain (p. 41) ; and if the sole be tickled, the leg is wildly thrown about, or both legs or the whole body respond to the stimulation. In the further progress of cerebral haemorrhage we find that the features become vacant and devoid of all expression. The face is distorted, and either livid and swollen or ghastly pale. The cheeks are flabby and blown out by each expiration. The mouth is either xmiformly open, or half open, and drawn to the opposite side; at each expiration the commissure of the lips is raised at the paralysed side, and lets a frothy saliva run down the chin. The naso-labial sulcus is effaced, or appears drooping and drawn to the non-paralysed side. The speech is entirely lost. A strong light, loud sounds, powerfully smelling or sapid substances, no longer convey any impressions to the brain ; the patient cannot be roused by shouting to him, or by any other of the usual modes of reviving consciousness. The conjunctiva is insensible, either in both eyes or only in the eye of that side which is afterwards found paralysed. The pupil of the paralysed side is generally found dilated ; but this is by no means invariable, as the iris receives nervous supply from various sources, and there may be constric- tion or dilatation, or inequalities in the size of both pupils, according to irritation or paralysis of certain portions of the nervous system of the iris. Irritation of the third nerve causes constriction of the pupil : but when the attack is accompanied by severe convulsive seizures, the pupils become extremely wide, and contract after the convulsion is over. If both pupils are extremely contracted, the haemorrhage is generally in the pons Varolii, and is sometimes confounded with opium-poisoning. The superficial veins of the head and extremities are either gorged with blood or scarcely visible. The skin may be quite APOPLEXY. 101 dry, or bathed in clammy perspiration. Where from imperfect respiration the blood does not receive a full supply of oxygen, the skin generally appears livid. These symptoms also depend to a great extent upon the previous habit of the patient. In the full-blooded and those liable to congestions of various parts, we find gorged peripheral circulation ; while in anaemic persons the skin is pale and cool. A severe attack of cerebral haemorrhage is always accom- panied with involuntary evacuation of the urine and fsces. The sphincter ani does no longer offer any resistance to the introduction of a finger or an instrument. The automatic movements of circulation and respiration, which at first con- tinued much in the same manner as they do during a heavy sleep, after a time become affected in their turn. Inspiration is short, superficial and irregular ; the soft palate is heard to flap to and fro, producing stertor; and from having been accelerated, respiration becomes retarded and intermittent. Mucus accumulates in the air-passages, and laryngeal, tracheal, and bronchial rales are heard. A frothy liquid, which is a mixture of saliva, mucus and air, is seen to run down the chin. The pulse Is large, hard, and incompressible, more especially in the carotids — not from congestion, as has been erroneously supposed, but from the resistance encountered by the current of the blood, which cannot enter the intracranial bloodvessels, compressed as they are by the effusion. This symptom, how- ever, loses its significance if there is hypertrophy of the left ventricle, and equally strong pulsation of other arteries. For some time during the progress of apoplexy, the symp- toms are, as it were, of a mixed character, viz. partly paralytic and partly spasmodic. The former, which have just been described, are owing to the pressure of the escaped blood upon the brain matter, while the latter are caused by the irritation of the brain from the blood undermining the central ganglia, previously to its destroying their texture. While the corpus striatum is being irritated and destroyed by the blood flowing out from the opening of one or several miliary aneurisms, there are often severe convulsive attacks shaking the arm and leg of the opposite side of the body ; or there is great rigidity of the muscles of the limbs. 102 DISEASES OF THE NEBVOUS SYSTEM. An important and pathologically interesting symptom is the conjoint or synergic lateral deviation of the head and eyes, which is not unfrequently observed in corpus striatum haemor- rhage, and also occurs where blood is effused into the meninges. The head and eyes look away from the paralysed side, and are turned towards that side in which the cerebral lesion has occurred. Thus, in right hemiplegia and aphasia from a clot in the left hemisphere, the head and eyes are turned to the left side. This is sometimes seen shortly after the commencement of the attack, when the patient is quite unconscious ; but it may persist after the return of consciousness, and it is then seen that the patient has no power in overcoming the deviation. Sometimes it is so complete that the irides almost disappear ; while at other times it is less marked. "When such is the case, the patient may, at our request, turn the eyes still further away from the paralysed side, but not in the opposite direction ; but sometimes he is able, on making an effort, to turn the head in the opposite direction. Where this deviation is after a time followed by deviation to the opposite side, we may conclude that the effusion has entered the lateral ventricles, or that a new cavity is forming in the other hemisphere. This symptom, which is purely spasmodic, and not paralytic, is also occasionally seen in em- bolism of the mid-cerebral artery, and after a succession of epileptic seizures ; and it always denotes a sudden and extensive injury to the brain, which mostly proves fatal. Conjoint deviation of the head and eyes is produced by irritation of the following cerebral nerves: 1st. the sixth, which causes external strabismus on the side of the lesion ; 2nd. the third nerve of the opposite side, which causes internal strabismus of the opposite side ; and 3rd. the spinal accessory nerve, which produces rigidity of the sterno-mastoid muscle, and deviation of the head. The temperature of the body undergoes at the same time considerable alterations ; for while in the commencement of the attack, and particularly where the haemorrhage is not abundant, the body-heat remains normal, after ten or fifteen minutes the thermometer placed in the rectum or armpit, shows signs of falling, and may go down to 95°. This fall must be looked APOPLEXY. 103 upon as a symptom of irritation or spasm of the controlling- centres of heat-production, and has the same clinical significance as convulsions of the muscles of the extremities. After a time, which varies from thirty minutes to thirty-six' hours, the spasm in the centre ceases, from the blood breaking into the lateral ventricles and into the fourth. The symptoms then become purely paralytic in their character; the lateral deviation of the head and eyes disappears ; convulsions and rigidity cease, and the body-heat begins to rise more or less rapidly. Where this rise is extensive, it has the same un- favourable meaning as a great fall in the commencement ; and the mercury, now at 103° to 105°, corresponds in significance to the low readings of the first period. More especially when the temperature runs up rapidly, it is a sure sign of collapse, which is soon followed by death. On the other hand, we find cases in which the thermometer, after a comparatively slight fall, rises only little, if at all, above the normal mean, but remains stationary at 98° or 99°. This means that the haemorrhage has been arrested ; the opening in the miliary aneurism having been as it were sealed up by contraction of the clot, before the blood could have broken into the lateral ventricles. There is therefore now only a com- paratively small cavity filled with blood, which may be expected, in course of time, to undergo its appointed changes. There is no lateral deviation of the head and eyes ; no rigidity or con- vulsion of the limbs ; the body does not appear so completely relaxed as before ; the difference between the sound and the paralysed side becomes more marked, one being quite relaxed, while the other offers some resistance on being moved, or carries out semi-voluntary movements ; the patient can be roused on being spoken to ; he begins to talk in a dreamy fashion, and the coma gradually lightens into consciousness. The pulse becomes steadier, and the respiration more regular, although the contraction of that side of the diaphragm which corresponds to the paralysed side, is more feeble than that of the other side. The patient has now escaped death from collapse, but he is still liable to be carried off by the consecutive cerebral fever from secondary encephalitis, which in cases that are to end 104 DISEASES OF THE NERVOUS SYSTEM. fatally, is apt to come on after the partial recovery just described has taken place. The first symptoms of cerebral fever are generally headache, restlessness, and sensory delusions; the patient is throwing himself about in a terrified manner ; there is moaning, and muttering delirium ; but the pathognomic symptom in such cases is an acute bedsore on the buttock of the paralysed side (tdche cerSbrale). An erythematous spot, or macula, appearing on the second, third or fourth day, on the part just mentioned, almost in- variably heralds a fatal termination of the case ; for this change in the nutrition of the skin and subjacent parts shows paralysis of the intracranial trophic centres, which precedes paralysis of the volitional centre only by a short time. The pathology of the process is the same as that of ulceration of the cornea after section of the fifth nerve. The cerebral macula has an irregular shape and varies in size ; from being pink at first, it gradually changes into purple. Pressure will cause it to disappear, show- ing that in the beginning there is only hyperaemia. Eapidity of progress, however, a hyper-acute course, is characteristic of the affection. The hypersemia is soon followed by effusion of serum, and phlyctsense are formed, which contain a liquid that is at first colourless, but shortly becomes sanguinolent and livid. The raised cuticle then gives way, and an open sore is left, which has a scarlet surface, and appears covered with livid granulations. Gangrene is now fully established, and if the patient survives long enough, inflammation sets in, by which the gangrenous parts are to be eliminated. It is quite evident that pressure alone is not sufficient to account for the appearance of this acute decubitus ; for the pressure is equal for both buttocks, and yet there is no eschar formed on the non-paralysed side. Moreover, it is not pre- vented by letting the patient rest habitually on the non- paralysed side, so as to avoid pressure on the paralysed side. Nor can the irritating effect of the urine on the skin be accused ; for Charcot, who has studied this condition more particularly, has found that it occurs also where the urine is drawn off with the catheter at short intervals by day and night, so as to avoid such an influence. It is indeed quite different from chronic decubitus which occurs habitually, in consequence of prolonged APOPLEXY. 105 pressure on the back and other parts, in the course of protracted disease, where the patients are bedridden, and where there is frequent involuntary evacuation of the urine and fseces, which aids in the production of gangrene. Moreover, the bedsore which occurs in protracted cases of spinal and other diseases, affects more the sacrum than the buttock. Acute cerebral decubitus must therefore be ascribed to collapse of the trophic centres in the brain. A similar occurrence takes place in severe cases of myelitis, where a decided difference is found to exist between acute decubitus from collapse, and chronic bedsores from pressure. (FicZe Chapter V.) In some cases appearances similar to those just described are observed on the heel, ankle, and knee of the paralysed leg ; and where the effusion has burrowed its way into the lateral ventricles, phlyctsenae may appear on both nates. The viscera sometimes show traces of similar affections. Congestive patches or real ecchymoses are sometimes seen at post-mortem examinations in the pleura, pericardium, and the mucous membrane of the stomach, and which are undoubtedly produced by the same cause. A rise in the temperature may be expected with certainty after the cerebral macula has begun to form ; and the mercury will in a comparatively short time run up to 103°, 104°, and even 105°. At the same time, other symptoms manifest them- selves which point to the impending dissolution. The patient throws himself about in a restless manner, and a low muttering delirium sets in, which is occasionally broken by loud meanings. The pulse becomes small and compressible, and runs up to 120 or more beats. Eespiration is hurried and superficial, at the rate of 42 to 60 in the minute ; and the abdomen is drawn in during inspiration, showing commencing paralysis of the phrenic nerve and the medulla oblongata. The extremities become cyanotic, and completely relaxed. The face, and sometimes the whole body, is bathed in clammy perspiration ; the neck is flabby, and the head will retain any position in which it is placed. Pulmonary complications sometimes set in before death, and the temperature occasionally reaches its maximum shortly after the fatal issue. Cerebral fever rarely occurs later than the fourth day of 106 BISEASES OF THE NERVOUS SYSTEM. the attack ; and if the patient, therefore, survive the fifth or six day without there being phlyctsenae and undue elevation of temperature, his prospects of recovery become favourable. Nevertheless the condition of his arterial system renders further attacks probable. When the attack and the reaction are over, that is, in about ten or eleven days after the commencement of the illness, we have simply to do with symptoms owing to the presence of the clot. "We now find either complete hemiplegia, i.e. paralysis of one side of the body ; or it is seen that a gradual recovery of voluntary power takes place, and which is in direct proportion to the anatomical changes which have been previously described (p. 95). Motor Paralysis is the most striking consequence of an ordinary attack of cerebral hsemorrhage, and its degree depends upon the quantity of the effusion, and the part of the brain which has suffered from it. Where the entire corpus striatum is destroyed, there is complete and permanent hemiplegia of the opposite side of the body. While, however, the commands of the intellect can no longer be carried out by the paralysed muscles, the reflectory and emotional movements do not suffer, and may even be increased. The patient may be unable to laugh at the affected side when told to do so ; but when his emotions are excited he may laugh on both sides of the face. Tickling of the sole causes extensive movements of the paralysed leg, or both legs, and on gaping, arm and leg are drawn up- wards ; showing that the spinal cord still retains its influence over the paralysed muscles, while the inhibitory influence of the brain is withdrawn. At a later stage of the complaint, how- ever, there is generally diminution, and sometimes even utter abolition, of reflex movements. I have already adverted (p. 48) to the theory of Dr. Broad- bent, according to which the parts which are really paralysed are those which have the power of acting singly, and independ- ently of the corresponding parts of the opposite side; while those muscles which escape act laterally, or at least in concert with the corresponding muscles of the opposite side ; and I shall now proceed to consider the paralysis of motion after corpus striatum haemorrhage, in accordance with this theory, which is fully borne out by the facts of the case. APOPLEXY. 107 The muscles which escape are chiefly those of the eye, neck, back and chest. The movement of the eyes, which are under the influence of the third, fourth, and sixth nerves, are generally perfect ; the patients may also move their head forwards, back- wards and sideways ; the motions of the chest do not differ on either side, and inspiration and expiration is not only performed automatically, but may also be carried out by the command of the will. The paralysis, however, is marked in the face, arm, and leg of the side which is opposite to the lesion. The paralysis of the face is always incomplete, and thereby easily distinguished from facial palsy caused by disease of the portio dura. In the latter affection every muscle animated by that nerve has lost its motive power ; and the paralysis appears particularly striking in the orbiculares palpebrarum et oris, owing to which the patient cannot close the eye of the affected side, and has lost the power to purse up his lips, to kiss and to whistle. In cerebral palsy, on the other hand, the patient can always close his eye, and has lost only very little power over the orbicularis oris, being able to blow and to whistle. The muscles which chiefly suffer in this form of facial palsy are the straight muscles going to the lips and the angle of the mouth ; that is, the levator anguU oris, labii superioris et alse nasi, and the zygomatics. The affected lip therefore droops and is drawn to the healthy side, and this deformity augments when the patient speaks or laughs. The cheek is flabby, and does not partake in movements of the face : while the lip of the opposite side stands higher, being drawn upwards and outwards. The nostril is narrowed, and during expiration the cheek is puffed out like a sail by the wind, there being no muscular tone to resist the passage of the air. We also find that, while in paralysis of the portio dura the orbicularis palpebrarum is so completely paralysed that the patient cannot shut his eye even if he makes the greatest efforts to do so, and the eye remains open even during sleep, the patient affected with cerebral facial palsy can shut it apparently quite well. Yet the muscle is weakened, for the patient cannot squeeze the eyelid as tightly over the eye as he can do with the other ; when the eyes are closed, that of the paralysed side is less so than the other ; and while he can close the eye of the unaffected side by itself 108 BISSASBS OF THE NERVOUS SYSTEM. unilaterally, he cannot close that of the affected side by itself, or at least experiences considerable difficulty in doing so. The corrugator supercilii and the occipito-frontal muscles are likewise weakened ; for although the patient can frown a little when told to do so, yet there is a perceptible difference between the two sides. Moreover, habitual want of tone is shown by the diminution of the horizontal and perpendicular wrinkles on the forehead. In facial palsy from affection of the portio dura these wrinkles disappear completely on one side ; in cerebral facial palsy they do not disappear, but are less marked. The minor portion of the fifth nerve is likewise affected ; and if the patient be requested to close the jaws firmly, it is found that the temporal and masseter muscles of the sound side contract sooner and more energetically than those of the para- lysed side. Mastication is therefore not so easy, and the patient cannot well move the bolus in the mouth, owing to partial paralysis of the biiccinatorius and the tongue. The tongue is in the large ma,jority of cases deviated towards the paralysed side. This apparently strange fact finds its ex- planation in the peculiar action of the genio-glossus muscle, which draws the tip of the tongue, when the organ is pro- truded, in an oblique direction towards the opposite side. In health both genio-glossi act together, so that when the tongue is protruded, the lateral movements are neutralised by the antagonistic action of the two muscles. But as soon as one genio-glossus is paralysed, the other loses its antagonist, and directs the tip of the tongue to the opposite, that is, the para- lysed side. In a few cases we find indeed that the tip of the tongue is directed to the healthy side ; but these are instances, not of corpus striatum haemorrhage, but of lesions of the medulla, where there is crossed paralysis of the tongue and the limbs. While therefore the imilateral action of the tongue is in- terfered with, combined movements may still be carried out by it. Thus its two lateral halves appear generally symmetrical, and it may be fiattened and elongated as a whole. The muscles of the back almost always act together ; and even when the body is inclined to one side, the muscles of one APOPLEXY. 109 side produce, and those of the other side regulate, the movement, in order to prevent falling over. The same is the case with the muscles of the neck. The diaphragm is not affected, as the phrenic nerves con- tinue to act normally; but the recti abdominis muscles are weakened on the paralysed side. This is seen when the patient attempts to raise himself from the recumbent to the sitting posture by the help of these muscles. If we then place the hand on the abdomen, we feel that the muscles of the paralysed side do not contract so quickly nor so energetically as those of the healthy side. The greatest degree of paralysis is found in the arm, which acts habitually more singly than any other portion of the body, and if recovery takes place, this is in the direction from the centre to the periphery. In severe cases the shoulder-blade is quite devoid of motion, from paralysis of the serratus, trapezius, latissimus dorsi, and other muscles. The arm itself cannot be abducted, from paralysis of the supra-spinatus and deltoid muscles, nor adducted, through paralysis of the coraco-brachial ; it cannot be drawn forward, as the subscapularis and the pectoralis major muscles do not obey ; nor backwards, from want of power in the infraspinatus and latissimus. Flexion and extension, supination and pronation are likewise impossible, through paralysis of the muscles intrusted with those move- ments. Where no or only slight improvement takes place in the muscles which move the arm and forearm, contractions of their tissue are not slow to appear. The flexor muscles are generally much more contracted than the extensors. The arm often appears adducted to the side, from contraction of the coraco- brachial muscle, and the forearm is bent on the arm, from con- traction of the biceps. The triceps being an extensor, is more paralysed than contracted ; but it does not altogether escape contraction, which is shown by its becoming so far rigid as to prevent complete passive flexion of the elbow, so that the tips of the fingers cannot be placed on the acromion of the same side. Endeavours to carry out these movements cause pain. The wrist is particularly affected. The four typical move- ments of it are dorsal and volar flexion, and radial and ulnar 110 BISEASHS OF THE NERVOUS SYSTEM. flexion, each movement being performed by two muscles, viz., volar flexion by the flexor carpi radialis and ulnaris; dorsal flexion (commonly called extension) by the extensor carpi radialis and ulnaris ; radial flexion, by the flexor and extensor carpi radialis, and ulnar flexion by the flexor and extensor carpi ulnaris. Amongst these four movements, that of dorsal flexion is most obstinately and permanently afiiected in cases of hemi- plegia ; and a patient who has recovered this action may be considered fortunate. The contractions are most severe in the muscles which provide for volar flexion ; and the flexor carpi radialis suffers more than the flexor carpi ulnaris. Like the wrist, the fingers have four different kinds of motion, viz. flexion, extension, abduction and adduction, which are produced by four separate muscles for each finger, and which all suffer more or less in hemiplegia from corpus striatum haemorrhage, either by contraction or paralysis. Among these muscles, the extensors and abductors suffer chiefly from para- lysis, and the flexors and abductors from contraction. More- over the thumb and the little finger lose a movement peculiar to them which is carried out by two separate muscles, viz. that of opposition of their volar surfaces. The contraction of the flexors is often so strong that the fingers are forcibly bent into the palm, and that the growing nails irritate the skin. The adductor and opponent of the thumb are in such a state of con- traction that the last phalange of the thumb touches the second or even third finger with its volar surface ; and the movements of abduction or extension are only rarely recovered from. Although at first the leg is quite as much paralysed as the arm, we find that in most cases a difference soon becomes apparent between the upper and lower extremity ; for while the arm remains unable to obey the orders of volition, the leg begins to execute sluggish movements, and the patient is sometimes able, within the first week of the stroke, to get out of bed and to hobble about the room, with the arm dangling by his side like a piece of inanimate matter.' The same law which obtains for the upper extremity, also holds good for the lower, viz. that recovery progresses from the centre to the periphery. The hip-joint therefore gains its motion before the knee, and the latter before the foot and the toes. An occasional APOPLEXY. Ill exception to this rule is made by the toes, which in some in- stances recover before the ankle-joint. In these cases great care must be taken to distinguish voluntary from reflex move- ments, which latter are sometimes excited by the least cause, and which are apt to deceive the observer into the belief that there is recovery of volitional power. In the lower extremity likewise the extensors are chiefly subject to paralysis, and the flexors to contraction. In most cases the latter do not recover thoroughly, in consequence of which the paralysed leg appears shorter than the opposite one, and a limp in the gait is the consequence. In some cases the patient walks chiefly with the muscles of the back and hip-joint, those of the thigh, leg and foot remaining more or less inactive. This explains the peculiar swinging motion of the leg which is so often seen in hemiplegia from corpus striatum haemorrhage. The sphincter muscles generally recover completely within a few days of the stroke, unless the patients are very much advanced in age, or the effusion of blood has been very copious. Combined movements which require a certain amount of skill, especially where the right hand is concerned, such as writing, sewing, playing on musical instruments, dressing, and more particularly buttoning, continue awkward and troublesome long after a fair share of coarse muscular power has returned. Associated movements may occur together with involuntary or reflex movements. Thus the paralysed Umbs are seen to jiunp about during the acts of gaping, sneezing, coughing, and laughing. Voluntary movements of the healthy limbs of the opposite side have no such effect. The muscles of the face sometimes recover their physiognomical expression for a short time, when the patient is under the influence of excitement or indignation, and lose it again as soon ' as he has calmed down.' Aphasia, or loss of language, being more frequently pro- duced by softening than by hEemorrhage, will be considered in the following chapter. The automatic movements of circulation and respiration are generally impaired for some time after the seizure. The pulse is often irregular and intermittent. Eespiration is sometimes entirely diaphragmatic. There is diflSculty in swallowing ; re- gurgitation of liquids is not uncommon; digestion is tardy, and the action of the bowels sluggish. 112 DISEASES OF THE NERVOUS SYSTEM. Do patients ever completely recover from an attack of corpus striatum haemorrhage ? This question used formerly to he unhesitatingly answered in the afiBrmative. Even so recent an observer as Durand- Fardel states that of twenty-seven such cases which came under his care, nine were cured, two nearly so, four remained weak in the affected limbs, one retained difficult articulation, one be- came imbecile, and ten remained hemiplegic. This proportion of recoveries, however, does not really occur ; and if we were to accept it without reserve, it would imply a far greater vitality of the previous than the present generation, or more effective modes of treatment employed by our predecessors in practice than by ourselves. We shall be nearer the truth in assuming that our search for symptoms of disease is now keener than previously, and that we consequently discover them more fre- quently. Having had more than four hundred cases of hemi- plegia from corpus striatum haemorrhage under my care in hospital and private practice, I am enabled to state that com- plete recovery is the exception, and that even in those patients who professed to enjoy good health after a seizure, the memory was as a rule less ready, the speech less fluent, the power of application less enduring, and the sense of touch and the co- ordination of movements less quick than before the attack. Nor should it be a matter of surprise that such patients do not as a rule entirely regain their faculties. The blood which has been effused, must in the nature of things destroy a number of nerve-cells which can never be regenerated, and whose place will ultimately be taken by connective tissue. The eventual loss of function will be proportionate to the extent and impor- tance of the destroyed parts, and to the degree to which their place can be taken by allied structures in the neighbourhood of the lesion. A somewhat analogous case is that of a man who has had a portion of his lung consolidated by tubercular deposit, and who, although the activity of the disease may have been arrested, and retrogressive changes taken place in the tubercle which renders it innocuous to the system, can never be so strong as he might have been with the entire organ in full functional activity, although he may certainly enjoy a measure of health and strength. AFOPLEXY. 113 The extent to which recovery of function may take place depends — 1. Upon the quantity of blood which has been effused. This varies from a few drops to several ounces, and the less escapes, the better will be the patient's prospects. 2. Upon the portion of the brain in which the effusion has taken place. Hemiplegia affecting the right side of the body is not only more serious in its aspect than the left, because it is almost invariably combined with loss or great impairment of speech, which is rarely entirely recovered, but it also appears that the patients regain the use of the left side more readily than that of the right side of the body ; to which must be added the circumstance that the left arm and hand are not nearly so essential to the patient as the corresponding limbs of the right side. 3. Upon the manner in which the effused blood is disposed of (p. 94) ; and lastly 4. Upon certain secondary alterations which in many cases occur subsequently in the nervous centres, peripheral nerves and muscles, and which begin probably soon after the stroke. If any such occur, ultimate recovery is rendered impossible. The chief symptom in these cases is that the paralyssd limbs become permanently contracted. Some observers have thought this to be owing to secondary encephalitis, but the researches of Tiirck, Charcot, and Vulpian have shown that the nature of the affection is sclerosis of the lateral columns of the spinal cord. This sclerosis proceeds in a de- scending direction from the seat of the lesion, affecting the cerebellum, the peduncles, the medulla oblongata, and the spinal cord. It is chiefly seen after corpus striatum, and less after thalamus opticus, haemorrhage. A grey band is found on the cerebral peduncle corresponding to the destroyed corpus striatum, occupying the external, middle, or internal portion, according as the primary lesion has affected the external, middle, or internal part of the striated body. This grey band may be traced throughout the medulla and the lateral column of the cord. The medulla is flattened and lessened in size, and the pyramid small and grey. The degenerated fasciculus crosses over in the anterior pyramid to the opposite side, and I 114 BISEA8ES OF THE NERVOUS SYSTEM. the lesion in the cord is therefore found in the side opposite to the cerebral lesion. The sclerosed part is situated just before the posterior roots, in the lateral columns, and quite limited in extent. To the naked eye these changes are visible about four or six months after the stroke, but with the aid of the micro- scope they may be discerned much sooner. There is a forma- tion of granular cells, and the nerve-fibres and coats of blood- vessels are beset with oil-globules. The intermediate connective tissue is proliferated, and an amorphous and nearly transparent substance is formed, in which crowds of nuclei are seen. We have therefore the symptoms of chronic inflammation of the neuroglia, and this may eventually creep up to the opposite column of the spinal cord, causing diffuse interstitial myelitis. It is not yet settled whether these secondary lesions are owing to irritation spreading from the seat of the primary lesion, or to the withdrawal of the nervous influence of the ganglion cells of the grey matter of the brain upon the nutri- tion of the nervous matter below the lesion. Professor West- phal, of Berlin, has artificially produced a secondary degeneration of this kind in animals by destroying the corpus striatum and thalamus opticus, and dividing the cord ; while Vulpian has seen negative results from the same operative procedures. In some cases senile atrophy of the entire cerebral matter, involv- ing more especially the hemispheres,, is seen to follow an attack of h&morrhage. Interstitial inflammation may spread eventually from the cord to the peripheral nerves. They become swollen, their tissue denser, and the several fibres are seen to be separated and com- pressed by an excessive formation of connective tissue. The bulk of the nerves may occasionally be felt increased during Ufe. The muscles under these circumstances become pale, and waste away ; the primitive fibres lose their stripes ; oil-globules appear and the nuclei of the sarcolemma are multiplied. The joints are often painful a few weeks after the stroke ; the syno- vial membrane is congested, its fringes hypertrophied ; the quantity of synovial fluid is increased, and the tendinous sheaths become vascularised. Dr. Scott Alison was the first to draw attention to the fact that secondary affections of the joints are not infrequent after APOPLEXY. 115 cerebral Ljemorrhage. The joints mostly implicated are the knee, elbow, wrist, and ankle. They are hot and swollen, and pain is experienced not only on moving them but also when they are kept quiet. This affection is not connected with gout, rheumatism, or any other diathesis, but the direct consequence of the cerebral lesion; and always spares the joints of the healthy side. Charcot has seen a case in whicb there were deposits of urate of soda, either crystallised or amorphous, in the cartilages of the joints of the paralysed side, while those of the healthy side did not show any such alteration. According to the same observer, there is in these cases a regular synovitis with vegetations, proliferation of the nuclei and fibres which constitute the serous membrane of the joints, and increase of the size and number of the capillary vessels. These affections are distinguished from rheumatic affections by being limited to the joints of the paralysed limbs ; the time at which they appear, in relation to hemiplegia ; and by the co-existence of other trophic disturbances of the same character, such as de- cubitus. If the spine is affected, acute muscular atrophy of the paralysed limbs, cystitis, nephritis, etc., may be present. Where the paralysis and contraction have lasted a consider- able time, the joints undergo further 'degeneration, probably in consequence of their long immobility. The synovial membrane appears thickened, and there may be ulceration and formation of false membranes, and complete ankylosis. The limbs waste away in their entirety, and more particularly so in children, where the growth is arrested and the spinal nerves may become altogether wasted. The nails become yellow, crooked, and fis- sured ; the hair thicker and longer ; and the skin hypertrophied. The late rigidity of the muscles, which is observed as a consequence of the pathological changes which have just been described, is different from the early rigidity, by appearing some months after the stroke, and by being progressive and permanent. It affects certain sets of muscles more than others. In the face the commissure of the lips is eventually drawn to the paralysed side, in the same way as is sometimes seen in old cases of paralysis of the portio dura, with consecutive con- traction. Errors in diagnosis have been occasioned by this circumstance, for a hasty examination has sometimes induced I 2 116 DISEASES OF THE NERVOUS SYSTEM. the practitioner to take the paralysed for the healthy side. The sterno-cleido-mastoid muscle may, by its rigidity, draw the head towards the shoulder of the paralysed side. But the muscles chiefly subject to it are those of the upper extremity, and amongst them again chiefly the flexors. The forearm is generally pronated, and where the contraction of the fingers is very great, the nails may penetrate the skin and cause ulcer- ation. On endeavouring to stretch the contracted fingers consi- derable pain is caused, and resistance encountered ; sometimes the patient turns faint and sick during the time. As soon as the effort is discontinued, the fingers resume their previous position. The faradic and galvanic excitability of the paralysed mus- cles is in the large majority of cases normal; and this serves as a good test, in addition to others, to distinguish cerebral from peripheral paralysis, lead-palsy, and other affections in which the electric contractility of the muscles is either greatly dimi- nished or entirely lost. That this should be so is owing to the fact that trophic alterations of the paralysed muscles are on the whole rare in cerebral palsy. Even where this has existed for many years, there may be hardly any wasting of their substance, while in cases of injury to the motor nerves, in saturnine poi- soning, and also in some forms of myelitis, viz. where the grey matter in the centre of the cord is suffering, rapid and extensive wasting of the muscles is encountered. In some cases of cerebral palsy, however, we find great diminution of electric excitability, and we then have to trace this either to simultaneous affections of the intracranial trophic centres, or to Tiirck's secondary degeneration. In other cases there is an increase in the galvanic and faradic excitability of the muscles, which is owing to chronic sub- inflammatory irritation of the nervous centres. In paralysis of the portio dura from effusion into the pons Varolii there is generally early diminution of the electric contractility of the muscles. Occasionally the paralysed nerves and muscles show the phenomena of convulsibility and exhaustibility. It is then noticed, that on first using the current, the contractility may APOPLEXY, 117 be either normal or diminished, but that, as the eurrent con- tinues to act, there is a rapid increase in the response of the muscles, which sometimes becomes most violent. In other cases the response of the muscles is at first normal, but dimi- nishes considerably as the current continues to act. The two conditions may even occur together in the same case, so that on commencing to act we find convulsibility, which after a time is followed by exhaustibility. The mental functions generally suffer in corpus striatum haemorrhage ; and as this organ is not the seat of these functions, we must assume that the deterioration of the psychical faculties is owing either to the shock received by the hemispheres during the attack, or to the secondary degeneration of nervous tissue which takes place after it. Amongst the mental faculties, the memory is raost apt to fail, and more particularly so for occurrences which have taken place since the attack. The temper of the invalid generally becomes peevish, irritable, and capricious. When atrophy of the hemispheres sets in, there is considerable mental decay^ and at last complete imbecility. The nerves of special sense are rarely much affected. There is sometimes deficiency of smell on the paralysed side, but this is more owing to paralytic narrowing of the nostril than to any affection of the olfactory nerve, A deficiency of taste which has sometimes been noticed is probably owing to affection of the chorda tympani, and not to anaesthesia of the glosso- pharyngeal or fifth nerve. The hearing is occasionally less keen. Optic neuritis is rare, but hemiopia somewhat more frequent. Charcot and Veyssiere have shown, both experimentally and clinically, that hemianaesthesia occurs after disorganisation of the posterior part of the internal capsule ; but Dr. Ferrier ' thinks that the cause of the hemianassthesia in this case is not due to disorganisation of true centres of sensation, but merely to interruption of the path of transmission from the organs of sense to the sensory centres in the cortex, and these latter he believes to be the hippocampus major and the uncinate convolu- ' Loc. cit. p. 182. 118 DISEASES OF THE NERVOUS SYSTEM. tion. Destructive lesions of the Hppocampal region have in his hands produced abolition of tactile sensation on the opposite side of the body. A limb which has been deprived of tactile sensation becomes really inanimate, although there may be no motor paralysis. It may still be moved, but only under the guidance of the eye ; and as soon as this latter is withdrawn, the condition of the limb for the time being drops out of consciousness. Thus, in Demeaux's case,' the woman moved her muscles by the com- mands of the will, but was unconscious of the movements which she made. She did not know in what position her arm was, whether flexed or extended. When she was requested to put her hand to her ear, she did so at once ; but if the doctor put his own hands between the patient's hand and ear, she was not aware of it ; nor did she know when her arm was prevented from carrying out a movement. If the doctor held the patient's arm on the bed, and then requested her to put her hand to the head, she made an effort towards it, but soon after ceased to do so, being under the impression that she had carried out the move- ment. In these cases there is also a contraction of tlie field of vision, and difficulty to distinguish colours, on the side opposite to the cerebral lesion. In most cases of corpus striatum haemorrhage sensibility appears dull during the first few days after the stroke ; but this is generally owing more to the torpor which exists at that time throughout the system than to any special lesion of sensibility. Dr. Broadbent, who looks upon the thalamus opticus as the centre of conscious sensation, in the same way as the corpus striatum is Tjelieved to be the central motor ganglion for the opposite side of the body, explains the absence of permanent or even complete anaesthesia in most cases of cerebral haemorrhage by the circumstance that sensation is altogether more easily transmitted, even by diseased structures, than motion. Dr. Brown-Sequard has experimentally shown that injury to the white motor columns of the spinal cord is at once followed by appreciable muscular paralysis, while considerable injury may ' ' Thfese des Hernies crurales.' Paris, 1843. APOPLEXY. 119 be done to the grey matter before any loss of sensation becomes apparent ; and a certain degree of sensibility may persist in the whole of that part of the body behind the seat of the injury, provided only a slender bridge of grey matter is allowed to remain. Although it has not been experimentally demonstrated that this condition also prevails in the higher portion of the sensory tract, including the thalamus opticus, there would be no stretch to assume that this is so ; from which it would be fair to conclude, that only such an amount of destructive change as would leave no fragment of the thalamus in connection with the lower sensory tract, would lead to complete ansesthesia. The temperature of the paralysed limbs undergoes con- siderable changes during the progress of the disease. At first there is increased heat in the affected side, which generally amounts to 1° or 2°, but may be much higher in exceptional cases. This initial increase of temperature is no doubt owing to paralysis of the vasomotor nerves which course with the crura cerebri, and which must be affected by the lesion, pro- vided this occupies the crura cerebri or the central ganglia. Where there is progress towards recovery, the temperature gradually becomes equalised in both sides ; but where the paralysis persists, the affected limbs are eventually found to be colder than those of the opposite side. This diminution of temperature we have to explain by the diminished energy in the cellular changes going on in the tissues, and which are the ultimate source of the body-heat. Circulation is generally sluggish under these circumstances, and there is passive hyper- semia in the paralysed parts. The skin does not accommodate itself to varying circumstances ; there is cedematous swelling in the arms and hand ; the conjunctiva and the mucous mem- brane of the nose are congested, and secrete mucus more profusely than usual. There is sometimes a dull ache or violent pain in the paralysed limbs, which is increased by pressure ; and when the patient attempts voluntary movements, there is often tremor which lasts as long as the effort. Eulenburg has made sphygmographic researches on the radial pulse of the paralysed and healthy side, and found that there is diminution or loss of arterial tone in the paralysed limb. The artery no longer becomes expanded by the primary 120 DISEASES OF THE NERVOUS SYSTEM. •wave, or by the succeeding secondary wave, nor constricted' after these have passed off, so that both elevations and depres- sions are not well marked, and the whole tracing resembles the simple monocrotous pulse. Dr. Broadbent has pointed out, that in that form of cerebral haemorrhage which is owing to blood-poisoning from contracted kidney, and accompanied with hypertrophy of the left ventricle, the pulse is peculiarly large and hard ; there is little pulsatile movement in the artery ; the vessel slips and rolls about under the finger like a piece of thick whipcord, and it is difficult to control pulsation by pressure. We have, therefore, the long, hard, large pulse of arterial tension, which gives a sphygmo- graphic trace of gradual ascent, low elevation, rounded summit, and gentle unbroken fall. Coexisting with this is re-duplication of the first sound of the heart over the inter-ventricular septum, extinction of the first sound, and exaggeration of the second sound over the aorta. The re-duplication of the first sound is best heard with the double stethoscope, one mouth being placed over the right and the other over the left ventricle ; and the phenomenon is due to want of coincidence in the contraction of the two ventricles. The contraction of the left ventricle is retarded by the extreme resistance to the entrance of more blood into the already distended arteries, and thus the right ventricle has a slight start in advance. The diminution or extinction of the first sound over the aorta is likewise explained by increased ai'terial tension, inasmuch as this latter prevents the left ventricle from throwing its contents rapidly into the aorta, the action being thus rendered more gradual. In old cases of hemiplegia we often find convulsive seizures, and even true epileptiform attacks, or choreic movements and irregular contractions in the paralysed muscles, owing to sclerosis of the pons and medulla oblongata. Eelapses of the apoplectic stroke are frequent, inasmuch as the vascular lesions are progressive in their nature ; but the popular notion that it is the third stroke which kills, is quite fallacious, for in a large number of cases the first proves fatal. It is, however, a fact that many patients succumb to a third attack. Others survive a third and even further strokes. APOPLEXY. 121 although in so enfeebled a state that they are left, as it were, only shadows of their former selves. There is gradual but plainly perceptible decay of the mental and physical faculties, owing to secondary atrophy. Senile marasmus thus becomes established, and as there is much less resistance to injurious external influences than there was previously, a slight incident, such as a cold affecting the bronchial tubes, or intestinal catarrh, win rapidly destroy life. The ultimately fatal result is often much accelerated by the enforced rest, the bad hygienic conditions in which these patients live, and by decubitus on the sacrum. The effects of haemorrhage into various portions of the cineritious substance of the brain, into the cerebellum, pons Varolii, the medullary matter of the anterior, middle and pos- terior lobes, and the medulla oblongata, will be considered when the diagnosis of the various forms of cerebral hsemorrhage comes under discussion. 2 . HcEmorrhage into the Membranes of the Brain, Meningeal Hcemorrhage. This form of haemorrhage is not nearly as frequent as the one which I have just described. It may be caused by rupture of aneurisms of the cerebral arteries at the base of the brain ; by cerebral hasmorrhage extending into the meninges; by a general hsemorrhagic diathesis, in which effusions of blood take place into diverse other organs besides the meninges ; and by injury, such as a blow or fall, in consequence of which healthy bloodvessels are ruptured. Meningeal haemorrhage is frequent in newly-born infants, and seems to occur in them chiefly when labour has been tedious and instrumental delivery found necessary. By the application of the blades of the forceps the meningeal bloodvessels are squeezed and ruptured, just as the vessels of the skin and cellu- lar tissue ; and this is more especially the case where the head of the child is large. The forceps is, therefore, not an absolute boon in these cases, as children who have been delivered by its aid may subsequently become paralytic, epileptic, and imbecile. Sometimes, however, meningeal haemorrhage is produced where labour has been easy, and it then seems to be owing to the 122 DISS ASUS OF THE NERVOUS SYSTEM. edges of the skull-bones being squeezed against each other, whereby the bloodvessels of the pia mater become ruptured. The following was the proportion of deaths in children under five years of age in England and Wales, from ' apoplexy ' — which in this experience, to 1872:— instance we take, mean meningeal in accordance with clinical haemorrhage — in the year Males Females 1872 Under 5 years 394 All ages 5840 Under 5 years 291 All ages 5953 While, therefore, generally speaking, the proportion of women dying from apoplexy is greater than that of men, it would seem that in the infantile period of life the relations are reversed, boys being more liable to die of meningeal haemor- rhage than girls. Dr. Braxton Hicks,' who has likewise noticed this peculiarity, explains the greater death-rate of boys than girls during and shortly after birth, by the fact that at full term the male is larger than the female, being on the average ten ounces heavier and half an inch longer. Moreover, the cranium is in boys more completely ossified, and the delivery of the head through a narrow pelvis more difficult than in girls, as it cannot be so easily moulded into shape. In con- sequence of this state of things the circulation in the uterus, placenta, and umbilical cord becomes more easily obstructed, causing effusion of blood in various organs, and also inspiratory efforts, by which fluids are drawn into the larynx and trachea, producing asphyxia. The quantity of blood which is found effused in the meninges varies from a few drops to twenty ounces ; but it is generally large. As a rule the blood is coagulated, and spread in all directions, either in the subarachnoid space or between the arachnoid and dura mater, and extends to the base and con- vexity of the brain, and to both hemispheres. Where the effusion has taken place between the arachnoid and dura mater, the blood accumulates on the tentorium and the base of the ' ' Croonian Lectures on the Difference between the Sexes, etc' Medical Journal, 1877. British APOPLEXY. 123 skull, from where it may enter the arachnoid space of the spinal cord. In adults the convolutions appear flattened, and the cerebral matter anaemic ; but such is not the case in infants, -where abundant meningeal haemorrhage may be found together with hyperaemia of the brain. Occasionally there is haemor- rhagic softening in the neighbourhood of the effusion. The symptoms of meningeal haemorrhage are more simple and less diverse in character than those of cerebral haemorrhage, which is explained by the circumstance that the blood presses not upon certain circumscribed portions, but more or less upon the whole of the brain. As both hemispheres are compressed, there is no hemiplegia, or other special forms of paralysis, but muscular debility, which soon passes into complete relaxation and paralysis of all four extremities. Before paralysis sets in, there is sometimes rigidity or convulsions of the limbs. There is no localised anaesthesia but a generally diminished perception of impressions, which gradually deepens into stupor and coma ; and this latter is in some cases the first symptom of meningeal haemorrhage. Occasionally, however, there are such premoni- tory symptoms as headache and vertigo ; and towards the end there is generally involuntary discharge of the urine and faeces. The respiratory movements then become stertorous, sighing and interrupted, showing that the blood compresses the medulla oblongata, which speedily results in asphyxia. Death generally takes place on the first day ; but in exceptional cases patients survive two or three days or even more. Infants in whom meningeal haemorrhage has taken place in utero are either born dead or in a state of partial asphyxia, which soon ends in death. Sometimes the children remain alive for five or six days, but are in a state of excessive debility; they show the condition of apoplexy, cannot be roused, and those functions of life which are still exercised proceed with extreme sluggishness. At last vomiting and convulsions set in, and death follows more or less suddenly. In cases where the symptoms are protracted, we may assume that the haemorrhage began previously to birth, and only tardily reached such a degree as to be incompatible with life. Adults who die of meningeal haemorrhage are generally habitual topers or drunkards, and suffer at the same time from 124 DISEASES OF THE NERVOUS SYSTEM. disease of the liver. That form of meningeal hemorrhage which is known as hcematoma of the dura mater will be con- sidered in the fifth chapter under the heading of Cephalitis. 3. Hypercemia of the Brain, or Determination of Blood to the Head. This is another pathological state which may cause the condition of apoplexy. There are two kinds of hyperaemia, viz. the active, or arterial, and the passive, or venous form. We speak of active hypersemia where a larger quantity of blood than usual is supplied to the brain and its membranes ; while this passive congestion means that the supply of blood sent up to the head is not actually increased, but that the blood does not return freely from the brain through the jugular veins to the right side of the heart, and is therefore allowed to accumu- late in the intracranial cavity. Active hyperaimia occurs chiefly in simple hypertrophy of the left ventricle of the heart, without valvular disease. This condition occurs in gluttons, and likewise in persons who are habitually obliged to undergo great physical exertion, such as blacksmiths, navvies, &c. We also find it in contracted granular kidney, where the blood is poisoned through insuffi- cient elimination of effete matters, and the coats of the arterioles and ultimately the left ventricle itself become hypertrophied. The left ventricle thus acquires an excessive impulsive power, which will lead to congestion of the brain, and indeed some- times to rupture of its bloodvessels. Hypertrophy of the left ventricle in connection with disease of the aortic valves may also lead to it, although in many instances of this disease one condition compensates the other, the excessive force of the heart's action being counterbalanced by the imperfect closing of the valves ; but where the two states do not strictly correspond, active hypersemia of the brain will be the result. Certain pathological conditions of the blood, such as anaemia, chlorosis, and hydrajmia, are also instrumental in inducing active hypersemia. The impoverished state of the blood causes a condition of irritable debility in the motor centre of the heart, and the distribution of blood is then carried out APOPLEXY. 125 in an irregular manner, the general result being determination of blood to the head, and chilliness of the extremities. It would, however, be erroneous to look upon all cerebral symptoms which occur in acute diseases, and amongst them more par- ticularly upon somnolence and delirium, as arising from cerebral hyperaemia, and to treat the condition with bleeding and other active measures, as was the fashion formerly. We now know that cerebral symptoms in febrile diseases are generally owing to the high temperature of the blood circulating in the cerebral vessels, and to its altered composition. In acute mania, how- ever, intense hypersemia of the brain and its membranes is generally discovered. Active determination of blood to the head is likewise caused by the habitual use of opium, morphia, and alcohol, which paralyse the vasomotor system of nerves. In some persons, a few glasses of wine are sufficient to cause such congestion, and for these, total abstinence from intoxicating beverages is imperative. Inflammatory conditions of organs in the neigh- bomrhood of the brain, such as erysipelas of the face, mumps, quinsey, severe bums, and the sudden suppression of habitual hemorrhages such as menstruation and piles, have a like effect. Violent emotions, more especially after meals, may cause such severe hypersemia as to lead to sudden death. In such cases the irritation is propagated from the peripheral end of the pneumogastric nerve, or from the sentient nerves of the skin, or from the nerve-cells of the cerebral convolutions, to the vaso- motor centre in the medulla oblongata. From there it spreads to the vasomotor nerves of the pia mater, and causes dilatation of the arterioles. Eedness of the face and conjunctiva is gene- rally observed at the same time, showing that the irritation has been transmitted to the fifth pair of cerebral nerves. Passive or venous hypercemia of the brain is induced where there is some impediment to the return of venous blood from the brain, in consequence of which the capillary vessels and the veins become gorged. This condition is observed in cases where the jugular veins are compressed by tumours in the neck or the superior cava by tumour in the mediastinum ; in newly-born infants, by constriction of the umbilical cord ; in insufficiency of the tricuspid valve, and stenosis of the left 126 DISHASIIS OF Till! NERVOUS SYSTEM. atrium, where at each systole the blood returns into the auricles and the cavse. In such cases the jugular vein appears distended, and sometimes pulsating. Fatty degeneration of the heart, dilatation of the right ventricle without hypertrophy, certain diseases of the lungs, as emphysema, and pleuritic effusions, rnay also lead to it. It is true that the mechanical obstacle to the return of the blood which exists in all these conditions is some- times counterbalanced by increased force of the right side of the heart ; but in acute cases of such diseases there is no time for a greater development of muscular fibre in the right ventricle ; while in chronic cases it sometimes fails to occur from the age or general debility of the patient. Sudden obliteration of an artery will cause partial hypereemia in the neighbourhood; and cerebral tumours may lead to congestion, either by irritating the substance of the brain, or by compression of the veins. Chronic inflammation of the arteries and thrombosis of the veins have a like influence. Severe mental application, pro- longed waking, more especially when nursing the sick ; great muscular efforts, which augment the , intra-thoracic pressure and prevent the emptying of the jugular vein — such as violent coughing, more particularly in whooping-cough, vomiting, straining, playing on wind instruments, and singing — are also liable to be .followed by passive cerebral hypersemia. The employment of compressed air in certain branches of industry has led to the same result in workmen habitually engaged in such occupations. In the last stage of fevers we find that failure of the heart's action, together with the alterations of the blood produced by the disease, and the approaching paralysis of the vaso-motor centre, tend to produce the condition which we are now considering. Where it is only produced just ante mortem, it is generally confined to the meninges and the super- ficial portions of the brain, while the true pathological hyper- pemia affects chiefly the deeper portions of the encephalon. A liability to determination of blood to the head seems to run in certain families, and is often associated with general plethora and free living. It occurs more in adults and the aged than in the young, and more in men than in women. The most powerful predisposing causes are, however, pericarditis and endocarditis. APOPLEXY. 127 Hyperjemia of the brain is generally less intense than that of other organs, as for instance the lungs and spleen ; and im- portant symptoms of disease may be caused by an apparently insignificant increase in the quantity of blood circulating through that organ. The brain and its membranes are mostly affected simul- taneously, in consequence of the same causes acting upon both parts, and it would be impossible to separate these conditions clinically. There are, however, certain sources of error which should be carefully avoided in forming an opinion. In the first instance it must not be lost sight of that different parts of the brain have a different vascularity. The grey matter is more vascular than the white, the corpus striatum more so than the grey matter, etc., and in childhood the entire organ is more vascular than in old age. Again, there is a simple post-mortem hypersemia, produced after the body has been for some time lying on the back, from gravitation of the blood to the lowest level. This is chiefly seen in persons who have been of full habit during life, or where death has occurred from chest disease, or where the blood has remained unusually fluid, as after delirium and maniacal excitement. In other cases, on the contrary, it is found that all the symptoms of determination of blood to the head have been present during life, and yet the condition is absent on the post-mortem table. We may explain this by assuming that, where there was active congestion, the loaded arteries have, just previous to death, emptied their contents into the veins ; or that the congestion has been relieved by transudation of serum through the coats of the capillary vessels, producing oedema of the pia mater and the brain ; or that the blood may not have remained sufliciently fluid after death to show the condition of hyperemia. In general, however, we find the following post-mortem appearances : — the skin and cellular tissue of the skull are swollen, and on opening the skull a great deal of blood is seen to escape. The vessels of the diploe are congested, the sinuses of the dura mater distended, the bloodvessels of the pia loaded with blood. On incising the dura mater the brain protrudes through the opening Uke a rupture, and appears swollen and more voluminous than usual. The convolutions are not well defined ; 128 DISEASES OF THE NERVOUS SYSTEM. the pia is not adherent, and may easily be lifted off from the surface of the brain. The grey matter appears dark red, or of a violet colour : the white matter is not actually red, but shows more coloration than in health. Where the hypersemia has been very severe, as in infants just after birth, the white matter may appear almost as dark as the grey substance. On making a section, a number of small points are seen — the mouths oi opened bloodvessels — from which drops of blood are seen to ooze more or less profusely. On microscopic examination the cerebral capillaries appear to be dilated, having often double their ordinary diameter. The hyperemia is mostly general, but where the causes are limited to the sphere of certain blood- vessels, it may be local. Where this condition has existed a long time previous to death, or where there have been repeated attacks of it, per- manent lesions are apt to occur in the cerebral bloodvessels, from having been subjected to prolonged pressure. The large and medium-sized veins of the pia mater appear wider and tortuous, especially on the convexity of the brain ; the smaller veins, the capillaries and arterioles, when examined by the microscope, are seen to have attained twice or even three times their original width. Oh section the coats of the capillary vessels are plainly visible to the naked eye {etat crible of the French observers). Sometimes the capillaries are ruptured, with consequent extravasation of blood ; but more frequently the liquid constituents of the blood are effused through the coats of the bloodvessels, producing oedema of the brain and pia mater, and thickening of the arachnoid membrane. The brain itself ultimately wastes away, and its ventricles become dilated and filled with serum. The symptoms of determination of blood to the head vary according to the causes which give rise to it, the degree of con- gestion which is present, and the extent to which it affects the different portions of the brain ; but they are commonly charac- terised by being midtiple, not very severe, and lasting only a short time. In mild cases the symptoms are those of increased excita- bility, such as we would expect from slight compression of an organ which is enclosed in rigid walls. There is headache, in- APOPLEXY. 129 creased by the horizontal position ; or a feeling of pressure and heaviness in the head, probably owing to compression of the dura mater, which is richly endowed with sentient fibres. There is also great disinclination to mental exertion, intolerance of strong light, noise, or of being touched ; singing in the ears, sparks or black specks floating before the eyes ; crawling sen- sations about the face and limbs, as of a procession of a thou- sand ants ; drowsiness in the day, but restlessness at night, or sleep broken by vivid dreams or visions ; grinding of teeth, and involuntary muscular jerkings. The face and conjunctiva are generally red, the head hot. The pupil is constricted through increased excitability of the third cerebral nerve. The heart's action is strong ; the pulse large, hard, and slow, from irri- tation of the pneumogastric. Owing to this there is also often a feeling of sickness, and vomiting ; and the bowels are confined. These symptoms last for a few days, and then disappear ; but they are apt to return at any time, and may ultimately become habitual, more especially in hysterical, nervous, and alcoholised persons, and also in those who are subject to heart disease, and are of full habit. The slightest cause will then suffice to produce such attacks ; for instance, some mental or physical effort, being in a heated room, in a theatre or concert, or ' dining out.' "When the degree of hypersemia is more severe, additional symptoms make their appearance. There is giddiness, inability to stand, throbbing in the head, and mental disturbance. The patient is peevish and inclined to cry ; there is delirium, or at least a rapid succession of foolish ideas, and incoherent chatter- ing ; the patient does not know where he is, throws himself about in a restless manner, is constantly in and out of bed, and walks from one room to another. There is inclination to run away : the face expresses terror ; the patient hears voices which abuse and threaten him ; he sees loathsome animals run about ; and after a period of more or less prolonged excitement, ulti- mately falls into a deep sleep, which is accompanied by total relaxation of the limbs, and involuntary evacuation of the faeces and urine. On awaking there is deficient memory of what has occurred, great depression and prostration, and an imbecile countenance. Blenorrhcea of the conjunctiva and of 130 DISEASES OF THE NERVOUS SYSTEM. the buccal mucous membrane is often associated with it. Where these symptoms come on in the daytime, there is generally some immediate exciting cause, such as an annoyance or a quarrel. Sometimes the principal symptoms of cerebral hypersemia are delusions and hallucinations. Such was no doubt the state of Luther's brain, when, overcome by mental strain and excite- ment in his translation of the Bible, he hurled his inkstand at the apparition of the devil. Where cerebral hypersemia has reached this degree, there is generally elevation of temperature, great thirst, loss of appetite, constipation, and the urine is scanty and loaded with lithates. The condition may last only for a very short time, and completely yield to rest and proper treatment ; but where it becomes habitual, insanity, either in the form of melancholia or maniacal excitement, must be the ultimate result. In other cases convulsions of an epileptiform character, with temporary loss of consciousness, may be observed. This seems at first sight strange, since we associate the occurrence of convulsions with anaemia rather than with hypersemia of the brain ; but it is capable of explanation if we consider that passive hypersemia, when it has reached a considerable degree, really deprives the brain of useful arterial blood ; and on the other hand, active hypersemia, when severe, may lead to oedema, which renders portions of the brain ansemic. The severest degree of hypercemia of the brain causes the symptoms of apoplexy. Some recent authors have denied that such can be the case, and it certainly is less common than was formerly assumed ; yet I do not entertain any doubt about its actual occurrence in practice. The capillary vessels and veins become sometimes so gorged with carbonised blood that no oxygen can reach the -cerebral matter, and functional paralysis of the brain ie the consequence. We find in such cases pre- monitory symptoms, viz., dizziness, pain and heaviness in the head, great indifference to the occurrences of daily life, and hypersesthesia on the part of the special senses. All of a sudden the patient exclaims that the blood is rushing to his head, and he falls down in a state of insensibility. There is now more or less complete anaesthesia and paralysis. He may still APOPLEXY. 131 be roused by shouting to him, letting him smell ammonia, or dashing cold water in his face ; but the perception of things in general is lost ; there is difficulty of swallowing, the breathing becomes slow, stertorous, and intermittent, and the pulse quick, and so small as to be almost imperceptible. Eeflex excitability persists, and may even be increased. In the majority of cases the patient rallies, and that much more quickly than would be possible after cerebral haemorrhage ; and there remains no decided loss either of motion or sensation. Sometimes, indeed, after consciousness has returned, the motor power inay be en- feebled ; there may even be hemiplegia, but this lasts only a few days, and disappears without leaving any traces behind. In a few exceptional cases, however, the symptoms gradually become worse ; there is involuntary discharge of the excretions, and the patient dies in the deepest coma. The symptoms of cerebral hypersemia, such as I have just described them, are probably not so much owing to the increased intra-vascular pressure, as to the chemical changes which are going on in the blood during the time which the hypereemia lasts. I have already adverted to the experiments of Pagen- stecher (p. 99), who has shown that the intracranial pressure may be very much increased without the production of severe cerebral symptoms ; besides which we have to consider that the blood, in the active as well as in the passive form of the disease, remains longer in the brain than is compatible with physio- logfical laws. It thereby loses oxygen too largely, and becomes- unduly charged with carbonic acid. Now we know carbonic acid to be a powerful excitant of the nerve-cells, and it appears natural that it should, when accumulated in undue quantity, cause symptoms of increased excitability of the brain. The symptoms of depression may be explained either by over-stimu- lation or by the transudation of serum which so often takes place under the influence of increased vascular pressure, pro- ducing cerebral oedema. The progi'ess of this disease is rapid where the hyperaemia is arterial ; but in the passive form of it the symptoms are slowly developed. Sometimes nothing is complained of but sleepless- ness, which may persist for years, before other signs of the aflfection make their appearance. Eelief is afiforded where a E 2 132 DISEASES OF THE NERVOUS SYSTEM. collateral return of the blood from the head is effected ; where the large veins dilate, and the right ventricle becomes hyper- trophied; and finally by spontaneous haemorrhage from piles and menstruation, and by augmented secretion of the bowels and kidneys. Actual recovery cannot be looked for unless the causes which have first led to the complaint should cease to act. Where death occurs from this disease we generally find that there is also pulmonary congestion. In seventy- nine cases of sudden death, the fatal issue was nine times owing to hypersemia of the brain, and in six out of these nine cases congestion of the lungs was likewise present. Cerebral hyperaemia is not a very fatal disease, but repeated attacks of it lead to cedema, and subsequent wasting of the brain and pia mater, causing paralysis and imbecility. 4. Embolisw, of Cerebral Arteries. This pathological event may give rise to the symptoms of apoplexy ; but as it generally causes softening of the brain, with paralysis, I think it preferable to consider it in the next chapter under the heading of ' Paralysis.' 5. Aewte Alcoholic Intoxication. Everybody knows that an acute excess in alcoholic drink may produce the appearances of apoplexy ; and the question, ' Drunk or dying ? ' is one that is only too often, in the streets of London, submitted to the discrimination of the police. There are three degrees of acute alcoholic intoxication, in all of which the functions of the brain are considerably altered. The first degree, which is caused by imbibing a comparatively small quantity of diluted alcohol, is characterised by symptoms of cerebral excitement, which are mostly of a pleasant character, with subsequent slight depression, which is decidedly unpleasant. Persons in this condition are described not as ' drunk ' but ' fresh ; ' as ' having taken luncheon ' or been ' dining out.' The second degree, which is actual drunkenness, is produced by taking large quantities of diluted or undilute'd alcohol ; and the nervous system is then more deeply affected. After a period of excitement, which is of a variable character according APOPLEXY. 188 to the temper of the person concerned, and the kind of alcoholic stimulant which has been taken, the speech becomes indistinct; the gait tottering ; memory and judgment fail ; there may be maniacal excitement and delirium, followed by a profound and prolonged sleep, from which the toper awakes with symptoms of considerable brain-depression and acute gastric catarrh. We are here, however, principally concerned with the third degree of alcoholic intoxication, in which a person is ' dead drunk.'' This occurs either subsequently to the second degree, or it may come on rapidly without premonitory symptoms of importance, after the ingestion of enormous quantities, mostly of raw spirits. This degree is characterised by the symptoms of apoplexy and collapse. The face is at first livid and swollen, and later on pallid and collapsed ; the eyes are staring, fixed and glassy ; the conjunctiva is injected ; the pupil generally dilated, more rarely constricted, sometimes oscillating between dilatation and constriction. The heart's action is at first tumultuous, but later on weak and intermittent ; the pulse is feeble, and often hardly perceptible. The skin is at first hot and streaming with perspiration, afterwards cold and clammy. Eespiration is at first accelerated, but afterwards slow and stertorous, from paralysis of the soft palate. A viscid mucus is seen to flow from the mouth, and there may be vomiting of sour mucus and particles of imdigested food smelling of alcohol. The muscles do no longer obey the orders of volition, and if the drunken man is still about, he staggers, and seems semi- paralysed. This muscular debility ultimately reaches such a degree that he falls down anywhere ; and having entirely lost the sense of danger he may be frozen or burnt to death, or get drowned, or fall into a precipice. He is now in the condition of apoplexy. Speech, which was at first stuttering, is entirely gone ; the organs of special sense have lost their power of re- sponding to ordinary stimulation ; reason, memory, and judg- ment are absent. Before the induction of coma, passion and brutality sometimes gain the upper hand, and acts of violence are committed, of which, if recovery takes place, the drunken man has no recollection, but which may nevertheless lead him to the scaffold. "When coma has once set in, there is generally involuntary discharge of the urine and faeces, deathly pallor, 134 i)is:easi:s of the nervous system. and general convulsions of the face and body. In cases which end fatally, the pupil becomes widely dilated, respiration rare and jerky, the muscles relaxed, the pulse imperceptible, and froth is seen issuing from the mouth. Cases of this kind in their severest form are seen in the London Docks, where men sometimes suck raw spirits through a straw from a cask until they become insensible. In such cases the specific gravity of the urine has been known to fall below 1000. Death may occur within ten or fifteen minutes after the ingestion of enormous quantities of raw spirit (' twelve ounces of whiskey at a gulp '), and in such cases coma may set in directly without a previous period of excitement, or the uncon- sciousness may continue twelve or twenty-fours before death. Occasionally the drunken man has appeared to be in a fair state of recovery, when suddenly dyspnoea comes on, and ends in asphyxia ; or he will sleep on heavily for many hours, and at last awakens deadly sick, with a splitting headache, a coated tongue, staring eyes, and all the signs of a severe acute gastro- intestinal catarrh, which may assume the form of cholera. This is not the place for entering into the question of how we are to decide between the coma of drunkenness and the coma of cerebral haemorrhage, which will be considered hereafter : suffice it to say that in some cases such a diagnosis is impossible during life, and can only be made on the dissection table. In death from acute alcoholism a strong alcoholic smell is observed in the cavities of the body and in the muscles. The liver, spleen, and kidneys are hyperffimic, the mucous membrane of the pharynx, oesophagus, stomach, small intestines, and bron- chial tubes is red and injected. The membranes and sub- stance of the spinal cord and brain are hypersemic, the left ventricle and the arteries empty, the right side of the heart, the large veins and the tissue of the lungs contain a very large quantity of dark fluid blood. The brain is firm and white, and in the ventricles a quantity of serum is found which smells strongly of alcohol. 6. Acute Intoxication by Opium and other Narcotic Poisons. This occurs by intentional poisoning and suicide, and like- wise by taking or giving a medicinal overdose through mistake APOPLEXY. 135 or ignorance. The latter is often the cause of death in infants, whose mothers or nurses administer to them ' soothing syrups ' and similar nostrums containing opium. Many deaths which are registered in the first few years of life must be attributed to this baneful practice. Children are known to be extremely sensitive to the influence of opium ; and a case is on record where a dose of the compound tincture of camphor corresponding to g^oth grain of opium killed an infant one month old. For adults a fatal dose of opium is 20 to 30 grains, and of morphia from 3 to 6 grains. If subcutaneously administered, two-thirds of a grain of morphia have proved fatal. The symptoms of opium poisoning are generally those of depression, not of excitement. In the lower animals, where the brain is only imperfectly developed, more particularly in frogs, convulsions are produced, and coma is not so pronounced, while in man stupor is the principal symptom. In infants, how- ever, and also in the lower races of mankind, as in the Negros and • Malays, convulsions are observed after its ingestion. Vertigo, ful- ness in the head, drowsiness fast developing into stupor, great itch- ing of the skin, constipation, and an opiaceous smell of the breath and perspiration, are the principal symptoms in adults. Pria- pism, retention of the urine, and constipation distinguish this condition chiefly from cerebral htemorrhage. In cases which are to end fatally, the muscles become completely relaxed, the pulse imperceptible, respiration arrested, and the body-heat lowered. Death may take place within an hour from taking the opium, but it generally occurs within six to eight hours. Occasionally, however, the case runs on for one or several days, and there may be secondary asphyxia, so that patients who appeared to be in a fair way towards recovery sink more or less suddenly with the symptoms of collapse. This is no doubt owing to further absorption of the poison, portions of which had not at first entered the circidation. It would be extremely difficult, if not impossible, to find out how many deaths from ' apoplexy ' which have been regis- tered have really been owing to opium poisoning confounded with meningeal or cerebral haemorrhage ; but little doubt can exist that especially in former years this has not unfrequently been the case. Opium poisoning is now a special entry in the 136 DISEASES OF THE NERVOUS SYSTEM. Eegistrar-G-eneral's Eeports, and showed the following par- ticulars in the year 1874 : — Males Females Opitun ..... Morphia Laudanum and syrup of poppies . Godfrey's cordial Chlorodyne .... 13 6 39 4 4 11 2 22 The same remarks apply to poisoning by other substances. Hydrocyanic or prussic acid will cause sudden coma, with the symptoms of apoplexy, if very large doses, say one or two drops of the anhydrous acid, or one or two drachms of the diluted acid, are taken. Death is almost instantaneous under such circumstances. When the dose is somewhat smaller there may be coma lasting for a few minutes, and then ending in death. In still smaller doses there is a feeling of giddiness, tightness of the chest, and stertorous respiration. The breath smeUs of bitter almonds. Suddenly there is a scream, followed by convulsions, involuntary discharge of the urine and faeces, and loss of consciousness. The patient is now in a state of apoplexy. The pupil is dilated, the muscles relaxed, froth streams from the mouth, respiration and the heart's action become irregular, and at last extinguished. Death generally ensues within an hour from the ingestion of the poison. Prussic acid is contained in the kernels of bitter almonds, peaches, apricots, plums, cherries, and quinces, and children have shown symptoms of poisoning after eating from four to six such kernels. Poisoning by prussic acid is now a special entry in the Eegistrar-G-eneral's Eeports, and caused, together with its con- veners, the following mortality in 1874 : — Males Females Prussic acid .... Oil of almonds .... Cyanide of potassium . 14 2 1 1 3 APOPLEXY. 137 Some other narcotic poisons produce the symptoms of apo- plexy, but poisoning by them occurs so rarely that it need not occupy us here. 7. Sunstroke. Sunstroke, or, more correctly speaking, heat-stroke, is es- sentially a disease of tropical climates, but it occurs also in the temperate zone, more especially amongst infants and young children, soldiers, and agricultural labourers. I have already adverted to the circumstance that for the production of heat- stroke in infants no direct exposure to the rays of the sun is necessary (p. 74) ; but in adults it scarcely ever occurs except during or shortly after exposure to a powerful sun, more es- pecially when the system has been lowered by great fatigues and over-exertion. Marches of troops in the heat of the day ; sleeping in the foul atmosphere of crowded and ill-ventilated barracks or cabins ; the regulation dress of the soldier, including the stock, tight coat, and cross-belt, which impede the action of the lungs, and thus block up to some extent one of the de- purating channels of the system — these and all other influ- ences which debilitate the system, predispose to the occurrence of sunstroke. There are two forms of this malady, one of which shows the symptoms of syncope, and the other those of apoplexy. The former of these is the most dangerous of the two ; indeed, not unfrequently a man who is walking in the street or working in a field, and appears to be in perfect health, is seen to drop down dead. In some cases, however, certain symptoms precede the stroke, which show that the blood is becoming over-heated. The skin is hot and dry ; the eyes look red and staring ; and giddiness and pressure on the head are complained of ; then there is a sudden faint, and death from cessation of the heart's action. In these cases the fatal result occurs so suddenly that treatment has no chance of saving life, more especially as the appliances, which would be of the first necessity, are generally not at hand. The apoplectic form of the disease is not so rapidly fatal. There are the same symptoms which have just been mentioned 138 BISEASUS OF THE NERVOUS SYSTEM. as premonitory of the first variety, in addition to which symp- toms of mental derangement manifest themselves, which may last for several hom-s. There are delusions, hallucinations, and at last maniacal excitement, in which the patient may commit homicide or suicide. In such cases there is frequent micturition, and constipation of the bowels. After the stage of excitement has lasted for some time, a period of depression follows ; there is great drowsiness, which at last merges into insensibility and apoplexy. Death takes place by the coma gradually deepening, or is preceded by an attack of general convulsions ; but if the case be treated in time it may end in recovery, which is, how- ever, often protracted for many weeks. Patients who have once suffered from sunstroke seem never to regain their health entirely. They become subject to epi- lepsy, and complain of headache, impaired memory, and want of energy. Their temper is irritable, and they cannot bear any alcoholic stimulants, which must be looked upon as a positive poison for such persons. The skin, having once been paralysed, is often slow to recover its function, and the bowels remain obstinately confined. The following appears to me to be the true pathology of heat-stroke. There is paralysis first of the heat-regulating centre in the cervical cord, and afterwards of the cardiac and vasomotor centres in the medulla oblongata. The first thing is that perspiration is arrested ; and as the evaporation of sweat from the surface is the principal contrivance in the system for neutralising the effects of a high external temperature, and for equalising the body-heat, the immediate effect of its withdrawal must be unchecked influence of the external heat, to which is added the rise in the temperature of blood caused simply by loss of control over internal heat-production. The unduly heated blood then becomes a poison for the cardiac and vaso-motor centres in the medulla oblongata, causing either of the two varieties of heat-stroke which I have mentioned, viz., syncope or apoplexy. The remarks made about the registration of. cases of opium poisoning as apoplexy, apply likewise to the relations of heat- stroke and apoplexy. Sun-stroke is, however, now a special APOPLEXY. 139 entry in the Eegistrar-Greneral's Eeports, and caused the follow- ing deaths in the three years from 1872-74 : — Males Females 1872 1873 1874 71 19 25 25 19 140 DISEASES OF THE NERVOUS SYSTEM. CHAPTEE IV. PAKALTSIS. The mortality from paralysis closely approaches that from apoplexy. The following table shows the exact number of deaths from the various forms of paralysis which have been registered during six periods of five years each : — Periods of five years Deaths from Paralysis Percentage of all Nervous Diseases Percentage of General Mortality 1838-42 1843-46 1847-51 1852-56 1857-61 1862-66 1867-71 26,465 35,975 42,044 44,447 61,301 55,895 12-61 14-93 16-28 16-33 17-50 18-11 1-62 1-77 2-02 2-05 2-14 2-25 Total of thirty years 256,127 16-31 1-95 This table shows the popular impression that paralysis has increased in fatality during the last decennia, to be correct, not only relatively to the mortality from nervous diseases, but also to the entire mortality from all causes. Up to the present time it has been believed that men are more liable to paralysis than women ; but the following table shows that the influence of sex on the occurrence and. fatality of paralysis is only a slight one, and that, on the whole, females are rather more apt to die of it than males : — PARALYSIS. 141 Males Per cent. Females Per cent. 1847-51 1852-56 1857-61 1862-66 1867-71 17,141 20,169 22,106 24,987 27,593 7-19 7-81 8-40 8-77 9-17 18,884 21,867 23,621 25,754 27,792 7-87 8-47 8-69 8'84 9-00 Having regard to the fact that there are more females in England than males, and that female mortality in general is less than male mortality, we find the following result for the year 1874: — Males Females Population General mortality t Death-rate in 1,000 . Deaths from Paralysis Percentage of general mortaUty . 11,512,956 272,178 23-6 6,869 2-34 12,135,653 254,454 21-0 6,203 2-42 While, therefore, the two sexes seem to die in nearly equal proportions of paralysis, we find th'at age has a most powerful influence on the fatality of that disease. Paralysis, contrary to apoplexy, carries off but few victims in the earlier periods of existence ; and this coincides with our clinical experience, which shows that that form of paralysis which is peculiar to infantile life, is but rarely fatal. The curve in the annexed diagram remains therefore low until the period of thirty-five years, when it points to 168 deaths. The rise is now pretty rapid, but more particularly so after fifty-five, when 576 deaths are recorded. The maximum of 1,199 is reached at seventy; at seventy-five the number is still very large, viz., 1,125. After that, however, there is a rapid fall, for at eighty, the deaths amount only to 567 ; at eighty-five there is a further great fall to 215, and at ninety to 49 deaths. Five are registered at ninety-five years, and three as occurring after that ; yet con- sidering how few people are alive after seventy-five, paralysis must be pronounced to be one of the most fatal diseases of old age. 142 DISEASES OF THE NERVOUS SYSTEM. K — ^ ,' = *i ] D, S I S in England andWales In 184 lO 01 lA 1 o e> ?/ CO ,-- ^ p» < o CO i- - k r" •^ ID a — " o 9 < in (0 V 4 < o "^ "- r s^ in in ■^ ^ ^ ^ I AGRA M eMortalitjf fromPARALY * O in V h in K V. o * ? h in • ^ o 1 in CM 1 \ JO u o < s ■s bO ..s o in ft 1" • + 1 10 a (M - 9 i- a 1 ^ o o o !2 o o o in o o o o o in o o 09 g CO o o 00 o in K s N O n o O (0 o in in o o in o o o o in o in o o o m o s J in > a -3 as I! ''I 1% if If PAHALYSIS. 143 The next diagram shows the deaths of males and females from paralysis at the different periods of life. The thin curve portrays these relations for women, and the thick one for men. It is seen that the two curves run a nearly identical course up to twenty years of age. At twenty-five the thick overlaps the thin curve, and continues to do so until forty-five ; but at fifty the relations become reversed, and the thin curve keeps gene- rally at the top from that time. Both reach the summit at seventy, but the thin apex is considerably higher than the thick, there being 616 female against 553 male cases. At seventy-five there is a slight, and at eighty a quick descent, but the difference between the sexes remains pretty much the same ; the excess for women being 63 at seventy, 71 at seventy- five, and 63 at eighty. At eighty-five the difference is reduced to 39, and after that period both numbers are nearly alike. Paralysis always proceeds from disease of the three great divi- sions of the nervous system, viz. the brain, the spinal cord, and the peripheral nerves; and we distinguish accordingly between cerebral, spinal, and peripheral paralysis. Of these three forms, cerebral paralysis is by far the most frequent, important, and fatal ; spinal paralysis occurs much more rarely, and peripheral paralysis does not interfere with life, except in a few rare cases. Cerebral paralysis may be caused by injury to the skuU and membranes of the brain, more especially fractm-e of the fekuUbones, with penetration of foreign bodies. Exostoses, caries, and necrosis, and tumours pressing upon the brain from without, as well as the various inflammatory conditions which affect the membranes, may have the same influence. Haemor- rhage into the central ganglia of the brain, more particularly the corpus striatum, we have already seen to be a most frequent cause of paralysis. Hyperaemia of the brain, on the contrary, rarely causes paralysis, except where it leads to oedema with subsequent anaemia of the brain, as is seen particularly where it is complicated with chronic encephalitis and cerebral tumour. Encephalitis, which will be fully considered in the next chapter, may not cause paralysis if the degree of inflammation is slight, and the disease does not affect the neighbourhood of the central gangUa or motor convolutions ; while palsies varying in degree will be brought about where the neighbourhood of the motor ]44 DISEASES OF THE NERVOUS SYSTEM. Diagram E. Showing the Influence of ACE ontiio Mortality of MALES & FEMALES fium PARALYSIS in Engjand & Wales in 184-7. c- — ~ V \ a 1 o 99 p, a S J' ^ O CO J ==s =**=* K tJ '^ ssss *^ «3 R ? <, to S ^ > ^ ■^ ^ :\ I, K Id "1 ^ i^ o s^ 2S A;> o ^, S , ^f a 4v S ^ £ s 2 o s V U5 £ ^ 1-, 3 ' =( .•«* A (< )7 n ■n * CM "5 1 '' - ♦ 1 >n E * 1 t O m 1 o o o o o t8 o 8 o § o 12 8 O C in : SOFTENING OF THE BRAIN. 145 centres is invaded. "Where encephalitis leads to cerebral abscess, the intracranial space is reduced, the capillary vessels of the brain are compressed, and portions of the brain rendered anaemic. Sclerosis or proliferation and hardening of the neuroglia, with simultaneous wasting of the nerve-cells and fibres, causes peculiar forms of paralysis, which does not assume the form of hemiplegia, or even paralysis of one limb, but is unequally distributed over certain individual muscles. It is often seen that in the sphere of the same nerve some muscles have lost their power, while others continue in functional activity. This disease has a most insidious course, is often believed to be merely functional, and shows a tendency to progress downwards to the spinal cord, causing ill-defined forms of paraplegia. Cerebral tumours may cause palsy by destruction or com- pression of the motor centres. They often lead to cedema, secondary inflammation, softening, and capillary haemorrhage. Where, in consequence of the size of the tumour, the intracranial space is reduced, paralysis results from slowly-produced anaemia. It generally assumes the form of hemiplegia, which is apt to be associated with affections of the cerebral nerves. These are irritated or compressed by the growth of the tumom-, whether the latter proceeds from the skull and the membranes of the brain inwards, or from the cerebral substance itself outwards. Occasionally haemorrhage takes place in the tumour, and there may then be clinical symptoms of apoplexy from cerebral haemorrhage, as described in the preceding chapter. Softening of the Brain. The most important cause of paralysis, apart from cerebral haemorrhage, is, however, embolism and thrombosis of the cerebral arteries, which lead to softening of the brain. Soften- ing was formerly believed to be an independent disease, which some pathologists thought owing to inflammation, while others considered it to arise from non-inflammatory disturbance of nutrition. The observations and experiments of Virchow and Cohnheim have, however, entirely traneformed this department 146 DISEASES OF THE NERVOUS SYSTEM. of pathology, and given us a very complete insight into the morbid condition which is now under consideration. The cerebral bloodvessels may be blocked either by small clots carried into them from a distance (embolism), or the clot may originate in the bloodvessel itself (thrombosis). Embolism results most frequently from previous endocar- ditis, whether this be chronic or acute. In the acute form of the disease there is ulceration, and consequently embolism of capillary vessels may be caused ; while in the chronic form warty excrescences are formed on the valves of the heart, more especially of the left ventricle, leading to insufficient action of the valves and stenosis of the ostia. Portions of these ex- crescences may be detached from their seats in the pulmonary veins, the left side of the heart, and the aorta, and carried with the current of the blood into the carotid or vertebral arteries, and from there into a cerebral artery. They generally follow the left rather than the right carotid artery, on account of the anatomical peculiarities of these bloodvessels, and go even more rarely through the vertebral than the right carotid. They proceed as a rule «n cheeked in their course beyond the circle of Willis, but become impacted in the mid-cerebral artery. Other vessels which are also liable to be obstructed are the internal carotid, the profunda, the basilar and vertebral artery, and the artery of the corpus callosum. Emboli consist of clots of blood, fibrine, proliferated connective tissue, and chalky concretions. Embolism may also come on without previous endocarditis after myocarditis ; from fibrinous coagula in aneurismal sacs ; in abscess and gangrene of the lungs, and altogether in con- ditions where the activity of the heart is considerably lowered, which leads to the formation of clots in its cavities. This occurs chiefly in the later stages of tuberculosis and cancer, in empyema, and fatty degeneration of the heart. Throwhosie is either venous or arterial. Coagulation of the venous blood' is apt to occur when the power of the heart is diminished, and the circulation has consequently become sluggish. As this is more particularly seen in the condition known as marasmus, viz. in the advanced stages of phthisis and cancer, after febrile diseases, and chronic inflammation of the SOFTHmNG OF THE BRAIN. 147 joints, Virchow has termed it marcmtic thrombosis. Cardiac debility is in such cases combined with general anaemia and atony of the coats of the bloodvessels; and the thrombus is formed behind the valves of the veins, in the angle in which the valves adhere to the coat of the bloodvessels. When the vessel has lost its tone, the valves do not adhere properly, whereby the movement of the blood is impeded, and part of it retained. A slight coagulation then takes place, which rapidly increases by further deposits of fibrine from the blood ; it soon fills the valvular sinus, projects beyond the edge of the valve, and proceeds in a direction towards the heart. After a time the vein becomes more and more constricted, and at last com- pletely bldcked up. When a thrombus has been formed, parts of it may be detached, and carried forward with the stream of blood, until they become fixed in remote parts of the vascular system. Those thrombuses which are formed in the venous blood, and the right side of the heart, are carried into the pulmonary arteries, while those formed in arterial blood, viz. the pulmo- nary veins, the left side of the heart and the large arteries, may be carried into any portion of the arterial system of the body. Plugging of the cerebral arteries by degeneration of their coats, and consequent thrombosis, is rare ; it is chiefly found in the aged, and connected with general decrepitude. The principal changes in the arteries which give rise to it, are fatty degeneration, sclerosis, ossification, and deposits of chalk in the coats of the bloodvessels. All these changes tend to diminish the elasticity of the arteries, and their diameter is at last con- siderably narrowed. The condition is frequently associated with atheroma of the coronary arteries of the heart, which leads to impaired nutrition of that organ, diminished energy of its action, and sluggish circulation of the blood in the cerebral vessels, whereby the process of thrombosis in them is promoted. Thrombosis of the cerebral arteries is observed, apart from old age, in syphilis, pressure from tumours and effusions, leukaemia, septicaemia, in the puerperal state, in diffuse suppuration, caries, and after acute diseases and exhaustive discharges. Ligature of the carotid artery for aneurism rarely causes softening of the brain. The thrombosis which is produced in L 2 148 DISEASES OF THE NERVOUS SYSTEM. the bloodvessels by this operative procedure, extends generally only to the division of the common carotid, or at most to the circle of Willis, so that there is no impediment to the speedy establishment of collateral circulation. If thrombosis, however, proceeds beyond the circle of Willis, necro-biotic softening is the inevitable consequence. Occasionally a thrombus breaks up into several pieces by the current of the blood, each of which may penetrate into a cerebral artery, and thus cause several centres of softening. Thrombosis of the veins and of the sinuses of the dura mater may occur in consequence of injuries to the head, and otitis with caries of the petrous portion of the temporal bone, or it may come on spontaneously. In the former class of cases there is generally antecedent phlebitis, while in the latter the structure of the veins is not primarily altered, and the cause is marantic, i.e. there is great cardiac debility with its well-known consequences. As the sinuses of the dura mater have rigid walls, and are traversed by layers of connective tissue, the oc- currence of thrombosis in them is considerably facilitated. When an artery has been plugged, either by a travelling embolus, or a thrombus, serious disturbances in the nutrition of the parts supplied by that bloodvessel are the inevitable conse- quence, unless collateral circulation can be established in the vascular sphere of the plugged vessel. The brain matter being particularly vulnerable, necro-biotic destruction of the same is the necessary consequence when it has for some time been deprived of nutritive material. Heubner and Cohnheim distinguish a hasal sphere of nutri- tion, providing the central ganglia and the mesocephale, and a CoHical sphere of nutrition, the arteries of which supply the cineritious substance and the adjacent medullary matter. The mid-cerebral artery, which is the principal victim of embolism, provides the entire lenticular nucleus, part of the corpus striatum, the external capsule, and the anterior peduncle of the internal capsule, while its terminal branches reach the second and third frontal convolutions, those parts of the central, pari- etal, and temporal convolutions which are turned towards the convexity of the brain, and the insula. Necro-biosis in the sphere of this artery therefore leads most commonly to hemiplegia. SOFTENING OF THE BRAIN. 149 If the obstruction in the cerebral bloodvessels occurs on the near side of the circle of Willis, the nutrition of the brain does not generally suffer, because collateral circulation is quickly- established ; but if the obstruction is on the far side of the circle, necro-biosis is speedily established. The first event is ansemia of the parts supplied by the artery, without softening. This stage probably lasts only one or two days, as the brain matter is easily starved, and further changes are now produced ; viz., either hyperaemia with cedematous swelling and haemor- rhage ; or neither hyperaemia nor haemorrhage, but yellow, or white softening. Where the first of these eventualities takes place, viz., hyperaemia, cedematous swelling, and haemorrhage, we have the condition known as red softening ; and this chain of events has given rise to the theory of inflammatory softening, which was so long held by the French school. The bulk of the cerebral matter appears increased, while its consistency is diminished. The hsemorrhage from the capillary vessels is sometimes so extensive that the parts look as they do in cerebral haemorrhage from the rupture of miliary aneurisms. The colour may vary from a bright pink to dark red, but as time goes on, generally within three or four weeks, it fades away, and the parts now present the appearance of yellow softening. This change in the colour is owing partly to the changes occurring in the effused haematine, and partly to the development of fat, which appears in connection with the retrogressive metamorphosis of tissue. In red softening the microscope shows at first nothing but red corpuscles, and later on gradual degeneration of the nervous elements ; granular globules are formed from the nuclei of the neuroglia, the cells of the capillary vessels, the adventitious tissue, the nuclei of the muscular coat of the bloodvessels, the connective-tissue-nuclei of the perivascular lymphatic spaces, and the spindles and ganglionic cells of the cerebral substance ; and ultimately nothing is found but fatty detritus mixed with crystals of haematine. Cohnheim has given the following rationale of this process : — Physiological experiments show that, when a terminal artery which has no further communication with any other arteries, is 150 DISEASES OF TSE NERVOUS SYSTEM. blocked up, there is a reflux of blood from the proximate artery which is still pervious, into the corresponding vein and the entire stagnating vascular sphere belonging to the plugged artery. The consequence of this is hypersemia and haemorrhage by diapedesis of the red blood-corpuscles. As the blood cannot circulate in the artery, the coats of the bloodvessels are altered, and the blood-corpuscles transudate. If the patient survives a sufficient time, white softening ultimately becomes produced. The brain matter is now changed into an emulsion of milky appearance, i.e., a liquid with solid particles floating in it. Sometimes a cyst is formed which is filled with liquid, and resembles the cysts which are found after an attack of ordinary cerebral haemorrhage. The second eventuality is ■primary yellow softening, without hyperaemia and haemorrhage. This is simple necro-biosis, the parts undergoing at once fatty degeneration, without any other previous alterations. Cohnheim has also shown experimentally under what cir- cumstances no haemorrhage, but primary yellow or white soften- ing, is produced. It occurs where the blood coagulates so quickly in the entire vascular sphere of the plugged "artery that any reflux of blood through the vein becomes impossible. In practice it is found that simple necro-biosis, or yellow softening, without hyperaemia and haemorrhage, occurs chiefly where the functional energy of the heart is considerably below par. The symptoms of softening of the brain vary considerably according as they are produced by an embolus or a thrombus. Their invasion is always much more sudden in embolism than in thrombosis. The symptoms of embolism are owing partly to the shock caused to the brain by the sudden entry of a foreign body, and partly to the anaemia which we have seen to be the immediate consequence of such an event. When the detached embolus settles in the mid-cerebral artery, there is for a short time vertigo and headache, and then all the symptoms of apoplexy, as seen in corpus striatum haemorrhage. The apoplexy from embolism however lasts, as a general rule, not so long as that from rupture of miliary aneurisms in the same portions of the brain ; and in many cases there is only sudden SOFTENING OF THE BRAIN. 161 hemiplegia without loss of consciousness. Where however there is apoplexy, it differs in no way clinically from the description which has been given iu the previous chapter. It was formerly believed that we could distinguish the two kinds of apoplexy by the different colour of the face, a different behaviour of the pupils, the absence or presence of vomiting, and some other signs ; but more ample experience has shown that all symptoms which have been described may be present in either of the two forms of apoplexy. Sometimes convulsions are observed, generally in the form of a regular epileptic fit, affecting all the muscles of the body, while in other cases the convulsions are confined to that side which is afterwards found paralysed. Occasionally the paralysis is incomplete, there being only weakness in the muscles of the face, arm, or leg, or im- paired speech. When the embolus has blocked the basilar artery, vomiting is present. The left mid-cerebral artery being most commonly the seat of embolism, aphasia is connected with hemiplegia, as anasmia and softening of the third left frontal convolution (p. 51) is the result. When the central artery of the retina, or the ophthalmic artery are plugged by an embolus, sudden amaurosis is observed. Embolism of the mid-cerebral artery causes the ophthalmic artery to be gorged with blood ; the papilla then appears red, and there is arterial and venous hyperaemia of the retinal vessels. The symptoms of paralysis from embolism of the cerebral arteries may vanish more or less suddenly ; and in such cases we may be certain that the attack has not been one of cerebral haemorrhage, and that the changes in the brain induced by the embolus have only amounted to anaemia, and not to softening. Such recovery can therefore, in the nature of things, only occur a day or two after the stroke ; for if necro-biosis is allowed to commence and to proceed unchecked, the symptoms of paralysis must be more permanent. After ligature of the carotid artery there has occasionally been hemiplegia of a few hours' duration, and which disappeared as soon as collateral circulation had been established. If the latter is imperfect there is proportionate improvement in the paralytic symptoms. The arm and leg may regain a degree of voluntary motion, but nevertheless remain useless for practical purposes ; the speech returns but is 152 DISEASES OF THE NERVOUS SYSTEM. imperfect, and the mental functions, though not destroyed, are impaired. "Where the lesion is extensive, death may be the consequence, but this is never sudden. It may occur twelve hours or later after the commencement of the symptoms, and is not unfrequently preceded by pneumonia, and a great elevation of temperature. In general there is no initial decrease of temperature in softening, such we have seen to occur in cerebral hasmorrhage (p. 102) ; or if it should occur, it is much less marked. Bour- neville has shown that in many cases of softening soon after the attack, the temperature rises suddenly to 102° or even 104°; it then falls again, reaches the normal average, and shows irregular oscillations. It sometimes remains stationary for a couple of days, or shows morning or evening falls. In cerebral haemorrhage, on the other hand, the temperature, when it has once reached 102°, does not go back to the physiological stan- dard unless a fresh effusion of blood should take place ; and the oscillations are more regular, and occur in a narrower compass, than in softening. After the temperature has been stationary in softening for a more or less considerable time, it begins gradually to rise, and reaches 103° and 104° ; but towards the end it is not nearly so high as in cerebral haemorrhage, where it sometimes reaches 108°. After death there may be a slight increase, but as a rule the temperature falls more rapidly than it does in cerebral haemorrhage. In hemiplegia from embolism of the mid-cerebral artery, the paralysed muscles are also liable to contraction, although not so frequently as after cerebral haemorrhage ; and the character of these contractions appears to differ somewhat according to the cause of the lesion. In a case at present under my care at the Hospital for Epilepsy and Paralysis, Eegent's Park, in a girl aged 17, the contraction of the paralysed flexor muscles of the arm, after embolism from endocarditis, presents this peculiarity that it is chiefly marked when the hand is touched ; while when the hand remains undisturbed, it is well open. I have noticed this peculiarity in several similar cases, but whether it will be eventually found a distinguishing symptom between hemiplegia from embolism, and from cerebral haemorrhage, will have to be settled by future experience. SOFTENING OF THE BRAIN. 153 Convulsions in the paralysed limbs, which ultimately develop into epileptiform seizures, are occasionally observed after the paralysis has lasted for some time. Where smaller arteries are obstructed by embolism, there is only partial or incomplete paralysis, or no palsy at all. This is explained by the circumstance that only very limited areas of the brain are deprived of blood, and that collateral circulation is more easily established. If portions of the brain which do not belong to the motor centres are rendered anaemic and softened, of course no paralysis is produced. The further course of the disease is determined by the extent of the necro-biotic process, which is often progressive in its character ; and a number of fresh cerebral symptoms may therefore make their appearance as time goes on. Treatment may incline the balance to improvement or further decay ; for as the establishment of collateral circulation affords the only prospect of a cure, the treatment must be tonic and stimulant, while lowering measures, as suggested by the old notions of inflammatory softening, are invariably followed by the worst results. Virchow's and Cohnheim's researches on embolism would have been impossible without the aid of vivisection ; and as a great improvement in our mode of treating such an important disease as softening of the brain is directly owing to these researches, the importance of vivisection for practical medicine, which has been denied by a set of ignorant fanatics, is by this fact alone clearly established. The symptoms of cerebral thrombosis are more gradually developed than those of embolism. There is as a rule a large number of premonitory symptoms, which are owing to the gradual constriction and plugging of the artery. These are headache, vertigo, stammering, impaired memory, numbness and chilliness in one side of the body, local palsies, especially of ocular muscles, tottering gait, contractions of fingers, incon- tinence of urine, and other symptoms which have been fre- quently described as the initial mementos of ' softening of the brain.' Finally there may be hemiplegia, which is either gradually developed or occurs suddenly, when the vessel is completely blocked up ; and this is either followed by death or 154 BISEASHS OF THE NERVOUS SYSTEM. improvement. In the latter case the patient may remain tolerably well for some time ; but the attack is likely to be repeated, as the causes continue to act. The symptoms vary according to the portion of the brain which is the seat of these retrogressive changes. Where the left mid-cerebral artery is plugged, aphasia and right hemiplegia will be produced, while if the same artery suffers on the right side, there is left hemi- plegia without aphasia. Where a considerable number of small arteries is plugged, or where there is gradual and progressive thrombosis of large vessels, as is so frequently seen in the aged and decrepit, there is gradually progressing paralysis accom- panied with muscular contractions, and impairment of the mental faculties. Marantic thrombosis of the sinuses of the dura mater is often seen in strumous infants, who suffer from exhaustive diarrhoea. The symptoms in these cases are generally those of infantile cerebral ansemia or hydrocephaloid, as described in the second chapter. Eigidity of the muscles of the neck, back, and extremities is the rule, and these are soon followed by som- nolence and coma. Nystagmus, strabismus, and ptosis are like- wise occasionally present. The principal seat of the thrombosis in these cases is the sinus longitudinalis superior. In adults the symptoms are sometimes ill-defined. There is great depression and apathy, headache, combined with sickness and vomiting ; alterations in the size of the pupils ; clonic con- vulsions and tremor of the limbs. In some cases the external veins which communicate with the sinuses are seen to swell. When the sinus longitudinalis superior, which communi- cates with the veins of the nose and the upper portion of the skull, is affected, there is epistaxis and dilatation of the veins on the temples and ears. In thrombosis of the simus transversus, local oedema behind the ear may be encountered, from plugging of a vein proceeding from that sinus and the mastoid process. In a similar manner there may be hypersemia of the fundus of the eye, exophthalmus, and cedema of the eyeKds in thrombosis of the sinus cavernosus, which communicates with the ophthalmic veins. The phlebitic form of thrombosis is found after otitis, with caries of the petrous portion of the temporal bone, and may APHASIA. 155 lead to meningitis and cerebral abscess. In phlebitis of the sinuses there are symptoms of septicaemia, such as rigors, a typhoid condition, dry tongue, loss of appetite, delirium, som- nolence and coma. If paralysis or convulsions occur, they must be ascribed rather to the meningitis and abscess of the brain than to phlebitis of the sinuses. I now proceed to consider the more important forms of paralysis separately. 1. Aphasia. Loss of intelligent language was at first called ' aphemia ' (Broca), but Trousseau, on the advice of Krisaphis, a learned G-reek, introduced as more classical the term aphasia, from privative alpha, and (paais, speech. We have seen in the first chapter that the nervous contrivances for the mechanical execution and connection of the movements of articulate speech are situated in the medulla oblongata, pons, and corpora striata ; while the intelligent formation of syllables, words, and sen- tences, or intelligent language (logos), resides in a definite portion of the cortical substance of the hemispheres (p. 51). The principal current of speech goes through the left hemi- sphere, while a weaker, collateral current goes through the right hemisphere. This greater development of the left hemi- sphere for speech co-exists with the right-handedness of most people — that is to say, the left hemisphere is, during the period of infancy and childhood, chiefly trained for speech, as well as for combined voluntary movements. That the left hemisphere is not the exclusive seat of language is shown by the fact that, after destruction of the area for language within that hemi- sphere, emotional language and the faculty to use interjections is still possible. Thus most persons suffering from aphasia are still able to swear, or at least to say ' yes ' or ' no,' while utterly unable to converse. There may therefore be loss of language without complete loss of words. This has led Dr. H. Jackson to think that the automatic faculty to speak words resides in the right, and actual intelligent language in the left hemi- sphere; but this seems a somewhat forced explanation of the facts which come clinically under observation. There can be no doubt that emotional excitement is more powerful and more 156 DISEASHS OF THE NERVOUS SYSTEM. widely spread than that which is induced by thinking and imitation. It therefore not only implicates the motor centres in the brain, but also the spinal and sympathetic ganglia. In . children, roughs, and savages the emotional language is always accompanied by pantomime; and as gestures are made with either or both hands, we must conclude that emotional excite- ment may lead to movements presided over by both hemi- spheres. Simple analogy would therefore show that the lan- guage of the affections and the faculty of using interjections are as much bound to both hemispheres as pantomime. It is well known that facial expressions, such as laughing or crying, may continue to come on emotionally when they can no longer be produced at will ; and under such circumstances the slightest cause is apt to give rise to them. The person so affected has a silly appearance, owing to the removal of f'.e influence of the higher centres. An analogous case is that of the decapitated frog, in whom spinal reflex actions are produced in the wildest manner. The language of music, which is entirely one of sentiment and emotion, may persist after the loss of intelligent language. ■ Behier has recorded the case of a man who could say no other syllable but ' tan,' but who could still sing the two French national songs — viz. the ' Marseillaise ' and the ' Parisienne,' but without singing any other words in the text except ' tan.' The history of the localisation of intelligent language is identified with the names of Gall and Spurzheim, Bouillaud, Dax, and Broca. Gall,' in whose great work much that is sound and new is given side by side with fantastic theories which have obscured his otherwise well-deserved fame, found the seat of language in that part of the anterior lobes of the hemispheres which is situated above the orbital plates, Bouil- laud^ likewise located the faculty of the formation and memory of words in the anterior lobes, as he had found that loss of language and memory of words was the inevitable consequence of disease of the anterior portion of the brain. Dax ^ showed in ' ' Anatomie et Physiologie du Systfeme Nerveux.' i vols., Paris, 1810-19. ^ ' Traits de I'Encgphalite.' Paris, 1825. ^ ' Lgsions de la Moitie Gauche de I'Encfiphale.' (Being a paper read in 1826, before a medical meeting at Montpellier.) APHASIA. 157 a remarkable paper — which was lost to the world until its republication by his son in 1861 — that the left anterior lobe was the seat of language, and that therefore hemiplegia of the right side was generally combined with loss of language. It was, however, chiefly Broca' who gave precision to this doc- trine, and laid down the principle that the left hemisphere is specially trained by education in early life for speech as well as for the more subtle kinds of work ; that this is the cause of the dextral pre-eminence which obtains in the vast majority of men ; that the posterior part of the third left frontal convolu- tion has a special importance for intelligent language ; and that most men, and all right-handed men, during their educational development, train only that convolution for the verbal expres- sion of thoughts and ideas. Broca's first proposition, that the third left frontal convolu- tion has never yet been found diseased without there having been during life loss or impairment of intelligent language, has remained uncontradicted up to this time ; but his second state- ment, that aphasia never occurs unless with disease of this con- volution or those portions of white matter by which it is connected with the parts below, has not stood the test of time. Nevertheless it is unquestionable that in the vast majority of cases of aphasia disease of that convolution is discovered. Thus in fifteen post-mortem examinations of cases of aphasia in Paris, Broca's convolution was found diseased fourteen times, while in one case (Charcot's) the left insula and the left parietal lobes were extensively softened, and the only sign of disease in Broca's convolution was fatty degeneration of the capillary vessels. Such cases, however, are exceptional. Many of those in which no disease was discovered in the left side of the brain have been described by men who were ignorant of the theory, and therefore paid no particular attention to the region involved. Dr. William Ogle ^ has recorded a typical case of aphasia, in which there was a lesion in the exact spot fixed upon by Broca, but which would certainly have escaped notice imless it had been specially looked for. The brain looked healthy on its surface, and it was only on removing the pia ' ' Bulletins de la Soci^te Anatomique.' Paris, August, 1861. ' ' St. George's Hospital Reports.' London, 1867, vol. ii. p. 105. 158 DISEASES OF TSE NERVOUS SYSTEM. mater that the almost diffluent condition of that limited spot was discovered. In this case there had been' first rheumatic fever and valvular disease of the heart ; later on, formation of fibrinous clots on these, and consequent embolism of a branch of the left middle cerebral artery, which contained a hard shotty bit of fibrine, completely obstructing the passage, so that when water was injected into the vessel it could not pass, although considerable force was used. A second consideration is, that in exceptional cases not the left but the right cerebral hemisphere is trained during the educational development for language; and this appears to coi^icide with left-handed pre-eminence. Thus Moreau, of Tours, has related a case in which the whole third left frontal convolution was congenitally absent. The woman, however, could speak and read very well ; she was able to sew with the left hand, and she had evidently during childhood trained the right cerebral hemisphere for language and the finer kinds of movements, on account of deficiency of the left. A third consideration is, that not unfrequently during life mistakes in the diagnosis of the disease are made. Not every- thing that has been said to be aphasia has, on stricter scrutiny, turned out to be aphasia. Dr. John Ogle once had a case brought to him as one of aphasia, in which, however, it was found on examination that the patient had no tongue, and could therefore not articulate properly. Dr. Morell Mackenzie has informed me that cases of aphasia are occasionally sent to him for examination by the laryngeal mirror under the impres- sion that the patient has simply lost his voice ; and I well remember that in a discussion on this subject at one of our learned societies some years ago, an esteemed physician, since deceased, complained bitterly that the good old word 'aphonia' had recently been dropped for the new-fangled term ' aphasia,' the use of which he was utterly unable to understand ! The most convincing cases are those in which the lesion is limited ; in which there is no other disturbance of health ; and in which aphasia has been quickly and permanently developed. Of such cases there is at present no lack. A boy, aged five, who was a great chatterbox, fell out of the window and injured the left frontal bone, which was found depressed. There was APHASIA. 159 no hemiplegia or other kind of paralysis, but the boy had entirely lost his language. The wound healed in twenty-five days, but the child, although intelligent, remained dumb. A year afterwards he was drowned, and at the autopsy a cyst of the size of a filbert was found in the left third frontal convolu- tion and the adjacent portion of the left frontal lobe. A man fell with his horse, but got up, took hold of the reins, and wanted to jump into the saddle, when a physician who happened to accompany him expressed the wish to make an examination. It was then found that he could not speak, but had to make himself understood by pantomime. A small wound in the left side of the head was found, with depression, but there was no paralysis of any sort. The patient ultimately died of purulent meningitis, and the autopsy showed that a fragment of bone had penetrated into Broca's convolution, which, together with the second left frontal and the island of Eeil, was found softened. Besides cases of localised injury those instances are chiefly important in which we find necro-biotic softening from embolism or thrombosis of small branches of the middle cerebral artery. A large clot of blood, a cerebral abscess, tumour, and advanced sclerosis of the brain, do not allow of very convincing conclu- sions. Embolism and thrombosis of the middle cerebral artery or its branches are found to be the most frequent causes of aphasia. Jaccoud has attributed this to the more frequent occurrence of such a lesion altogether, but other cerebral arteries are nearly as liable to the disease as the one just mentioned. In order to subvert Broca's theory it would be necessary to bring forward a thoroughly well-described case of sudden de- sti'uction of the third left frontal convolution in a right-handed, or of the right frontal convolution in a left-handed person, without aphasia ; or destruction of both frontal convolutions should be shown at the autopsy of a person who had been able to talk intelligently until death. As yet this has not been done, and a large number of indisputable facts make it most imlikely that it ever will be done. The frequent coincidence of aphasia with right hemiplegia has been disputed, but unsuccessfully. Dr. Seguin, of New 160 DISJEASES OF THE NERVOUS SYSTEM. York, found that in 260 cases of hemiplegia and aphasia, the left hemisphere suffered in 243, and the right only in 17. It has been said that lesions of the left hemisphere are altogether more frequent than those of the right ; but Charcot and Vulpian have shown that disease of the two hemispheres occurs in a nearly equal proportion, for out of 110 cases, there were 58 in which the lesion was in the right, and 52 where it was in the left hemisphere. The centres of innervation are doubly arranged for all the different kinds of work which it falls to the lot of man to do ; nevertheless most people are left-brained and right-handed. For most kinds of iiher work, such as writing, drawing, &c., only the left hemisphere is trained, even by persons who are in other respects left-handed ; and only for a few kinds of work both hemispheres have to be educated. This is chiefly the case with musicians. Pianists have to train both hemispheres simi- larly, while violinists and violoncello-players have to educate them dissimilarly. That, as a rule, the left hemisphere is trained in preference to the right, for language is, according to Dr. William Ogle, due to the following circumstances : greater weight and specific gravity of left hemisphere ; greater develop- ment of convolutions in left frontal parts ; earlier foetal develop- ment of left hemisphere, and greater supply of blood to it; and, finally, greater width of the left carotid artery than the right. Aphasia may in children and young persons be only tem- porary, as they are able to train the right hemisphere after loss of the left ; just as persons, who suffer from scriveners' palsy in the right hand, may train the right hemisphere for writing with the left hand. Dr. Ogle has done good service by dividing aphasia into two classes : viz., amnemonic and atactic aphasia. In the amne- monic variety there is difficulty of remembering the spoken or written word, while in the atactic variety there is loss of motor co-ordination of words. In the former variety the idea is there, but the idea does not suggest the proper symbol ; and either no word or a different one, with a different meaning, is forth- coming. In this latter case it is curious to notice that the grammatical form is observed — substantives being substituted APHASIA. 161 for substantives, verbs for verbs, proper names for proper names, &c. In tbe atactic variety, on the other hand, the patient is unable to say the words which are suggested by the memory, for want of co-ordinating power over the muscles of articula- tion. Patients of this class are generally either entirely de- prived of speech, or say only ' yes ' or ' no ' or some other mono- syllable. The two varieties may occur together or separately. It is, therefore, probable that each of these faculties has its separate centre, capable of a separate lesion, but that the centres lie so near one another that the same lesion is likely to injure both. An interesting case of atactic aphasia is that which M. Lordat,' Professor of Medicine at the University of MontpeUier, has described as having occurred in his own person. He suddenly lost the faculty of speaking and reading after a fever, yet was able to think and to go mentally through the whole course of his lectures. He heard the spoken words, but they remained unintelligible. He had, however, only lost his syntax and not his alphabet ; for though unable to read written words,, he could read letters. This state of things had been going on for several months, when suddenly one day, while he was in his library and glanced over the bookshelves, the words ' Hippo- cratis opera ' appeared to him. Tears rushed from his eyes, for he saw that he was better, and he ultimately regained the power of speaking and reading. Yet he did not entirely recover, for,, from having been an excellent extempore speaker, he was after- wards obliged to read his lectures from a copy. The same considerations which apply to the spoken language also apply to written words. Dr. Ogle has called the loss of the faculty of intelligent writing agraphia, and again distinguished the amnemonic and atactic variety. In the former the patient can write letters and words, but without rhyme or reason, so that the letters do not convey any meaning ; while in the latter variety the power of writing separate letters is lost. Some- times in the amnemonic variety there is still power to write a few words properly. A lady aged sixty, who was some years ago under my care, and who had lost her speech five years before, could with difficulty write her own and her husband's name, but not ' 'Analyse de la Parole.' MontpeUier, 1843. M 162 BISWASES OF THE NERVOUS SYSTEM. quite grammatically, as instead of - Jackson ' she wrote - Jac- ton,' instead of 'Eectory,' 'Bignoral,' and instead of '1866' '1665.' She had had right hemiplegia, from which liowever she had recovered, and there was no motor paralysis at the time. She could dress and feed herself, do her hair, thread her needle and sew, make pies and puddings, and walk four or five miles without fatigue ; yet she could only write by holding the pen in the left hand and then guiding it with the right. She could say ' yes ' and ' no,' and occasionally said ' indeed ' and ' thank you.' But sometimes she would say ' yes ' when she meant ' no,' and vice versa ; and she then corrected herself by pantomime, as when she nodded her head, she always meant ' yes,' and when she shook it, she always meant ' no.' Aphasia and agraphia generally occur together, but they are occasionally separate, which points to the existence of distinct cerebral centres for the two faculties, which are in close proxi- mity to each other. The loss of pantomimic expression {amimia) is much rarer than aphasia and agraphia, and points to a more extensive lesion than the latter. For all these conditions we find numerous analogies in persons whose brain is on the whole working physiologically. Forgetfulness of words, more especially names and dates, is common in the aged, although not amounting to amnemonic aphasia. A well-known university professor, who forgets his own name, and on being asked for it by a stranger to whom he had been courteous, buttonholes a passing friend, and exclaims in a distressed tone : ' For heaven's sake, tell me my name ! ' — is an instance of this. In the same case there was sometimes difficulty in properly appreciating written words, of which the following is an instance. Professor had for some time been in the habit, when going out, of hanging a card over his library door, on which he had written the words : ' Professor is not at home.' One evening, when returning home, he stopped at the door, looked at the card, said, 'How very annoying that that man is not at home ! ' and went away again. Some persons who have entirely lost their language are still able to play chess, backgammon, and whist ; and they have been observed to cheat at cards with some ingenuity. They may also APHASIA. 163 be sharp in business matters. Musicians who suffer from aphasia and agraphia of written words may still be able to compose music, and write it down in notes. The intellect and speech do not run in identical grooves ; and if aphasia is con- nected with impairment of the mental faculties, the latter is not owing to the former, but both are caused by a more exten- sive cerebral lesion. There is another variety of aphasia, which Kussmaul has called ' verbal deafness and blindness,^ in which the patient is still able to speak and write words, but does not understand anything that is said to him, although the hearing is quite good ; nor anything that is written, although the sight is good. The patient who suffers from verbal deafness is sometimes be- lieved to be deaf or insane, because he speaks words in a sense- less connection, and does not seem to imderstand what is said ; but his thoughts and hearing are perfectly correct, and he is in the position of an European who should suddenly find himself in the midst of South Sea Islanders, whom he would hear talk, but could not understand, nor would he be understood when talking to them iu his own language. In some cases there is a perfect chorea or delirium of words, ■which may be called 'paraphasia. Dr. Osborne ' has recorded a case in which the intellect of the patient was unimpaired, and who could express himself well by writing, understood every- thing that was said to him and what was given him to read ; but the connection between ideas and spoken words was broken, so that when he attempted to talk, or to read printed matter, an unintelligible jargon was the result. For instance, he read a sentence from the bye-laws of the College of Physicians, viz., 'It shall be in the power of the college to examine or not examine any licentiate, previously to his admission to a fellow- ship, as they shall think fit,' as follows : — ^ An the he what im, the temother of the trothotodoo to majorum or that emidrate em einkrastrai mestreit to ketra totomhreidei to rafromtreido asthat kekritest.' The same passage was presented to him a few days after- wards, when he read it as follows : — ' Be Tnather be in the kondreit of the compestret to samtreis ' ' Dublin Quarterly Journal', November 1833, p. 157. u 2 164 DISEASES OF THE NERVOUS SYSTEM. aTntreit eratreido am temtreido mestreiterso to his eftreido turn bried roderiso of deid daf drit des tresU Dr. Osborne observes in the above jargon ' several syllables of frequent occurrence in the Grerman language, which had pro- bably made a strong impression on the memory of the patient,' who had been a good linguist ; but to this I must demur, the words given being particularly unlike German ; and it seems much more likely that they were, if anything, reminiscences of old native Irish. In the same manner we might speak of paragraphia and paramvmia, in cases where the patient is able to write or ges- ticulate, but does so in a way which is wrong or unintelligible. There is a kind o{ functional aphasia, in which connection between the cortex and the tongue is severed, either by mental emotions, more particularly fright, or in consequence of fevers, especially typhoid, but also scarlet fever, measles, erysipelas, &c. ; and which appears also to be congenital. Herodotus re- lates that the son of Croesus was dumb ; but that when after the capture of Sardes he saw a Persian running, with sword drawn, to kill his father, he exclaimed : ' Man, do not kill Crcesus ! ' and he afterwards retained the use of language. Kussmaul mentions the case of an hysterical woman who lost her speech on her wedding-day, and only regained it when she saw a church on fire. She then screamed, ' Fire ! ' and spoke as well as ever after that. 2. General Paralysis of the Insane (Dementia Paralytica, Folie Paralytique). This disease, which has been for the last decennia a favourite subject of study for alienists and neuro-pathologists, consists essentially of a diffuse chronic interstitial inflammation of the brain and spinal cord, which leads in time to destruction of ganglion cells and wasting of the nervous centres.- It may aptly be compared to the atrophic form of Bright's disease of the kidneys. Its progress is generally slow, but occasionally acute. In the latter case symptoms of inflammation predo- minate : the brain appears swollen, the convolutions bulky, the fissures small, the cortex thickened, and on section hypereemia and multiple softening is discovered. The coats of the arterioles GENERAL PARALYSIS. 165 -and capillaries are studded with nuclei, and distended by white corpuscles. In the great majority of cases, however, the disease has a more protracted course, and leads to atrophy, as the ulti- mate result of the inflammation. The dura mater adheres firmly to the skull, and may show thickened and opaque osteo- mata. The pia mater is oedematous, and a quantity of serum is found over the parietal and occipital lobes of the brain ; the membrane often appears white or yellow, and is thickened chiefly at the sides of the longitudinal fissure, and in the neigh- bourhood of the large bloodvessels. The pia generally adheres to the surface of the brain, and on attempting to separate it, the cineritious substance is torn. The convolutions, more es- specially those of the anterior lobes, are wasted, and changed into an inert mass. The ganglionic cells are completely altered in form and colour, and have undergone retrogressive degenera- tion. Their place is taken by amylaceous bodies, and a quantity of new connective tissue, which binds the structure together and hardens it. The bloodvessels of the brain sometimes undergo a calcareous change, standing out like bristles ; they appear tor- tuous and varicose. Dr. Lockhart Clarke has also found widen- ing of the peri-vascular canals (i.e. the sheaths of the cerebral l)loodvessels), from wasting of the brain-tissue, and granules of hsematoidine in the sheaths and the vessels. The ventricles of the brain are dilated, and the ependyma is covered with small •or large rough granulations ; the medullary matter is softened, and the surface of the central ganglia puckered. The weight of the brain is much diminished, and often amounts only to thirty ounces. In the spinal cord the signs of sclerosis of the pos- terior columns are met with ; viz., wasting of nerve-fibres, pro- liferation of connective tissue, and formation of oil-globules and amyloid corpuscles : or those of granular myelitis (Westphal), viz., enormous masses of fat-globules, chiefly in the neighbour- hood of the bloodvessels of the lateral columns, with thickening of the septa of the cord. Similar changes have been discovered in the cerebral nerves and the posterior roots of the spinal nerves. The optic discs are generally wasted. General paralysis of the insane affects chiefly males, the proportion being of about seven men to one woman ; and the age at which it proves most fatal is between thirty and forty- 166 DISEASES OF THE NERVOUS SYSTEM. five. The greater prevalence of the disease in the male sex is probably owing to the fact that males are more exposed to in- jurious influences, and drink harder, than women. Hard work, combined with anxiety and excesses in alcohol and sexual in- dulgence, seem to predispose to the malady ; but injury to the head, affecting the cineritious substance, is no doubt frequently the real cause. The disease may also become developed in persons saturated with the syphilitic poison, and in conva- lescents from acute diseases. It is more frequent amongst the lower orders than the higher classes, for many more cases of it are seen in public than in private asylums. Whether the affection is hereditary or not, remains as yet an open question. As a rule the brain is first affected, but in some cases sym- ptoms pointing to disease of the spinal cord, such as progressive locomotor ataxy, or paraplegia, precede the cerebral symptoms. The disease then gradually creeps upwards through the pyramids into the crura cerebri, the corona radiata, and ultimately into the cortical substance of the hemispheres. The first symptoms are those of mental excitement. There is considerable irritability of temper ; the memory is impaired, chiefly for recent occurrences and names ; and vertigo and headache are complained of. Little oddities in the patient's behaviour also begin to attract attention ; he loses his self- control and reasoning powers ; but the most important symptom at this stage is a peculiar tremulous or quivering motion about the lips and facial muscles generally. The speech now be- comes altered ; it assumes a nasal twang ; articulation is diffi- cult, and sometimes there is actual stammering, which, however, may be overcome by an effort of the will. These symptoms point to an affection of the medulla oblongata, or the cerebral ganglia of the hemispheres ; but in other cases there is an em- barrassment of language, which partakes more of the nature of aphasia, and must be ascribed to degeneration of the cineritious structure of the convolutions. In such cases articulation may still be quite perfect, and there is no apparent loss of power in the lips, tongue, and palate. Temporary fits of complete aphasia may also occur under these circumstances. Sometimes the pitch of the voice is altered ; in most cases it is lowered. Differences in the size of the pupils are also noticed, one being QENESAL PARALYSIS. 167 larger than the other, which is a most valuable sign to the examiner of a proposal for life insurance. As a rule the pupils are narrow. This stage of the disease may last for several months, after which other important symptoms make their appearance. There is a decided want of power, but as yet no paralysis. The speech is thick, like that of a drunken man, and sometimes quite un- intelligible ; the saliva runs away ; the expression is vacant and silly ; the tongue is put out with difficulty, and appears tre- mulous when protruded. The patient is apt to smack the tongue and grind the teeth. The walk is often grotesque ; the patient sets off at a tremendous pace, then suddenly stops, and will not go any further ; or he stops every minute, and wants much persuasion to proceed. There is tremor in tlie hand ; he can no longer dress or feed himself properly. There is inability to write, or at least great clumsiness in guiding the pen. The character of the handwriting is altered, and mistakes in spelling- are frequent. At the same time the memory fails more largely ; the patient becomes unable to manage his business ; or, if he is left to attend to it, makes fatal mistakes which may ruin him- self and his family. He loses all ideas of the value of money, and signs away large sums for trumpery things. If unmarried, he will contract an absurd alliance. In the married the affec- tions are weakened ; he does no longer care for his family. If contradicted about a slight matter, he is apt to fly into a terrible rage. At the same time there are delusions, which have a de- cidedly ambitious and exalted character. The patient often be- comes an emperor or a king, lives in a palace, and has an annual revenue of a million sterling ; he has ten thousand horses in his stables, and feels perfectly happy in this magnificence. He shows an incapacity for dwelling on painful or troublesome sub- jects. In other cases, again, the mind seems a perfect blank, or perverse impulses are developed. Kleptomania is one of these, and such patients have been sent to prison with hard labour in- stead of to an asylum. Attempts at rape and homicidal mania also occur, and it is therefore generally advisable to place the patient under restraint. Depression sometimes alternates with exaltation, and although the loss of physical power is great, yet in sudden attacks of maniacal excitement a prodigious force is 168 DISHASIIS OF THE NERVOUS SYSTEM. sometimes developed. This oscillation between depression and irritation is generally accompanied with analogous changes in the pulse, which is very slow, viz. from 40 to 50 beats in the former condition, whUe it may rapidly rise to 100 or 120 as soon as exacerbation becomes established. In the last stage of the disease there is paralysis of motion and imbecility. It sometimes commences with a fit of apoplexy, followed by hemiplegia. The latter may improve as time goes on, but the intellect becomes progressively more clouded and physical decay more marked. The patient now leads a vege- tative existence ; he sits in a chair, or lies in bed, callous to anything which may go on around him. Sometimes he shows the symptoms of complete paralysis of the portio dura on one side ; the body may be anaesthetic, so that surgical operations are undergone without flinching, and self-mutilation is practised without evidence of pain. Epileptiform seizures occur at this time in all their various forms, from the slightest attack of * petit mal ' to the most violent fit of convulsions, and the patient sometimes dies in a fit two or three years after the first appearance of the symptoms, or he becomes bed-ridden, affected ■with paralysis of the sphincters, and is ultimately carried off by decubitus, pneumonia, or acute tuberculosis. In such cases there may be great wasting of flesh, or an excessive develop- ment of fat. In exceptional cases the disease lasts much longer, and ends in recovery ; while, on the other hand, it may run an exceed- ingly rapid course, and end fatally in a few months. 3. Paralysis agitans {Shaking Palsy, ParJansori's ^ Disease). This disease, which has frequently been confounded with senile tremor, chorea, and multiple sclerosis of the cerebro- spinal centre, is characterised by two principal symptoms, viz. tremor and paralysis of voluntary muscles, both being decidedly progressive in their course. The tremor precedes the paralysis, and generally commences in a single limb, mostly one of the upper extremities ; but where a powerful cause — -such as terror or a great shock — acts suddenly, it may at once affect all four ' 'Essay on the Shaking Palsy.' London, 1817. PAHAZrSIS AGITANS. 169 extremities. I have seen this in the case of a woman aged fifty- nine, whose husband had been accidentally killed before her eyes. The tremor varies considerably in degree, from hardly per- ceptible vibrations to violent clonic convvilsions. Sometimes it is so slight that it escapes the eye except on the most careful observation, but reveals itself at once to the sense of touch. It also affects the neck, and more particularly the sterno-mastoid and trapezius muscles, by which the head is moved forward and laterally. In cases of long standing this peculiarity is some- times neutralised by paralysis of the long extensors of the spine, which is followed by tonic contraction of the sterno-cleido- mastoid muscles. The head then falls forwards, the chin rests on the sternum, and sometimes great force is necessary to pull the head back so as to give it for a time its proper position. The tremor becomes less in the horizontal position, and ceases completely during sleep. Even those patients whose limbs are most violently agitated throughout the day, sleep as quietly as children. The shaking re-commences, however, almost immediately after awakening; and becomes as bad as ever on getting up. It is much increased by excitement and by efforts of the will to stop it; but it can be arrested for a minute — where it occurs in the upper extremity — by knocking the hand forcibly on the knee or a table, and in the leg, by stamping the foot on the ground. It also becomes less when the patient makes a voluntary movement of whatever kind. Paralysis only appears after the tremor has lasted for a more or less considerable time. There is sometimes only a slowness in carrying out intended movements, and great mus- cular fatigue after in'significant efforts ; while in other cases there is nearly complete paralysis, excepting only the muscles of the eyes. As a rule the palsy affects chiefly the extensor muscles, and is connected with greater contractions of the antagonistic flexors than are found in other forms of paralysis. The body therefore eventually becomes quite deformed. Not only does the head droop, but the entire figure is bent forwards ; the arms are rigid ; the fingers half flexed, as if for writing ; the knees are so closely approached to one another that it is difficult to separate them ; and the foot assumes the position of 170 BISSASJES OF TSE NERVOUS SYSTEM. pes equinus. This extreme muscular rigidity makes the patients peculiarly helpless, and they require powerful attendants to minister to their wants. A singular feature of shaking palsy is the tendency to forced movements. Some patients have the impulse to run forwards, and find it impossible to check it ; and they often fall down, as they run in an awkward manner. One of my patients could only move about in the following way : — he clasped with both hands the hands of his attendant, and then commenced running briskly backwards while the attendant followed him running forwards, and thus kept the invalid's balance. Some patients can walk but cannot stand. In one remarkable case which I had the opportunity of observing for two years at the Hospital, the patient, when placed upright in the centre of a room, would at once reel backwards imtil he found a support for his back — such as a table or the wall ; and he could then stand for a long time. He had a difficulty in getting started for walking ; but when he had once commenced, he could walk several miles without stopping. When he was obliged to stop, he would reel back directly. On crossing a street he had therefore to walk round and round if the road was not clear, as standing still was out of the question. He had no difficulty in going downstairs, but found it impossible to go uphill. The most singular feature of this case, however, was that the patient only had the use of his arms and hands while walking. When standing and resting his back against the wall, his hands were utterly paralysed ; but as soon as he set off walking through the room, he could move his arms in all directions. Thus, it was while walking that he dressed and undressed himself, being too poor to pay for an attendant; and he even took his meals while promenading about his room, unless there happened to be somebody charitable enough to feed him. I unfortunately lost sight of this case before its fatal termination, but I should, in a post-mortem examination, have expected to find disease of the posterior part of the middle lobe of the cerebellum. In spite of the incessant muscular action, there is no increase of temperature on the sm-face. The patient, however, has a feeling of increased heat, particularly when the shaking is violent. The faradic and galvanic excitability of the muscles PARALYSIS AOITANS. 171 is generally normal, but where there is a high degree of para- lysis and contraction it appears diminished. Sensibility only becomes affected in the later stages of the complaint, when there are sensations of pins and needles, numbness, and a degree of anesthesia in the arms and legs. The speech is often drawl- ing and indistinct; the patient, instead of 'yes' says 'yeeeeeeees' — sometimes spreading one such word over nearly a minute. The mental faculties also become dulled ; there is headache, giddiness, depression, and not rarely delirium in the small hours of the morning. There may be profuse perspiration, which I have occasionally found to have a most villanous smell, even in persons who were well attended to and quite cleanly in their habits. The course of the disease is protracted over a number of years. It generally occurs after fifty years of age. Most of my patients were between sixty and seventy, but I have seen one who was only forty. The chief causes are anxiety, losses in business, hard work and bad living, and lastly injury. It is much more frequent in males than in females. In my practice the proportion has been 10 males to 1 female, but this does not appear to be the general rate ; for amongst 69 fatal cases which occmred in 1874 in England and Wales, there were 42 males and 27 females. Death takes place from exhaustion of the nervous force, and is often preceded by decubitus, pneumonia, and other acute diseases. No peculiar anatomical lesion appears to be invariably con- nected with shaking palsy. Some observers have found sclerosis of the corpora quadrigemina, pons, medulla oblongata, and spinal cord, and wasting of the thalamus opticus and cornu Ammonis ; but in many cases the results have been negative. 4. Labio-glosso-phai^ngeal Paralysis, progressive bulbar Paralysis, Paralysie labio-glosso-laryngee progressive,. DiJbchenne^s Disease. We have seen in the iirst chapter that the medulla oblongata is the co-ordinating centre of the movements of deglutition, for which it associates the muscles of the lips, tongue, palate, and pharynx, and of articulate speech ; the integrity of pronun- ciation of letters being bound to the integrity of the motor 172 DISEASES OF THE NERVOUS SYSTEM. nuclei of the hypoglossus, pneuinogastric, and spinal accessory nerves. A most interesting pathological illustration of these physiological conditions is given by the disease which we have now to consider. Progressive bulbar paralysis was first described in 1860 by Duchenne, who believed it to be a muscular disease ; but Trous- seau, who had soon afterwards the opportunity of making several autopsies, was led to the conclusion that it was rather a disease of the nerves than the muscles, and that it was owing to atrophy of the nerve-roots. Since then a number of post-mortem examinations have been made by Charcot, Joffroy, Kussmaul and others; and the microscopic examination of the medulla oblongata, according to Dr. Lockhart Clarke's method, has yielded most satisfactory results, which in a very great measure explain the symptoms of the disease. Examination of the medulla by simple inspection teaches us little or nothing; but microscopic specimens which have been hardened in chromic acid or bichromate of potash, coloured by carmine and rendered transparent by glycerine, show marked changes in the nuclei of the motor nerves. The application of chromic acid allows tis to distinguish healthy and diseased parts by the naked eye, for the former then assume a dark-yellow colour, while the latter remain light. On the other hand, • carmine colours the diseased parts more deeply, but the healthy parts, which have already taken up the chromic acid, absorb carmine less easily. Another peculiarity is, that car- mine colours the ganglion cells, their processes, and the neuro- glia, but not the nerve-fibres, which are therefore plainly per- ceptible. By using these tests it is discovered that there is degeneration of the ganglion cells in the motor nuclei of the rhomboid fossa, which generally assumes the form of yellow pigmentary atrophy. The ganglionic cells appear dark yellow or reddish yellow, greatly shrunk in size, and with their pro- cesses indistinct or absent. The nucleus of the cell perishes, and its place is taken by brown granules which appear in crowds. Ultimately, nothing remains of the cell except yellow granules, which are seen singly or heaped together. Of the nuclei of nerves in the rhomboid fossa, that of the hypoglossus is most constantly affected. In a case which Charcot DUCHENNE'S DISEASE. 173. observed together with Joffroy, he compared one of Dr. Lock- hart Clarke's original preparations of a normal hypoglossus- nucleus with that of the diseased specimen, and found that the number of ganglion cells in the wasted nucleus amounted to only about ^th or J^th part of those contained in the normal preparation. The nuclei of the accessory and pneumogastric nerves are also most generally affected, while those of the portio dura and the motor portion of the fifth are more rarely diseased, and the sentient nucleus of the fifth, the auditory, and glosso-pharyngeal nerve are found normal. Another anatomical change which has been discovered is chronic sclerosing myelitis. This was shown by finding number- less oil-globules in the medullary matter ; the neuroglia had become granular or fibrous, and appeared proliferated by show- ing larger spaces between the several nerve-fibres. The blood- vessels were thickened and smTounded by a large sheath of connective tissue, in which oil-globules and shining disc-like corpuscles could be seen. The nerve-fibres appeared much reduced in number and size, their contents were in a state of granular and fatty degeneration, and the cylinder axis was either thickened or wasted and entirely gone. This myelitis was chiefly found in the rhomboid fossa and the anterior pyra- mids, less in the corpora oUvaria, and not at all in the restiform tracts. That the corpora olivaria should only slightly suffer in this disease speaks strongly against Schroder van der Kolck's theory of these bodies being entrusted with the function of regulating articulation. Jaccoud has accepted this theory, but Dr. Lock- hart Clarke has shown that parrots — which have great facility in imitating articulate sounds — have no olivary bodies at all, and that seals — who never articulate — are provided with enor- mous corpora olivaria. These facts suffice to render Van der Kolck's theory untenable. Although therefore a definite lesion has been discovered which accoimts for the symptoms observed in patients suffering from progressive bulbar paralysis, it is nevertheless a singular fact that in some cases the wasting of ganglion cells has not been proportionate to the wasting of the muscles which are under their influence. Thus there has been great wasting of 174 DISEASES OF THE NERVOUS SYSTEM. the nucleus of the hypoglossus, where there was only a slight degree of atrophy of the tongue. Brown-Sequard and Charcot have atterapted to explain this by assuming that there is a difference between simple atrophy and wasting accompanied with irritation, and that the former only causes paralysis while the latter will produce paralysis and atrophy combined. On the other hand, Duchenne and Joffroy are of opinion that the ganglion cells in the motor nuclei are partly motor and partly trophic. Wasting of the motor nuclei would, according to them, cause paralysis ; while atrophy of the trophic structures would lead to atrophy as well. No proofs have as yet been given in support of either theory. Progressive bulbar paralysis seems to occur more in males than in females. It is rare before thirty years of age ; appears • to follow cold, mental anxiety, and injuries to the head ; and is sometimes complicated with progressive muscular atrophy. It is not really a special disease, but a complex of symptoms owing to a peculiar degeneration ; and it shows in this respect the greatest analogy to progressive locomotor ataxy, chronic diffuse myelitis, multiple sclerosis of the nervous centres, and secondary degeneration of the lateral columns of the spinal cord after an attack of cerebral haemorrhage. If it generally kills more rapidly than the diseases which I have just mentioned, this is owing to the affected organ being more essential to life (no^ud- vital, p. 37). "While therefore ataxy will sometimes be pro- tracted over twenty years, progressive bulbar paralysis rarely lasts longer than two or three years and oftentimes not so long, since it kills its victims either by suffocation from morsels of food arriving in the aii-passages, or by inability to expectorate mucus, or finally by apnoea and syncope. The commencement of the disease is generally insidious. The patient finds that eating and talking fatigue him ; the tongue feels heavy, and deglutition is uncomfortable. Some- times he also complains of headache, pain at the nape of the neck, and a feeling of constriction in the throat and the chest. An early symptom may be excessive salivation, which cannot be explained by the mouth being generally kept open, but is most probably a neuro-lytic phenomenon; for Claude Bernard has found extreme salivation in animals in which he had divided DUCHENNE'S DISEASE. 175 the tympanico-lingual nerve, which is a branch of the portio dura. After these symptoms have lasted a variable time, a sudden change for the worse takes place in the patient's condition, which seems sometimes to be owing to a severe cold, but may also occur without a perceptible cause. Symptoms of impaired articulation (alalia, anarthria), are now prominent. There is not only general difficulty in speak- ing, which becomes slower and laboured, but also loss of certain letters, which depends in its essential features upon the course which the destruction takes in the motor nuclei, as it varies in proportion to the affection of the lips, tongue and palate. Where the lips suffer principally, the consonants b, jo, f, m, and v become difficult or impossible ; just as is found in persons suffer- ing from hare-lip which has not been operated upon. The vowels which chiefly suffer are o and u ; afterwards e and a. Helmholtz has shown that we pronounce the vowels by effecting certain changes in the shape of the cavity of the mouth, more especially by the action of the lips ; and that the vocal cords by their vibrations only serve to alter the pitch in which the vowels are spoken. In a case of total occlusion of the lar3mx, in which laryngotomy had been performed, the patient could neither talk nor whisper ; nevertheless she contrived to lisp by alternately increasing and reducing the column of air in the cavity of the mouth. On account of this paralysis of the lips, the patient is unable to whistle or to blow out a candle. The respiratory portion of the facial nerve is the only one affected in progressive bulbar ^paralysis, causing loss of power in the muscles of the mouth and nose, while the orbicularis palpebrarum, and other muscles which serve for physiognomical expression, remain in their normal condition. By paralysis of the respiratory muscles of the mouth and nose, the mouth appears wider, or quite open ; the naso- labial sulcus is deeper, and the face assumes a lachrymose ex- pression. On examining the affected muscles by galvanism and faradism, it is seen that their contractile power becomes dimin- ished as atrophy sets in ; but as long as muscular fibres are still present, these will respond, though sluggishly, to both kinds of current. The reflex excitability of these muscles 176 DISEASES OF THE NERVOUS SYSTEM. is likewise diminished or lost in the further progress of the disease. "Where there is difficulty in raising the tongue to the roof of the mouth, the vowel e is lost, and the consonants r, sh, s, I, k, g, t, d, and n. The same difficulties are observed where there is congenital or acquired defect of the tongue, for instance, after an operation for cancer ; in congenital and acquired hypertrophy of the organ ; where the frenulum is too short or too firm ; in tumours ; and also where the movements of the member are impeded by contraction and anchylosis of the jaws. Paralysis of the soft palate produces a nasal twang, and impedes the pronunciation of the letters b and p, because the current of air which goes through the mouth, is not powerful enough to overcome the resistance of the lips. That such is really the case is shown by the fact that such patients are still able to pronounce h and p by closing their nostrils, whereby the force of the blast is increased. The nasal twang is owing to the soft palate being unable to close up the posterior opening of the nose during the pronunciation of the vowels and of all consonants, excepting Tn, n, and ng. Such a twang is there- fore the saine as is observed in diphtheritic paralysis of the soft palate, in syphilitic ulceration, and in congenital fissure of hard and soft palate. Hypertrophied tonsils, polypus, and other diseases cause similar symptoms. B and p are sometimes pro- nounced as m and /. When all letters are lost, there is alalia, and this is in- variably combined with aphonia, from paralysis of the vocal cords. The patients are ultimately only able to grunt, and an examination by the laryngeal mirror shows that the vocal cords have ceased to vibrate. At the same time expiration and expectoration become difficult. The patient finds himself unable to clear his nose and throat, or to cough at will, although he may still cough when foreign bodies, such as particles of food, get into the larynx. When this stage has been reached, dyspncBa and syncope from parailysis of the pneumogastric nerve are to be feared. Another function which suffers and becomes ultimately an- nihilated in progressive bulbar paralysis, is that of deglutition ; and the distress caused by this must have been witnessed to be PROORESSIVE BULBAR PARALYSIS. 177 realised. Where the mouth cannot be properly closed, the food -which is taken is apt to fall out again. The tongue has no longer any power in assisting the movements of mastication and the formation of the bolus ; the morsel therefore remains lying between the teeth and cheeks, until the patient helps its pro- gress downwards by pushing it on with his fingers and throw- ing the head backwards. Where the pharynx becomes para- lysed, large pieces of food are apt to remain in it, and may cause suffocation by entering the air-passages. In some cases liquids, and in others a solid morsel, is more easily swallowed, according to the portion of the throat which is most affected. The tongue and the muscles of the pharynx ultimately become wasted, flabby, and tremulous; they show fibrillary twitches which are characteristic of muscular atrophy, and yet remain sensitive to Faradisation until the entire muscular structm-e is destroyed. Insufficient nutrition does not only constitute one of the most painful features of this disease, but also causes great systemic debility, from inanition. The patient is therefore soon confined to his bed or couch, and finds it very difficult to move about. In a number of cases the cervical portion of the cord becomes involved, causing the symptoms of progressive muscular atrophy, at first chiefly in the thumb and the other fingers, and afterwards affecting the whole of the upper and lower ex- tremities. Eespiration is now imperfect ; the skin is generally covered with clammy perspiration ; and paralysis of the sphinc- ters and delirium may set in towards the end. But generally the mind remains perfectly clear ; the patient spends his time in brooding over his terrible condition, and longs for the final deliverance which alone can put an end to his unbearable troubles. It is not only pigmentary degeneration and sclerosis of the motor nuclei of the medulla which lead to difficulty or impossi- bility of articulation, but any other morbid process by which these nuclei are disabled will cause a similar effect. Such are haemorrhage, inflammatory or embolic softening, abscess and tumour of the medulla ; as also injury or disease of the skull and periosteum, pressure of tumours of the cerebellum, and pro- pagation of any acute or chronic disease from the pons or spinal N 178 DISEASES OF THE NERVOUS SYSTEM. cord to the fourth ventricle. On the other hand, the medulla is sometimes found diseased without there having been any symptoms of alalia or anarthria during life ; and this is ex- plained by the fact that the medulla is a complex organ, includ- ing a large number of different centres and conducting fibres in different situations. The symptoms which are observed during life depend strictly upon the portion of the medulla which is diseased. Difficult articulation is also met with in disseminated scleroris of the cerebro-spinal centre. In sclerosis of the cord alone, the speech is not affected ; but where the medulla, and the central ganglia of the hemispheres suffer, dysarthria is generally the result. This disease does not however produce aphasia, as it spares the cortical centres of the hemispheres. Drs. Silver and Cheadle have described cases in which symptoms of bulbar paralysis were owing to syphilitic infection of the system, and cured by iodide of potassium. These cases, however, do not quite fit into the frame of Duchenne's and Trousseau's description of 'progressive labio-glosso-laryngeal paralysis.' The dysphagia and dysarthria of hysterical women likewise belongs to an entirely different department of pathology. 5. Diphtheritic Paralysis. Palsies after certain acute diseases, such as typhoid fever^ cholera, small-pox, etc., have been known for a considerable time ; but the connection which exists between diphtheria of the fauces and a peculiar form of paralysis was only pointed out by Bretonneau, Trousseau, and Lasagne. That this should have escaped the attention of previous observers, is probably owing to the circumstance that in most cases the paralysis does not immediately follow upon diphtheria, but that a con- siderable interval elapses between the primary and secondary affection. This interval often amounts to two or three weeks, but it may be as many months. There are two forms of this palsy, one of which is attended at once with severe constitutional disturbance ; there being nephritis, dropsy, oedema of the lungs, general paralysis, urae- mic convulsions and delirium ; and death takes place in a few DIPHTHERITIC PAHALYSIS. 179 days. But in most cases the affection is milder and generally ends in recovery, unless the patient should accidentally choke by a morsel of food finding its way into the air-passages. This latter form is distinguished by the peculiar succession of paralytic symptoms. The first part to suffer is the soft palate, which is shown by the patient speaking with a nasal twang ; and articulation, more especially of the guttural sounds, becomes difficult or impossible. On inspecting the soft palate, it appears flabby and drooping ; and when the tongue is depressed by a spatula, the palate is seen to remain immovable when irritated, instead of going up and down as in health. It may be touched, pricked, and even cauterised, without showing signs of reflex excitability. If the patient be made to expire forcibly, the palate remains motionless. Sometimes one half of it is more affected than the other half. In consequence of this the deglu- tition of liquids suffers, and they may be returned through the nose. Where the pharyngeal muscles are likewise paralysed, deglutition of solids is impaired ; the morsel of food is apt to lodge in the folds of the pharynx, and may cause suffocation by entering the glottis. The tongue and larynx are rarely affected, but paralysis of the motor nerves of the eyes is very common. The ciliary nerves which are supplied by the lenticular ganglion are more especially liable to it, causing diminished or lost power of ac- commodation, so that the patient cannot read or see small objects, but can see well in the distance. There may also be ptosis, strabismus and diplopia, owing to paralysis of the third nerve ; but what used to be called ' diphtheritic amaurosis ' does not exist, as there is no optic neuritis, and the ophthalmoscope shows the fundus of the eye to be perfectly healthy. Paralysis of motion also affects the extremities. The- patient experiences great difficulty in standing and walking. The dynamometer shows diminished grasping power of the hands. The neck is also affected, so that the head may tumble about on the pillow from one side to the other, the patient being unable to fix it. Affection of the diaphragm is shown by dyspnoea and accelerated respiration ; while the very slow pulse,, which is generally met with, shows loss of power in the sympa- thetic ganglia of the heart, with preponderance of the inhibitory N 2 180 DISEASES OF THE NERVOUS SYSTEM. action of the pneumogastic nerve. The pulse falls often as low as 42, and even less. Diphtheritic paralysis resembles that which is observed after other acute diseases and in hysterical women by a peculiar tendency to shift its place; it will leave one limb to go to another, and then spread to the rectum and bladder, causing incontinence or retention. There may also be loss of the virile power. Sensibility suffers frequently. The gums may be so anaes- thetic that the teeth do not feel the contact with the food. There are ' pins and needles ' in the fingers ; the sense of touch is dull, and the anaesthesia may be complete in the hands and arms, but rarely spreads over the whole body. Nevertheless the lower extremities do not escape : for the patient has the peculiar sensation as if he was walking on cotton ; he cannot feel the ground properly, and must have the assistance of the eyes in walking. The degree of the palsy is not proportionate to the severity of the primary affection; for it often comes on after a mild attack of pharyngeal diphtheria. Nor can the paralysis of the soft palate be ascribed to the local influence of the diphtheritic poison, because it may only come on long after the poison has been eliminated from the pharynx ; and it has also been observed when the diphtheria did not affect the fauces, but the skin. Von Graefe attributed the origin of diphtheritic paralysis to an affection of the sympathetic nerve ; and Dr. H. Jackson seems inclined to coincide in this opinion. It is however more probable that it is owing to migrating neuritis. Buhl found inflammatory proliferation of the nuclei of the connective tissue of the sheaths of the peripheral nerves and the anterior and posterior spinal nerve-roots. The inflammatory effusion may be absorbed, and in such cases recovery takes place, or the proliferated connective tissue shrinks and becomes sclerosed, when pressure on and con- striction of the nerves will cause more or less permanent para- lysis and anaesthesia. In such cases there is. generally atrophy of the paralysed muscles, with more or less complete loss of their faradic and galvanic sensibility. Oertel has also found haemorrhage in the spinal meninges, and great proliferation of nuclei in the nerve-sheaths and the grey substance of the centre PARALYSIS. 181 of the cord. The albuminuria which is so frequently present in these cases does not seem to have any influence upon the degree or extent of the paralysis. Peripheral paralysis from injury to the nerves, infantile paralysis, palsy occurring after acute diseases, such as typhoid fever, small-pox, scarlatina, pneumonia, erysipelas, etc. ; rheu- matic, reflex, and hysterical paralysis, as well as lead palsy, will be discussed when the affections of the peripheral nerves come under consideration. 182 DISEASES OF THE NERVOUS SYSTEM. CHAPTEE V. CEPHALITIS. Cephalitis, by which name the various inflammatory conditions of the nervous centres are comprehended, caused the following mortality during six periods of five years each, in England and Wales : — Periods of Five Years Deaths from Ce- phalitis Percentage of Nervous Diseases Percentage of all Diseases 1838-42 1843-^6 1847-61 1852-56 1857-61 1862-66 1867-71 12,088 vacat 16,747 17,246 17,250 19,818 23,078 6-78 6-71 6-71 6'36 6-80 7-51 ■69 ■83 ■83 ■83 •81 •93 Total of Thirty Tears 106,427 6-48 •82 It is seen from this table that there has been a rise in the mortality from cephalitis ever since registration was com- menced, with the only exception of the fom'th lustrum, in which there was a slight fall. ■ The influence of age and sex upon the production of cepha- litis is considerable. The annexed diagram shows that the infantile period of life is particularly subject to such infiam- Tnatory conditions, the first year showing a maximum of 448, and the first lustrum one of 1,414. From that time there is a decided fall, with the only exception of the period from 35 to 40, when a slight rise is noticed ; which is, however, again succeeded by a fall until the end. CEPSALITIS. 183 E r-«; »■■ - Diagram F. Showing the innuence of AGE on the Mortality from CEPHMITIS in England andWalesin 184 ^ c § Q 3 " S A tQ 4 R 7 t8 / g !f? 4 S 5 :s j 5I u s [_ g§ /: s to p7 ' s 7' «! a ?^ f ^ y m _J IT D : n: [ "* ~^ 7 CO ^1 ' eisi:asi:s of the nervous system. intense back-ache, which is chiefly felt on the part from where the inflammation starts, but afterwards extends throughout the length of the spine. Occasionally, however, the commencement is more latent ; there is no or only a slight increase of tempera- ture, but a feeling of general malaise and lassitude, which is followed by pain in the back, sensations of pins and needles in the limbs, constipation and difficulty in emptying the bladder. In acute cases the pain in the back is most severe; it is much increased by movements, such as sitting up or turning round in bed, emptying the bladder and the bowels. It is often not confined to the back, but shoots into the extremities and the front part of the body. Sometimes there is such a degree of rigidity of the muscles of the vertebral column that opisthotonos is produced, the head being drawn backwards and the spine arched ; there may also be convulsions in the limbs, similar to those of tetanus, but differing from them by not being brought on through touching the patient or otherwise exciting his sensibility. The symptoms vary considerably according to the anatomical seat of the inflammation. Where cerebral meningitis precedes the spinal inflammation, the symptoms show a downward course, so that the upper extremities suffer previous to the lower ones ; but in other cases the pia mater of the lumbar portion of the cord is first affected, and the inflammation then gradually creeps upwards to the cervical spine and the medulla oblongata. Cerebral symptoms, such as vomiting, delirium, coma, &c., are only observed where spinal is complicated with cerebral lepto-meningitis ; and where the medulla oblongata is affected, there is difficulty of articulation, deglutition, and respiration. Cervical meningitis is attended by great rigidity of the neck, pain shooting into the arms and hands, dyspnoea from compression of the origin of the phrenic nerve and rigidity of the diaphragm, difficulty of deglutition, various alterations in the size of the pupils — dilatation, constriction, and inequality — and signs of disturbed innervation of the heart. In dorsal meningitis the pain shoots into the body ; the chest-walls are rigid, and there is a feeling of constriction round the waist. In cases of lumbar meningitis the patients complain of pain in the loins, sacrum, hypogastrium, and lower extremities, a feeling of great MENINGITIS. 199 stiffness at the bottom of the back, and stiffness of the muscles of the lower extremities, which renders them immovable. The abdomen is hard and drawn in, and there is obstinate constipa- tion from spasm of the muscular coat of the bowel, abdominal muscles, and sphincter ani. The bladder is similarly affected, as is shown by dysuria, irritability of the viscus, and retention of the urine. Eeflex excitability is at first increased, afterwards diminished, and ultimately lost. Where the posterior roots are much affected, there is great hypersesthesia of the skin, muscles, and joints. In the further progress of the disease, symptoms of paralysis predominate. The limbs are now motionless more from weak- ness than from pain ; there is aneesthesia of the skin, incontin- ence of urine and fseces, an innumerable pulse, a temperature of 104° and more, and death takes place by asphyxia, from rigidity of the respiratory muscles, and consequent carbonisa- tion of the blood. In hyper-acute cases the patients may die within a few days from the commencement of the disease ; but such instances are exceptional. As a rule, death takes place in two or three weeks, either from exhaustion through pain, sleep- lessness, and insufficient oxidation of the blood, or from pneu- monia and cystitis. In other cases a temporary improvement sets in, which is soon after followed by a fresh exacerbation ; or there is a sudden crisis, with great fall of temperature, retarda- tion of the pulse, profuse perspiration, abundant excretion of urine, and epistaxis, bleeding from piles, or menstruation ; and the principal symptoms of the complaint then diminish or dis- appear rapidly. Many cases, however, drag on wearily, getting now better and then again worse ; but the patients do not rally thoroughly, and death occurs ultimately, after many months of suffering, from decubitus and blood-poisoning. Finally, there may be recovery as far as life is concerned, but the patients are greatly emaciated, have a tedious convalescence, and remain subject to partial or complete anaesthesia and paraplegia, and where the posterior columns have been principally affected, to progressive locomotor ataxy. Occasionally the course of the disease is chronic from the very commencement. Such is the case chiefly in persons whose 200 disi:as:es of the nervous system. systemic powers are exhausted by excessive drinking, smoking, and indulgence in the sexual appetite, or who have undergone great fatigues and privations, especially in time of war, where they are also much exposed to the iniluence of cold and damp. Under these circumstances spinal meniagitis is usually com- plicated with myelitis, leading to sclerosis. There is then no suppuration, but great venous congestion and proliferation of connective tissue ; the membranes of the cord adhere to each other and the cord ; the latter is frequently found indurated in its entire extent, and the spinal nerve-roots are pale and wasted. This form of lepto-meningitis commences very gradually with a feeling of heaviness in the lower extremities, difficulty in walking, and pins and needles in the legs and feet. There is tightness round the waist, difficulty of urination and de- fecation, and pain and stiffness in the back. The weakness eventually merges into a more or less considerable degree of paralysis. A peculiar feature is that the degree of the palsy varies a good deal from time to time, most probably in conse- quence of variations in the quantity of cerebro-spinal liquid and the degree of venous congestion that is present. It is in such cases that blistering is of wonderful service. "Where there is much venous congestion, the paralysis is worse after the night's rest, and improves by moving about and standing, in the daytime ; while where there is an excess of cerebro-spinal liquid, the motor weakness is greater in standing, because the liquid is then not equally divided, but gravitates downwards and compresses the lower portion of the cord more effectually. The inflammatory process may, in such cases, remain for years confined to the lower portion of the dorsal and the lumbar portion of the cord ; and unless recovery ensues under proper treatment, is apt to become aggravated in course of time. The patients often die of marasmus, decubitus, or cystitis; or the disease spreads to the cervical portion of the cord and the meduUa oblongata, producing numbness and loss of power in the upper extremities, together with difficulty of deglutition and respiration. Bronchitis and pneumonia are then apt to set in, or the patient ultimately sinks from sheer exhaustion. All forms of meningitis, excepting the tubercidar, caused in 1874 the deaths of 3,013 males and 2,457 females: in all, 5,470. jENCEPHALITIS. 201 7. Encephalitis {Inflammation of the Brain). ' Inflammation of the brain, with red and yellow softening,' caused in 1874 the deaths of 1,426 males and 931 females : in all, 2,357. There are few diseases the pathology of which has under- gone such striking changes in recent times as encephalitis.. The best observers are now agreed that many cases, which were formerly believed to be such of inflammation of the brain, were in reality cases of meningitis, or of softening from thrombosis and embolism ; and there can be no doubt that inflamviation of the brain is on the whole rare, and never general hut always partial. Encephalitis is in the large majority of cases owing to injury to the head, and therefore found chiefly in adult ma^, ""^o are more liable to accidents than others. In children it may arise from otitis and caries of the petrous portion of the temporal bone, under the influence of the strumous diathesis, or after scarlet fever. Where it occurs after injury, the skull and me- ninges are generally likewise afiected; but where there is simple concussion and no fracture, capillary apoplexy may be the primary result, and this may eventually lead to acute or chronic encephalitis. Erysipelas from injury to remote parts may creep up to the face and head, and give rise to inflamma- tion of the brain. In the same way diseases of the skull — such as syphilis, ozsena, caries — may propagate the morbid process to the cerebral tissue. In the aged, fatty or calcareous de- generation of the arterial coats, and compression of the brain by tumours and aneurisms, will sometimes give rise to it. Finally, certain general diseases, such as pyaemia, septicsemia, the puerperal process, typhoid fever, and glanders, may now and then be complicated with encephalitis. There seems to be a predisposition to this disease in persons who are given to drink- ing, or subject to disease of the heart, or have undergone much mental anxiety and excessive physical exertions. The chief seat of the inflammation is the cineritious sub- stance of the cortex and the central ganglia, viz. the corpus striatum and thalamus opticus. In the, cineritious substance 202 DISEASES OF THE NERVOUS SYSTEM. the inflammation may te diffuse, but in the other portions of the brain there is generally only one small area, which rarely exceeds the size of a filbert or walnut. The anatomical lesions are as follows : — there is hyperemia and capillary haemorrhage, whereby the cerebral matter assumes a red coloration and becomes softer and moister than usual ; the convolutions are swollen and pressed against each other; while the uninflamed cerebral matter in the neighbourhood, and the pia mater, are dry and anaemic. The microscopic examination of the affected parts shows crowds of white blood- corpuscles, nerve-fibres in a state of more or less advanced destruction, decayed red blood-globules, dilated arterioles with thickened and fatty coats, crowds of nuclei, amyloid corpuscles, and pus. If the patients survive long enough, further changes will be observed in the diseased parts ; and these vary according to the quantity of blood which has been effused. Where this has been large, things progress much in the same manner as after cerebral haemorrhage from rupture of miliary aneurisms (p. 94). The colouring matter of the blood-corpuscles is dissolved, and a dirty- yellow substance is left, which is incapsulated by the gradual formation of a cyst. This is mostly seen in the central ganglia, while in the cineritious matter yellow stripes or callosities are discovered, which consist of the remains of blood-globules and sclerosed connective tissue, and are intimately connected with the pia mater, which appears thickened and opaque. Where, on the other hand, only little blood was effused, we meet in the later stages with a kind of paste or jeUy, which contains the remains of the decayed cerebral matter. Abscess of the brain may also be the result of inflammation. In such cases there is rapid emigration of white blood-corpuscles, and all tissues are changed into a kind of emulsion of variable thickness, which is reddish where much blood has been effused, but otherwise shows a light yellow or greenish tint. Such abscesses occur chiefly in the medullary matter, and vary in size from that of a pea to that of an apple ; and there may be only one or a dozen of them. In pyaemia they are apt to be multiple. Where the morbid process is rapid, the abscess is diffused ENCEPHAZITIS. 203 and irregularly shaped ; the neighbouring cerebral matter is not well separated from it, but there is red and grey softening, and punctuated apoplexy in the neighbourhood, with tendency to spread. The pus ultimately reaches the' surface of the brain, or breaks through into the lateral ventricle, whereby the whole hemisphere is transformed into an abscess. Such cases are mostly owing to injury or caries of bones ; and as the air has therefore access to the pus, this is apt to become discoloured and offensive. In other cases the pathological phenomena are more chronic in character, and the abscess then generally assumes a regular oval shape. It is contained in a kind of capsule, which consists of connective tissue and bloodvessels, and is intimately con- nected with the surroimding cerebral matter. The inner sur- face of the capsule is quite smooth, and the pus has a variable appearance, according to its age and mode of formation. Such an abscess acts like a foreign body on the brain, producing pressure ; the convolutions appear flattened, and the pia mater is anaemic and dry. Eupture of the abscess is always fatal. There is a peculiar form of encephalitis which occurs in children of parents who have suffered from syphilis or small- pox. In these there is diffuse inflammation of the white sub- stance of the hemisphere, while the grey matter escapes. The cells of the neuroglia undergo fatty degeneration, and granular corpuscles and oil-globules are the ultimate morbid product. This variety of encephalitis occurs either previous to or shortly after the birth of the infant. There are few diseases in which the symptoms vary so much in character and intensity as they do in encephalitis. Some- times they are so indistinct throughout the course of the malady that it is impossible to diagnose it. In other cases the com- mencement only is indefinite and slow, but the cerebral symp- toms gradually become more distinct as the disease advances. Again, there may be apoplexy in the beginning, after which the course of the complaint may be protracted ; while, in excep- tional cases, we have severe inflammatory symptoms from the first, leading rapidly to a fatal result. Encephalitis has been generally believed to be attended 204 BISEASi:S OF THE NERVOUS SYSTEM. with fever, but the body-heat usually remains at its usual standard, or rises only veiy little above it towards evening. The pulse, instead of being accelerated, is generally retarded,, and may fall as low as forty beats in the minute ; the tongue is coated, the appetite deficient, the bowels confined. Where the cerebellum is implicated, there is generally vomiting, more particularly at the commencement of the affection. The mental faculties suffer in most cases from the beginning, there being either excitement or depression. Eestlessness is frequent ; the patients cannot sleep, are constantly in and out of bed, take their clothes off and put them on again, and are always busy about something. Delirium is not infrequent, but maniacal excitement is rare. Sometimes great indifference, forgetfulness, and confusion is shown, and this state of dreami- ness gradually merges into somnolence and coma. The nerves of special sense are generally affected. A com- mon symptom is hypersesthesia of the retina, causing sensations of stars, sparks, and coloured light ; and undue excitability of the auditory nerve, causing tinnitus aurium. Common sensa- tion suffers likewise, there being pains in the arms and legs, or numbness, and sensations of pins and needles. Headache, which is such a prominent symptom in meningitis, is less marked in encephalitis; and if at all intense, denotes that the meninges are simultaneously affected, as is always the case in inflammation after injury or from otitis. The power of motion is generally impaired. There may be hemiplegia or paralysis of one limb, but in most cases there is rather weakness than paralysis. Tremor is frequent. There may be paralysis of the ocular muscles, ptosis and strabismus, or facial palsy, which mostly arises from compression of the portio dura in the Fallopian canal after otitis. Articulation is imperfect ; the patients stammer, shuffle the tongue about in a peculiar manner, and rarely finish a sentence. They are awkward in using their hands, and the gait is tottering. Partial con- vulsions of the limbs are often observed, and towards the end regular epileptiform seizures take place. Where encephalitis is owing to injury, the symptoms are generally mixed with those of meningitis, more especially where the morbid phenomena become rapidly developed. In some of ENCEPHALITIS. 206 these cases the patients may appear perfectly well for eight or ten days after the accident, when suddenly formidable symptoms of cerebral disturbance come on, which either lead rapidly to a fatal issue, or may last for many months, with alternate inter- missions and exacerbations. Inflammation of the brain from otitis is preceded by head- ache, discharge of sanious pus from the external meatus, fistulous openings in the neighbourhood of the ear, and deafness. Thrombosis of the sinuses of the dura mater and pachy- and lepto-meningitis are commonly associated with it. In these cases the inflammation in the brain is mostly limited to the posterior lobe and the cerebellum of the same side ; while where ozsena gives rise to it, the frontal lobe of the brain is more apt to suffer. The onset may be gradual or sudden, according to the intensity of the intracranial lesions. There is fever, vomiting, headache, convulsions, somnolence, and coma. The pulse is either very frequent or very slow, and death may occur very suddenly. Where pyaemia leads to encephalitis, the progress of the disease is very rapid. This is seen after phlebitis, in the puer- peral state, and after otitis. There are rigors, followed by in- tense fever-heat, with delirium, which quickly subsides into coma and death. In idiopathic encephalitis of the aged, the symptoms may be protracted over months and years. The patients suffer from tremor, incomplete paralysis with contraction, epileptiform seizures, and impairment of the mental faculties. They show great disinclination to work ; the temper is irritable and depressed, the thoughts confused, and the speech drawling. The face has a peculiar expression of astonishment. Headache, giddiness, restlessness at night, and diflBculty in walking, are complained of. Ultimately the patients become bedridden ; epileptic and paralytic fits succeed each other, and death is, as usual, preceded by delirium and coma. In cerebral abscess, the chief symptom is localised headache, in accordance with the seat of the lesion ; and shivering fits and convulsive seizures are not uncommon. Spontaneous abscess is never cured ; but where it is owing to injury, the pus may be emptied spontaneously through the opening of the skull, or 206 DISUASHS OF THE NERVOUS SYSTEM. burst through the nose or ear, or be evacuated by trepanation ; after which there may be complete recovery. Encephalitis is almost always fatal, more especially where it is idiopathic, or where the inflammation spreads from neighbour- ing parts. Only where it is owing to injury, there are prospects of recovery. A quantity of brain-matter may be lost without much harm, provided there be complete cicatrisation and sepa- ration from healthy parts ; for certain portions of the brain are not absolutely essential to life, and their function may be transferred to neighbouring parts. A physiological illustration of this fact is afforded by the experiments of Nothnagel and Groltz, who foimd that, after experimental destruction of certain portions of the brain, there was loss or impairment of certain motor functions ; but that within a few weeks, more or less complete recovery of the function hM taken place (p. 49). 8. Myelitis. This disease caused, in 1874, the deaths of 160 males and 133 females. 'Spinal marrow disease' caused, in the same year, the deaths of 64 males and 61 females. Inflammation of the tissue of the spinal cord is much more rare than meningitis, and occurs either complicated with the latter disease (meningo-myelitis) or by itself. Its causes are the same which produce meningitis ; and amongst these the influence of wet and cold stands uppermost. An interesting physiological illustration of the influence of intense cold on the spinal cord is furnished by Feinberg's experiments, in which the prolonged application of ether spray to the spine of rabbits caused paraplegia, which was in some cases temporary, while in others death ensued, which was found to be owing to inflamma- tory softening of the posterior columns of the cord. Clinically cases of acute myelitis are met with in persons who have fallen into the water, more especially in winter, from breaking through the ice ; after standing in water for a long time ; or after getting wet and sleeping in wet clothes. The next influence is over-exertion, such as forced marches of an army in the field, or lifting heavy loads. Veterinary surgeons are familiar with a form of myelitis in horses, after severe and MYELITIS. 207 unduly prolonged running. Where cold and over-exertion are combined, as is so frequently the case in campaigns, the patho- logical influence becomes intensified. Myelitis also comes on after violent anger, terror, and other mental emotions ; in the course of ague, typhoid fever, pleuro-pneumonia, and puerperal fever ; from haemorrhage into, and tumours of, the cord ; from disease of the vertebrae, such as caries and cancer ; after injury, such as concussion of the spine and cord, fracture and disloca- tion of the vertebrae, sabre-cuts and gunshot wounds ; and from meningitis spreading to the medullary matter. The following are the anatomical lesions of myelitis. There is softening of various degrees and extent, which may be dis- tinguished by the naked eye. In slight cases it is barely per- ceptible, but sometimes it is excessive, so that the marrow appears to be changed into a thin paste. The colour of the inflamed parts varies according to the stage of inflammation which comes under observation. The first stage is that of red softening, with hypersemia, effusion of blood, and cedematous swelling of the affected parts. The second stage is that of yellow softenvng or fatty degeneration of the nervous matter ; and the third that of grey softening, or absorption and wasting. Purulent softening, or abscess of the cord, would seem to be exceedingly rare in men, but has been experimentally produced by Leyden,' with injection of liquor arsenicalis into the cord of cats and dogs. The microscopic examination of the inflamed parts, after they have been hardened in spirits of wine and a solution of chromate of ammonia, and coloured with carmine, reveals the following pathological appearances: — In the first or hcemor- rhagic stage, blood is either effused in considerable quantities,, or there is hsemorrhagic infiltration into the meshes of the parenchyma. Later on heaps of brownish and yellow pigment are found in the tissue. The veins appear much dilated, the arterioles are rarely distended, but their adventitia shows haemorrhagic infiltration (peri-vascular haemorrhage). The nervous matter itself is considerably altered ; the nerve-fibres are enlarged, the cylinder axis swollen, aud vascular spaces or vacuoles are encountered. The ganglion cells, particularly ' ' Klinik der Kuckenmarkkrankheiten.' Berlin, 1875, vol. ii. part ii. p, 125. :208 BISEASBS OF TSJE NERVOUS SYSTEM. those of the anterior grey horns, are also enlarged and swollen ; their nuclei are thickened, and their contours indistinct. The structural elements of the neuroglia are at first enlarged and swollen, they afterwards appear to become divided, and a few oil-globules are seen between the fibres. In the second stage of yellow softening or fatty degenera- tion, there is less hyperaemia ; the effused blood has undergone the usual changes ; the swelling is diminished ; the nerve-fibres become dissociated by oil-globules, appear compressed, reduced in size, and devoid of marrow. This latter and the cylinder axis undergo fatty degeneration ; the ganglion cells waste away, the cohesion of the stroma is loosened ; portions of the con- nective tissue become thickened and hypertrophied, while other parts of it disappear; and at last a loose puriform paste is formed, which consists of oil-globules, debris of nervous matter, and connective tissue. In the third stage of grey softening, or absorption, the oil- globules become less numerous, the nervous debris absorbed, and there are large lacunae containing a clear or turbid serum, small distended veins, and tough connective tissue. In such cases the continuity of the cord may be entirely destroyed, there being an upper and a lower cone left, with no intermediate nervous matter at all. Suppuration and abscess being excep- tional, the ultimate result of myelitis is generally sclerosis ; but in mild cases the inflammatory products may be absorbed, and a certain amount of regeneration of the nervous matter takes place. All the different portions of the cord may become the seat of inflammation ; but the grey substance is more especially liable to it. It is generally first affected, and the morbid process after a time may spread from the grey to the white matter and to the periphery. Where myelitis arises from disease or injury of the vertebrae and the meninges, it is chiefly peripheral; there are areas corresponding to two or more vertebrae, and the inflammation is found most severe in the centre of such areas, while it gradually vanishes towards their extremities. The most extensive areas are habitually found in the middle and lower portion of the dorsal cord, and the in- flammation is here seen to have spread either more in a longi- MYELITIS. 209 tudinal or more in a transverse direction. In the cervical cord and the medulla oblongata the inflammation is rather more discrete, the areas being only of the size of a pea or filbert ; and we then speak of insular, multiple or disseminated soften- ing. Under certain circumstances the morbid process, after having been for some time confined to a small area, shows the tendency to travel upwards or downwards, leading to myelitis ascendens or descendens. Ascending myelitis may spread to the brain ; and descending myelitis to the nerve-roots, nerves, and muscles, leading to neuritis descendens and myositis. Those parts of the cord which were at first unafifected may eventually undergo Tiirck's secondary degeneration, without- inflammation ; and this may likewise spread to the peripheral nerves and muscles, causing various degrees of wasting as their ultimate result. Myelitis from pressure of dislocated vertebrte or fragments of vertebrae is most frequently seated in the lumbar portion of the cord, and is one of the most dangerous forms of the disease, especially where the injury has been extensive. Complete destruction of the lumbar cord by fracture of vertebrae is almost invariably fatal, while injury higher up is not nearly so dangerous. In cases of lumbar myelitis from pressure, the symptoms are particularly marked in the sphere of the sciatic, and much less so in that of the crural nerves. There is generally complete paralysis of the hamstring muscles, and the legs and feet, while the ileo-psoas and the rectus of the thigh, retain their mobility. The ansesthesia is proportionate to the paralysis, being considerable in the ham, about the nates, anus, and urethra, but much less in front of the thigh. The sphincters of the rectum and the bladder are paralysed. The- reflex excitability of the muscles of the lower extremities is at first increased, and afterwards lost. The faradic and galvanic excitability of these muscles, and their nutrition, are likewise much diminished ; they become flabby and wasted in a very short time. General disturbances of the nutrition of the affected parts also make their appearance, the most important of these being decubitus, which is often accompanied by oedema of the feet and legs. Spontaneous myelitis may affect all the different portions 210 BISSASHS OF THE NERVOUS SYSTEM. of the organ, but is most common in the lower portion of the dorsal cord. There is rarely any fever, i.e. increased body-heat, even where the course of the disease is rapid. In many cases general symptoms are quite absent ; the patients look in their usual health, have a good appetite, and sleep well. The pulse is not raised above the normal standard. There is rarely any pain, except where there is complication with meningitis. In exceptional cases, however, the temperature runs up to 101° and 102°, and there are rigors, a frequent pulse, vomiting, abundant perspiration, restlessness, and delirium at night. Sometimes the paralysed limbs have a higher temperature than the rest of the body. The progress of the disease may be extremely acute, so that the patient becomes paralysed in a few hours or days. In such cases the diagnosis of spinal haemorrhage is apt to he made, but inflammatory softening may occur almost as rapidly as haemorrhage. The disease occasionally progresses as it were by fits and starts, there being regular attacks of it which are separated by a few days' interval ; and each fresh attack leaves the patient more helpless than he was before. Or the myelitis may follow a subacute course, so that the paralysis, from being at first insignificant, gradually increases in severity, and becomes complete in a. few weeks. The first symptoms are often stiffness and heaviness of the limbs ; a feeling of ' pins and needles ' as if the legs were going asleep ; and a sensation of pressure in the region of the bladder and rectum. In some cases there is great restlessness in the limbs, which are constantly thrown about and cannot be kept quiet. When the affection is seated at the periphery of the cord, an acute dragging pain is experienced, more particularly at night. The ' pins and needles ' generally begin in the feet, or, if the seat of the disease is in the higher portions of the cord, in the fingers, and spread from there upwards until they seem to have invaded the whole of the limbs. In meningo-myelitis there is great hypersesthesia of the skin, so that the slightest touch or pressure is intolerable. Pain, which is confined to the seat of the lesion, and increased by pressure on the vertebrae, may also be present. Finally there is a feeling ■of tightness and constriction, which, according to the seat of MYELITIS. 211 the disease, is felt more round the waist, or more round the neck. The principal symptom of myelitis, however, is always paralysis of motion, which corresponds exactly to the seat and extent of the disease. It is first noticed in the feet or hands, and is incomplete, so that the muscles do not properly obey the ■commands of volition, and the movements are awkward and clumsy. Paresis, however, gradually increases to paralysis, ■which is accompanied with rigidity, where there is compli- cation with meningitis. Sometimes the toes and feet may be moved, or the knees flexed, when the patient is in bed, yet walking is impossible; or the patient may be able to walk, but the gait is tottering, the feet can hardly be lifted from the ground, support is wanted, and fatigue induced by the slightest exertion. Inflammation of the lumbar cord leads to paraplegia ; where the dorsal cord suSers there is also paralysis of the sphincters, and if the disease is somewhat high up, irregularity of the heart's action. In cervical myelitis the upper extremities alone may be paralysed — a condition which is called brachial diplegia or cervical paraplegia. Where, however, the entire transverse section of the cord is inflamed, there is complete paralysis and anaesthesia of all parts below the lesion. Myelitis above the origin of the phrenic nerve leads to dyspnoea and cyanosis from paralysis of the diaphragm. If the disease is below the origin of the phrenic nerve, inspiration may still be properly performed, jet there is pai'alysis of the expiratory muscles, and the patient, who is still able to gape, cannot cough or sneeze. "Where the inflammation spreads to the medulla oblongata, or even higher up, respiration, deglutition, and the heart's action are involved, and death is preceded by delirium and coma. Myelitis is mostly bilateral; but in some cases only one half of the cord may be aflected, and then there is hemi- paraplegia or spinal hemiplegia. In accordance with physio- logical data (p. 24), it is found that in such instances there is pai-alysis corresponding to the side of the lesion, and an- aesthesia on the opposite side. There is, however, a general tendency inherent to this disease to spread to the entire organ, where it commences with cervical paraplegia. Again, the p 2 212 I)Is:easi:s of the nervous system. unilateral variety is apt to progress intp the bilateral form, but ordinary paraplegia of the lower extremities has less tendency to spread upwards. Spasmodic symptoms are also commonly observed. The muscles of the legs particularly are subject to convulsions, combined with shooting pains through the limbs. Fibrillary twitches in the muscles are a later symptom, which shows wasting of the contractile fibre. Sometimes the convulsions of the lower extremities are exceedingly severe (Brown-Sequard's ' Spinal Epilepsy '), and occur spontaneously, or are excited by some kind of irritation, such as the application of cold, tickling- of the soles, the introduction of a catheter, or a tap on the muscles. This shows that reflex excitability is largely in- creased. The limbs may be so ' violently flexed that the heel touches the hip, or there is complete rigidity of the limbs or of some parts of them. In such cases the seat of the disease is always above the lumbar enlargement. As a rule, however, the paralysed muscles are completely relaxed, and do not offer any resistance to passive movements. In the later stages of the disease contractions are frequent, more particularly of the adductors and the hamstring muscles. Sometimes there is permanent extension of the knee, resembling Charcot's permanent hysterical contraction. The state of sensibility varies considerably in the difierent forms of myelitis. In some cases there are in the commence- ment of the disease hardly any abnormal sensations, such as pain, pins and needles, or numbness ; while in others such symp- toms are very striking. This may be explained by the inflam- mation attacking sometimes more the grey substance in the centre of the cord, and at other times more the periphery of the organ, implicating the pia mater and the posterior roots. Where there is a moderate degree of inflammation in the grey centre or the antero-lateral columns, no pain is expe- rienced. In such cases the spine is not unduly sensitive to pressure, percussion, and the applications of heat and the various forms of electricity, nor do movements of the body cause pain. There is, however, frequently a feeling of tightness round the waist, more especially in lumbar myelitis from pressure, and round the neck in cervical myelitis. MYELITIS. 213 Where the posterior. roots and the pia are involved, there is pain in the back and the extremities, especially at night. This pain is of a throbbing or shooting character, and often combined ■with painful tingling and convulsion. Such symptoms, how- ever, disappear in the later stages of the disease, when a feeling of coldness and numbness is the rule. There is rarely complete anaesthesia, even where there is total paralysis of motion. Hypersesthesia, increased reflex excitability, and a feeling of numbness are more frequent. Where reflex excitability is lost in a few days or weeks, the affection is severe, and involves the grey substance in the centre of the cord. The faradic and galvanic exploration of the muscles affords important indications as to their condition and to the seat of the disease. At first the electric excitability is normal, but later on it becomes diminished. This is more particularly the <3ase where the lumbar enlargement suffers, and less so where the seat of the disease is higher up. In severe cases it is often rapidly lost ; and we then sometimes notice the curious pheno- menon that while faradic excitability is gone, the continuous current may produce abnormally exalted effects. Where faradic or galvanic excitability return after having been absent or considerably diminished, a healing process in the cord may be safely predicted, and recovery of voluntary motion is then generally not slow in following. This condition is therefore important in a prognostic point of view. The nutrition and electric excitability of the muscles depend upon the state of integrity of the grey centre of the cord, more particularly in the lumbar and cervical enlargements. Where only the white matter suffers, both remain normal ; while, when the grey substance is diseased, both suffer, even if the white matter should have remained quite healthy. The condition of the trophic centre in the grey substance of the cord may there- fore be recognised with certainty by the state of the nutrition and electric excitability of the muscles. Where these are much impaired, there is great destruction in the grey centre ; and where they are normal or nearly so, the centre is shown to have escaped the lesion more or less. If myelitis be followed by descending neuritis and myositis. 214 DISUASSS OF THE NERVOUS SYSTEM. great wasting of the muscles takes place, mostly with total loss of their electric excitability. Sometimes these changes are confined to certain sets of muscles, leading to contraction of the, antagonists and more or less considerable deformity of the limbs. The contracted muscles may become hypertrophied, and this is more particularly seen in the ham. Where the paralysis is not complete, the degree of it is generally grea!ter after rest and less after moderate exercise. It is also more marked where the inflammation affects chiefly the antero-lateral columns, while there is more deficiency in co- ordination and muscular sensibility where the posterior columns are the seat of disease. Paralysis of the sphincters is one of the most important consequences of myelitis. It is generally preceded by spasm and hyperesthesia of the bladder and rectum, there being frequent but ineffectual desire to pass water, and complete or partial retention of the urine ; and spasm and pain in the rectum, with retention of fsecal matters. In the majority of cases the affection of the bladder is more marked than that of the rectum. After the period of spasm and hyperesthesia has lasted for a short time, the sphincters become paralysed, with the result that there is incontinence of the urine and faeces. The paralysis of the sphincters is intimately connected with lesions of sensibility. We have seen in the first chapter (p. 29) that in the normal state, when the bladder is full, a desire is experienced to empty it, and a contraction of the detrusor urinae takes place by reflex action ; but where there is anses- thesia of the bladder, the desire to evacuate the viscus is lost. Urine therefore, unless drawn off by the catheter, accumulates in the bladder until at last the tension of the sphincter is over- come, and the urine begins to dribble away. When this con- dition is caused, the bladder cannot be completely emptied except by the catheter ; and cystitis, or catarrh of the bladder, is the result. This is produced in the following manner : — When urine accumulates and stagnates in the bladder, an alkaline decom- position of the secretion takes place ; triple phosphates are formed, and vibriones and bacteria are found to swarm in the fluid, which also contains muco-pus in more or less considerable MYELITIS. 215 quantities. The smell of the urine is offensive when it is passed, and much worse after standing for some hours. In consequence of the inflamed condition of the mucous membrane, the muscular coat of the bladder loses its tone, and paralysis of the detrusor urinse is combined with ansesthesia of the viscus. Unless very great care and cleanliness are observed, this con- dition of the bladder must lead to decubitus ; but a still more dangerous consequence of it is, that the inflammation is apt to spread through the ureters into the pelvis of the kidneys and produce pyelitis and nephritis. This again leads to blood- poisoning, which is evidenced by rigors, heat, and hectic fever ; and the patient is then carried off by uraemia, pyaemia, or exhaustion. It was formerly believed that after injury to, and subsequent inflammation of, the cord, the urine was secreted in an alkaline state ; but such is not the case. The urine is found to be acid in the pelvis of the kidneys, and only becomes alkaline in the bladder, from catarrh of the mucous membrane of that viscus. The sphincter ani is at first spasmodically affected, as shown by hypersesthesia, spasm, and tenesmus. The faeces are ejected suddenly by spasmodic contraction of the muscular fibres ; or there is obstinate constipation, with tympanitic distension of the abdomen. Later on the sphincter becomes paralysed, so that involuntary alvine discharges occur, whereby decubitus is powerfully promoted. Decubitus, bedsores, or local gangrene occurs in two dif- ferent forms in this disease. There is first an acute variety, which corresponds in most particulars to the acute decubitus which comes on after cerebral haemorrhage (p. 104). This is not owing to pressure, or to the contact of the excreta with the skin, but to paralysis of the trophic centre in the grey substance of the cord, and generally forebodes a fatal result. It is com- bined with an increase of temperatm'e, which is, however, not so great as when the cerebral macula makes its appearance, the mercury rising rarely beyond 101°. The succession of pheno- mena is otherwise the same as during cerebral fever — that is to say, there is at first a macula, which is soon changed into a vesicle or bulla, resembling herpes or pemphigus. The bulla bursts after a short time, and an ulcer is left which- has the 216 DISUASHS OF THE NERVOUS SYSTEM. tendency to spread, and occasionally lays open the whole sacrum in a few days. Skin, muscles, ligaments, and hones are all destroyed in a very short time ; and this often leads to pyaemia and pulmonary embolism. Where the spinal canal is laid open, acute ascending spinal meningitis may be the result. Thus decubitus may kill in a variety of ways. The acute variety of it is chiefly observed in myelitis from injury, and destruction of the lumbar enlargement. Although most of such cases end fatally, this result is not quite so uniform as it is in the cerebral form of -decubitus. Occasionally, indeed, an eliminative inflammation is established, and the sore ultimately heals well. A physiological illustration of this is afforded by the experiments of Groltz and Leyden, who found great tendency to acute decubitus shortly after artificial production of myelitis ; but where the animals survived, it soon became considerably diminished. Acute decubitus is observed not only in the sacrum, but also on the hips, knees, and ankles. An entirely different form of bedsore is that which is developed after myelitis has lasted for a considerable time, and entered the chronic stage. Then local gangrene is slowly developed in those parts which are chiefly subject to pressure. There are two circumstances which promote a long-continued pressure of the body on the bed, viz., the helplessness of the patient, who has the greatest difficulty in changing his position, and is sometimes entirely unable to do so without the aid of an attendant ; and secondly, the anaesthesia which is combined with the paralysis, and which enables the sufferer to support the same position without discomfort for a much: greater length of time than he could in health. Circulation therefore becomes sluggish, and when irritation by the contact with the excreta is superadded to this, the bedsore is sure to appear. This form of decubitus may generally be prevented by frequently changing the patient's position, scrupulous cleanliness, and the use of stimulating lotions to the parts ; while acute gangrene cannot be prevented by any treatment whatever. Chronic decubitus is characterised by the slow appearance of dry leathery eschars, which are separated after a time by inflammation in the subjacent and neighbouring structures. MYELITIS. 217 and then leave an open sore of varying extent, but mostly very large, with putrefaction and destruction of the affected tissues. It is generally absent in the milder forms of the disease, where there is only incomplete paralysis and anaesthesia, so that the patient is enabled to change his position frequently without assistance, and has enough sensibility left to be disagreeably impressed by the effects of prolonged pressure. In such cases the bladder and bowels likewise often retain their tone, so that a further cause, viz., contact with irritating excreta, is absent. Other trophic disturbances which occur as a consequence of myelitis, are observed in the skin and the muscles of the affected parts. The wasting of the muscles is, like decubitus, of a twofold character, viz., either more or less acute, from the inflammatory process cutting off the influence of the trophic centre in the grey substance of the cord ; or it is more chronic, and then chiefly owing to disuse of the muscles. As long as the muscles are connected with the trophic centre, there is only little wasting, just as in hemiplegia from cerebral haemorrhage and softening; and atrophy, if there be any, affects chiefly the calves of the legs. Where, however, the centre of nutri- tion is considerably damaged or destroyed, the wasting is uni- form and rapid ; and such cases resemble progressive muscular atrophy in its later stages. This wasting of the muscles may be simple atrophy, and then there is an extraordinary diminution in the bulk of the limbs ; or there is an enormous development of fat between the muscular fibres, so that pseudo-hypertrophy of the muscles is produced. The muscular fibres ultimately vanish completely, and the hypertrophied masses are found to consist of fat, con- nective tissue, nerves and bloodvessels. The nutrition of the skin is generally much impaired where there is wasting of the muscles. The circulation in the corium and subcutaneous cellular tissue is slow, and stagnant ; the epidermis appears wrinkled, and is apt to desquamate. The skin is discoloured, showing a dirty yellow brownish tint. There may be an excessive growth of hair, and of the nails, which have to be cut several times a week. The appearance of the nails may also be changed; instead of pink, they look yellow, are clubbed, and break easily. Herpes zoster is not 218 DISHASHS OF THE NERVOUS SYSTEM. imfrequently present. The temperature of the limbs which was at first increased, is in the later stages of the disease lowered by 2° or 3°; there is oedema from paralysis of the bloodvessels, and a difference in the perspiration of the para- lysed parts and of the rest of the body. Sometimes the body perspires freely, while the lower extremities remain dry and cold ; and in other cases there is profuse perspiration in the paralysed limbs, while the rest of the body is quite dry. Cerebral symptoms, which are common in some other affec- tions of the spinal cord, such as insular sclerosis, and progres- sive locomotor ataxy in its last stage, are generally absent in myelitis. They may, however, become developed when blood- poisoning takes place in consequence of cystitis or decubitus. Uraemia, or ammoneemia and septicaemia, are generally ac- companied by headache, delirium, and somnolence. Where ascending myelitis or meringo-myelitis creeps up to the brain, there are likewise cerebral symptoms, which are at first those of excitement, and afterwards of depression. The patient appears then in a typhoid condition, with muttering delirium and somnolence, which soon deepens into coma. Cerebral symptoms also occur in neurolytic bronchitis, when the phrenic nerve becomes paralysed through caries, cancer, or fracture, and subsequent inflammation of the cervical cord above the third vertebra ; and death is then likewise preceded by delirium and coma. The speech is affected where cervical myelitis spreads to the medulla oblongata, and destroys the motor nuclei of the hypoglossus and other cerebral nerves. The pupils may be contracted, dilated, or unequal in size, not only in cervical, but also in dorsal myelitis. This is ex- plained by affection of the cilio-spinal region of the cord, which is situated between the seventh cervical and the sixth dorsal vertebrae. Pathological irritation of this region has the same influence as experimental Faradisation, viz. to dilate the pupil ; and this is seen in the commencement of dorsal myelitis. On the other hand, the pupil becomes constricted by destruction of the region, which occurs in the later stages of dorsal myelitis. Inequality of the pupils may be caused when only one lateral half of the cord is diseased, while the other half remains healthy. . MYELITIS. 21&' Eespiration and circulation remain normal in myelitis, unless the pathological process invades the upper portion of the cervical cord, where the pneumogastric and phrenic nerves are erposed to the pathological influence. More especially after fracture of the cervical spine there is not unfrequently neuro- lytic bronchitis, which sets in on the second or third day after the accident. Eespiration is insufficient from paralysis of the diaphragm ; it becomes very frequent ; mucus accumulates in the air-passages and cannot be expectorated, as coughing is impossible, owing to paralysis of the expiratory muscles„ Hypersemia and oedema of the lungs are then developed, and the patient dies in a state of cyanosis. The appetite is generally good, and digestion satisfactory. Vomiting appears only to occur from ursemic and other forms of blood-poisoning, after cystitis and decubitus. The lower portion of the bowel is, however, often in a state of catarrh, which causes diarrhoea, accompanied with tenesmus. Priapism is not a constant symptom of myelitis, but occurs now and then, more especially where the cervical and dorsal cord are affected. It may occur at the commencement or in the further progress of the disease, and last sometimes for several days consecutively, with excitement of sex ual desire. It causes much pain and inconvenience, although the erection is as a rule not so complete as it is in health. In the later stages of myelitis, the sexual power is completely lost, and erection impossible. When myelitis occurs in children, the symptoms of irritation, are more marked than in adults. There is much fever, choreic restlessness, clonic convulsions, and sometimes tetanic rigidity of the whole frame. The neck is stiff, the jaw locked, and the- issue generally fatal. In the few patients who survive, motor paralysis remains after the attack is over. Myelitis is always a severe disease, which in a large number of cases proves fatal in two or three days, or as many weeks. It is more dangerous to life when seated high up in the spinal canal. Fracture of the odontoid process of the atlas, and other kinds of injury near the medulla oblongata, cause death almost directly, and before inflammation can be developed ; but even where the morbid process is lower down in the cervical spine,. 520 DISEASES OF THE NERVOUS SYSTEM. the patient's life is in great jeopardy. Inflammation of the middle portion of the dorsal cord is also dangerous, the spinal •canal being very narrow in that locality, owing to which the ■cord is more easily disorganised in its entirety. In cervical myelitis, death generally occurs from respiratory paralysis, while in dorsal and lumbar myelitis it is more frequently owing to blood-poisoning from decubitus and cystitis. When myelitis does not kill within two or three weeks, its progress becomes of a more chronic character. The patient is even then by no means out of danger, more especially where the affection has come on spontaneously ; while that form of inflammation which occurs after injury has generally a more favourable course. There have been cases of perfect recovery from cervical myelitis after a stab in the cervical region, :and fractm-e and contusion of vertebrae; and this accords Tvith the physiological fact that animals in which the cord was divided, so as to produce complete paralysis and ansBsthesia below the seat of the lesion, have entirely regained the lost- functions, perfect healing and regeneration of the injured organ having taken place. In such cases the reflex excitability which had been lost is seen to return ; the condition of the bladder and the nutrition of the muscles improve; and ultimately common sensation and motor power are re-established. ■This healing process is generally protracted over six months, and sometimes even a longer period. In other cases the condition of the patient remains sta- tionary. The paralysis and anaesthesia remain nearly the same as they were at the end of the first fortnight ; the symptoms on the part of the bladder and rectum vary, getting sometimes better and sometimes worse ; the decubitus heals and breaks out again ; and the patient, now an incurable invalid, may live for many months and even years, in a most uncomfortable condition. Finally, myelitis may have become chronic, and yet be progressive in its character, so that from time to time fresh attacks occur which always leave the patient worse off than he was before. This progressive myelitis occurs in the descend- ing or ascending variety. If descending, the grey substance MYELITIS. 221 becomes more profomidly affected, as shown by loss of reflex excitability, and muscular atrophy and contractions ; while decubitus and oedema may be rapidly developed. In ascending myelitis the principal new symptoms are dyspnoea, cyanosis, delirium, somnolence, and coma, which insensibly merges into the final dissolution. 222 BISHASUS OF THE NERVOUS SYSTEM. CHAPTER VI. EPILEPSY, HTSTEEIA, AND CATALEPSY. 1. Epilepsy. This most formidable of all diseases of the nervous system was, from its violent and terrible symptoms, and the reputed inefficacy of all remedies employed for its cure, by the ancients believed to be a direct and irrevocable infliction of Providence, and was therefore distinguished by the term ' Morbus sacer.' It is also known by the synonyms faUing sickness, morbus divus, astralis, caducus, sorticus, lunaticus, herculeus, daemoniacus, vitriolatus, comitialis, deificus, analepsia, apoplexia parva, St. Valentine's and St. John's disease, mal St. Jean, mal St. Grilles. The following table shows the mortality from epilepsy in England and Wales during six periods of five years each, as ■well as the percentage of mortality, first of nervous diseases, and secondly of all diseases : — • Periods of five Deaths from Percentage of Percentage of years Epilepsy Nervous Diseases all Diseases 1838^2 5,585 2-66 •32 1843^6 vacat vacat — 1847-51 8,667 3-62 •42 1862-56 10,339 4-01 •49 1857-61 11,689 4-31 •54 1862-66 12,359 4-21 •51 1867-71 12,290 3'98 •49 Total of thirty years 60,929 386 •47 It will be seen from this table that there has been a decided EPILEPSY. 223 increase in the mortality from epilepsy during the first four lustra which have been registered ; while more recently it seems to have become less fatal, there having been a decided fall since 1862 ; but this fall has not been as great as the previous rise had been, so that the first lustrum is still much above the last. The following table shows the Influence of Sex on Epilepsy. Periods of five years Males Percentage Females Percentage 1847-51 1852-56 1857-61 1862-66 1867-71 4479 5441 6972 6585 6483 1'86 2-10 2-41 2-21 2-10 4188 3998 5717 5774 5805 1-74 1-55 2-10 1-96 1-87 Men are therefore more liable than women to die from the faUing sickness, the mean average for the former being 2*1 3, against 1"84 for the latter. Age has likewise a decided influence on the mortality from this disease, which appears, from the annexed diagram Gr, to be very fatal in the first year, and altogether so in the first lustrum of life. At five the curve descends, rises slightly at ten, jumps up high at fifteen, and reaches the summit at twenty. At twenty-five it descends, and more considerably so at thirty. Another rise is perceptible at thirty-five and forty, and then a more decided faU occurs until fifty-five. At sixty it suddenly rises again, but after that the fall is steady, and at ninety the curve has descended to zero. The influence of age on the occurrence of epilepsy in the two sexes is shown in diagram H. It is seen from this that the thick curve for males overlaps that for females in the first year of life, but that for the first period of five years both curves are nearly equal. From this until twenty-five the thin curve keeps at the top, but falls below the thick at thirty, ahd remains there until forty. After that a kind of zigzag movement is observed, there being no very decided prominence of one over the other, except between seventy and eighty, when the thick curve predominates. 224 DISEASES OF THE NERVOUS SYSTEM. Diagram G. wing the influence of AGE on the Mortality From EP 1 L E P S Y in England and Wales in 1847 cw ■ M« a o ; oO r o CO ,«- J >0 / > -^ o ; / — 1 »^ \ / ^ o 5< k o ^ > 3 ■A CM ,^ ! > o Sf< ^ N lO s. t o — ^ s. •o — s ■s !«. a' c: "^ a * ■^ -1 9 ««) ' ^ CM ; - ^ s- ■^ '' JC CO L i 1 ? o o 1 i s o 8 o s S o ? o o o o EPILEPSY. 225 Diagram H. Showing the Influence of ACE on iho Mortality of MmeS ftFEMMES frwm EPILEPSY in England & Wales in 1847 Ck- 4 0) ^ = o 05 J° CO / ^ o ^ b *, -^ •1 ^ y ^ ? o to E =<^ ^ m to ^ S5 o r-^ «; f ^ 1 ? < <. a °\ ^ ^ \, o to J\ 3 15 -^ O o CM §< ^ % 12 ^ ^» O ' ♦ ^ ?- 1 lA iBiiiiiT ^ ^=43 3 < 3^ ^ '^ ==i *a ^t- CO a (f* (M ■/^ - ^ L I- S^ o CM o o o o o 00 o O (8 o O o o CM 9 o s 9 226 BISHASES OF THE NERVOUS SYSTEM. The principal divisions of epilepsy which have been current are centric and eccentric, sym/ptomatic, sympathetic, and idio- pathic epilepsy. Centric or idiopathic epilepsy, which results from a morbid condition of the pons and medulla oblongata, is, however, the only complaint which should be properly called epilepsy, and it is this which I mean whenever I employ the term. Authors speak of eccentric epilepsy where there is some palpable source of irritation outside of the nervous centres ; such as disease of the kidney, stone in the bladder, worms in the intestines, uterine disturbances, etc. Now, it is quite true that under such conditions, epileptiform convulsions may be induced ; but as a general rule these latter are merely reflex phenomena, arising from an irritation of the sympathetic nerves being trans- mitted to the nervous centres ; and have only the outward mani- festations in common with true, centric, or idiopathic epilepsy. Epilepsy has been called symptomatic or reflex where con- vulsions arise from fracture of the skull, cerebral tumour, or spinal disease ; where the patient is under the poisonous in- fluence of alcohol, lead, or mercury ; where there is a systemic cachexia, such as anaemia, struma, rickets, or syphilis ; or where there has been injury to the extremities or peripheral nerves. The term sympathetic epilepsy is used where it appears to arise from irritation of the sentient or ganglionic nerves ; such as neuralgia of the face, foreign bodies, insects or worms in the nostrils and frontal sinuses ; the irritation of dentition ; urethral and viscal calculus ; indigestion ; worms in the intestines ; uterine and ovarian irritation, and masturbation. Some authors have assumed a further form of vaso-motor epilepsy, which they thought was caused by affection of the nerves of the arterioles accompanying the •sympathetic nerve and its ramifications ; as, for instance, after getting wet feet, etc. Dr. Brown-Sequard has described spinal epilepsy, which however consists in some cases of simple convulsions of the lower extremities, as seen in myelitis, and in others foUows injury of the peripheral nerves. Some ob- servers have gone so far as to deny that epilepsy is a real disease, and consider it only a symptom, the epileptic attacks being, in their opinion, invariably owing to some coarse structural disease affecting either the nervous system or remote parts. Such an opinion can only be attributed to insufficient observation EPILEPSY. 227 of the complaint, and will certainly never be endorsed by those who have studied the symptoms and habits of epileptics more particularly ; for it is then seen that epilepsy is a true general neurosis, which, although principally located in the pons and medulla, affects the whole cerebro-spinal and sympathetic system of nerves, presents striking featmes in the sphere of mind, sen- sation, motion, and nutrition, and impresses upon the patients suffering from it a peculiar appearance, physiognomy, character, and habits of intellect. It is quite true that it may originate from peripheral or central irritation, as in Brown-Sequard's guinea-pigs ; but the symptom becomes a disease when it has been reproduced several times, and may then be transmitted to the next generation. If, therefore, any distinction is to be made, it would be only justifiable to speak of primary and secondary epilepsy. Primary epilepsy would then be identical -with the idiopathic or centric form of the disease, owing simply to a peculiar alteration in the pons and meduUa oblongata, without any coarse structural alterations; while secondary epilepsy would comprise the reflex form, in which the first out- break of the disease is owing to some definite irritation in the brain, spinal cord, or peripheral nerves. It should, however, be understood that both forms are identical in this way: — that although secondary epilepsy may originate in a remote lesion, it will not cease after the removal of the irritation, but that, when the characteristic alteration in the pons and medulla has once become established, fits wiU occur spontaneously. That the pons and medulla oblongata are the principal seat of the disease is shown by the fact that epileptic attacks may still be caused in animals after removal of all other encephalic centres, while destruction of the two parts just named renders such attacks impossible. The spinal cord — which Marshall Hall thought the true epileptic centre, causing trachelismus and laryngismus, or tetanic convulsion of the muscles of the neck and larynx, with consequent asphyxia, loss of consciousness, and convulsions — serves only as a conductor between the medulla oblongata and the pons on the one hand, and the motor nerves and muscles on the other hand, but is of itself of no importance in the production of epileptic seizures. We have already seen (p. 65) that cerebral anaemia suddenly Q 2 228 JDISBASJSS OF THE NERVOUS SYSTEM. induced will cause all the symptoms of the epileptic attack, but although this anaemia unquestionably exists in the begin- ning of the fit, it is soon succeeded by venous congestion, in consequence of respiration being arrested though spasm of the glottis. Pathological anatomy has as yet not helped us in explaining the nature of the peculiar condition of the brain which gives rise to epilepsy. In recent cases the post-mortem appearances are quite negative. Where, however, death takes place after a series of attacks, there are generally signs of venous hypersemia in the nervous centres. The sinuses of the diira mater are gorged, the veins of the pia dilated, more particularly in the neighbom-hood of the pons, medulla oblongata, and cerebellum ; and there may be capillary haemorrhage in the cineritious sub- stance, as well as in other remote organs, such as the heart, lungs, mediastinum, and mesentery. In a few cases the heart has been found ruptured, but otherwise healthy, and this must have been owing either to spasm or to the violent efforts of the ventricles to squeeze the blood into the compressed arteries. The changes which I have just mentioned have of course nothing to do with the causation of the epileptic attacks ; and the peculiar alteration of the nervous system which causes epilepsy is as yet entirely unknown. Perhaps this alteration is only molecular ; but be this as it may, it must be considered one of the great aims of the pathology of the future to elucidate this condition. The following is only a slight instalment of what remains to be done. The slmll has a peculiar shape in epileptics, more particu- larly where the disease has existed from childhood, or has come on in consequence of hereditary predisposition. There is a want of symmetry in the bones of the two sides; and they appear thickened and sclerosed, while in other cases they have been found attenuated. Stenosis of the foramen magnum and the spinal canal has also been discovered; and Virchow has drawn attention to the circumstance that stenosis of the skull is frequent in epileptics as well as in insane persons, and that in such cases there is a corresponding aplasia of the brain, which may be limited to a small region or spread over a considerable area. EPILEPSY. 229 Benedict,* who has recently given much attention to this matter, has found that in many habitually epileptic persons the tubera parietalia appear considerably displaced, the frontal tuberosity asymmetrical, and the forehead irregular. This want of symmetry is found to be most striking when a line is drawn and measured which extends from the root of the nose right across the skull to the spinous processes of the uppermost cervical vertebrae ; as it is then seen that the frontal, parietal, or occipital part of one side is much less developed than that of the other, or that the frontal part is more developed on one side, and the occipital more than on the other. It may be assumed that under these circumstances a kind of compensation can be brought about, not only in the asymmetry of the skull but also in the corresponding aplasia of the brain. Provided such compensation be perfect, the irregularity may be devoid of pathological significance ; but if imperfect, abnormal function of the brain may be the consequence. That aplasia and atrophy of nervous matter are often connected with convulsion and pain is well known ; and I may here advert, as an instance of it, to the late Dr. Anstie's theory of neuralgia being caused by wasting of the posterior roots of the spinal nerves. The importance of these discoveries cannot be over-estimated, as predisposition, hereditary influence, and similar agencies may thus be ex- plained. A different skull-shape, corresponding to a dif- ferently-developed brain, appears to give a more defined base for comprehending different functions than can be obtained if we seek refuge in generalities. The first glimpse is thereby afforded into certain well-marked anatomical differences, which would go far to render prognosis bad, if it was not also known that such irregularities may gradually disappear more or less under the influence of treatment, and that what was once a cause of disease, may come to be only a predisposing influence, which may remain latent under favourable conditions. Benedict has also found that the condition known as oxyce- phaly is of frequent occurrence in epileptics. If the head be so fixed that the zygomatic arch is in a horizontal position, or so that the direction of the visual axes of both eyes is parallel, and ' ' Berliner Klinische Woclienschrift.' 1877. No. 32, 230 DISEASES OF THE NERVOUS SYSTEM. that the plane of these visual axes is parallel to the g[round, it is found that the highest point of the forehead and the vertex have only a slight vertical difference from one another. In idiopathic epilepsy, on the contrary, this difference is very con- siderable, and is particularly noticeable when the highest point of the parietal bone is more forward in the region of the angulus bregmaticus. This shape of the skull is also found in habitual criminals, and more particularly -in confirmed thieves. The membranes of the brain have been found either normal, or thickened and adherent to each other. With regard to the brain itself, the weight has been found increased by Echeverria,' and diminished by Meynert. The increase does not appear to have been owing to any greater development of nerve-cells, but to proliferation of the nem-oglia. Want of symmetry between the two hemispheres, the left side being less developed than the right, has also been discovered. Meynert has met with atrophy of the cornu ammonis in several cases of epilepsy ; other observers mention tumours, more especially of the cortex, syphilitic deposits, neuroma, sclerosis, softening, cancer, tubercle, and general wasting, with hydro- cephalus, but it is evidently impossible that so great a variety of pathological lesions should have given rise to one and the same complaint. Most of the structural alterations which have been hitherto described have evidently been complications co-existing with, but foreign to, epilepsy itself. The microscope has, up to the present time, assisted us very little in these matters. Schroder van der Kolck came to the conclusion that in the commencement of the disease there were no alterations of the nervous matter at all ; but that after a time an intercellular albuminous effusion took place between the nervous fibres, causing sclerosis and fatty degeneration of the nervous matter and dilatation of the capillary vessels, with thick- ening of their coats. This ectasy of the capillaries was seen chiefly about the roots of the hypoglossus (in cases where epi- leptics had been in the habit of biting their tongue) and the pneumogastric nerves (where there had been no tongue-biting). ' On Epilepsy: Anatomo-Pathological and Clinical Notes. New York. 1870. EPILEPSY. 231 Van der Kolck, however, did not look upon these changes as causative of epilepsy, but as consequences of the hyperaemia developed by the attacks. Echeverria has described the following as primary lesions of epilepsy : — capillary ectasy in the medulla oblongata, granu- lar albuminous effusion, granular cells, abundant amylaceous bodies, not only in the neuroglia, but also in the transverse section of the floor of the fourth ventricle. The ganglion cells appeared pigmented, more especially in the nuclei of the hypoglossus and pneumogastric nerves. The same changes were found in the hemispheres, the centra ganglia, the cerebellum, and the cervi- cal sympathetic nerve. In all these cases the connective tissue was found hyperplastic. Labimoff, however, has shown that the ganglionic cells are frequently found pigmented in the aged, without there having been any epilepsy, so that the importance of these alterations appears somewhat doubtful. Ludwig Meyer, who has most carefully gone over the same ground, has come to the conclusion that all the vascular changes which have been described by various authors are secondary and not primary ; and we agree with him in thinking that any uni- form histological alterations causative of epilepsy have still to be discovered. AH we know is that there is undue excitability of the ganglionic cells in the pons, where there is the central termination of the motor nerves ; and on the floor of the fourth ventricle, where there are the grey nuclei for the motor cerebral nerves, as well as the vaso-motor and respiratory centre. These parts respond to stimulation more energetically than usual, so that instead of movements convulsions are produced, while the coma is a secondary phenomenon. Dr. Todd was of opinion that the epileptic attack was owing to a morbid poison which gradually accumulated in the blood, and produced a state of undue excitability of the brain. This view is unquestionably right for the convulsions of uraemia, but no proof has been given that there is a poison producing epilepsy. It is true that carbonate of ammonia has been found in the urine several hours before the attack ; and that after the attack is over, the perspiration and the expired air have been found to contain a considerable quantity of the same compound ; but such changes are by no means constant. 232 DISEASES OF TJSE NERVOUS SYSTEM. We have in practice to distinguish three principal forms under which epilepsy presents itself, viz. : 1st. The true falling sickness, epilepsia gravior, haut mal, which is characterised by the sudden appearance of unconscious- ness and general convulsions ; 2nd. The milder form of epilepsy, epilepsia mitior, petit mal, the lesser evil, where there is only loss of consciousness, but no convulsions ; and 3rd. Epileptic vertigo, which consists of irregular attacks of the disease, there being generally slight attacks of epilepsia gravior or mitior, with subsequent mental aberration and auto- matic action, for which the patient is not responsible. A. The Epileptic Fit. The true epileptic fit is generally preceded by premonitory syraptoms, which may be remote or immediate. Eemote precursors are often found before the very first attack which takes place altogether, and are chiefly observed in chil- dren, and where the exciting cause of the complaint is fright. These precursors may indeed be looked upon as incomplete attacks. There is general tremor ; pallor of the face, alternating sometimes with blushing; giddiness; a terrified appearance, which may be combined with excitement or depression ; noises in the head ; slight convulsive shocks in the hands and feet ; and a severe epileptic fit may take place after this condition has lasted for a few hours, days, or even months. What is called night-alarm, or ' night-mare,' in children, is often an incomplete epileptic attack. The children go to bed and to sleep in the usual manner, but after a time scream, en- deavour to get out of bed, stare at some imaginary object, break out into a profuse perspiration, faU back exhausted and relaxed, and go to sleep again. Such attacks may be repeated several times in the night, and the little patients have no recollection of them on waking in the morning. Those who have already had epileptic seizures may sufier in a similar manner when a fresh attack is threatening them. They feel depressed, tired, and excitable ; are restless at night ; the eyes are brilliant ; there is a peculiar physiognomical expression, which EPILEPSY. 233 is easily recognised by those who have watched them in previous attacks ; they complain of pressure on the head and palpitations of the heart. Or they have hallucinations, perceive a bad or a nice smell which is not perceived by anybody else ; hear voices threatening them, cocks crowing, and cats howling ; they see disagreeable faces, have terrifying dreams at night, and sexual ' excitement during the day. The immediate precursor of the epileptic fit is called aura. This means originally a soft breeze ; and the sensation described by some patients is, indeed, that of a hot or cold wind ; but in general the aura may be defined as a sensation which seems to arise from a peripheral part of the body, and thence proceeds to the head. The aura may be cerebral or mental, vaso-motor, motor, sensorial, sentient, secretory, visceral, or indefinite. The first of these is the one most frequently experienced, and charac- terised by sudden excitement, swimming in the head, seeing everything spinning round, and certain definite hallucinations. Children appear frightened and run to their mother, shouting, ' Mother, I am going to have a fit ! ' Occasionally there is a peculiar idea which the patient cannot describe when he is in his ordinary condition, but which is always suggested to him previous to an attack, and which is not only the last thing he perceives before the fit breaks out, but also gives him during that instant the certainty that he is going to have an attack. The vaso-motor aura consists of a feeling of chilliness in the extremities, wliich gradually rises upwards. The parts become really cold, pallid, and anaesthetic, as firom the prolonged influ- ence of external cold, when all the blood seems to be withdrawn from the periphery by vaso-motor spasm. The motor aura consists of convulsions in certain muscles or sets of muscles, which are mostly clonic and rarely tonic. They seem to arise chiefly from irritation of Hitzig and Ferrier's psycho-motor centres, as they have mostly a definite type, and resemble physiologically combined movements, only appearing in an exaggerated form. They may last for a few seconds or a few minutes. In a lady at present under my care, they occur in the right wrist (Jackson's regional spasm) almost inunediately after lying down at night ; they continue for two or three 234 DISEASES OF THE NERVOUS SYSTEM. minutes, can be stopped by pressure, and lead to an attack unless so stopped. I consider them owing to irritation of the ascending frontal convolution of the opposite side. Occasionally we meet with spasm of accommodation of vision, so that objects, appear to become larger, or nearer, or further off. The sensorial atua may proceed from all the different nerves of special sense. The most frequent aura appears to be a dis- agreeable smell, resembling tar, brandy, iodine, rancid fat,, tainted fish, or high game ; after that follow ' epilepsy of the retina,' viz., a sensation of coloured light or stars floating about, noises in the head, and a disagreeable sweetish taste in the mouth. The sentient aura consists of a feeling of pins and needles which begins in the toes and fingers, and from there proceeds to the head ; or there may be unilateral headache, and numbness in one side of the face. The secretory aura is evidenced by profuse perspiration, laehrymation, and salivation ; while the visceral aura consists of palpitations of the heart ; a feeling of constriction, choking,, pressure and heat in the epigastrium, retching, nausea, vomiting, intestinal colic, and tenesmus of the bladder and rectum. Some- times there is only an indefinite sensation of malaise, and odd sensations which the patients find it impossible to describe. An aura may be present without leading to an attack ; and the latter may often be cut short when a sudden impression is made on the nervous system ; as, for instance, tying a ligature round the arm or leg, shaking the patient, shouting to him, violently flexing the big toe, letting him smell ammonia, or giving him powerful medicines to swallow. Is the nature of the aura peripheral or central ? Some ob- servers are inclined to look upon it as a peripheral sensation, while most consider it as simply an echo of a central condition. The aura appears to us part and parcel of the epileptic attack, and differing from the latter only in degree. Thus giddiness is a lesser degree of coma, and localised convulsions in the muscles of the wrist a slighter degree of general convulsions. We can only assume the aura to be peripheral in those cases where injury of peripheral nerves, such as the sciatic or the fifth, appears to give rise to epilepsy. The fact that an attack can EPILEPSY. 235- sometimes be prevented during the aura by a powerful im- pression being made upon certain peripheral parts, does not by itself speak for the peripheral nature of the aura ; for under such circumstances there is no interruption to any peripheral excitement spreading towards the centre, but on the contrary reflex inhibition, spreading from the centre to the periphery. In a case of Odier's the aura consisted of convulsions of the brachial muscles, and could be stopped by ligature of the arm ; yet at the necropsy a cortical lesion was discovered, which had to be looked upon as the starting-point of the aura as well as of the attack. The epileptic fit consists of three periods, and generally commences with a scream, which used to be considered as a sign of pain, surprise, or terror of the patient, but is really owing to the spasm of the respiratory centre in the medulla oblongata,, which causes a sudden convulsive action of the laryngeal muscles, by which the glottis is closed and a column of air expired. The face is at first pallid, but afterwards livid, and consciousness is lost. This is owing to irritation of the vaso-motor centre in the medulla, by which sudden anaemia of the face and the cere- bral hemispheres is brought about. At the same time the patient goes down like a shot, whether he be standing or sitting, and there is only rarely time for him to lie down in a place of safety. The fall is not owing to loss of consciousness and sen- sibility, as has been supposed, but to the sudden convulsions of the muscles ; for in that form of epilepsy which is called ' petit mal ' there is also loss of consciousness, but the patient remains sitting or standing as quietly as before. If in the convulsive attack he goes down in the street, he may be run over ; if in a room, he may fall into the fire, and seriously injure himself in a variety of other ways. Sometimes the skull is fractured, and death may result from purulent meningitis. The coma is, how- ever, so deep during the attack that no pain whatever is ex- perienced. The conjunctiva is quite insensible ; the pupils are dilated and do not respond to the influence of light. The pulse is generally small, but sometimes quite unchanged ; or the pulse of the radial artery may be imperceptible, while the heart's action is normal and the carotids are felt to throb violently. At the same time there is tonic rigidity of the whole frame ;. 236 DISEASES OF THE NERVOUS SYSTEM. the eyes axe drawn backwards and upwards, so that the cornea is concealed under the upper eyelid. The face, and particulai-ly the mouth, is fearfully distorted ; the teeth are pressed against each other with great force, so that the tongue or the mucous memhrane of the cheek is bitten. The head is drawn to the side, or forwards or backwards. One arm is generally drawn up and the other down. The body is in a state of opisthotonus, and respiration is arrested. The pallor of the face, from anasmia of the blood-vessels, sometimes lasts through the entire first period of the fit. An ophthalmoscopic examination of the fundus of the eye is impos- sible under such circumstances, but it has occasionally been made just previous to an attack, when anaemia of the blood- vessels was observed. GreneraUy, however, the pallor is quickly succeeded by lividity of the face, with swelling of the cheeks, lips, and tongue. This is owing to the closure of the glottis and the immobility of the chest-walls, which leads to accinnu- lation of blood in the capillary vessels. The pressure on these is sometimes so great that they are ruptured, and effusions of blood take place. The whole surface of the body, but more especially the face, may thus become covered with petechise, looking like flea-bites. The complexion is sometimes quite coppery, and the patient looks like a red Indian. These petechise always show that the attack has been severe. In some cases they remain only for a few hours, but a degree of congestion may still be seen about the face for a few days after, a.nd by means of a magnifying lens we may even then be able to distinguish traces of the petechise themselves. They are chiefly marked in the neighbourhood of the eyes and sometimes affect the conjunctiva. Capillary haemorrhage, from excessive pressure, may, however, take place in other organs, such as the brain, and occasionally causes bleeding from the mouth and tongue where these parts have not been bitten. In the second period of the attack, the insensibility con- tinues, but the tetanus of the muscles is replaced by clonic con- vulsions, which consist of sharp, quick, short, and most violent muscular contractions separated by quiet intervals. They .are sometimes so severe that the bones are fractured or dis- located, more especially the shoulder, elbow, and the lower jaw, EPILEPSY. 23r teeth are pulled out, muscles ruptured, and the tongue entirely bitten through. Nevertheless the occurrence of these clonic convulsions shows that the excitability of the pons and medulla is diminished. The convulsions are hardly ever quite bi- lateral; and when this occm-s it should raise our suspicions whether the patient may not be simulating epilepsy. Some- times there is tonic rigidity in one side, and clonic convulsions in the other, while in other cases the convulsions are strictly unilateral. They affect the flexors more than the extensor muscles. There is now foam at the mouth, which is often mixed with blood, either from the bitten tongue or cheek, or simply from rupture of the blood-vessels of the mucous membrane, causing extravasations, just as petechise of the skin are caused by rupture of the blood-vessels of the corium. The face is more awfully distorted in the second than in the first period. Eespiration is now forcible and accelerated, accompanied with rales, and the buccal and pharyngeal mucus is thrown backwards and forwards by the inspired and expired air. The patient now often begins to moan, and may do so for several minutes, which is not owing to pain, but to irritation of the corpora quadrigemina (p. 42), At the same time there are borborygmi in the intestines ; flatus, faeces, urine, and even semen may be discharged, and projected to a considerable distance. There are now all the signs of venous hypersemia, viz., swelling of the jugular veins, deep cyanosis, and prominence of the eye- balls. The pulse is now full and frequent, but occasionally very slow. The third period is that of relaxation of the muscles ; the clonic convulsions cease, either suddenly or gradually, the limbs become completely relaxed, and sometimes a kind of tremor is seen to run through the body. There is stertor and tracheal rales ; the skin is bathed by a clammy perspiration, which frequently has an offensive smell, from containing carbonate of ammonia. The insensibility may continue for a few minutes longer, but generally consciousness now begins to return. The patient opens his eyes, and closes them again ; he talks or mur- murs in a dreamy fashion, and seems absent. The colour of the face becomes less livid, and the pupils begin to contract. Eespi- ration is more tranquil and regular, the pulse continues full and .238 DISS ASUS OF THE NERVOUS SYSTEM. frequent. The ophthalmoscopic examination of the fundus of the eye shows considerable hypersemia, which sometimes con- tinues for twenty-four hours. The temperature is generally found normal or only slightly increased. The quantity of the urine is often increased; sugar, albumen, and spermatozoa have been found in the urine by some observers, but this is excep- tional. The entire duration of the epileptic fit is from two to ten or at most fifteen minutes. In the large majority of cases it lasts from three to five minutes. The first or tetanic period is generally the shortest, lasting from a few seconds to half a minute, or one minute, while that of the clonic convulsions is the longest, and lasts from three to six minutes. As a rule the third period is followed by a deep and tranquil sleep, which lasts from one to several hours, and from which the patient awakens sometimes quite well. At other times there is utter want of recollection of what has happened ; irritability of temper and great depression, or maniacal excitement, which may last for several days ; or a state of confusion and imbecility combined with severe headache and soreness in the limbs. Sometimes aphasia and hemiplegia are discovered after the attack, but in such cases the latter was not one of true epilepsy, the convulsions having been owing to a coarse anatomical lesion, such as tumour of the brain, or cerebral haemorrhage, or embolism of the sylvian artery. Unilateral or bilateral anaesthesia and parsesthesia have also been observed after epileptic seizures, owing probably to -capillary haemorrhage at the time when venous congestion was at its acme. The temperature may rise to 99° or 99°*5, and continue so for a few hours. The epileptic fit is often simulated for purposes of extortion, and on the Continent in order to escape military conscription. Epilepsy is more easily simulated than other diseases, as only an occasional performance is required, and the malingerer is after the exhibition at liberty to do what he likes. On the whole, however, it is not difficult to distinguish between real and simulated epilepsy. It is true that the malingerer may fall, scream, get red in the face, imitate the foam by chewing a bit of soap, lock his thumb into the hand, and pass his water and EPILEPSY. 239 faeces ; but he cannot get his pupils dilated during the attack, and sensitive to light after it ; he cannot make his temperature rise ; lie cannot get petechise in the face ; and generally kicks both legs about in the same manner, whUe the true epileptic convulsion is more unilateral. The malingerer has no scars in the face, which are very frequently seen in the true epileptic ; and he rarely has sufficient force of mind to bite his tongue. The sphygmograph has also, in the hands of Voisin and others, furnished some interesting data. According to Voisin, the pulse becomes quicker shortly before the attack, has less force, and the sphygmographic elevations are lower and more approached to each other. During the attack, when the pulse is small, the undulations are slight, showing irritation of the vaso-motor nerves and contraction of the arteries. This, how- ever, is soon succeeded by a paralytic condition of the sym- pathetic nerve, when the pulse becomes full and large, and the sphygmographic tracings higher and more pronounced. The convexity of the elevation points upwards. A few minutes after the attack is over, the elevations rise three or four times higher than before, make an acute angle, then descend and show dicrotism. Voisin explains these tracings by primary irritation and subsequent paralysis of the vaso-motor nerves. Magnan has recently studied the state of circulation during the epileptic attack in dogs, in whom he induced convulsive seizures by the injection of absinthe, and then employed Lud- Tvig's kymographion and Marey's polygraph. He found that during the first period of tonicity the pulse was accelerated and the arterial pressure increased ; but that, as soon as the second period of clonic convulsions commenced, the pulse was greatly retarded, and arterial pressure very much diminished. With the beginning of the third period of muscular relaxation, the pulse regained its normal rate, or was slightly accelerated. All these phenomena, however, did not occur if the pneumogastric nerve was previously divided. Magnan concludes from these observations that during the period of tonicity the heart is in a state of partial tetanus, much the same as the other muscles, and cannot dilate properly, and that this state is brought about through the influence of the pneumogastric ; while the retarded pulse and diminished arterial pressme of the second period are 240 DISEASES OF THE NERVOUS SYSTEM. due to temporary exhaustion of the cardiac muscle. It seems to us, however, better to explain them by assuming that there is at first irritation and afterwards paralysis of the sympathetic ganglia, the former causing a rapid, and the latter a slow pulse j for when the influence of the sympathetic system of nerves is removed, the inhibitory influence of the pneumogastric becomes paramount for the time being, with the result of cardiac action being retarded or even entirely suspended. Death in the epileptic attack is rare, but it may occur if the patient is seized with a fit while bathing, when he may be drowned, or while eating, when he may choke. It is also occa- sionally consequent upon injuries received through the fall, but occurs only exceptionally from asphyxia or syncope. Epileptic attacks may occur either both night and day, or only in the night, or only in the day ; and in some patients they only come on at certain hours of the day. One of my hospital patients, a domestic servant, never had fits except the first thing in the morning, when she was lighting fires. Noc- turnal attacks leave the patient less exhausted, both mentally and physically, than those which occur in the day-time. In women the menstrual period, including a few days before and after the discharge, is most exposed to fits ; and in some women these come on only during cohabitation. In certain febrile diseases the attacks cease completely, and only reappear when the body-heat has fallen to its normal standard. Some patients have fits only once in two or three years, while others have a very large number in a single day. A patient whose case I have described elsewhere ' had had over 10,000 attacks at the time she came under my care, and as many as 165 in one week; for several years past the minimum had been twenty in the week, not a single day having been free from them. Some months ago a boy was under my care at the hospital, who had between 40 and 50 attacks in the day, which makes about 1,350' in the month ; and Delasiauve has described a case in which 2,500 fits occurred in one month. Where severe attacks succeed each other very rapidly, a peculiar condition is produced which French observers have ' ' On Epilepsy, Hysteria and Ataxy.' London, 1866. EPILEPSY. 241 called etat de mal epileptique, and which I propose to call by a shorter term, epilepticism. There is then no recovery of consciousness between the seizures, which follow each other like thunderclaps ; the respiration is much accelerated ; the pulse rises to 140 or 160 beats in the minute, and is excessively small ; the temperature ascends to 106° and 107°; there is deep stupor and collapse ; and the patient dies after two or three days, without having recovered his consciousness. Epilepticism is, however, not invariably fatal, and the most reliable sign of improvement in the patient's condition is a lower temperature. The same person generally has the same attack. One person gives the same initial scream, falls forwards, the tongue is bitten in the same place, and the convulsions last exactly five minutes. Another patient never screams, nor bites the tongue, but falls towards the left side, foams much at the mouth, and passes his water in the attack. There are thus infinite varieties of the attack, and the classical type of it which I have just described may undergo numerous modifications. B. The Lesser Evil. The second form of epilepsy is the petit mal, the lesser evil, epilepsia mitior. This consists of loss of consciousness without convulsions ; is preceded by vertigo, or a strange sensation rising from the epigastrium to the head, and followed by confusion. The loss of consciousness is generally short, that is, a few seconds or a minute ; but in exceptional cases it is prolonged to half an hour or more. The patient does not fall, but remains sitting-^ or standing ; he looks confused and astonished, and if he holds anything in his hand at the time he drops it. The loss of con- sciousness in these attacks is so complete that no pain whatever is experienced. A patient of mine, a retired merchant, aged 47, once had an attack of ' petit mal ' while standing with his back to the fire. He remained standing, but it is supposed that he leant heavily against the chimney-piece, and that it was in this way that his clothes caught fire. However this may be, he was found, still standing erect and unconscious, leaning against tba mantle-shelf, with his clothes all burnt to cinders and lying about the carpet in charred bits. On his back there was a deep B 242 DISEASES OF THE NERVOUS SYSTEM. bum as large as the hand, and he must have remained exposed to the fire for a considerable time, yet had not felt anything at all of the burn as it proceeded to consume his flesh. C. Epileptic Vertigo. This is one of the most singular manifestations of epilepsy, and possesses not only great pathological but also considerable medico-legal interest. It is not yet known throughout the profession that patients, while in this condition, perform auto- matic acts which may be perfectly innocent and harmless, but which may also be criminal ; and it is my firm conviction that they are absolutely irresponsible for anything they may do while thus affected. The subject of epileptic vertigo attracted some time ago considerable public attention, on account of a peculiarly unprovoked murder having been committed by an epileptic while in this state ; and as it is still comparatively new and only little explored, I subjoin the particulars of a number of cases of it, which have been under my care in private and hospital practice. A married lady, aged 28, childless, had her first fit on her wedding day. She continued afterwards to have regular epi- leptic attacks with convulsions, and simple losses of conscious- ness. In one of these latter, which lasted about five minutes, she took a set of false teeth, which she wears,, out of her mouth, and washed it in a tumbler, without knowing anything at all about it when she awoke. An unmarried lady, aged 24, fell on the ice when fifteen years of age. At that time she had her catamenia, which were suddenly arrested, and she had her first fit the day afterwards. Ever since she has been subject to nocturnal epilepsy, which at first selected the time of menstruation, but afterwards showed itself at irregular intervals. She gives a scream, bites the tongue, foams at the mouth, and has convulsions which last about four minutes. As soon as the attack is over, she gets up, lights a candle, and wants to get out of her bedroom window. This desire lasts for about half an hour. A maid is always with her to see that she is safe. She is quite unconscious during this time; but on one occasion, when her mother sharply told her to go to bed again, she did it. Her mother then left the room, EPILEPTIC VERTIGO. 243 upon wHch the patient said : ' Now I may get up again ! ' I may add that there is not the slightest symptom of hysteria in this case, and that there is perfect unconsciousness while the tendency to somnambulism lasts, A French polisher, aged 40, has for some time past had the following attacks : — He suddenly feels a severe pain at the back of the head, and ' a thrilling sensation seems to run through him as if he were about to die.' Or 'a vapour seems to rise on his brain and muddles him,' and he then entirely loses his consciousness. While in this condition he g^eraUy does something odd ; for instance, when at dinner, scratches the plate with the knife, or tears up paper, or his clothes, or pulls a handkerchief over his head. If in the street, he puts mud on his clothes. When he comes out of these attacks, he feels very confused, and sees double for two or three minutes. He recovers himself generally in an hour or two, and has such fits two or three times a week. Another patient, who was subject to great convulsive seizures, described his attacks of vertigo as follows: — On read- ing aloud from a newspaper, he suddenly stops, being imable to proceed any further ; he then remembers nothing, but wakens up in four or five minutes, finds the paper crushed into a very small compass between both hands, and then goes on reading, but does not conunence at the place where he stopped, and is not aware of what has happened. He has never committed any acts of violence while in this condition ; but on one occasion, when his mother was near, he seized one of her hands between his two, and held it ' as with a death grasp ' the whole time that the fit lasted. Another time he crushed his hands between the iron rails of his bed, and found that the nails of the first and second fingers of the left hand had been torn from the quick. A common occurrence with him is that, when he is walking in town or country, he is suddenly, as it were, 'wakened up ' ; he finds that he has been unconscious, but that he has gone the ' correct road,' and left nothing behind. Once, how- ever, he found that he had thrown away his pocket-handkerchief while in this condition. If in town, he sometimes 'wakens up ' in some shop, just on the point of being ' put out.' He once went to his bank to pay in some money shortly after a fit ; and B. 2 244 DISEASES OF THE NERVOUS SYSTEM. after having put a sum down for the clerk to count it, he took four sovereigns back, and put them into his waistcoat pocket. When the clerk told him that he must alter the entry, as he had taken four sovereigns back, he stoutly denied it. The clerk then requested him to feel in his waistcoat pocket, and ' sure enough, the money was there.' Another patient has, after slight epileptic seizures, attacks of vertigo, in which, although utterly unconscious, he goes on doing what he happened to do before. For instance, he may, when at dinner, suddenly lose himself while eating from the joint, then eat pastry and cheese, and get up from the dinner table without knowing anything whatever about it. At times he is quite silent when in this condition ; but at other times he wiU talk incoherently — for instance, tell his brother on a Sunday, ' "Well, turn up the card ; what's trumps ? ' The same patient, being very fond of playing at billiards, has gone into a public billiard-room, and, during one of these attacks, taken away the cue from the player and begun to play, without being in the game. On another occasion, while walking in the City, he suddenly lost himself, ran up a scaffolding, and began to shout that he wanted to knock the Queen and the Prince of Wales down. He became so violent that he had to be taken to- the workhouse infirmary, and when awakening there had no re- collection whatever of what had taken place. In this case the epilepsy came on from drinking a large quantity of new rum when the patient was out in the West Indies. A young lady, aged 21, who is now under my care, fell from a great height when a child, which produced concussion of the brain. She had to be in a dark room for two or three years, and has always remained rather childish. When she was 20, attacks of vertigo came on, chiefly about the time of the period, in which she suddenly gets up and stands against the wall, repeating all the time, ' Oh, yes ! oh, yes ! oh, yes ! ' This will sometimes go on for a whole afternoon.. She is per- fectly unconscious all the time, and does not hear anything when spoken to ; nor is she at all aware that she is subject to such attacks. A clerk, aged 29, has losses of consciousness which last baout five minutes. They take him anywhere ; and he is par- EPILEPTIC VERTIGO. 245 ticularly distressed about the matter, because while in this state he will unbutton his trousers and pass his water, wherever he may be. He has done this in a crowded thoroughfare, and in his office ; and he has several times ' got into trouble ' in con- sequence. The transition from such states as I have just described to those of epileptic mania, in which the patient commits suicide, homicide, rape, and arson, is easy and natural. Some observers are inclined to think that epileptics may suddenly become maniacal without having had an epileptic attack, the mania taking the place of the fit; but from what we have seen in practice, we are inclined to the opinion that vertigo, as well as mania, always occur after attacks, and more particularly when these have been slight. During the fit there is a severe dis- chai-ge or explosion, which affects not only the pons and medulla, but also the cineritious structure of the hemispheres. While, however, the pons and medulla recover more or less rapidly, the higher nervous centres, more particularly those re- presenting the intellect and the moral control, remain in a state of exhaustion, or at least reduction ; and what takes place after such an attack is due to the automatic action of the lower centres, which are healthy, except that they are for the time being deprived of the control of the higher centres. Under these circumstances an epileptic may be capable of very elabo- rate actions ; and it is a general rule, that the slighter the fit the more elaborate and the more full of apparent intention are the actions which follow. Epileptic mania is only a severe degree of vertigo, character- ised by furious excitement. The face has an expression of rage ; the breath an ammoniacal smell. The patient destroys any- thing which comes in his way, spits into peoples' faces, stamps with his feet, knocks the first comer down, and then suddenly becomes perfectly quiet, and has no recollection of what he has done just before. A man in this state may commit atrocious murders, rape, arson, and robbery. Sometimes the patient feels the attack of mania coming on, and warns the bystanders that he is going to do something dreadful. Griesinger has described a class of cases to which he has given the name of epileptoid. Such patients suffer from 246 DISEASES OF THE NERVOUS SYSTEM. megrim, vertigo, dyspepsia, syncope, hallucinations, and all kinds of abnormal sensations. These symptoms come on periodically and paroxysmally, and occur in persons who have a hereditary neuropathic disposition. The close relation of some of these conditions with epilepsy cannot be questioned; yet Griesinger seems to us to have gone somewhat too far, and to have drawn more things into the epileptic vortex than is really justifiable. Even where there is no epileptic vertigo and automatic actions of the lower nervous centres, the mental condition of epileptics is almost always peculiar. They are not really insane, but eccentric, suspicious, ill-tempered, perverse, fretful, and difficult to get on with. They seem to expand only with those who are similarly afflicted, but are otherwise shy, peevish, gloomy, and exclusive. Their intellect is below the average, and their memory impaired, more especially after attacks. Their judgment is often incorrect, and they are generally un- happy. This, however, is in a great measure owing to the cir- cumstance that most careers which are open to other people are closed to them ; they generally lose their situations as soon as they are known to have fits, and are looked upon with dread and dislike. They are fond of remaining an indefinite time in hospitals, where they amuse themselves with playing at cards and reading the papers, without showing any desire for real work ; yet, on appealing to their better instincts, we may often encourage them to acts of real devotion. Dr. Eadclifife has always found deficient circulation in epileptics ; but such is not my experience. Epilepsy occurs in extremely powerful men, with a splendid circulation, and whose health is, in every respect but this, perfect. Indeed, some epileptics are perfectly well between their attacks, and look the very picture of health, even where the disease has lasted a very considerable time. It is related that Caesar, Petrarca, and Napoleon I. were subject to epileptic fits ; and these men could not have accomplished what they have done unless their general health had as a rule been satisfactory. Amongst the causes of epilepsy, the most important is hereditary predisposition. Brown-Sequard found that the young of guinea-pigs, which had been artificially rendered epileptic, EPILEPSY. m? became subject to attacks without having been operated upon themselves. Echeverria could trace the hereditary influence in 80 out of 306 cases ; and I have reason to believe that it is even more frequent. Such an influence is often denied, as it seems to reflect injuriously on the family; and it is often shown to be present only when the history of the patient becomes better known. It occasionally overlaps a generation, and appears in the next. Moreover, it is not actually necessary that there should have been true epileptic seizures in preceding genera- tions ; for chorea, insanity, severe forms of neuralgia, and more particularly pronounced hysteria of the mother, are of great in- fluence in the production of epilepsy in the offspring. "Where epilepsy is hereditary, the infant is liable to attacks of eclampsia, and true epilepsy is developed about, or at any time previous to, puberty. If the twentieth year is passed without the occur- rence of epileptic attacks, the hereditary predisposition may generally be considered as having worn itself out in that par- ticular instance. The next cause is alcohol. Magnan has produced epileptic attacks in dogs by injecting absynthe into their veins ; and the drunkard is frequently attacked by epilepsy. The first fit often takes place during alcoholic intoxication ; and hospital experi- ence has shown me that by far the largest number of fits amongst the lower orders in London takes place on Saturday night or early on Sunday morning, after a prolonged stay at the public-house. Excessive mental work, grief, and anxiety come next ; but masturbation and sexual excesses are not so important in this respect as they were formerly believed to be. Bad nutrition from want of food, haemorrhage, and exhausting diseases seem to produce epilepsy only occasionally. The in- fluence of syphilis in this respect will be discussed in the last chapter of this volume. The temperament of the individual has a considerable influence. Epilepsy is more likely to be- come developed in persons who are very impressionable, ex- citable, and show the neuropathic disposition in a general way. Structural lesions of peripheral nerves may likewise cause this disease. In such cases there are generally weeks or months between the infliction of the injury and the first attack ; but during the intervening period there is often pain and convul- 248 DISJEASHS OF THE NERVOUS SYSTEM. sion in the area of the injured nerve. If an attack ultimately takes place, it is preceded by an aura in the sphere of the affected nerve. This kind of epilepsy has been termed reflex- epilepsy, as it appears to be owing to a continued morbid stimulation proceeding from the periphery to the centre, and ultimately causing convulsibility of the pons and medulla. The nerves in the sphere of which this occurs more particularly are the sciatic and the fifth, and the lesion is generally lacera- tion of the nerve and less pressure from tumours, such as neuroma. Injury to the skull and to the cortex of the brain by frag- ments of bone may have the same effect. Circumscribed lesions of the cineritious substance cause that form of ' cortical epilepsy' which Dr. H. Jackson has studied with so much attention. The exciting causes of the first attack are extremely nume- rous ; but it must be remembered that these causes are unable to produce real epileptic fits, unless the peculiar alteration in the pons and medulla which causes the epileptic condition was pre-existent in a latent form. Amongst these exciting causes the most frequent are fright, grief, rage, terror, disgust, and excessive joy; the first appearance of the catamenia; the accomplishment of marriage ; over-eating and excessive drink- ing, especially after prolonged abstinence ; over-exertion ; severe diarrhoea ; and convalescence from acute diseases. The favourite time for the outbreak of the complaint is the second dentition, puberty, and the climacteric period. 2. Hysteria. This disease has been known from the commencement of civilisation, and was so called by the physicians of Ancient Greece, who believed it to arise from the freaks and vagaries of a dissatisfied and ill-tempered uterus (varspa). Plato and his followers described this organ as an animal endowed with spontaneous sensation and motion lodged in another being, and ardently desirous of procreating children. If (argued these philosophers) it remained sterile long after puberty, it became indignant at its unnatural condition, travelled through the HYSTERIA. 249 -whole system, arrested respiration, and threw the body into ■extreme danger, until it became pregnant, whereby its wrath was appeased, and it behaved well ever afterwards. Pressure of the uterus upon the various organs of the body was considered to be the mainspring of all the sufferings of hysterical patients. Where there was a feeling of suffocation, it was due to the uterus compressing the throat and the bronchial tubes ; coma and lethargy in hysterical women pro- ceeded from the womb squeezing the blood-vessels which go to the brain ; palpitations arose from the uterus worrying the heart ; and if there were a feeling of pain and constriction in the epigastrium, it was again the womb engaged in a relentless attack on the liver. Even so recent a writer as M. Landouzy has endeavoured to prove that the sick or dissatisfied uterus is the only source of hysteria. A more accurate observation of facts, and a less prejudiced interpretation of the same, has gradually led us to different views on this subject. The credit of having upset the uterine theory of hysteria belongs chiefly to M, Briquet, who was the first to apply the numerical method to this branch of patho- logical enquiry, whilst at the same time carefully guarding against the dangers which beset the path of statistical inves- tigation. Eomberg first directed attention to the fact that reflex excitability is largely increased in hysteria ; but he did not lay sufficient stress on the emotional character of the ■disease. And yet it is this which serves to explain not only the infinite variety of symptoms, but also the causation and pro- cess of hysteria. The multitude and apparent incongruity of its symptoms have perplexed and bewildered those observers who were without this clue to the comprehension of their nature, Eiviere called hysteria not a simple but a thousandfold disease. Sydenham asserted that the forms of Proteus and the colours of the chameleon were not more various than the divers aspects under which hysteria presented itself; and Hofmann said that hysteria was not a disease, but a host of diseases. Yet all the symptoms, such as convulsive attacks, fainting fits, pain, cough, difficulty of deglutition, vomiting, borborygmi, asthma, hic- cough, palpitations of the heart, tenesmus of the bladder. 250 DISJEASBS OF THE NEBVOUS SYSTEM. general and partial loss of power, catalepsy, coma, delirium, etc., flow from the same source ; and may be classified as functional spasms and paralysis, anaesthesia and hypersesthesia, resulting from painful impressions, whether mental or physical, which act on the emotional centres of the brain. Being guided by this fundamental principle, the transition from physiological to pathological manifestations is easy and natm-al. All symptoms of hysteria have their prototype in those vital actions by which fright, grief, terror, disappoint- ment, and other painful emotions and affections, are manifested under ordinary circumstances, and which become signs of hysteria as soon as they attain an undue degree of intensity. If an impressionable woman, who is naturally somewhat devoid of self-control, or who may have lost this faculty from being worn out by disease or anxiety, is suddenly told that the house is on fire, or that she has lost a near relative, the following symptoms are generally produced : — She has a feeling of constriction in the epigastrium, oppression on the chest, and palpitations of the heart ; a lump seems to rise in her throat and to choke her ; she loses the power over her legs, so that she is for the moment unable to move ; and she wrings the hands in a spasmodic manner. If these symptoms become intensified, the well-known signs of hysteria are developed, which I have just classified under the four heads of functional spasm and paralysis, anaesthesia and hypersesthesia, and which result from painful impressions being transmitted to the emotional centres of the brain. The natm-e of the peculiar constitution predisposing to hys- teria has to this day been a matter of controversy. Hippocrates believed that women who had an abundance of ' seminal fluid,' and who suffered from leucorrhcea — that is, the lymphatic and the pale — were liable to become hysterical ; while Galen held that the strong, the fleshy, the sanguine women had a greater tendency to it. Subsequent writers have sided sometimes with Hippocrates and sometimes with Gralen, but mostly with the latter. There is,, however, no peculiar j9^2/sicai constitution predispos- ing to hysteria, since the disease indiscriminately invades women of all kinds of such constitutions. Nor has the intellect any- thing to do with it ; for some hysterical women are very clever, HYSTERIA. 251 while others are the reverse ; it is rather the mental and moral peculiarity which exercises an all-powerful influence on the pro- duction of this disease. Women whose sensibility is blunt never become hysterical ; while those who are readily accessible to impressions, and who do not possess much volitional energy or force of character, who feel acutely and are liable to strong emotions, without being able to control themselves, are certain to become hysteri- cal if made to suffer mental agony or prolonged physical pain. This high degree of sensibility is not confined to any particular rank of society, but may be found equally strong amongst the lower classes as with the upper ten thousand. Hysteria, there- fore, occurs in women of all ranks and orders. It is frequent in the higher classes of society, in ladies who lead an artificial life, who do nothing, whose every wish or whim is often gratified as soon as formed, and who are very apt to go into hysterics at the slightest provocation or contrariety. For them, real honest work, the pursidt of an object in life, such as the education of children or some charitable undertaking, is often the best cure. Again, we find plenty of irritable and impressionable women in the lower classes; and as want, grief, and anxiety are common amongst them, they are very prone to hysteria. Such women are sometimes cured by an improvement in their social position. As emotion and anxiety on the one hand, and highly im- pressionable women on the other hand, are found in all inhabited quarters of the globe, hysteria is not confined to any particular climate or country. The common belief that this disorder is more frequent in tropical than in temperate or cold climates is not founded on fact, for we find hysteria not only in the South, but in the highest latitudes. The Eussian ladies are particu- larly hysterical. The same is the case with the Swedish, Polish, and Swiss ; and hysterical women are even found amongst the Esquimaux and Greenlanders, and in Iceland. On the other hand, there is no doubt that the circumstance whether women live in towns or in the country is of considerable influence in the production of the disease. Although hysteria does occur amongst rustics, yet it is far more frequent in large towns, where the emotions are keener and more apt to be played upon 252 DISEASES OF THE NERVOUS SYSTEM. than in the country ; and the Latin races are far more suscep- tible to it than the Anglo-Saxon. Similar considerations serve to explain the influence of sex in the production of hysteria. Those observers who believed the sick or dissatisfied uterus to be at the bottom of all the mis- chief, were obliged to maintain that hysteria occurred only in women. And it is certainly infinitely more frequent in females than males, although not on account of the uterus, but by reason ■of the higher degree of sensibility generally possessed by women. Yet it does occur in males as well as in females, if they are Mghly sensitive and subject to painful emotions. As cases of hysteria in male patients are rare, I will give the particulars of a case in pQint, which occurred some time ago in my practice. In July, 1868, I was called to see a foreign gentleman, aged 23, who had, as I was informed, been suffering from ' brain fever ' during the last three days. His friends gave me the following history : — About a week ago he received a letter informing him that a young lady to whom he was attached had engaged herself to another gentleman. On receipt of this news he flew into a violent rage, and smashed a good deal of ^lass and china which happened to be on the table. He then began to talk about the frailty of women, indulging in most sarcastic remarks on the sex in general. Two days afterwards a friend took him to Eichmond for a change. The whole of that day he was silent and morose, and returned in the even- ing in a very bad humour. During the night he again became violent, and broke several pieces of furniture. Next morning, about nine o'clock, he had a severe convulsive attack, in which he bit his tongue and foamed at the mouth, the limbs being considerably distorted for about fifteen minutes consecutively. After the attack he was exhausted, and remained so for about a quarter of an hour, when a similar paroxysm occurred, which was followed by many others in the course of the day In all these attacks consciousness was not entirely lost. Between the fits he would either lie quietly in bed, or suddenly jump up, roll about the floor, and try to strangle himself, or to smash furni- ture. A medical practitioner was called in, who prescribed five grains of bromide of potassium several times daily. On an HYSTERIA. 253 attempt being made to give him this medicine in a wineglass, he ground the glass to pieces between his teeth, and it was be- lieved that he had swallowed some pieces of it. I saw him the day after, at iive o'clock p.m., when I found him in much the same condition as just described — viz., occasionally seized by convul- sive attacks, half-conscious, and violent. He would not answer any questions. There was evidently no meningitis, as the pulse, the skin, and the pupils were in their normal condition. Under these circumstances, I looked upon the case as one of acute hysteria, caused by sudden and severe mental emotion. As it was impossible to make the patient swallow any medicine, I rapidly injected, during a temporary lull in his strugglings, half a grain of acetate of morphia into the cellular tissue of the forearm. Five minutes afterwards he was perfectly composed. In fifteen minutes he went to sleep, and slept for five hours con- secutively. He then awoke, and was violently sick several times, although he had eaten nothing for two days. He got out of bed next morning about ten a.m., and was quite calm, making no allusion to what had occurred. I saw him again at five p.m., and as there were then slight symptoms of restlessness returning, I repeated the injection, but used only one-sixth of a grain, the patient not offering the least resistance. The next day I was informed that he had had a good night's rest, and was perfectly rational and collected. I saw him again (not professionally) six weeks afterwards, when, in answer to my inquiries, he said that he was quite well, and never alluded to his having been ill. I heard subsequently from his friends that he had continued in excellent health ever since, and was en- gaged to be married, having quite dismissed from his mind all thoughts of his former attachment. I will only add that I generally, in cases which require the subcutaneous administration of sedatives, use one part of atropia to twelve parts of moi-phia, in order to counteract the sickness and vomiting; but in the case just recorded,.! thought it best to utilise the emetic effects of morphia simultaneously with its sedative action. The common belief is, that hysteria does not occur in child- hood and advanced age ; but this is erroneous, for amongst 820 well-marked cases of hysteria which I have collected from -254 DISEASES OF THE NERVOUS SYSTEM. medical literature, there were 71 patients under ten years, and 28 over the age of forty-five. Hysteria is, therefore, not con- fined to the period of puberty, as the advocates of the uterine theory would have it. During childhood, the female sexual organs are in a state of perfect repose, and do not give rise to sufferings; but nervous sensibility is high, and reason still dormant ; so that, if painful emotions be frequently repeated or be unusually powerful, we have all the necessary conditions for the development of the disease. In accordance with this view, we find that when children are hysterical, the cause is almost always maltreatment by the parents (especially stepmothers) or nurses, and excessive sensibility inherited from the parents. In accordance with this we find that the chief cause of hysteria is hereditary predisposition; hysterical parents beget hysterical children. Chorea, epilepsy, insanity, delirium tremens, and a generally increased excitability and eonvulsibility, i.e., the neuropathic disposition on the part of the parents, have, however, the same influence as the actual existence of hysteria itself. Nevertheless it is found in practice tliat the education of children, and more particularly of girls, may considerably modify the original tendency. Where there are germs of hysteria in a child, they may be destroyed by firmness com- bined with kindness on the part of the parents, and particularly of the mother; while, on the other hand, a foolish or bad- tempered mother may foster a slight predisposition, so that it develops into rampant hysteria. Two extremes have to be guarded against in education, viz., 1st, unreasoning kindness which yields to every whim, and renders the child capricious and Tmhappy ; and 2nd, too great sternness, which must cause moral shocks to an imaginative girl. Coddling is therefore as bad as excessive hardening. But probably the worst influence is that of a capricious education, where the mother is apt to run from one extreme to another, and the child never knows what to expect, so that the mind becomes completely unsettled. The circumstance that the education of boys is generally •entrusted to masters, explains, apart from the influence of sex, ■why hysteria is rare in males. The hysterical mother also develops the germs of hysteria in HYSTERIA. 255 ter daughters by her own example. This is more especially the case where convulsive fits take place habitually. There exists a nervous contagium as well as a physical one, and it acts in an equally subtle manner, selecting some and sparing others, but it is frequently found that the nurses of epileptic or hysterical persons become ultimately themselves hysterical; and epidemics of hysteria in hospitals, convents, ladies' schools, manufactories, and prisons for females, are for this reason of frequent occur- rence. Between 15 and 20 years of age, hysteria is most frequent, in consequence of the radical change which the nervous system undergoes during that period. Within those years girls begin, as it were, a new existence ; they leave the nursery and its habits, and, imagination reigning supreme, they enter upon the world with its passions, troubles, and disappoint- ments ; and if painful emotions be frequently and powerfully experienced, hysteria is the inevitable result, provided the system is predisposed for it. After 20, the disease becomes more rare — a circumstance which cannot possibly be explained by the uterine theory; for at no other age are the female sexual organs subject to more considerable disturbances than -after that time of life. The condition of the nervous centres, how- ever, gives us a satisfactory clue to this circumstance. A? imagination gives way to a more matter-of-fact view of life and the world, illusions vanish, and impressions and sensations are kept more under control than previously. As age advances, hysteria is still more seldom met with, because the mind has become settled and critical, and is less accessible to sudden impressions and emotions. Anaemia, either primary or after hemorrhage, a generally defective state of nutrition, convalescence from acute diseases, phthisis, and certain diseases of the sexual organs, may act as exciting causes of hysteria where there is the nervous predis- position already in existence. Amongst the latter diseases it is chiefly flexions and chronic inflammation of the womb and ovaries which are of influence in this respect, while cancer or other severe maladies do not seem to lead to the outbreak of hysteria. The reason for this is probably that cancer only appears at a later period of life, when there is but little consti- 256 DISEASES OF THE NERVOUS SYSTEM. tutional tendency to the production of hysteria. Enforced abstinence or excessive indulgence in the sexual appetite rnay also act as an exciting cause ; and hysteria is generally more intense during menstruation, pregnancy, and lactation.. Yet in a very large number of hysterical women the sexual functions are in every way in perfect order, and the disease is not in any way influenced by the events in the sexual life of the patient. Hysteria is almost always a chronic disease, the symptoms of which are developed in a regular manner. At first the com- plexion becomes pale and sallow, the skin dry and hard, the patient loses flesh, and complains of headache. The appetite is fanciful and feeble ; some patients having great dislike to any- thing but water, vinegar, and confectionary. Biliary secretion is tardy, and constipation habitual. Many hysterical women only go to stool once or twice* a week, and in exceptional cases constipation may last for a fortnight or three weeks. There is generally a large accumulation of gas. in the intestines, giving^ rise to colics or borborygmi. The epigastrium is very tender to touch, and pain in this region is much complained of; it i^ worse after emotions or walking, but not after meals. There is also pain at the level of the middle part of the left false ribs and the left side of the spine. Abdominal pulsation is frequent,, and menstruation generally troublesome. The blood is often impoverished, the pulse being quick, small, and feeble. The temper is irritable. The smallest contrarieties of daily life which have scarcely any effect on other people, are sufScient to annoy or to upset the patient. A trifling variation in the day's temperature, a shower of rain, a change in the wind, a some- what prolonged walk, and any little disappointments, are suffi- cient to make her thoroughly miserable. AU of a sudden, how- ever, things take a turn, and she is charmed with everything, more particularly so with a new doctor. Yet as a number of small miseries have to be encountered in life, the temper is as a rule bad, and the character capricious. There is great aversion to certain animals, such as spiders, frogs, and mice, the mere sight of which will cause fainting and convulsive attacks ; while on the other hand, intense devotion to birds and cats is displayed. A tendency to lie, cheat, and intrigue is HYSTJEBIA. 257 developed; and other people's misfortunes are enjoyed. The imagination sometimes takes a decidedly erotic turn, more espe- cially in those whose appearance is not attractive to the other sex. In order to make themselves interesting, hysterical girls and women will swallow pins, starve themselves, attempt suicide, drink urine and eat fseces. They have been known to put frogs into the rectum and the vagina, and pretended not to have gone to stool for months or even years. The Welsh fast- ing girl and Louise Lateau, the stigmatist, are well-known examples of this condition. On the other hand, if we succeed in rousing their enthusiasm they are often capahle of intense devotion and exertions — for instance, in nursing the sick and wounded in time of war. Hallucinations and delirium occur in the severer forms of the disease. The patient then has frequent and intimate inter- course with the saints and the Virgin Mary, while the Evil One generally lurks in the background. Eeligious hypersesthesia is usually combined with erotic tendencies. Stories of rape are sometimes invented, and perfectly innocent men have been put into prison on such false accusations. Sometimes even a murder is committed, and suspicion most ingeniously diverted from the perpetrator to somebody else. The story of Constance Kent, who murdered her brother at Eoad, and made it appear that her father was the murderer, is an illustration of this condi- tion. Somnambulism and the phenomena of animal magnetism, hypnotism and ecstasy, frequently become developed under these circumstances. Convulsive attacks are of frequent occurrence in hysterical women, and are often confounded with epileptic seizures, although there are numerous points of difference between the two. The hysterical fit occurs almost always after painful emo- tions, maltreatment of children by their parents, or of wives by their husbands, terror on seeing some disgusting object or wit- nessing a convulsive attack in somebody else. Or a sudden sup- pression of the menstrual flow ; while epileptic attacks generally come on without any appreciable cause. The starting-point of the hysterical fit is generally in the epigastrium; while the epileptic attack occurs either without any warning, or with an aura of a different kind. The epileptic patient falls down as if 8 258 BI8EA8ES OF THE NERVOUS SYSTEM. struck by lightning, no matter where he may be ; the hysterical patient has almost always time to find a suitable place (a bed or sofa) upon which to fall. The epileptic convulsion is a sort of tetanus which does not resemble physiological movements, and scarcely ever lasts more than five or ten minutes ; while the hysterical fit mimics physiological movements, and lasts often half an hour or more. At the end of the epileptic attack the patient falls into a deep coma, or he recovers consciousness at once, and feels shaken and exhausted ; at the end of the hysteri- cal fit, there is generally crying and sobbing. Urine of a pecu- liar character is passed, after the hysterical, but not after an epileptic, attack. The chief peculiarity of this urine is its great abundance, as it may amount to several pints at a time. It is clear and devoid of colour, almost inodorous and tasteless ; it has a specific gravity of little over 1,000, and consists of scarcely any- thing but urinary water. The cause of this phenomenon is a spasm of the capillary vessels of the skin, which contain less blood than usual, and therefore throw additional work on the kidneys. Acute hysteria is far more rare than the chronic form of the disorder, and is only developed if a powerful cause acts upon a system already predisposed to the disease ; for instance, a great fright during menstruation. It is generally ushered in by one or several convulsive seizures, which are followed by delirium, paralysis, coma, and febrile symptoms. Where the patients re- cover their consciousness they complain of violent headache, thirst, loss of appetite, and a feeling of great lassitude ; the pulse beats at the rate of above 100, and the temperature rises to 104° or «ven 106°. Diagnosis is sometimes difficult in these cases, which are not unfrequently confounded with typhoid fever or meningitis. Yet the result is only rarely fatal. In 1874 there died only 17 women of hysteria in England and Wales. The causes of death are generally asphyxia or syncope, from repeated convulsive fits, in which the patient does not recover from the •coma. In other cases death takes place by suicide or self-mutila- tion. Swallowed pins have caused fatal peritonitis. Generally, however, the attempts at suicide are not seriously meant ; when the hysterical woman cuts her throat, jumps into the water, or swallows laudanum, she almost invariably does so in the pre- SYSTERIA. 269 sence of other people, of whom she is certain that they will do everything in their power to save the ebbing powers of life in the interesting patient. The progress of hysteria is powerfully influenced by the ■events of life. If these be happy, the disease may come to a speedy end, but if the reverse, it may continue unabated to an advanced period of existence. The duration of hysteria is, therefore, very variable ; and it is altogether much longer than is commonly believed. The symptoms of it may be very readily relieved, but the actual cure of the complaint is most difi&cult, as it depends to a great extent upon circumstances over which the physician has no control. Marriage has often been recom- mended as a cure for hysteria, but this can only act beneficially in a very limited number of cases. Pregnancy and lactation fre- quently aggravate the symptoms, and the illness and loss of children, the annoyances of housekeeping, and the bad temper of a husband, are apt to do the same. Moreover, there is great tendency to miscarriage in hysterical women ; their children are ■often still-born, and, if they survive, they are generally delicate and sickly, and liable to inherit hysteria and other nervous affections. Marriage acts beneficially only where the circum- stances of the patient at home are highly unfavourable, and where in consequence of marriage she is rid of aU anxiety, em- barrassments, and painful emotions. . Many patients only get well as age advances and sensibility becomes blunted ; while others do not recover at all, or are troubled throughout life by the consequences of the malady. During the best years of their existence, they are subject to pain or convulsions, loss of voice or paralysis, they are unable to fulfil their duties, and a burden to themselves and others. Strong moral emotions, affecting the will and the imagination of the patients, may cure hysteria temporarily or permanently, especially if they be of a sublime and exalting character. Such miraculous cures, apparently wrought by the agency of Faith, have been denied by some physicians, but are never- theless as real as any cures obtained by other more tangible remedial agents. All is not humbug in the pilgrimage to Lourdes. Sir Benjamin Brodie has related the case of a patient affected with severe arthralgia, who had been in bed for several s 2 260 DISHASHS OF TBE NERVOUS STSTUM. years, but who, at the command of her spiritual adviser in the name of our Saviour, to get up and walk, actually did it. A striking instance of the same sort occurred in 1844 at Treves, in Grermany, where a lady of rank, who had been completely paralysed for a number of years, was carried to the cathedral where the bishop had caused a sacred relic to be exhibited, at the sight of which she immediately regained the use of her limbs. Partial or complete loss of muscular power is a frequent manifestation of hysteria, and invades with preference the left side of the body. Hysterical hemiplegia occurs either suddenly after painful emotions and hysterical attacks, or it creeps on gradually and unawares. It differs from hemiplegia from cere- bral disease, by there being no distortion of the face, nor deviation of the tongue. The paralysis is scarcely ever complete, and mostly more severe in the leg than in the arm. It is subject to considerable and sudden variations under the influence of emo- tions or treatment. A woman affected with hysterical hemi- plegia may, under the stimulus of great excitementj get out of bed, walk several miles, and perform other feats of power ; and may then, after the excitement has subsided, relapse into com- plete immobility. No such thing is possible in a case of hemi- plegia from intracranial disease. In the hysterical affection there is likewise generally hemiansesthesia, viz., great weakness or loss of sight and hearing, and of the sense of taste on the same side, and partial or complete anaesthesia of the skin ; but no rigidity of muscles. Faradisation causes the muscles to contract, but the patients do not feel the passage of the current, unless this be one of great power. The electric contractility of the muscles is diminished only in cases of very long standing. Hysterical hemiplegia is often accompanied by retention of urine, sensations of pins and needles in the paralysed parts, febrile symptoms, with sleeplessness, and dyspepsia. The affection sometimes wanders about the body as in paralysis after acute diseases. At first there may be left hemiplegia ; in a few months the left side will recover and the right side become affected ; hemiplegia may then gradually become changed into paraplegia, and this into paralysis of the left hand. Hysterical paraplegia is sometimes confounded with para- HYSTERIA. 261 plegia from myelitis and other diseases of the spinal cord or its membranes. It is, however, on its first appearance always accompanied by severe headache, showing the part played by the brain in the causation of the complaint, and many other symptoms which suflaciently distinguish it from paraplegia owing to structural disease. By far the most common form of hysterical paralysis, how- ever, is that which affects the vocal cord and the muscles of the larynx, and is known as hysterical aphonia. It almost always appears suddenly, after some violent emotion, or after taking cold ; and it may last only an hour or two, or be protracted for years. The laryngoscope shows total absence of any structural lesion, the vocal cords being merely powerless, and incapable of movement. In May, 1862, I treated an interesting case of this kind, together with Professor Czermak, who had just then introduced the laryngoscope into this country. It was the case of a domestic servant, aged 30, who had lost her voice two months before, on the sudden death of her master. The laryngeal mirror showed that both vocal cords were perfectly motionless, and that there was a large cleft between them. After two applications of faradism the patient could speak again, although still in a hoarse tone only. It was then discovered, by another examination with the laryngoscope, that the right vocal cord had to a great extent recovered, and approached the median Hne when the patient endeavoured to pronounce a prolonged ' ah,' but there was as yet no improvement in the left. By further treatment, the left vocal cord was also restored to its normal condition, and the patient entirely recovered. Hysterical paralysis of the portio dura is rare, and is found together with anaesthesia of the skin and of the special senses of the same side, whereby it is easily distinguished from the ordinary form of facial palsy. The muscles of the pharynx and oesophagus may also lose their power, causing difficulty or im- possibility of deglutition. The rectum is occasionally found paralysed and ansBsthetic, which entails involuntary fgecal discharges. The power of the diaphragm may also be impaired. After bad hysterical attacks, the patient, at intervals, gasps for breath, and dyspnoea may be severe. The accessory muscles of 262 BISHASIIS OF THE NERVOUS SYSTEM. inspiration, more especially the scaleni, work hard ; but the epigastrium and the base of the thorax do not project during inspiration, indicating a semi-paralytic condition of the diaphragm. The cardiac muscle may suffer in the same manner. Palpitations are frequent, and the pulse is sometimes hard and small, at other times full and soft, either from spasm or a semi-paralytic state of the vasomotor nerves. The skin is sometimes as cold as ice, and soon after becomes hot and per- spires profusely. Pallor and blushing often alternate in the face. After convulsive attacks the pulse is sometimes imper- ceptible, and the heart's sounds may be inaudible. Occasion- ally death results from syncope, or trance from paresis of the heart. The commencement and progress of all the different forms of hysterical paralysis leave no doubt on the mind that this is a functional disorder, and in no way owing to structural lesions in the nervous centres, the peripheral nerves, or the muscles. Affections which come on suddenly, which may vary in degree from day to day, and are sometimes cured by a single applica- tion of galvanism, cannot be due to organic lesions of impor- tant organs, but are produced under the influence of mental emotions, and chiefly determined by them in their further progress. In accordance with this view we find that in cases which have ended fatally, the most careful post-mortem examin- ations have failed to show any structural lesions to which the affection might have been fairly traced. In a few cases where anatomical alterations have been discovered, they were due to complications. Charcot has found sclerosis in the lateral columns of the cord in a woman who had for many years suffered from contractions of the limbs ; but in cases of acute fatal hysteria, just as in fatal eclampsia, the microscope in the hands of most competent observers has shown all the different portions of the nervous system to be perfectly healthy. Whether the changes which rmdoubtedly take place in the nervous centres in this disease are chemical or simply molecular remains a problem for future investigations. Paralysis is frequently accompanied with anaesthesia, but the latter may occur without the former. Of all the different kinds of loss of sensation which occurs in hysteria, hemi-ancesthesia is SYSTERO-EPILEPSY. 263 the most interesting ; and Charcot's researches on this condi- tion are worthy of the greatest attention. It affects the head, neck, body, and limbs in a perfectly imilateral manner. All forms of sensation are in abeyance : common sensations, pain, touch, heat, cold, and electricity are unperceived ; and temperature may be greatly reduced. The muscles, bones, mucous membranes, and nerves of special sense participate in the affection. Thus the sight is either diminished or absolutely lost ; yet the ophthal- moscope does not reveal the slightest difference between the healthy and the blind eye. Where vision is not entirely sup- pressed it is less keen, and there is a concentric and general narrowing of the field of vision. This is particularly marked for the different colours ; violet is lost first, then green, red, orange, yeUow, and last of all blue. This crossed hysterical amblyopia is in all respects, except its causation, identical with cerebral hemi- ansesthesia from a lesion of the posterior part of the internal capsule, and the corona radiata. The anaesthetic parts sometimes show diminished tempera- ture and pallor ; punctures made with large pins do not cause any blood to flow. The power of motion may be normal or even increased ; there is no want of co-ordination, so that the finer movements, such as sewing, etc., are easily performed. Charcot has drawn attention to a peculiar combination of hemi-ansethesia with ovarian hypercesthesia and attacks of hystero-epilepsy, which forms one of the most singular mani- festations of this proteiform disease. There is spontaneous pain and tenderness in the ovary of the same side on which there is hemi-aneesthesia ; and this is, as most other hysterical symptoms, on the left side. Attacks of hystero-epilepsy occur chiefly during menstruation, but also at other times, and are occasionally excessively frequent. They are ushered in by ovarian pain, palpitations, choking in the throat, tinnitus aurium, and throbbing in the temples, which is followed by coma and convulsions. The convulsions resemble the ordinary epileptic seizure, with a first period of rigidity, and a second of clonic convulsions, both being of shorter duration than the usual epileptic fit. A short stage of relaxation follows, but is in its turn succeeded by violent delirium, dming which the patient throws herself wildly about, screams at the top of her voice. 264 mSJEASES OF THE NERVOUS SYSTEM. laughs, cries, flies off the bed, and is most fearfully distorted. Finally there is a stage of exhaustion and general relaxation of the body, while the mind appears clear and bright. These attacks of hystero-epilepsy may be stopped at any stage by forcible pressure on the painful ovary. Tonic contraction of the ansesthetic Hmbs often occurs suddenly, and disappears as quickly. Metallo-therapy (i.e., the application of a chain of gold coins, or a bracelet of copper or iron, to the ansesthetic limbs), at first transfers the anaesthesia to the opposite side, and after a time removes it altogether. Another symptom of frequent occurrence in hysterical women is neuralgia, which seems to select the joints, and more par- ticularly the hip and knee. Pressure causes violent pain, but more so in the soft parts surrounding the joints than in the bones. Most cases of joint-affections which occur in the upper classes are of this description. They often last for years, and then get suddenly weU, in consequence of a mental impression. Haemorrhage may occur from the skin and various internal organs, more especially where there is amgenorrhoea, and where it forms the so-called vicarious menstruation ; but it also some- times takes place without any such relationship. If the bleeding proceed from the stomach, ulcer or cancer may be suspected ; but the diagnosis is mostly rendered easy by the concomitant hysterical symptoms. Where this haemorrhage occurs in the skin, it is called atigmatisation ; and although this has been simulated by girls anxious to attract attention and excite interest, there can be no doubt that it sometimes occurs as a vasomotor neurosis under the influence of hysterical disturbance. In Louise Lateau the stigmata appear chiefly on the hands and feet, the forehead and the chest, and this is believed by the vulgar to be a repetition of the wounds of our Saviour on the cross. Bloody tears and perspiration may be seen under similar circumstances. 3. Catalepsy, morbus attonitus. This condition is closely allied to epilepsy and hysteria, but presents certain peculiarities of its own which seem to constitute it a separate disease. It is not unfrequently seen in hysterical CATALEPSY. 265 ■women, but is also sometimes a symptom of chronic cerebral disease, which ultimately leads to insanity, and more particularly to melancholia and dementia. Such is generally the case when it occurs in males. In children it is occasionally met with as a sequela of tubercular meningitis. In advanced age it is rare, for most cases occur shortly after the development of puberty, in consequence of violent emotions, and more particularly shock to the affections. It has also been known to occur after severe fits of ague ; and is occasionally followed by attacks of religious mania, mysticism, somnambulism, and ecstasy. The fit of catalepsy generally comes on suddenly, and without a warning. The patient remains standing or sitting as if charmed ; she has evidently lost her consciousness, and the life of relation has ceased for the time being. Circulation and re- spiration are barely perceptible, and aU the muscles, but more especially those of the upper extremities, are in a state of rigidity. The muscles have a firm feel, and resist a change of position ; but by employing more force the position of the limbs may be changed, and then remain unaltered for hours or even days. This condition has been called fiexibilitas ccerea. It sometimes lasts only for a few minutes ; a kind of tremor is then seen to run through the muscles, and the limbs gradually drop into their natural position. There is a degree of anaesthesia, which is, however, not absolute, even in severe cases. Thus pricking and pinching may not be perceived, but faradisation by a powerful current will elicit signs of pain, and rouse the patient from her dormant state. I have found that faradisation of the s^n of the face by metallic conductors is the most power- ful agent for restoring consciousness in these cases. The pulse if perceptible is slow and feeble, the temperature normal or diminished, and respiration retarded. Occasionally there are all the signs of suspended animation ; and it is not impossible that patients while in this condition may have been buried alive. Faradisation is under these circumstances of great diagnostic value, because muscular contractions are by its means as readily produced as during health. The fit may last from a few minutes to a few days, and show occasional remissions and exacerbations. Eecovery is generally 266 DISEASES OF THE NERVOUS SYSTEM. gradual, but sometimes sudden, and the patient then behaves as if nothing unusual had occurred. Uncomplicated catalepsy does not prove fatal. In cases where necropsies have been made, there has been as a rule com- plication with mania, epilepsy, chorea, tetanus, and other con- ditions, so that we are at present in the dark about any patho- logical changes which may occur in the nervous centres. It is, however, difiBcult to believe that any such alterations can be of a coarse nature, seeing the rapidity with which the cataleptic state originates and vanishes. INSANITY. 26f CHAPTEE VII. INSANITY. I DO not purpose in this chapter to enter into the pathology of insanity, which on account of its great importance is most properly looked upon as a specialty belonging to the alienist physician. I will, therefore, only for the sake of completeness, give the results of my researches on the prevalence of, and the mortality from, mental affections. The following table shows the number of deaths from in- sanity which have been registered during six periods of five years each : — Periods of Deaths from Percentage of Percentage of five years Insanity Nervous Diseases all Diseases 1838^2 1,773 •84 •10 1843-46 — — — 1847-61 2,600 1-08 •12 1852-56 2,412 1-07 •12 1857-61 2,046 ■75 •09 1862-66 2,969 1-01 •12 1867-71 3,861 1-25 •15 From this table it appears that the first lustrum showed the comparatively low mortality of 0*84 ; in the second a not inconsiderable rise took place, which was succeeded by a slight fall in the third, and a decided fall in the fourth, in which it reached a minimum of 0*75. A second rise then took place, and continued up to the last lustrum, which attained the faaximum of 1*25. I have also found that each year, singly, of the last lustrum shows a rise over its predecessor, the maximum of 1-54 having been attained in the year 1871. The popular 268 niSEASm OF THE NERVOUS SYSTEM. notion that the mortality from insanity has increased during the last ten years is therefore shown to be correct. The influence of sex on the mortality from insanity is shown in the following table : — Periods of five years Males Percentage Females Percentage 1847-51 1,223 •51 1,377 •57 1852-56 1,087 •42 1,325 •51 1857-61 1,055 •38 1,394 •55 1862-66 1,391 •47 1,569 •55 1867-71 1,818 •59 2,043 •m Women are therefore seen to die more from insanity than men, the mean average for them being 0*56 against 0*47 for men, showing an excess of 0'09 for women. The smallest excess was in the first lustrum, viz. 0"06, and the largest in the third, viz. 0*17. In men insanity showed a decided fall during the second and third lustra, while in the fourth and fifth an even more decided rise took place, so that the last lustrum is 0*08 higher than the first. For women the variations have been less striking. There was a slight fall in the second lustrum, a slight rise in the third, the fourth proved to be identical with its predecessor, and the last showed a somewhat more considerable increase. The influence of age on the mortality from insanity is shown in diagram. H. This disease is shown to carry ofi' isolated victims as early as two years of age. The curve rises gradually in the subsequent periods, and more especially so at thirty-five, fifty, and sixty-five. At the latter age the curve attains its summit, and from thence falls rapidly to the end. The influence of the sexes in this respect is shown in dia- gram I. The thick curve for men shows a slight ascendancy over the thin one for women until ten, after which the latter rises and keeps steadily overlapping the former, although otherwise the excursions of the two curves appear very analogous. The summit of the thick curve is at fifty, and that of the thin one .at sixty-five. INSANITY. 269> Diagram H. Showing the influence of ACE on the Mortality from 1 N SAN 1 TY in England and Wales in 1847. <«■• - 7 ■ s > 00 n o CO — =« f -^ g s ^ -^ to 3 o "•' h ■ ifi "\ '^ 1 «*> / -1 M 1 — o 1- o* o to lO U) g ^ 1 CO o o CM «> o in u 270 DISEASES OF THE NERVOUS SYSTEM. ■ Diagram I. i c n OB •n c « ■So c UJ c i Z a c w 3 C i J CO &-• - •v o en J^ £ / in s :^ K r -^ N J z' s ^ ^ V a n < ^ i s \ ^ ^ IS ■*H ^ o ^^ ^ s 4^ a ? t'- <^ »? \ s o r ^ C ^, i V \ g i > 12 n"^ o *A/ m "\ 1- pA ■J — — & * 1- e O ■.■r.-.-:'=: — in o O BfS o U) o INSANITY. 271 Insanity is the only disease of which we actually know the number of living sufferers year by year ; while for finding out the prevalence of other nervous complaints, as distinguished from mortality, we have to lean on clinical experience. It appears from the Eeports of the Commissioners in Lunacy to the Lord Chancellor, that there were in 1859 under treatment in the various public and private asylums of England 36,762 lunatics ; in 1869 this number had risen to 53,177; and in 1875 to 63,793. The deaths of all lunatics in 1859 amounted to 2,332, or 7-22 of the total number under treatment; in 1869 to 3,805, or 7-94 of the entire number; and in 1875 to 4,210, or 7-79 of the entire number. It will be seen that the deaths of all lunatics, as given by the Commissioners in Lunacy, do not at all correspond to the deaths from insanity recorded by the Eegistrar-Greneral ; which is explained by the circumstance that in the former reports the deaths from all causes occurring amongst the lunatic population, and in the latter only the deaths from the various forms of braia-disease producing insanity, are included. Thus, the Eegistrar-Greneral gives only 446 deaths from insanity in 1859, against 2,332 of the Lunacy Commissioners ; the numbers being 722 and 3,805 respectively for 1869. This gives a proportion for the two years of 1 to 5*2 ; from which it appears that out of five lunatics only one actually dies of lunacy, while the other four die from other diseases. The ratio of lunatics to 10,000 of the population was 18*67 in 1859, and had risen to 26-64 in 1875. This would at first sight appear to constitute a very considerable increase of insanity during the last seventeen years ; but it should be con- sidered that this increase of insanity, under care, has occurred chiefly among the pauper class ; for, while during the period just mentioned the insane paupers have increased from 16'14 to 23*55 for 10,000 of the whole population, the private patients have during the same time increased only from 2'53 to 3"09. Nevertheless, there can be no question that there has been an increase, not only in the mortality from, but also in the preva- lence of, insanity within the last few lustra. The excess of females over males, which I have already adverted to in the mortality from insanity, is likewise per- 272 DISEASES OF THE NERVOUS SYSTEM. ceptible in the 'prevalence of that disease during life. The ratio for living male lunatics was 17*44 in 1859, against 19'85 for living female lunatics. In 1869 the respective numbers were 22-51 against 25-27 ; and in 1875, 24-87 against 28-32. These numbers show that the greater liability of women to go out of their mind has decidedly increased of late, as the excess over males was only 2-41 in 1859, and had gradually risen to 3-45 in 1875. The average proportion of deaths from insanity to the living lunatic population, was, for the ten years from 1862 to 1871, 1 in 88. DELIRIUM TREMENS. 273 CHAPTEE VIII. DELIEITJM TREMENS. The following table shows the number of deaths from delirium tremens which have been registered during six periods of five years each, and the percentage of mortality, first of nervous diseases, and second of all diseases : — Periods of Deaths from Percentage of Percentage of five years deliriuin tremens Nervous Diseases all diseases 1838^2 1152 •54 •06 1843^6 — — 1847-51 2588 1-07 •12 1852-56 2534 •99 •12 1857-61 2325 •86 •10 1862-66 2683 •90 •10 1867-71 1948 •63 •07 From this table it is seen that the minimum was registered in the first period, and the maximum in the second. Since then there has been a fall which was particularly marked in the last lustrum. The influence of age is shown in diagram J, There is a blank until after fifteen years ; at twenty the curve begins ta rise, advances more at twenty-five, and reaches its maximum at thirty-five. The greatest number die between thirty and forty. A fall then takes place, which becomes rapid after fifty-five, when it may be assumed that most of the unfortunate votaries of drink have either learnt wisdom from experience or died off. The minimum is reached at eighty-five. This rate tallies on the whole with that found in the Greneral 274 DISEASES OF THE NERVOUS SYSTEM. J) I AGRA M J , Showing the influence of ACE On the Mortality from DELIRIUM TREMINS in England and Wales in 1847. CS- ^ o $ ft o at e S S jfe s — :> li IS iT n R / (0 " y. y ■a tf ■ S e 2 ^ > II S ^ x- -»•' aa ^ --' .11 5 =- >" ^f I? --g. r 1^ s \ •s S § \ .^ .J* : IJ in CM ""^ — - . — ^^ 8 ~- a is. - 1^ UJ ■"■> ^ 1^ o -I| lO . ii i« - s 3 ^ « - 2 2 C4 &^ — i— 1"" m CO a rs c If » C 1 in o LT ->* c » f o CM If ig m c 5 BELIRIUM TREMENS. 275 Hospital in Calcutta, from 1848-52, and the Medical College Hospital from 1851-53, as quoted by Dr. Aitken: — > Ages from Cases Deaths 20-30 100 20 30-40 124 18 40-50 86 10 60-60 7 60-66 5 1 The influence of sex on the occurrence of delirium tremens may be expected to be, in the nature of things, a considerable one. Some observers have denied that this disease occurs in women ; and in some continental countries, such as Italy, it is certainly never seen in them. In Norway and Sweden it is believed to occur in one woman to 170 men; and in Germany and France it is only exceptionally seen in women, by practi- tioners of the largest experience. In England and "Wales, how- ever, the rate of female mortality from delirium tremens is excessively high,' the 'proportion being of one woman to eight men. The numbers are as follows : — Influence of sex on Delirium tremens. Periods of five years Males Percentage Females Percentage 1847-51 2290 •96 298 ■12 1852-56 2217 •86 317 ■12 1867-61 2041 •76 284 ■10 1862-66 2350 •80 203 •09 1867-71 1718 •55 230 •08 It is seen that for men there was a steady diminution during the first three lustra, a recrudescence in the fourth, and a further great fall in the fifth ; and it is found that the mortality ' ' The Science and Practice of Medicine.' — London, 1870. Vol. i., p. 779. ' I have been informed that several hundreds of empty brandy-flasks are every day left behind in ' Ladies'-rooms ' at the London railway stations by female passengers as they arrive, and that the sale of these flasks is looked, upon by the attendants aa their chief emolument. T 2 276 BISSASJES OF THE NERVOUS SYSTEM. from this disease has diminished by 0*41 as between the first and last lustra. For women the first two lustra showed an identical percentage, viz., 0*12, after which there was a steady- fall, the last number being 0*08. Dr. Aitken gives the rate of mortality in the Indian hospi- tals just mentioned as twenty-five men to one woman ; which must also be considered very high. Seeing the great importance of the question of intemperance, I have taken the trouble to ascertain the death-rate from this disease in all the different counties of England and Wales, during the twenty-five years from 1847-72, and have arrived at very interesting results, which are shown in Diagram K. In doing this I proceeded in the following manner : — The mortality from delirium tremens, and the entire morta- lity from all causes, were first extracted for each of the twenty- five years, for London and all the different divisions of England. The deaths from delirium were then divided into all deaths, when the death-rate for each year and each division appeared,, and the results were then added together for the entire period. London, which was seen to be the highest of all, was then taken as a standard of 100, and the proportion of the other divisions to this found by the usual calculation. It is seen from the diagram that London heads the list with 100, the South- Eastern counties follow with 62, the North-Western with 57, the South Midland with 55, the Northern with 54, Yorkshire with 42, the Eastern division with 41, the West Midland with 40, the South- Western with 39, the North Midland with 36,, and last of all comes Wales with only 27. As the number of deaths from delirium tremens is known to correspond closely with the amount of strong alcoholic drinks consumed altogether by a population, it appears very significant that London, where we have seen nervous diseases to be at a comparatively low ebb, should consume proportionately so much more alcohol than Wales, where these maladies are so singularly rife. The question, therefore, naturally presents itself, whether the consumption of strong alcoholic drinks is really always pre- judicial for the nervous system, as has been perhaps too sweepingly asserted by many well-intentioned men of late years ; whether whisky is really ' the devil in disguise ' ; and DELIRIUM TREMENS. 277 - M rj ^ n U a> % • 1 ^' s / -^' ■cz. g :S ^' Z > o . E / K "le Severa ECTIVEL Z N \ \ . G R AM M TREMENS in t TO 18 71 RESP / 1 i ■ ^ S <%% CO MUf z j itJ s y from D FROM Ui / / a / r £? S / ? S 7 « / «> ft In^ UJ -* mf g- en t"^ s o y o / •e z o / ■& i^ / ^ ci o ■n o CO O iC o tn O « o o o m o iO o «o o lO o 0) 9> « CO K fs to lO lO "( 1 £ 7 s } ^ R .> / R A / 12 'i o (O SI in o I AG R A M Mortality from BRAIN DiS s A 5 ?v ? y >l is; < s V a s o CM a / jO r PI LU O «t s u c a> 1 ■s bfi c O U) irrn' _-. |« r^ — ■*». "♦ — A CO f M t / 1 - •1 i^ i- >• J CO o o o (0 o Hi to o o o 5 o O >o CO o o CO o 8 CO o o o o 10 • LOCOMOTOR ATAXY. 807 The influence of age appears to be very naarked on the ■diseases comprehended in this rubric. Like convulsions they are most fatal in the first year. The curve in Diagram N is seen to descend after that until the fifth, and reaches its summit in the first lustrum of life. After that it descends, rises again somewhat at thirty-five and forty, and falls more decidedly at fifty-five. At sixty there is another small rise, but after that the fall is steady, and at ninety there is nothing left. The influence of sex is also considerable, for the following table shows throughout a larger death-rate for males than for females, and this difference between the two sexes has of late years become more marked ; for while the mortality of males shows a decided rise in each lustrum, there was for females a fall in the second lustrum, a rise in the third and fourth, and the fifth has been identical with its predecessor. Periods of five years Males Per cent. Females Per cent. 1847-51 1852-56 1857-61 1862-66 1867-71 8,239 9,743 12,815 14,802 16,060 3-42 3-77 4-71 5-07 5-20 6,840 7,706 10,056 11,086 11,665 2-85 2-65 3-70 3-78 3-78 I now proceed to consider the following structural diseases of the spiaal cord and brain, which have not found place in the preceding chapters : — 1. Progressive locomotor ataxy. 2. Progressive muscular atrophy. 3. Pseudo-muscular hypertrophy. 4. Disseminated insular sclerosis. 5. Hypertrophy of the brain. 6. Atrophy of the brain. 7. Tumours of the brain. 8. Syphilitic affections of the nervous system. 1. Progressive Locomotor Ataxy. Tabes dorsalis is first spoken of in the works of Hippocrates, and was by the father of medicine believed to arise from excesses X 2 308 DISUASHS OF THE NERVOUS SYSTEM. in sexual intercourse, the chief symptoms of the disease being spermatorrhcea, marasmus, and hectic fever. This meaning of the term, however, has gradually changed, and those authors who wrote on tabes in the j&rst decennia of this centiu-y, under- stood by it atrophy of the posterior portion of the spinal cord, brought on, not merely by sexual exhaustion, but also by expo- sure to wet, rheumatism, gout, and other causes, the chief symptom being a peculiar form of paraplegia. The disorder was chiefly investigated by English and German physicians, such as Abercrombie, Hufeland, Steinthal, Eomberg, and others. Their descriptions, although in some instances most eloquent, were, however, to a certain extent, wanting in accuracy, inas- much as several different affections of the cord were compre- hended under the name of tabes, and a clear distinction was not drawn between tabes and paraplegia. It was only after a more careful clinical study of the symptoms had been made, and after pathological anatomy, aided by the microscope, had stepped in, that a peculiar disease of itself, and one characterised by uniform structural lesions, could take its place in our nosologi- cal system. The chief credit of the anatomical investigations is due to Professors Virchow, Tiirck, Eokitansky, and Leyden, and in this country to Sir "William Gull and Dr. Lockhart Clarke, who have shown that, in well-marked cases of tabes, an actual waste of the posterior columns of the spinal cord takes place, together with the formation of amyloid corpuscles, and considerable pro- liferation of connective tissue. The first who drew a distinction between this disease and paralysis was Dr. Todd, who stated that two kinds of paralysis might be noticed in the lower extremities : the one consisting simply in the impairment or loss of voluntary motion ; the other distinguished by a diminution or total absence of the power of co-ordinating movements. In the latter form, while considerable muscular power remained, the patient found great difficulty in walking, and the gait was so tottering and uncer- tain that his centre of gravity was easily displaced. In these few words we have a good description of the symptom of ataxy,*- upon which so much stress has been laid by French phy- sicians. The term ' ataxy ' is as old as that of ' tabes,' for it also ' From T(i|is, order, and privative alpha (want of order) LOCOMOTOR ATAXY. 309 originated with Hippocrates; and it has likewise entirely changed its meaning in the course of time. Some authors have applied it to chorea, others to fevers, others to various nervous disorders. At present, however, we understand by ataxy, not a disease of itself, but merely a symptom to which various disorders may give rise, and which essentially consists of a want of co-ordination of voluntary movements, and a ten- dency on the part of the patient to lose his balance, but without actual loss of power, and apart from tremor, chorea, and paraly- sis. This symptom may be observed in disease of the cerebellum, and in poisoning by alcohol, lead, and mercury ; but it is more especially connected with that disease which has been long familiar to us as tabes. The best clinical study of this symptom we owe to M. Duchenne de Boulogne, who, in 1 858, described what he thought to be an entirely new disease, which he called ' pro- gressive locomotor ataxy,' and which he believed to be a func- tional disorder of the cerebellum. His apparent discovery was hailed as a real one in France, and Professor Trousseau actually proposed to call the new stranger ' Duchenne's disease ; ' but on looking more closely into the matter, it was discovered that Duchenne's description was altogether applicable to our old friend, tabes. This is not said in disparagement of the great ability and originality of M. Duchenne's researches, which were perhaps more strikingly displayed in this case just on account of his being unacquainted with the previous literature on the subject ; yet, if I thought it desirable to attach a proper name to this affection, I should prefer calling it ' Todd's disease,' as Todd first drew the distinction between ataxy and paralysis, eleven years previous to Duchenne. But the best plan is, perhaps, merely to drop the term ' tabes,' as being too vague, and to call the disease under consideration progressive locomotor ataxy, or wasting of the posterior columns of the spinal cord. The following are the anatomical features of the disease: — The vertebrae and the vertebral canal are healthy, but the sac of the dura mater often contains a somewhat considerable amount of clear or turbid liquid. The membranes themselves may be normal, but in some cases the posterior part of the dura has been found thickened, and adherent to the pia by thin false membranes, the anterior part of the dura being unaffected. 310 DISEASUS OF THE NERVOUS SYSTEM. The posterior part of the pia is less transparent than it should be, and presents a yellowish or milky appearance. It often adheres so firmly to the substance of the posterior columns that it cannot be separated from them without tearing ofif some portions of the medullary matter. These changes have, how- ever, only been noticed in about one-half of the cases examined, and we must, therefore, consider them rather as incidental, than as pathognomonic appearances. The latter are found in the cord itself, which shows, in its posterior columns, a peculiar grey coloration which is not superficial, but embraces their entire depth, and constitutes the characteristic anatomical feature of the disease, being always connected with a definite alteration of the intimate structure of the cord. In cases where the pia is opaque, it is necessary to remove it to show the grey coloration, but where that membrane is transparent, it becomes visible immediately upon the removal of the dura. We then see, instead of the white matter of the posterior columns, either one or two grey bands proceeding from the lower end of the cord to the middle of its dorsal portion, and occupying the whole space between the opposite insertions of the posterior roots. As we proceed higher up, these bands become narrower, and often separate into smaller stripes, which run up to the calamus scriptorius and the floor of the fourth ventricle. The grey colour of the posterior columns is sometimes uniform throughout, in other cases it is dark in the median line, and light laterally. Occasionally the grey merges into amber, pink, or reddish yellow, according to the stages of the degenerative process. Generally, however, it is so similar to that of the healthy grey matter, that Olivier believed the whole process to be one of hypertrophy of the latter substance. Laterally the grey coloration is mostly limited by the posterior horns, and centrally by the commissure. This commissure and the central part of the grey matter are sometimes also affected, and in far advanced cases the disease may extend to the lateral columns; while the anterior horns, columns, and roots have always been found healthy. The shape of the cord is altered, and being flattened from before backwards, it would seem at first sight to be actually LOCOMOTOR ATAXY. 311 enlarged. Such, however, is not the case, for the flattening results from the diminution of the bulk of the posterior columns. Where the disease has been severe, they may be entirely gone, being replaced by a thin band of connective tissue. The con- sistence of the grey matter and of the antero-lateral columns is normal, which may also be the case with the posterior columns ; occasionally, however, these latter are found softened, and even semi-fluid. The posterior roots are, in most cases, similarly afi"ected to the posterior columns. Sometimes the whole substance of the root is in a state of degeneration, while ia other instances grey stripes alternate with healthy white bands. The lower roots are generally more affected than the upper ones. This affection of the roots is secondary to that of the colmnns, because in a certain number of cases the columns have been found diseased, while the roots were healthy, and because in other instances where both were diseased, the columns were in a far more advanced stage of degeneration than the roots. Moreover, it is found that in most cases, although columns and roots may be diseased at the lower part of the cord, yet, further upwards, the columns may show extensive disease, while the roots appear healthy. In no case has there been atrophy of posterior roots without simul- taneous atrophy of the columns. In the upper portion of the cerebro-spinal axis the disease is less severe than in the lower part. The calamus scriptorius occasionally shows traces of it, but the cerebellum which has in all cases been examined with the greatest care, has always been found healthy. This latter circumstance has caused considerable disappointment to certain pathologists who concluded a priori, from physiological premises, that structural changes of the cerebellum w/wst be found in progressive ataxy. Such, however, is not the case, and this fact well illustrates how necessary it is to be cautious in the application of physiological theories to pathological processes. The cerebral nerves may likewise show structural alterations. The optic nerves have been found softened or entirely destroyed, only a few fibrous strings being seen in place of nervous matter. The ulceration may spread to the chiasma, but stops short at the corpora geniculata. In the retina it proceeds from the 312 BISEASJES OF THE NERVOUS SYSTEM. papilla to the periphery of that membrane. The other cerebral nerves are rarely affected. In one case the olfactory nerves, although apparently healthy, were, on being examined with the microscope, seen to be almost smothered by amyloid cor- puscles. The motor oculi, the hypoglossus, and the vagus have occasionally been found wasted. These results correspond with the symptoms observed during life ; for while the cord and the optic nerves, when once thoroughly altered, are generally permanently disabled, the symptoms referable to the other cerebral nerves almost always disappear after a short time. In a case which was some time ago under my care in the hospital, there was total deafness from disease in the semi- circular canals. The patient recovered completely from all symptoms of ataxy, except the deafness ; and it is therefore probable that in this case wasting of the auditory nerve would eventually be discovered. The microscopic examination of hardened specimens shows that, whereas a section of healthy nervous matter taken from the anterior columns is dark, one from the diseased posterior columns is transparent. This results from the fact that in the anterior columns healthy nerve-tubes are crowded together, while in the posterior columns most of these have been de- stroyed by the disease, and are replaced by a clear and nearly homogeneous mass, which contains a number of small granules and connective tissue. The nerve-tubes, if not entirely destroyed, appear granular, varicose, more narrow than usual, and are nearly or entirely devoid of myeline and the cylinder axis. There is also proliferation of connective tissue ; the capillary vessels show thickening of the adventitia and appear surrounded by oil-globules. A large number of amyloid corpuscles, presenting the well-known mother-of-pearl appearance, are likewise met with. They are most numerous along the course of the blood-vessels, and abound chiefly where the degeneration is not far advanced, while they are less frequent where the nervous matter is quite destroyed. The lesions of ataxy are therefore destruction of nervous matter, proliferation of connective tissue, degeneration of blood-vessels, and formation of corpora amylacea and oil- globules. It resembles both chronic inflammation and simple LOCOMOTOR ATAXY. 313 atrophy, but neither of them altogether, and should therefore be looked upon as a lesion ' svA generis.^ Duchenne has distinguished three stages of the disease, but these are by no means always so well dej&ned as this author would lead us to believe. The first stage is marked by certain affections of the cerebral nerves, pains of a peculiar character, and diminution of sexual power ; it generally lasts from four to five years, sometimes much shorter, and in other cases longer. In the second stage the symptom of ataxy supervenes, together with loss of sensibility ; this may last ten years and more. In the third stage the symptoms of the first and second stage become more severe ; complications, such as paralysis and spasms, supervene, and death results from exhaustion, or from intercurrent diseases. The commencement of progressive ataxy is either slow or subacute. One or more of the cerebral nerves are generally the first to suffer, those most frequently affected being the optic, and the third, fourth, and sixth pairs. The chief symptoms are, therefore, amblyopia, double vision, strabismus, and ptosis. Sometimes there is even treble vision, or two images may be observed by one eye while the other is closed — symptoms which have not yet found a satisfactory physiological explanation. The ophthalmoscopic examination of the fundus oculi shows, at first, symptoms of congestion ; the vessels are diseased, and the ■whole fundus has a violet colour. Strabismus and double vision have the tendency to disappear within a few months, with or without treatment ; ptosis is liable to continue much longer, and amblyopia almost always, in the course of time, merges into amaurosis. The ophthalmoscope then shows signs of atrophy of the retina ; the diameter of the blood-vessels is (diminished, the disc is of a greyish or mother-of-pearl hue and excavated, and a white circle is seen at its margin. The other cerebral nerves may also show signs of paralysis, with the only exception of the olfactory ; there may be loss of taste, deafaess, difficulty of mastication, dysphagia, and numb- ness or loss of sensation of the face, lips, tongue, and gums. These latter symptoms are, however, comparatively rare. Most diseases of the cord are accompanied by paim,, but progressive ataxy more frequently than any other. Pain of a 314 DISHASHS OF THE NERVOUS SYSTEM. peculiar character constitutes, indeed, one of the most distress- ing symptoms of this affection. It is short, sharp, and sudden, similar to electric shocks. After a second or two the pain is gone, and the patient has a short interval of rest ; but soon there is another pang, and this may go on for two or three days consecutively, after which there is a free interval of a few weeks- or even months. The pain often begins in the feet, then migrates about the body, sparing only the head, and finally settles in one of the legs, from where, as the disease advances, it gradually proceeds upwards. During the attacks neither swelling nor redness is perceptible in the parts affected, but after some time considerable hypersesthesia sets in, so that the patient is exceedingly sensitive to touch or even a slight draught of air. In other cases there is no hypersesthesia, but numbness, and strong pressure relieves the pain. If the eyes are attacked, a flow of tears, heat, and dilatation of the pupils are caused; if the bladder is invaded, catarrh of that organ may be produced. As time wears on, the pain generally increases in severity, appears at shorter intervals, and lasts much longer. It is most liable to come on when sudden atmospheric changes occur, after exposure to wet, after excesses in walking, drinking, or sexual intercourse, and from indigestion. The patients gene- rally dread winter. As spring advances they frequently improve, and this is often believed to be due to the remedies which happen to be employed about that time. Some patients consider them- selves weather-glasses, as they are by an increase in the severity of the pain generally able to predict an impending change. Spermatorrhoea is another important symptom, but it is wanting in a number of cases. "When present, it seems to accelerate the progress of the disease. Emissions occur first at night, and with erections ; after a time they likewise occur in the daytime, and without erections, more especially on voiding the bowels, and impotence is the final result. In exceptional cases the disease is ushered in by priapism and satyriasis. Eisenmann has recorded a case in which these latter symptoms continued more or less for thirty years, and were only relieved by large doses of opium. The bladder and rectum generally suffer at a somewhat LOCOMOTOR ATAXY. 315- early stage of the complaint. Constipation is the rule, while involuntary fsecal discharges are rare. The bladder is not com- pletely emptied, and the urine passes tardily. Incontinence may also be present. After a time, other symptoms come on, either suddenly or gradually, by which the second period of the complaint is marked. The most important of these, and from which the disease has received its name, is the locomotor ataxy, or loss of co-ordination. Volition loses its influence over the muscles, which, although still possessed of great intrinsic force, are nevertheless unable to execute complex movements, or preserve the equilibrium of the body in its erect position. The ataxy generally begins in the lower extremities. The patient notices an awkwardness in his movements when he walks in the dark, or in the morning while he is dressing. He soon takes to a stick when out of doors, but even with such aid he finds that he has to make considerable efforts to prevent himself from falling. In order to appreciate the degree of ataxy which may be present, we must examine the patient in all. positions, whilst standing, walking, and lying down. If he is told to stand with both feet close together, he can seldom keep his balance. He staggers from one side to the other, and manoeuvres desperately with his arms, almost like a rope- dancer ; but unless supported, he would go down at last. If told to stand with his eyes closed, he has to struggle very hard to maintain himself. But this alone is not sufficient to enable us to diagnose progressive ataxy, because the same symptoms may be found in convalescents from acute diseases, in certain cerebral affections, or in persons who are reduced by bad living, and in a weakly condition. The ataxy becomes much more apparent if the patient attempts to walk. He throws the legs forward with a jerking mo- tion, and puts the feet down with great force. In turning round, he is especially awkward. At the commencement of the affection he can still walk a considerable distance, and feels the difficulty chiefly on first starting, or changing his direction ; but as the disease advances, walking becomes almost, or quite, impossible. He is still able to make powerful muscular efforts, and flexors as weU as extensors feel hard and contracted; yet he does not succeed 316 SISSASUS OF THE NERVOUS SYSTEM. in doing that -which other persons accomplish without an effort. At first the ataxy is more striking in the pelvic and femoral muscles. But after a time it becomes also apparent in the leg and foot. The sole seems continually to search for support, one leg is crossed over the other, or jerked about in a disorderly manner, without the slightest intent or purpose. All efforts of the will to check these movements are ineffectual and only serve to increase them. The patient soon becomes exhausted by the expenditure of so large an amount of muscular force, and is glad to get back to his couch. While laying down, the patient is able to move the legs in all directions, showing that there is no paralysis; but these move- ments are often abrupt and sudden. In a somewhat advanced stage of the disease no graceful or easy movement is possible : he does not know what force to use, or where to stop, and he cannot continue a movement for any length of time. The dif- ference between this condition and paralysis is very striking. The atactic patient has a great deal of muscular power, and is able to make efforts to do what he is requested to do, but he does not know how to set about it, and expends his force in vain. In the paralytic, on the contrary, the power is lost, or greatly diminished ; he cannot move, or if he succeeds in doing so, it is a feeble motion, although one not devoid of pur- pose. In the upper extremities ataxy is not so well marked, nor so frequent as in the lower ones ; and it mostly appears only at a later period of the disease. If the patient be requested to touch his nose with the tip of the forefinger, to pick up a pin or a piece of money, to describe a circle in the air, &c., the ataxy becomes apparent, more especially if the eyes be closed at the same time. He cannot write in a straight line, and is awkward in dressing and feeding himself. The muscles of the face are only rarely affected ; sometimes, however, there is facial spasm and difficulty of articulation. Sensibility always suffers at this stage of the complaint. The patient experiences a feeling of numbness or heaviness in a limb or part of a limb, which may exist without any loss of cutaneous sensation. It generally commences in the toes, or the soles of the feet, and from there gradually spreads upwards LOCOMOTOR ATAXY. , 317 to the abdomen and the chest, which feel as if constricted by a circular band, a net, or a tight string. Where this feeling in- vades the chest, dyspncsa is also present. In the upper extremi- ties the numbness is generally confined to the third and little finger, and only seldom spreads higher up. Numbness in the legs and feet is one of the most constant symptoms of the disease, and if absent, must make us doubtful whether the case is really one of ataxy or not ; and when it diminishes or disap- pears, we may say with certainty that an improvement has taken place. Cutaneous anaesthesia is a frequent, but by no means constant symptom of ataxy, and generally appears only at a somewhat later period of the disease. We may observe all the difierent forms of anaesthesia, viz. — loss of the sensation of pain, or anal- gesia ; loss of the sense of touch, which is anaesthesia properly so called ; and loss of the sense of locality, temperature, and pressure. Sensibility to pain may be diminished or entirely gone. Neither pricking nor pinching are felt, or instead of a sharp sensation, a dull kind of touch may be perceived. Cruveilhier mentions the case of a man who had fractm-ed the leg, and neither at the time of the accident, nor afterwards, had felt any pain whatever. The sensibility to galvanism and faradism is also diminished, as the patient is able to bear the application of a powerful current without inconvenience. The sense of touch is duU or gone. The patient cannot distinguish the nature of an object by touching it with his fingers, but has to be assisted by his eyes, and this is not confined to the upper or lower extremities, but may extend to the neck, tongue, and soft palate. A common symptom is tardy sensation, so that when touched, the patient only feels it five or ten seconds afterwards. If the soles of the feet are tickled, there are scarcely any or no reflex movements, and the perception of tickling is dull or absent. The sense of locality is often wanting, so that the patient, if touched in a particular part of the body, cannot tell you where he is touched. The distance at which two separate sen- sations are perceived as such, is increased, as may be shown by examining him with Weber's pair of compasses. In the legs, where the normal distance for two separate sensations is an inch 3] 8 BISJEASm OF THE NERVOUS SYSTEM. and a half, the patient is sometimes altogether unable to feel them as such, while in the face and fingers he may still be able to do so. The sense of temperature is only rarely deficient. "We are generally able to distinguish with certainty a difference of one, or half a degree, and this faculty may remain after all other kinds of sensation have vanished. , M. Topinard has recorded such a case which was under Trousseau's care in the Hotel-Dieu. The patient had double amaurosis, absolute anaesthesia as regards touch, pain, and locality, ataxy of motion to such an extent that he had been unable to get out of bed for two months ; he had ■completely lost his muscular sense, and had only the sensation of heat and cold to tell him that he still bad his limbs. Some- times his legs would be jerked out of bed by spasms which he did not feel, and which, being blind, he could not see. Then, after a time, a sensation of cold would creep upon him, and the poor fellow would ask whether anything was the matter with his legs. This patient existed, as it were, only by his memory, as he had lost the consciousness of his body. But even the sense of temperature may be wanting. Leyden mentions the case of a man who prepared a warm bath for himself, and not being able to distinguish between heat and cold, he made it too hot, and was severely scalded on going into it. The sense of pressure, which is only a modification of that of touch, resides in the nerves of the skin, cellular tissue, muscles, and periosteum. A sensation of pressure is produced by weights resting on certain parts of the body, more especially on bones. M. Eigenbrod, who had studied the changes which this sense undergoes in various affections, has found that there is a con- siderable diminution of it in ataxy. Persons in good health are generally able to distinguish a weight of thirty from one which is only twenty-nine pounds, but the atactic patient loses this faculty to a great extent. If the sense of pressure in the soles of the feet is artificially diminished by the application of ice or chloroform, the gait becomes tottering: and it is, therefore, permitted to suppose that the uncertain walk of atactic patients is partly owing to the diminution of this sense, a firm gait being only possible where there is a proper sensation of resistance offered by the ground on which we walk. LOCOMOTOR ATAXY. 319 In the third period of the disease we observe all the symp- toms which are present in the second, only in a more marked degree. Sensation becomes more impaired, the ataxy more striking, and muscular force, which was previously intact, begins to fail. The patient cannot grasp anything with sufficient force ; he cannot offer any resistance to movements imparted to his limbs by others ; he has difficulty in raising his legs when in bed ; and if he attempts to walk, the feet drag on the ground. The muscles waste away and undergo fatty degeneration. Spasms often supervene, which are most troublesome at night and when the weather is damp. Amblyopia merges into amaurosis ; there is paralysis of the bladder, incontinence or retention of urine, involuntary evacuation of faeces, and at last decubitus on the sacrum, unless great care is taken to prevent it. The bones and joints also become affected ; fractures are produced without in- jury while the patient is in bed, or standing, and in a similar way the hip-joint and other articulations may become dislocated, without any apparent cause. Death ultimately takes place from bedsores or inflammation of the bladder and kidneys, or from intercurrent diseases, such as bronchitis, pneumonia, and phthisis. A curious symptom remains to be mentioned — viz., the state of mind of such patients. Unless the pain be severe, they are mostly, if not happy, at all events resigned to their fate. They do not complain much, and axe inclined to think lightly of their affection. In this respect progressive ataxy resembles pulmonary . consumption, in which the mind is also often composed and cheerful, while in diseases of the brain and the liver there is almost always great depression or irritability, or both combined. Ataxy rarely occurs before thirty years of age, being more frequent after forty; and it is seldom seen after sixty. The male sex is more liable to it than the female. Eomberg says that scarcely one-eighth of the cases are females. In the observa- tions recorded by French authors and tabulated by M. Topinard, the proportion is of one female to four males. Of thirty-four cases which I have seen, only one occurred in a woman. Persons who are much exposed to cold, damp, and fatigue, are more liable to it than others. Several of my patients were commercial travellers, who had to be continually on the move. In another case the cause of the illness was attributed by the patient to his 320 disi:asi:s of the nervous system. having been obliged, after a ball in which he had taken active part, to walk home in thin boots in a pelting rain, having been unable to get a conveyance. In this case the symptoms super- vened with great rapidity. Soldiers are also very liable to it. ' The malady is rife,' says Eomberg, 'when the strength is much taxed by continued standing in a bent posture, by forced marches, and the catarrhal influences of wet bivouacs, followed by drunkenness and de- bauchery, as is so often the case in campaigns ; and this is the reason why tabes dorsalis was so frequent during the first decennia following the gTeat French wars of the present century.' Accidents are unquestionably a fruitful cause of ataxy ; and a fall from a horse seems to bring it on more particularly. Sometimes two or three years elapse between the accident and the outbreak of the disease. Ataxy is more liable to come on in autumn and winter than in spring and summer. Most patients improve during the summer months ; and we must, therefore, not be hasty in ascribing any beneficial results which may appear during that season to the treatment employed ; while, if they get better in winter, there is more probability of the remedies used having been of actual service. This malady is believed to be mostly owing to sexual ex- cesses, but experience goes far to prove that such excesses tend to produce cerebral rather than spinal affections, and it is erroneous to look upon them as the chief cause of ataxy. 2. Progressive muscular atrophy. This disease, which was first described by Duchenne and Aran (1849-50), is characterised by a gradual wasting of the voluntary muscles of, and proportionate loss of motor power in, the extremities. Friedreich,' to whom we owe the most careful description of the morbid process which takes place in the muscular tissue, has described it as 'progressive chronic polymyositis. There is at first proli- feration of the interstitial connective tissue of the internal perimysium, between the several primitive bundles. The ■ ' Ueber progressive Muskelatrophie, imd wahre und falsche Muskel- hypertrophie.' Berlin, 1873. PBOGRESSiri: MUSCULAR ATROPHY. S21 muscular corpuscles are at the same time seen to be swollen and increased, their nuclei proliferated, and the transverse stripes appear cloudy and granular. In some cases there is hypertrophy of the primitive fibres, and dichotomic or tricho- tomic division of the same. As the connective tissue continues to proliferate, the muscular fibres perish, either by simple wasting, or after previous division, or by fatty and lirdaceous degeneration. Ultimately the muscle is found to have under- gone cirrhosis or fibrous degeneration, and then has the appear- ance of a tough thin chord or a tendinous mem.brane, which only shows a few remaining insular patches of reddish mus- cular tissue. There is consequently considerable decrease of bulk. Occasionally, however, myositis may become complicated, either at an early stage or towards the end, with diffuse lipomatosis, which never commences in the muscles them- selves, but always in the interstitial connective tissue, when this has commenced to proliferate. Fat-cells originate from the connective-tissue-corpuscles, which are seen to be filled with small globules, and these latter gradually conglomerate so as to form regidar drops of fat. When this occurs, the bulk of the muscle is again augmented, and may even increase beyond its original size. Within this fatty mass, however, the originally fibrous structure of the muscle and the arrangement of the bundles may still be recognised by the peculiar arrange- ment of the different layers of fat. Chronic polymyositis and diffuse secondary lipomatosis are, however, not the only anatomical changes which are found in this disease, for certain morbid alterations of the nervous system are likewise, if not invariably, at least commonly, present. Cruveilhier was the first to draw attention to these, and discovered wasting of the anterior roots of the spinal nerves in the celebrated case of the rope-dancer Lecomte. Such lesions have since then been discovered by many observers, while others again have found the nerve-roots perfectly healthy. In Lecomte's case the cord itself was not diseased, but in other cases softening of various parts of that organ was discovered. Luys first directed attention to certain alterations of the grey matter in the centre of the cord, having found the ganglionic cells of the anterior horns wasted, and replaced by granular Y 32a DISEASES OF THE NERVOUS SYSTEM. masses containing oU-globules. This was confirmed by the observations of Dr. Lockhart Clarke,> who noticed in six cases dilatation and hyperaemia of the blood-vessels, and granular disintegration of the ganglionic cells, resulting from an irrita- tive process, or induration with hyperplasia of connective tissue, and wasting of nervous structures. Sir William Gull has described a similar condition of the grey matter, with great dilatation of the spinal canal between the fifth cervical and third dorsal vertebrae, the vacuum being filled with serous liquid, while the white columns and the nerve-roots were found normal. Other observers have noticed atrophy in the antero- lateral and posterior columns, the posterior cornua, the posterior roots, the intervertebral ganglia, the cervical sympathetic nerve (Schneevogt and Jaccoud), the peripheral nerve-trunks, and the intra-muscular nerve-fibres, which latter are found to have undergone peri-neuritis and interstitial chronic neuritis. Seeing these extensive changes found in the muscles as well as in the nervous structures, the question has naturally arisen and been much discussed whether the origin of the disease is myopathic or neuropathic. Friedreich, who has with great ability contended for the myopathic theory, is of opinion that progressive muscular atrophy commences as primary myositis, and may in its turn lead to secondary changes in the nervous system, which consist of neuritis affecting first the intra- muscular nerves, afterwards the nerve-trunks and the spinal roots, and ultimately the cord itself. This inflammation may, according to him, become arrested at any part ; and its further propagation within the nerve-substance essentially depends upon the more or less active character of the myositis, which has to be looked upon as the source of irritation. The dege- nerative processes occurring in the peripheral nerves and ganglionic cells of the anterior horns of the cord would, there- fore, have to be considered as simple consequences of disturbed motor function and ascending neuritis. It is difiScult to explain by this theory why the nerve-roots and peripheral nerves have so often been found healthy when the anterior horns were diseased ; but it is more especially the ' ' Medico- Chirurgical Transactions ; ' London, 1868, p. 249. PROGRESSIVE MUSCULAR ATROPHY. 323 association of progressive muscular atropLy with progressive bulbar paralysis, which occurs in many cases, that militates most strongly against the myopathic theory of the complaint. Nobody now looks upon progressive bulbar paralysis as a muscular disease, for it has been conclusively shown to arise from wasting of the ganglionic cells of the motor nuclei in the rhomboid fossa ; and as towards the end of progressive muscular atrophy the symptoms of bulbar paralysis frequently become developed, it is reasonable to assume that the disease is then spreading from the grey matter of the spinal cord to the medulla oblongata. Again, the later stages of locomotor ataxy may be combined with complete wasting of the muscles, when the disease has extended from the posterior columns right through the substance of the cord to the anterior horns of the grey matter. The symptoms of all these diseases are therefore seen to depend upon the areas of the cord and medulla which are affected in the first instance, and upon those which are afterwards involved in the morbid process. Progressive muscular atrophy is thus seen to be a disease of the spinal cord ; and chiefly of the ganglionic cells of the anterior horns of the grey matter, from where the motor roots emerge, and which preside over the nutrition of the muscles. The number of wasted muscles is fairly proportionate to the degree of atrophy which is found in the anterior cornua. The nature of the process is very similar to that which takes place in progressive locomotor ataxy — viz., grey degeneration of the nervous matter, increase and thickening of the connective tissue and fatty degeneration of the nerve-tubes ; and only the seat of the disease differs, being in the one instance the posterior columns and in the other the anterior cornua. It also closely resembles the sclerosis which is found in the lateral columns of the cord, after attacks of apoplexy ; and finally a form of disease which we shall presently consider under the heading of disseminated insular sclerosis of the brain and spinal cord. In progressive muscular atrophy the sclerosis proceeds in a peculiar manner, affecting some ganglionic cells more, and others less, completely, some sooner and others later, while some are entirely spared. This explains the peculiarity of the symptoms of the disease, in which muscles in different parts of Y 2 324 DISEASES OF THE NERVOUS SYSTEM. the body are to all appearance capriciously attacked ; and yet' there is the tendency that certain sets of muscles which are either co-ordinated in their function, or symmetrical, suffer at the same time. There is nothing specific in the lesion, for there may be ordinary grey degeneration, or* sclerosing myelitis, Clarke's granular disintegration, or pigmentary dege- neration of the cells, but the ultimate result is always the same — viz., atrophy of the ganglionic cells, which perish one after the other. Friedreich, who considers the seat of the disease to be exclusively in the muscular tissue, thinks that it is caused by a nutritive and formative debility of the muscular tissue, which leads to diminished powers of resistance, and creates a tendency to irritative and degenerative disturbances of nutrition. Those, on the other hand, who look upon it as a disease of the cord find the cause of it in the neuropathic con- stitution, which in this instance manifests itself by debility of the ganglionic cells of the anterior horns, and which is evidenced by the simultaneous occurrence of such diseases as progressive bulbar paralysis, locomotor ataxy, and general paralysis of the insane. That there is a constitutional tendency to the production of this complaint seems evidenced by the fact that a decided heredi- tary influence has been shown to exist in a considerable number of cases. Hemptenmacher' has given the details of a series of cases in which the males of three different families, which descended from a couple living 150 years ago, were subject to the complaint, and where the unaffected females transferred the germ of the disease to their descendants ; and Trousseau has mentioned a family in which the great-grandfather, grand- father, father, and son suffered from this affection. Adult males are particularly liable to the disease, the pro- portion being of about five men to one woman. This is pro- bably to a great extent owing to the circumstance that men have harder muscular work to do than women, and that they are also more liable to accidents. The complaint is, however, not unfrequent in childhood, where the hereditary tendency is all-important. Accidental causes, which seem to give rise to • 'De aetiologia atrophias musciilaris progressivae.' Berlin, 1862, PROGRESSIVE MUSCULAR ATROPHY. 323 its outbreak, are certain acute diseases, such as measles, rheumatic and typhoid fever, and the puerperal state. Over- exertion of the muscles can be traced in another set of cases, which occur chiefly amongst the working classes, in males, and in which the right hand and shoulder are more affected than the left. In sixty-nine cases collected by Dr. Eoberts this was the case in twenty-five. Friedreich has shown that out of 146 cases the disease com- menced in 111 in the upper extremities, in 27 in the lower limbs, and in 8 in the muscles of the loins. The muscle which is generally first affected is, according to Eulenburg,' the first external interosseous of the right hand, as shown by the follow- ing experiment : — If the thumb is adducted, and the second, third, and fourth finger are fixed, the patient experiences some difficulty in moving the extended first finger towards the radial side of the hand ; and where the disease begins in one upper extremity, a great difference is noticed in this respect between the affected and the healthy side. Other observers, myself included, have seen the disease to commence in the ball of the thumb, affecting more particularly the opponens and adductor pollicis, while extensors, flexors, and abductors remained healthy. The muscles of the forearm and arm are generally spared in the commencement of the affection, which makes a sort of jump from the muscles of the fingers to the deltoid muscle, which in some cases has even been the very first attacked. The trapezius and serratus follow, and this causes displacement of the shoulder-blade, which is twisted round its axis ; the upper angle of the bone is pulled down by the weight of the upper extremity, and the lower angle then becomes raised and withdrawn from the chest-wall. From the shoulder the disease spreads towards the arm, destroying the biceps and triceps ; the patient can then no longer raise the arm or bend the elbow-joint, and has great difiiculty in dressing and feeding; and although he learns in time to manoeuvre cleverly so as to compel muscles which have escaped destruction to do the work of those that are wasted, he nevertheless becomes at last com- pletely helpless. ' ' Vasomotorisoh-lrophische Neurosen.' In 'Ziemssen's Handbuch,' vol xii. pai-t i. p. 114.' Leipzig, 1877. 326 I)l,fiEASES OF THE NERVOUS SYSTEM. Contractions and deformities are also noticed in the hand, which assumes the shape of a bird's claw from wasting of both internal and external interossei : the thumb is abducted and extended in the first, but flexed in the second phalange. The shoulder-joint may become dislocated, the caput humeri being directed towards the coracoid process. This is more particularly seen in children. Wasting of the muscles of the lower extremities causes great difficulty in walking, and particularly in going upstairs. The rectus femoris and the hamstring muscles are generally the first to suffer, and after them follow the adductors of the thigh and the gastrocnemius muscles. The pectoralis major is usually at- tacked about the same time, and the chest then appears shrunk, more especially beneath the collar-bones. Where the disease begins in the lower extremities, the patients are mostly children, and it is then not real atrophy, but pseudo-hypertrophy of the muscles, which will be presently considered. Farado-muscular contractility diminishes in the same ratio as the fibres waste ; but as long as any such exist, they remain excitable to faradisation. The same may be said of galva- nisation, but there is this peculiarity with the latter, that the motor nerves respond differently to the current in different portions of their course between the spinal cord and the muscles, so that they may be still excitable near the cord when their excitability is diminished or entirely gone in their more peripheral portions. A curious symptom is the occurrence of fibrillary twitches in the wasting muscles, which indicate that the disease is advancing ; when they cease, there is either improvement, or it is owing to total destruction of the suffering muscles. Eegular cramp occurs likewise, especially towards the end, and when the patient is in bed. The adductors of the thighs are then often in a constant spasmodic motion, so that the knees keep knocking against one another, which prevents the patient from sleeping. We rarely meet in this disease with any symptoms pointing to altered sensibility, but in some cases paroxysmal pains have been observed in the beginning, and ansBsthesia towards the PROGRESSIVE MUSCULAR ATROPHY. 327 end. The temperature may be at first increased, and later on diminished. Sometimes there is sudden ischaemia of the hands and fingers with subsequent hyperaemia, or profuse per- spiration. The skin is often wasted, rough, and discoloured, and painful affections of the joints are not uncommon. The pupils are sometimes narrowed, and respond sluggishly to the action of light, most probably from affection of the cervical sympathetic nerve. The urine has now and then been found alkaline. The large joints seem occasionally to offer a certain amount of resistance to the propagation of the disease, which, as we have seen, does not affect the muscles in a contiguous fashion. Thus atrophy of the muscles of the hand rarely, if ever, proceeds straight to the muscles of the forearm ; and when it commences in the deltoid, the elbow-joint seems to prevent it from extend- ing lower down. The muscles of the neck and head, as well as of the eyes, are generally spared; and the diaphragm and abdominal muscles suffer, if at all, only in the later periods of the disease. The course of progressive muscular atrophy is generally slow, and protracted over a good many years. It is never, or hardly ever, cured, but its progress is sometimes arrested, and the patient may then live on for years in tolerable comfort, provided the disease has ceased to be active before too much loss of tissue has occurred. Death generally occurs from bron- chitis, as the expiratory muscles suffer, and the expectoration of mucus becomes diflScult or impossible ; or from decubitus and blood-poisoning ; or from the disease spreading to the medulla oblongata, and bulbar paralysis, with all its consequences, being developed. Wasting of the facial muscles, which causes the physiognomy to lose all expression, is a sure sign that the end is near. 3. Pseudo-hypertrophy of the muscles. This disease, which is closely allied to progressive muscular atrophy, was first described by two Neapolitan physicians, Coste and Gioja, in 1838, and afterwards more fully by my colleague. Dr. Meryon, in 1852. In spite of these and numerous later 328 DISEASES OF THE NERVOUS SYSTEM. observations, the pathology of the affection, and more especially its relation to progressive muscular atrophy, are still somewhat obscure. Its principal feature is proliferation of the connective and adipose tissue, by which the circumference of the affected limbs is very much increased, and simultaneous wasting of the muscular fibres, which causes loss of motor power in the ex- tremities. The morbid process in the muscles is probably of an in- flammatory nature, and begins with proliferation of the con- nective tissue from the internal perimysium and the adventitia of the small blood-vessels. Occasionally the process is arrested at this stage, but in the large majority of cases, the spindles and nuclei of the connective tissue are gradually changed into oil-globules ; and interstitial and inter-fibrillary de- velopment of fat then becomes the essential feature. The nutrition of the muscles suffers considerably in consequence of this ; and the primitive fibres waste away under the influence of pressure. Sometimes a few truly hypertrophied fibres are found in the neighbourhood of the wasted fibres, and are seen to have two or three times the diameter of healthy fibres. The muscular nuclei may be increased in number, and the fibres show a certain amount of granular cloudiness which disappears on adding acetic acid, signs which must be attri- buted to an irritative process in the muscular fibres themselves. To tlie naked eye the muscles appear pale, white, and shining, and are scarcely to be distinguished from the subcutaneous adipose tissue. Whether any alterations of the nervous centres are connected with this disease, is as yet undecided. The results of most necropsies have been negative, but in a few cases granular disintegration of certain portions of the cord, and proliferation of connective tissue in the sciatic, tibial, and peronseal nerves, has been discovered. Friedreich has expressed the opinion that pseudo-hypertrophy of the muscles is only a form of progressive muscular atrophy, which is somewhat modified by occurring particularly during childhood, and showing somewhat greater intensity of the morbid predisposition. The fact that when children begin to suffer from this disease, they are soon disabled from moving about, and condemned to repose, as well as the circumstance PSEUDO-MUSCULAR HYPERTROPHY. 329 that their principal food, more particularly where the affection occurs in the lower classes, consists of articles which either are fatty or changed into fat in the system, seem to lend con- siderable support to this view. It is well known to farmers that the formation of fat in animals is powerfully promoted by a tender age, want of exercise, and fatty food ; and all these circumstances are found combined in the pseudo-muscular hypertrophy of childhood. Dr. Ord has shown that the invasion of the malady is ac- companied by an increase of temperature in the legs, which is evidently dependent upon the inflammatory nature of the connective tissue proliferation by which the complaint is vishered in. In the later stages of it, the temperature is lowered, some- times very much so (10 to 15"), and the diseased parts have either a pale or livid colour. The skin is dry and smooth, has a mottled appearance, and is somewhat attenuated by the ex- cessive tension of the parts underneath. As a rule the affection begins in the legs. The calves stand out conspicuously, ' like those of a practised pedestrian,' and yet the patient is unable to stand or walk properly. He keeps stumbling, has a waddling gait, and is easily exhausted. The thighs soon follow in their turn, and the disease gradually progresses to the buttocks, the muscles of the lumbar spine, and the abdomen. The legs are unnaturally far apart, while the feet are kept close together; the heels are drawn up, the knees and hip-joints are flexed, and the spine shows various forms of curvature. On measuring the Hmbs from time to time, a steady increase of their circumference will be noticed. They have a spongy, fatty feel, which is utterly unmuscular, and is more striking in the calves than in the thighs. As the disease progresses, the patient finds it difficult to sit down or rise from a sitting posture, and the aid of the hands and arms is requisitioned, which, however, often refuse the service de- manded of them, since they are liable to suffer from ordinary atrophy of the muscular tissue. Fibrillary twitches are occasionally present, but difficult to distinguish on account of the layers of fat which cover the muscles. The farado- and galvano-muscular excitability is at first diminished, and later on completely lost; while the electro-muscular sensibility is 330 DISEASES OF THE NERVOUS SYSTEM. sometimes increased. Pain in the back and in the lower extremities is complained of, especially when the patient attempts to move; and this is relieved by rest. Numbness and a feeling of coldness may likewise be present, but anaesthesia is rare. It is doubtful whether such children ever attain a great age ; but pseudo-hypertrophy is certainly not so dangerous to life as progressive atrophy. In cases which have ended fatally, death was generally owing to certain affections of the respiratory organs, such as bronchitis, pneumonia, &c. Apart from pseudo-hypertrophy, real inuscular hypertrophy has been observed in a few exceptional cases. There is increase in the bulk of the muscles, and the power may be increased or normal. It seems always to occm- in adults who have undergone considerable fatigues, such as soldiers during a campaign ; and is usually confined to one arm, or one leg, these being two or even three inches larger in circumference than their fellows. In some cases the power appears in- creased on first beginning to carry out certain movements, but soon becomes exhausted. The muscles have the proper consistency, and obey the induced as well as the continuous current, well, or at least tolerably well. On harpooning pieces of the enlarged muscles, and submitting them to microscopical examination, the structure appears normal, except that the cylinders are much wider than usual. Thus a muscular cylinder taken from the deltoid in Auerbach's ' case, showed the width to be double that of specimens from healthy muscles. There is no trace of myositis or lipomatosis. That fatigue should be easily induced in the hypertrophied muscle, may either be owing to the circumstance that the intra-muscular blood-vessels and nerves do not grow at the same ratio as the muscular fibres, or to the pressure of the swollen muscular tissue on the intra- muscular nerves. No case has as yet ended fataUy. 4, Bissemifnated insular sclerosis of the nervous centres, sclerose en plaques disseminSes, Charcoi's disease. This malady was first described by Cruveilhier, and after- wards studied by Tiirck, Rindfleisch, Zenker and Frommann ; ' 'Tirchow's Archiv,' vol. 53, p. 234. CHARCOT'S DISEASE. 331 but we owe almost all precise knowledge concerning its anatomy and symptoms to M. Charcot,' and I therefore propose calling it Cha/rcofs disease, a term which will advantageously replace the very long name by which it has hitherto been designated. It affects not only the hemispheres, pons, and cerebellum, but also the medulla and spinal cord, in which grey and more or less irregular patches are discovered, which form a striking con- trast to the healthy tissues in which they are embedded. They somewhat resemble the grey matter, but assume a pink colour by contact with the air, and they are then seen to contain nume- rous bloodvessels. The cineritious substance of the convolutions is rarely affected in this manner, the chief seat of the sclerosis being the central ganglia and the antero-lateral columns of the cord. Grey patches are likewise found in certain peripheral nerves, more particularly in the olfactory, optic, and fifth, and the anterior and posterior spinal nerve-roots. ■ Charcot distinguishes three different zones of these patches, viz., 1st, the peripheral zone, 2nd, that of transition, and 3rd, the central one. In the peripheral zone the trabeculse of the neuroglia are considerably thickened, the nuclei more bulky and numerous ; the nerve-tubes lie at a greater distance from one another, the cylinder of myeline being wasted, while the cylinder axis is either normal or hypertrophied. In the second zone or that of transition, the nerve-tubes have become even more attenuated ; the myeline cylinder has quite disappeared, while the cylinder axis appears much enlarged. The trabeculse of the neuroglia are more transparent, and now and then replaced by ordinary connective tissue. In the third or central zone the neuroglia has quite disappeared ; the nuclei are less nume- rous and bulky, and are not so well coloured by carmine as usual ; no myeline is seen in the alveolar spaces, and the cylin- der axis is considerably reduced in size. Nevertheless, a certain number of axis cylinders persists in the otherwise completely altered tissue, which constitutes an essential feature of this form of sclerosis, as it is absent both in the sclerosis of the lateral columns which follows apoplexy, and in the sclerosis of the posterior columns, which is characteristic of progressive locomo- ' 'Legons sur les maladies du systfeme nerveux.' Paris, 1872, p. 168. 302 DISEASES OF THE NERVOUS SYSTEM. tor ataxy. The coats of the bloodvessels are thickened in the peripheral zone, and contain a larger number of nuclei than usual ; in the more central portions of the patches these nuclei are still more numerous, and the coats so thickened that the caliber of the vessel is considerably reduced. Amylaceous bodies are found interspersed in the fibrillary tissue. Oil-globules ■which constitute the debris of the destroyed nerve-tubes are wanting in the central zone where the pathological process is finished, but occur plentifully in the more peripheral portions. This form of sclerosis is, therefore, anatomically speaking, a chronic interstitial myelo-encephalitis. Charcot's disease affects women rather than men, and appears with preference in comparatively young persons, between 20 and 25 years of age. If rarely comes on after 30 years, and patients suffering from it do not as a rule reach the age of 40. The influence of wet and cold, prolonged anxiety, and certain acute diseases such as cholera and typhoid fever, seem occasion- ally to have given rise to it. Three different periods may be distinguished in its course, which I shall now proceed to describe. In the first period the symptoms are often ill-defined. The patient complains of a gradual loss of power, not amount- ing to paralysis, in one or both lower extremities, which has a tendency to become aggravated and to spread to the upper limbs. Sometimes there are remissions or intermissions in this symptom, and the paresis is distinguished from other spinal complaints by there being no affection of sensibility, nor of the bladder and the rectum. The limbs feel heavy, are difficult to move, and ultimately refuse service altogether. This state is, contrary to ataxy, the same whether the eyes are open oi' closed. The muscles, however, do not waste, and retain to the last their galvanic and faradic contractility. The absence of pain and other affections of sensibility is, no doubt, owing to the fact that multiple sclerosis affects as a rule the antero-lateral columns of the cord, and therefore leads more to paresis or paralysis, with subsequent contraction, than to anaesthesia or neuralgia ; we cannot, however, be certain that we have really to deal with Charcot's disease, until other more characteristic symptoms present themselves, and these are, Ist, a peculiar CHARCOTS DISEASE. 333 kind of tremor, and 2nd, certain signs pointing to an intra- cranial lesion. The tremor which is peculiar to this afifection only becomes manifest when purposive movements of a certain extent are made, and ceases completely during rest. Restricted move- ments are possible without tremor. This peculiarity distin- guishes it from the tremor of shaking palsy, which continues during rest as well as motion, as long as the patient is awake ; and also from choreic movements which are disorderly and with- out purpose, while Charcot's tremor is rhythmic. Thus for instance, when a patient affected with chorea carries a cup of tea to his mouth, we notice at once movements of an entirely contradictory character, which have the tendency to counteract rather than to assist the intended movement ; while in Charcot's disease the general direction of the movement persists, in spite of the impediments which are occasioned by the tremor. Again, in progressive locomotor ataxy there may be movements which are devoid of co-ordination, when the arms and hands are affected, and which in a measure resemble choreic and sclerosic movements ; but in the movements of ataxy there is no real tremor or oscillations, and they are at fault by being too abrupt and extensive, and therefore devoid of order. The want of co- ordination in the atactic patient is always increased when he closes his eyes, which is not the case in Charcot's disease. Sclerosic tremor affects not only the upper extremities, but also the head, body, and lower limbs, as soon as purposive movements are made, or when these parts assume a position which can only be maintained by an active contraction of cer- tain sets of muscles. It has, however, been absent in a few exceptional cases, and disappears habitually at a later period of the "complaint, when permanent muscular contractions have become established. The tremor is probably owing to the cir- cumstance that the nervous influence is in such patients only transmitted by the cylinder axis, which is deprived of its sheath of myeline, owing to which there is no continuous action, but jerky and irregular oscillations. The persistence of the cylinder axis likewise explains the long duration of the disease, and the circumstance that there is rather paresis than paralysis. Double vision from paralysis of certain ocular muscles is 334 DISEASHS OF THE NERVOUS SFSTEM. now and then observed in the commencement, but is equally transitory as it is found to be in ataxy. Amblyopia is more frequent and permanent, but rarely merges into amaurosis. The ophthalmoscope shows sometimes negative signs, while in other cases there is partial or total atrophy of the optic disc, with extreme attenuation of the bloodvessels. Nystagmus may also be present, and is particularly noticed when the patient endeavours to fix an object with the eyes. The speech is drawling and slow, resembling that which is occasionally found in paralysis agitans ; so that a syllable takes nearly a minute before it is pronounced, and there are long intervals between the several syllables. The tongue may be tremulous when protruded ; and the symptoms of bulbar paralysis, more particularly difficulty of deglutition and dyspnoea, become sometimes associated with the complaint, and may carry off the patient somewhat suddenly. Where this occurs, we may expect to find patches of disseminated sclerosis in the medulla oblongata and the pons. A peculiar form of vertigo is frequently observed. All objects seem to the patient to be spinning round, and he him- self with them, so that in order to save himself he takes hold of anything near him. The face has a stupid expression ; the mouth is open ; the saliva is apt to trickle down the chin. The mental faculties, more particularly the memory, are much im- paired, and there is great indifference to things in general. Sometimes gastric disturbances such as retching, vomiting, total loss of appetite, are the initial symptoms, and are more or less quickly succeeded by the symptoms peculiar to sclerosis. The second period of the disease is characterised by aggra- vation of the symptoms of the first, and the appearance of spasmodic contraction of the extremities, with or without ' spinal epilepsy.' The patient, who until then has still been able to walk about, although with difficulty, is now reduced to the condition of a confirmed invalid. This rigidity of the limbs appears at first only temporarily, under the influence of excite- ment and other temporary causes. Such attacks may last from a few -hours to a few days, and are often separated by consider- able intervals, but ultimately a permanent contraction of the limbs is established. They are in a state of extension ; the knees are so closely pressed against one another that it is diffi- CHARCOT'S DISEASE. 836 cult to separate them, and the feet show the condition of varo- equinus. If the foot is forcibly stretched towards the leg, tremor supervenes at first in the limb acted upon, but may after- wards affect the whole body, and even communicate itself to the couch of the patient ; this tremor may last a considerable time, but may be at once arrested by forcible flexion of the big toe (spinal epilepsy). Such a manoeuvre also overcomes for the time being the rigidity of the limbs, which become perfectly flexible and relaxed. In the third period all the organic functions begin to suffer. There is more or less complete anorexia, diarrhcea, and general emaciation. The mind becomes confused, and speech unin- telligible, the patient being only able to grunt. Apoplectiform and epileptiform seizures are apt to make their appearance, and are ushered in by absence or complete coma. Hemiplegia is then produced, the limbs being either relaxed or rigid. Death may follow in a few days, and is generally preceded by acute decubitus of the sacrum ; but sometimes the patient recovers his consciousness, and the hemiplegia disappears in a short time. Attacks of this kind, however, always leave him more helpless than he was before. During the attacks the pulse is accelerated and the temperature rises to 103° and 104°. If it becomes higher than 104°, a fatal issue may be expected; but where it is less, the mercury often falls suddenly to the normal standard, with simultaneous improvement in all other respects. The apoplectiform attack of Charcot's disease may therefore be dis- tinguished from the apoplectic attack of cerebral haemorrhage or softening, by the absence of the initial fall of temperature, which is noticed in the latter (p. 102). Complete marasmus is the ultimate result. Paralysis of the sphincters supervenes ; there are the symptoms of cystitis and decubitus, with blood- poisoning, or death takes place by intercurrent diseases, such as pneumonia, phthisis, and dysentery. Cerebro-spinal sclerosis generally lasts from six to ten years, while purely spinal sclerosis may spread over twenty years and even more. 5. Hypertrophy of the brain. The weight of the brain varies considerably in different persons, and we have to distinguish between a large and heavy 336 DISEASES OF THE NERVOUS SYSTEM: brain, which is an anatomical and physiological peculiarity, and consistent with perfect health, and an hypertrophied brain, which is disproportionately large to the intracranial cavity in which it is enclosed. The intracranial space may be reduced by hypersemia, serous effusions, tumours, etc., and these condi- tions have to be excluded before we can truly speak of hyper- trophied brain. In this latter condition there is no excessive development of the cerebral matter itself, which on the contrary is generally found in a state of degeneration, but there is excessive formation of the neuroglia or interstitial connective tissue. The hypertrophy is generally found in the hemispheres, and also in the medulla oblongata and the pons, while the cere- bellum is not liable to it. After the skull-cap has been removed, and the dura mater opened, the brain is seen to surge forward and to project beyond the edges of the bones. The convolutions are compressed and flat, the fissiires indistinct, and there is a disproportion in the size of the hemispheres and. the cerebellum. The ventricles appear narrow, their walls being pressed against each other, and there is hardly any serum in them. The cerebral tissue is pale, anaimic, dry, tough, and leathery ; its membranes are thin and anaemic, and the pia mater is very dry. The skull-bones are thin, their internal surface appears rough, and is sometimes softened. Where the brain becomes hypertrophied in infants, the skull-bones yield to the pressure, and the cavity expands so much that at first sight hydrocephalus is believed to exist, and tapping has occasionally been suggested. In infants this condition is often connected with a strumous dyscrasia, and accompanied with swelling of the lymphatic glands, the thyroid body and the thymus, and a rickety condition of the chest and extremities. It also occurs in middle age, particularly in males, and is then owing to alcoholism, repeated attacks of active and passive cerebral hypersemia, and depressing mental emotions. Symptoms of disease come only under observation when the increased mass in the skull-cavity produces pressure, or when incidental circumstances cause irritation, or changes in the quantity of blood contained in the head. In children, however, where the skull is yielding, there is occasionally no distur- ATROPHY OF THE BRAIN. 337 bance of the mental functions, nor of motion and sensation, even when the brain is considerably hypertrophied. The case of a boy is on record who had an enormous head, but was other- wise quite well, except that he often fell when running, as the head fell forward and displaced the centre of gravity of the body. He died of an affection of the bowels, and the brain was found to be extremely hypertrophied. In adults, where the skull is rigid, symptoms of pressure on the brain are the rule, and first affect the power of motion. There is general muscular weakness, more particularly in the lower extremities. The gait is tottering, the patient stumbles easily, and cannot grasp anything with force, or lift anything heavy. Sometimes general paralysis is the result, and followed by convulsions, which are at first rare, pai'tial, of short duration, and mild ; but increase as time goes on, and at last merge into epilepsy and eclampsia, probably from the anaemia of the brain, which is habitual in this affection, being suddenly increased by inci- dental circumstances. Sensibility is not so much affected. There may, however, be headache, vertigo, tinnitus aurium, photophobia and dilata- tion of the pupils, and later on dulness of the sentient and sen- sorial nerves, but no actual anaesthesia. The mind is generally unhinged, there being either excitement, with delirium and mania, or what is more frequent, depression, stupor and idiocy. Vomiting and an extremely slow pulse are also sometimes observed. The progress of the disease is extremely slow. Where it occurs in children, death is generally owing to incidental diseases, which cause cerebral hyperaemia, and prove fatal from excess of intracranial pressure. When, in adults, convulsive seizures have appeared, the malady runs occasionally a very rapid course, death being comparatively sudden. 6. Atrophy of the Brain. Simple wasting of the brain without any particular degene- ration may be congenital, and children subject to it are affected with idiocy, epilepsy, and paralysis. As a rule the atrophy i'j confined to one hemisphere, most frequently the left, which z 338 DISJEASJSS OF THE NERVOUS SYSTEM. lias only about half the size as, or even less than, the right. The central ganglia appear shrunk and withered, and the aplasia extends to the cerebral peduncle, and the corresponding pyramid, and antero-lateral column of the spinal cord. The ventricles are in a state of extreme dilatation, and contain a large quantity of serum, which is also abundant in the subarachnoid space. The brain-matter appears hard and tough, but is occasionally soft, fragile, "and discoloured. This imperfect development of the brain is sometimes owing to premature synostosis of the skull-bones, whereby the intracranial cavity is reduced in size ; and the bones are then generally found thickened on the side corresponding to the aplasia. In other instances it arises from congenital hydrocephalus, from extravasation of blood into the cerebral tissue, or from injury and inflammation. Children who are born with an ill-developed brain, or suffer early in life from consecutive atrophy, lead a wretched and idiotic existence. Where the affection is congenital, or has come on soon after birth, the symptoms are more severe than where a few years have been passed in a physiological condition. The temper is sometimes vicious, the intellect at a low ebb. There is anaesthesia of the special senses, more particularly anosmia and amaurosis, and sometimes deaf- and dumbness. The limbs are paralysed and anaesthetic, but the paralysis is rarely complete, and often accompanied with contraction of the flexor muscles. This form of hemiplegia is also, in contradistinction to others, accompanied with wasting of the paralysed parts. The limbs are short and thin, while the body may appear like that of an adult. It is not only the muscles, but also the bones which are in a state of atrophy, while the skin is normal and there is often a great development of adipose tissue. There is also unilateral atrophy of the face, including the ear, and the symptoms are observed on the side opposite to the affected hemisphere. The bodily functions are otherwise carried on in a regular manner, and the poor idiot may reach a great age. Females menstruate and conceive, but where the aplasia is excessive, the patient generally dies early from incidental diseases. In exceptional cases one hemisphere has been found wasted, and yet there has been a fair development of the intellectual. ATROPHY OF THE JBHAIN. 339 faculties during life. This may be explained by assuming a compensatory development of the other hemisphere ; and it has generally been found connected with a small quantity of serum in the ventricles and subarachnoid space. Atrophy of the brain is likewise observed at any time after the organ has reached its full development, and may then be partial or general. Where it is partial it is owing to local pathological conditions, such as softening, haemorrhage, or' encephalitis, and affects all the tissues. Pressure by tumours has the same effect ; and where these grow slowly and eventually reach a considerable size, the corresponding atrophy of the tissues, and more particularly the nerve-cells, may be very extensive. Such partial atrophy is confined to one hemisphere, and may affect any part of it. There are often the residues of clots, such as cysts filled with serum or fibrous plates, and the brain-tissue appears withered. The wasting may be stationary or progressive ; the latter is chieflj"^ the case in the aged, or where there are several areas of the primary disease, as after repeated attacks of cerebral hEemorrhage, where the wasting spreads from the central ganglia through the pedunculi and pyramids to the lateral columns of the cord. The ultimate products of the disease are heaps of granular cells, and amy- laceous and colloid corpuscles. In such cases the first symptoms are generally those of apoplexy, encephalitis, etc., viz., unilateral and more or less stationary motor paralysis. There is little or no affection of the mental faculties, and of the sensorial and sentient nerves. Matters remain for some time in this state, but when the secondary atrophy progresses, there is gradual deterioration of all functions of the nervous system, and more particularly of the intellectual faculties. Where cerebral atrophy is general, it is symmetrical and progressive. In such cases chronic alcoholism, attended with the atrophic form of Bright's disease, meningitis, or some general cachexia, such as chronic poisoning by lead and opium, are at the bottom of the complaint. The chief seat of the morbid process is in the neuroglia, and the nerve-cells are only secondarily affected. It occurs mostly in the aged, but cannot be looked upon as mere senile decay, there being actual disease, z 2 340 niSHASES OF THE NERVOUS SYSTEM. Both hemispheres are equally affected. On removing the skull- cap and opeiiing the dura mater, the sarface of the brain is found, as it were, at a distance. The convolutions are thin and narrow, the fissures small, and interspersed with deep lacunse. There is a large quantity of serum in the meshes of the pia mater, in the subarachnoid space, and the lateral ventricles. This is called hydrocephalus senilis, or ex vacuo. The mem- branes are thickened and opaque, and the bloodvessels dilated and tortuous ; the cerebral substance is generally hard and tough, and only rarely soft and cedematous. The symptoms observed in this condition are those of gradual loss of cerebral power. There is rarely excitement, except when there are attacks of hypersemia owing to other causes. Then there may be garrulous delirium, restlessness at night, alternate laughing and crying, fussiness, and tremor. Otherwise we find paralysis and anaesthesia affecting all the different portions of the brain and cranial nerves. The patient is, as it were, in his second childhood : there is more or less imbecility, an entire want of energy or purpose, senile tremor, a slow and intermittent pulse and paralysis of the sphincters ; and he is ultimately carried off by bronchitis, decubitus, dropsy, or exhaustive diarrhoea. Cerebral atrophy in its later stages is therefore seen to resemble very closely the last stage of general paralysis of the insane. 7. Tuvnours of the Brain. The brain is liable to the invasion of numerous adventitious growths, some of which are peculiar to itself, while others are of the same nature as those found in other organs of the body. Tumours in the brain arise from the same causes which produce them elsewhere. There is considerable hereditary influence, and a greater liability of the male sex than of the female, which latter circumstance is probably owing to men being more exposed to injury, and consuming a larger quantity of alcoholic stimulants than women. Now apart from inherited tendency, injury has the greatest influence in causing a tumour to grow, and alcohol in promoting its development. A fall or blow on the head is the most frequent cause, as even where no TUMOURS OF THE BBAIN. 341 coarse lesions are induced at the time, cerebral circulation is upset and disturbed ; and rupture of the finer structural elements of the brain may be induced, which is followed by- fatty degeneration of the nerve-cells, and proliferation of the neuroglia. Virchow ' has shown that the most important tumour peculiar to the brain is glioma, which is owing to proliferation of the cementing substance. It is found in the white matter of the hemispheres, and may become as large as a fist. Its growth is essentially slow, and the symptoms caused by it may go on for years. It is either hard or soft, slightly transparent, and according to the vascular development in it, white or pink. The hard glioma is similar to fibroma, and is found to contain only scanty cells, which are generally furnished with several nuclei. The soft glioma has little protoplasma, but contains numerous cells which are mostly small. If the cells increase largely, the growth becomes similar to sarcoma ; and if the basal substance has the character of mucus, it resembles myxoma. Grlioma is probably always owing to injury, and as there is no constitutional dyscrasia connected with it, the symptoms are purely local and determined chiefly by the seat of the tumour. They are generally slow in their mode of onset, but where there is much vascularity in the growth, there may eventually be attacks of cerebral hsemorrhage, and we have then the well- known symptoms of apoplexy, which are identical with those observed after ordinary cerebral haemorrhage from rupture of miliary aneurisms. Another cerebral tumour peculiar to the organ ispsammoma, or sandy growth, which likewise arises from proliferation of the neuroglia, but contains in addition to it, deposits of chalk in the shape of loose round granules. Psammoma rarely exceeds the size of a cherry-stone ; it arises from the dura mater, is gene- rally found at the base of the brain, and has a white smooth surface. Melanoma, or pigmentary tumour, proceeds from the pigmentary cells of the pia mater. Neuroma is owing to hyperplasia of the grey matter, and is found on the surface of the convolutions, in the ventricles, and in the white medullary ' Die krankhaften Geschwiilste.' Berlin, 1873. 342 DISHASSS OF TRE NERVOUS SYSTEM. matter of the brain. It attains the size of a millet-grain or a pea. Cysts are rare, and if present, are owing to hydrops of the pineal gland or the septum lucidum. Cfiolesteatoma consists of epidermoid cells concentrically deposited, which have under- gone horny or fatty degeneration. It resembles epithelioma in structure, but is a perfectly innocent growth ; it has a shining mother-of-pearl-like appearance, and is devoid of blood-vessels. Its seat is at the base of the brain. Other tumours owe their existence to a peculiar consti- tutional dyscrasia, and the most important of these are cancel-, tubercle, and gumma. The gummatous tumour will be con- sidered in the next section. Cancer is generally of the en- cephaloid variety. It almost invariably takes its rise from the dura mater, and proceeds either from the external surface of that membrane towards the skull-bones, which become rarefied and are eventually laid open, when the well-known characters of fungus durce matris are developed ; or it grows from the internal surface of the membrane and invades the structure of the brain. It likes to follow the course of cerebral nerves, such as the olfactory and optic, and proceeds through the foramina of the skall, which are provided for the exit of these nerves. It may thus appear in the orbit, the ethmoid bone, and the spheno-maxillary fossa. Histologically the tumour consists of large cells imbedded in a scanty stroma of blood-vessels and degenerated glia-fibres. Its shape is round or puckered, and its colour varies according to the development of blood-vessels, and the degree of retrogressive metamorphosis, being either white, grey, or pink. Cancer is distinguished by rapid progress, and the signs of general dyscrasia, and is often accompanied with cancerous deposits in other organs. Tubercle of the brain is connected with the tubercular diathesis, and is chiefly found in children, where it is apt to select the grey matter of the cerebellum. It generally attains the size of a filbert, has a grey or yellowish colour, and is surrounded by a soft layer of blood-vessels and small miliary granules, or by fibrous connective tissue; and it may, as t^ibercle in other organs, either soften or undergo calcareous metamorphosis. It is generally associated with tubercle in TUMOURS OF THE BRAIN. 843 other organs ; frequently commences after acute diseases, sucli as measles, and is sometimes multiple. The general effect of tumours on the brain-substance is that of pressure, which produces local symptoms, but also acts on distant parts, in which it may cause fatty degeneration and atrophy. The structures in the neighbourhood of the growtli are generally displaced towards the opposite side ; the convolu- tions are flattened, the cerebral tissue is dry, and its blood- vessels anaemic. The principal symptoms of tumour of the brain are intense headache, vomiting, and optic neuritis ; but to these a number of others may be added, according to its seat, mode of growth, and the constitutional peculiarities of the patient. The initial signs are general malaise, want of energy, irritability of temper, and drowsiness. The patient is depressed in spirits, inclined to be lachrymose, indifferent to the events of daily life, and wishes to be left alone. The memory is im- paired, and the patient finds it difficult to fix his attention on any subject. As the tumour proceeds to grow, these mental symptoms become more marked. Depression progresses to melancholia, and where the island of Eeil, and the third left frontal convolution are affected, the speech becomes embarrassed, and aphasia is the ultimate result. Towards the end there is either complete imbecility, or attacks of mania with delusions and hallucinations ; and the patient dies comatose. The nerves of special sense suffer considerably from these adventitious growths. Where the seat of the tumour is at the base of the brain anteriorly, the olfactory nerve may be affected, and anosnaia caused ; but the optic nerve shows almost invariably symptoms of disease. According to Annuske,' with whom Dr. H. Jackson agrees, optic neuritis constantly accompanies cere- bral tumour, and takes the foremost place amongst the symptoms of intracranial growths. The ophthalmoscopic signs are there- fore of the utmost importance in these cases. Increase of intracranial pressure causes wasting of the nervous structures. The brain, being enclosed in a rigid capsule, cannot well escape any considerable amount of pressure, and the cerebro-spinal Grae£e's Archiv,' vol. six. part 2, p. 165. 344 DISEASES OF THE NERVOUS STSTEM. liquid is therefore forced between the internal and external sheath of the optic nerve ; and as the veins are likewise com- pressed by the tumour, the secretion of the cerebro- spinal liquid is increased, and hydrops of the ventricles caused, which in- tensifies the symptoms. The liquid between the two sheaths of the optic nerve is therefore blocked up ; the nerve, more especially where it enters the eyeball, is squeezed, and becomes the seat of an CBdematous swelling, by which the layers of the retina are ultimately destroyed. Both nerves are affected, although one often more severely than the other. Where the tumour invades the optic tract and the chiasma, the field of vision becomes limited, and there is unilateral or bilateral hemiopia. The amount of damage done depends upon the quantity of liquid which is present, and the amount of pressure by which it is forced onwards. Increased intracranial pressure causes the appearance of the choked disc, or ischsemia papillae (Von Graefe's Stauungs- papille). There may also be optic neuritis from propagation of the irritation (descending neuritis), and lastly there may be primary atrophy not consequent upon neuritis. Dr. Clifi'ord AUbutt' has made a most painstaking investigation into the different forms of optic changes connected with tumours of the brain according to their different localities; and those who wish for further information on this point, must be referred to his volume, and to the standard treatises on the diseases of the eye. Double vision and strabismus are likewise of frequent occur- rence, and arise from pressure on the third, fourth, or sixth nerve. The pupils are generally dilated ; they respond only sluggishly to the influence of light, and occasionally differ in size. The portio dura may also be paralysed. Deafness is so frequently owing to other causes that it cannot be looked upon as a distinctive symptom of cerebral tumour ; but it is not unfrequently produced by pressure of the growth on the portio mollis. There may be unilateral loss of the sense of taste. Headache is one of the most characteristic signs of tumour, 1 ' On the use of the Ophthalmoscope in Diseases of the Nervous aystem,' etc. London, ]871) p. 110. TUMOURS OF THE BRAIN. 34S more especially where this gi-ows rapidly and approaches the membranes. It varies from a simple feeling of heaviness and fulness, to the most agonising pain, which causes the patient to faint away and lose his consciousness for a long time. There are, however, occasionally remissions. It is mostly frontal, and increased by pressure, percussion, and reflex movements, such as coughing and laughing. Where there is localised pain and anaesthesia in the face, and paresis of the masticatory muscles, the fifth nerve is involved by the disease ; and where there is numbness and ' pins and needles ' in one upper or lower ex- tremity, there is a tumour on the opposite side of the brain. In tumour of the cerebellum, the muscular sense suffers ; the gait is tottering, more especially when the patient closes his eyes ; and there is vertigo, with an inclination to fall backwards or forwards. Epileptiform seizures are a common symptom of cerebral tumour, and may either appear in the form of general con= vulsions and coma, or as unilateral spasm in certain motor areas, without loss of consciousness. Such attacks are some- times followed by tremor, which may continue for houis. Hemiplegia is also frequent, and may come on from hsemorrhage in the tumour, or in consequence of retrogressive changes in the central ganglia. Where the tumour occupies the median line, or is multiple, or compresses both hemispheres, there may be paraplegia, which is generally associated with paralysis of the bladder. Vomiting is rarely absent in cerebral tumour, and is usually accompanied with a slow pulse, showing irritation of the pneu- mogastric nerve. According to the seat of the tumour the combination of symptoms differs as follows : — where the convexity suffers, there is intense headache and epileptiform seizures, but no paralysis or ansesthesia. In tumours of the frontal lobe there is frontal headache and anosmia, and symptoms of mental excitement ; in tumour of the parietal lobe there is slight unilateral paralysis and ansesthesia ; in tumour of the occipital lobes : severe head- ache, vertigo, and melancholia, but no paralysis. Tumour of the base near the chiasma causes anosmia, hemiopia, headache, anaesthesia of the fifth, paresis of the masticatory muscles. 346 DISEASES OF THE NERVOUS SYSTEM. paralysis of ocular muscles, and circus movements. Tumour of the corpus striatum and nucleus lenticularis causes hemiplegia ; of the cerehellum : occipital headache, vertigo, tottering gait, and deafness ; of the corpora quadrigemina : exquisite ocular paralysis, amaurosis, and hemiplegia ; of the pons : neuralgia, anaesthesia, and paralysis in the sphere of the fifth, third, and sixth nerve ; crossed paralysis of limbs ; difficulty of deglutition and paralysis of the bladder ; of the medulla oblongata : anoes- thesia, convulsions, difficulty of deglutition and articulation, paralysis of the bladder, and sugar in the urine. This section would be incomplete without some reference to aTieurisms of the large cerebral arteries, which I now proceed to consider. The bloodvessels which are most liable to aneurismal dilatation are the sylvian and the basilar arteries. Such aneurisms are probably more numerous than is gene- rally believed. It is true that we have at present only records of about 150 cases ; but in many instances the pathological lesion may have remained undiscovered, and the cases been classified as paralysis, apoplexy, or brain-disease. Aneurisms which are met with in these arteries do not differ in texture from those found in the aorta, the popliteal artery, &c. ; and it is, therefore, not necessary for me to describe them at length. Their size varies from that of a small filbert to a pigeon's egg, a walnut, or even a hen's egg ; their shape is oval, cylindrical, conical, or irregular, and their communication with the artery either narrow or extensive. ■ No age is spared, and the two sexes seem to be nearly equally affected. Aneurism of a cerebral artery may occur in the aged simul- taneously with extensive senile disease of the cerebral vessels altogether, and is then only part and parcel of a general affection. But where it occurs in the young it is, as a rule, unaccompanied by disease of other vessels, and is owing to injury to the head, such as a fall or blow, or to violent mus- cular efforts. The coats of the cerebral arteries are very thin, and the vessels which are chiefly apt to suffer are those which lie at the base of the brain, where the great irregularities which are met with on the inner surface of the skull, and the nume- rous and sharp projections of bone, promote the reception of injuries. AifEURISM OP THM SRAIN. 34? Small aneurisms, which do not cause much pressure on the cerebral matter, or large ones which grow very slowly, give sometimes no indications whatever of their existence during life, and are only accidentally discovered after death. In the majority of cases, however, there are symptoms of pressure on the brain and the cranial nerves. If the aneurism continues to grow, the pouch undergoes slow distension and is at last ruptured ; while in other cases it acts as a foreign body on the parts in its neighbourhood, causing inflammatory irritation. Eupture of aneurisms and subsequent haemorrhage has been observed in about one-half of the cases recorded. The effusion is then found either on the surface of the brain, in the meshes of the pia mater ; or it breaks up the corpus striatum and thalamus op- ticus, fills the lateral ventricles, surrounds the crura cerebri and the medulla oblongata, and gives rise to the symptoms of apoplexy which speedily proves fatal. Other symptoms differ considerably according to the locality of the aneurism, and to its causing simply pressure or irrita- tion. Thus an aneiuism of the mid-cerebral artery may cause epileptiform fits, if the aneurism in its growth irritates the striated body; it may also cause vertigo, throbbing frontal headache, amblyopia and araaurosis, and at last paralysis of one side of the body, either from rupture of the sac, and subsequent haemorrhage ploughing up the corpus striatum, or from softening of the ganglion. In a few cases, indeed, no symptoms whatever have been observed, probably because the tumour grew very slowly, and did not reach a great size, so that the parts in its neighbourhood had time to become accustomed to the presence of the foreign body. In aneurism of the basilar artery, on the other hand, the symptoms point more towards the posterior portion of the brain. There is throbbing occipital headache, which comes on in paroxysms, is exceedingly violent, and is excited or increased by pressure on the upper portion of the neck ; and deafness, which sometimes comes on quite suddenly, and is accompanied with noises in the head. This may be owing to obstruction of the small branches of the basilar artery supplying the auditory nerves, which have been found wasted. The pneumogastric nerve shows its pathological condition by 848 DISEASES OF THE NERVOUS SYSTEM. difficulty of deglutition, which may be at first slight and tem- porary, like laryngeal spasm, but later on becomes more intense and at last amounts to complete dysphagia. There may be nausea, vomiting, flatulency, and other symptoms of dyspepsia arising from irritation of the same nerve. The voice becomes hoarse or is altogether lost. That the cerebellum suffers is shown by attacks of vertigo, unsteadiness of gait, tremor, spasms, numbness, and incomplete paralysis of the lower extremities. Death ultimately ensues from rupture of the aneurism, and is, as usual, preceded by coma and paralysis. A different group of symptoms presents itself in cases where the posterior Gommunicati/ng artery, which establishes a communication between the carotidean and vertebral system of bloodvessels, is affected by aneurism. Here we have at first ptosis, showing that the third nerve, or motor oculi, is com- pressed. As the tumour grows, other cerebral nerves in the neighbourhood become affected; there is strabismus, an im- movable and dilated pupil, amblyopia and amaurosis with choked disc. Headache, vertigo, drowsiness, stupor, and certain forms of insanity come on at a later period, showing that the nutrition of the cortical substance of the brain suffers. 8. Syphilitic affections of the Nervous System. Nerve-syphilis is one of the most interesting chapters of pathology, and has only recently been thoroughly investigated, more especially by Professor Waller, of Prague, M. Lanceraux,' Dr. Wilks,^ Dr. Buzzard,^ Professor Heubner,* and Dr. H. Jackson.^ The practical importance of pathology in this instance is extremely great, since it has been found that the most formidable syphilitic diseases of the nervous system, such as epilepsy and paralysis^ are much more readily and thoroughly curable than the corresponding idiopathic maladies, which do not owe their origin to this subtle poison. ' ' Traite historique et pratique de la syphilis.' Paris, 1866. 2 ' Guy's Hospital Reports,' 1864 seqf[. ' ' Clinical Aspects of Syphilitic Nervous Affections.' London, 1874. ■i ' Die luetische Erkrankung der Gehirnarterien,' Leipzig, 1874 ; and in Ziemssen's 'Handbuch,' &c., vol. xii., 1877. ' ' Journai of Mental Science,' July, 1875. SIFHILIS OF THE BRAIN. S49 Neuro-syphilitic affections mostly belong to the latest period of the constitutional disease, viz,, the so-called tertiary stage, or to the later portions of the secondary stage. They are invariably preceded by a hard infecting sore, and generally by secondary symptoms affecting the skin and fauces ; but in some instances they appear as the first manifestations of con- stitutional syphilis, and that in from twelve months to twenty years from the appearance of the primary affection. In a few exceptional cases they have closely followed upon the first rash and sore-throat. They iaay occur at all periods of life, in children as well as in old persons, but are most frequent between twenty and forty years of age, and this circumstance is of diagnostic importance, as hemiplegia or paraplegia coming on in youthful persons is in nine cases out of ten of syphilitic origin. The male sex is more liable to them than the female, which is in accordance with the fact that constitutional syphilis is altogether more frequent in men than in women. Nerve-syphiHs appears to occur chiefly in those persons in whom there is evidence of the neuro-pathic constitution, either hereditary or acquired. There is almost always a family history of apoplexy, epilepsy, chorea, megrim, or other nervous maladies, and frequently the^ patient himself has previously suffered from neuralgia or fits. Persons who have put an undue strain on their nervous power, either by excessive mental labour, or by free indulgence in alcohol and the sexual appetite, are more liable, when rendered syphilitic, to become subject to nervous maladies, than those in whom there have been no such antecedents. Injury, such as a blow on the head, or a fall, and depressing emotions, act frequently as exciting causes of these diseases. Finally, an unsystematic and. too soon interrupted treatment of the primary affection, has to be looked upon as a powerfully predisposing cause of nerve-syphilis. Syphilis affects with preference the brain and cerebral nerves, but does not spare the spinal cord. Anatomically we find that the characteristic lesions are not meningitis or en- cephalitis, as was formerly believed, but repeated attacks of hyperaemia, tumour, and disease of the arteries. 850 DISSASHS OF THB NERVOUS SYSTEM. a. Syphilis of the Brain and Cranial Nerves. a. The congestive form of cerebral syphilis shows hardly any striking features on the post-mortem table, more especially where the case ends fatally at an early stage of the complaint, from such complications as cystitis, decubitus, phthisis or pneumonia. "Where the disease has lasted for a considerable time, the membranes of the brain are seen to have lost their transparency, and there is slight wasting of the cerebral convo- lutions, which latter, however, is not sufficient to explain the severe symptoms which have been observed during life. The lesions are the same, although in a slighter degree, as those which are found in general paralysis of the insane, and afifect more particularly Hitzig and Ferrier's psycho-motor centres in the cineritious substance of the anterior lobes. In some of these cases the cervical sympathetic nerve has been found in a state of pigmentary degeneration, and it is probable that disease of the superior cervical ganglion of that nerve may have an important influence in the production of the repeated attacks of hyper£emia,-by which this form of brain syphilis is cha- racterised. The symptoms which are observed under these circumstances, resemble very closely those of general paralysis of the insane. They are at first indefinite, come and go, and a change in the mind and temper is the most characteristic feature. There is excitement or depression, with confusion of thoughts, fussiness, and ambitious ideas or delusions. Apart from a general feeling of malaise, the patient does not complain of being ill. As time goes on there is loss of energy, debility, embarrassed speech, partaking of the nature of aphasia, and being cortical rather than medullary in its kind. The size of the pupil is unequal, the tongue is tremulous when protruded, there is tottering gait, and ' pins and needles ' and numbness in the extremities are complained of. When the symptoms on the part of the nervous system become more marked, there is often a simultaneous outbreak of fresh syphilitic manifestations on the skin, mucous membrane, or periosteum. The intellect and memory now suffer more decidedly, and symptoms of SYPHILIS OF THE BBAIN. 361 paralysis appear from time to time, viz., aphasia, agraphia, hemiplegia and paraplegia. Such sjmptoms may last at first only for a few hours or dajs, but they gradually become more permanent. The general debility increases -pari passu, and unless an energetic anti-syphilitic treatment be perseveringly followed, the patient dies -within a few years from the outbreak of the disease, from cystitis, decubitus, and general marasmus. /S. The second manifestation of cerebral syphilis is the syphilitic tumour, gumma, or syphiloma, which presents itself in two varieties, these being probably only different stages of development of the same deposit. There is the soft and hard variety, the soft tumour being the earlier, and the hard swelling the later phenomenon. The soft tumour consists of a reddish- grey jelly, from which on section a small quantity of pinkish liquid is seen to escape. Its histological elements are round cells and nuclei, mixed with spindle and stellated cells, and few, but large capillary vessels. The outline of such tumours is not well defined, and they seem gradually to merge into the surrounding normal tissue. They are chiefly found in the sub- arachnoid space, and grow from there to the surface of the brain ; but they also occur in the dura mater, and are in this situation generally harder than when situated in the soft and moist tissue of the pia. The hard tumour is in many respects similar to tubercle. It is dry, yellow, of a cheesy consistency, and on section homo- geneous. It occurs interspersed into the reddish-grey jelly, which I have just described, or as [^a well-defined tumour of variable size. It consists histologically of a granulated sub- stance otherwise devoid of structure ; there are no blood- vessels or spindle-cells, but now and then heaps of pigmentary gi-anules and crystals, and oil-globules near the periphery. Its size vai-ies from that of an almond kernel to that of a pigeon's or even a hen's egg, and its shape is frequently adapted to that of the spaces in which it is discovered. It is found between the two layers of the dura mater, which are much thickened, and more especially in the falx cerebri. The skull-bone, which corresponds to its situation, is generally in a state of dry caries, and appears rough and attenuated while the other portions of thcskuU are normal. The yellow, hard tumour is probably 362 DISHASES OF THE NERVOUS SYSTEM. owing to contraction and atrophy of the soft gumma. It is likewise found in the subarachnoid space, and from there proceeds to the bloodvessels, nerves, and cerebral tissue itself. Occasionally all the membranes and the cineritious substance are grown together into a uniform mass, and cannot be separated, and the two varieties of tumour are then seen together. Soft jelly is embedded between the dura and the surface of the brain, and one or several dry yellow tumours are lying in the fissures between the convolutions. The surround- ing brain-tissue is in a state of red or white softening, or a portion of the cortical and medullary matter is changed into the same cheesy mass of which the tumour itself consists. Under the influence of anti-syphilitic treatment, nearly the whole of these changes may be repaired, and cicatricial patches are then discovered on the surface of the hemispheres. At the base of the brain there is occasionally a diffuse infil- tration with grey jelly, which can no longer be called a tumour, but must be looked upon as gummatous meningitis. The effusion in such instances is seen to spread from the olfactory bulb to the posterior portion of the cerebellum, and may even invade the cortex. The symptoms of cerebral syphiloma differ considerably from those of syphilitic hyperaemia ; and one that is hardly ever wanting, and also the first to appear, is a peculiar kind of headache, which appears chiefly at night and is relieved towards morning. It is intolerably severe, and occurs in paroxysms which last for a few weeks, after which there is a remission, which is again succeeded by a fresh outbreak of it ; and unless specific treatment be adopted, this may go on for years. The seat of the headache is mostly at the sides of the head, but it may also be frontal and occipital. It is sometimes localised in a very small area, and then generally increased by pressure ; and it is owing to a gummatous deposit on the internal surface of the skull-bones, which irritates the periosteum and the dura mater. Sleeplessness is another symptom, which is generally caused by the pain, but also occurs during free intervals ; and it is apt to raise our suspicions, because it is mostly found in young persons, in whom insomnia is otherwise very rare. After these symptoms have continued for a variable time, SYPHILIS OF THE BRAIN. 853 epileptiform attacks are apt to supervene, which sometimes resemble iu every way the ordinary attacks of primary epilepsy. Unilateral convulsion without loss of consciousness is often connected with this condition ; the muscular spasm starts from the thumb or first finger, or the foot, or the face, and affects only the arm, or the leg of the same side, but - becomes bi- lateval where the nerve nuclei of the two sides are associated ; or there may be a regular epileptic seizure, i.e., general convul- sions and coma. When the hemispasm is on the right side, showing affection of the left hemisphere, temporary aphasia may be produced, and there may be hemiplegia with this, or left hemiplegia without aphasia. This hemispasm is due to irritation of the convolutions of the opposite hemisphere. "When such fits succeed each other more or less rapidly, the mind becomes affected. There is irritability of temper ; the patient is sometimes in a state of hysteria, laughing and crying alter- nately without any adequate cause ; he is generally depressed in spirits ; the memory is impaired, and the current of thoughts considerably retarded. The speech is embarrassed ; the patient is unable to finish a sentence, and sometimes stops for a minute without being able to go on. He tries to help himself with ges- tures, but even this aid after a time forsakes him ; and complete aphasia, agraphia and amimia may become developed. In such cases there is no hemiplegia or any other form of actual paralysis, but there is paresis such as we are apt to con- nect with disease of Hitzig's and Ferrier's psycho-motor centres, rather than with an affection of the central ganglia. The patient is still able to walk, dress, and feed himself; but the gait is unsteady, the foot drags on the ground, and there is ataxy in the movements of the hands and fingers. Even at this stage he may completely recover, if an energetic treatment is directed to the cause of the disease ; but without such inter- ference the symptoms gradually become worse. There are frequent epileptic fits, sometimes developing into epileptieism (p. 241) with coma, from which the patient does not awake ; or decubitus is developed, which leads to blood-poisoning ; or death supervenes from total exhaustion of the nervous force. The symptoms just described arise from syphiloma of the sub-arachnoid space, which gradually involves the cortex of the A A 354 DISEASES OF TSE NERVOUS SYSTEM. brain and the adjacent medullary matter. Where the third left frontal convolution and its neighbourhood is suffering, aphasia and agraphia will be the result ; where the anterior lobes are affected there will be symptoms of paresis ; while irri- tation of the posterior lobes causes melancholia without much, if any, loss of motor power. But whatever portion of the ciner- itious structure is affected, syphilitic epilepsy will be the most prominent symptom. The cerebral nerves generally suffer in exact proportion to the seat of the syphiloma, which causes irritation and finally destruction of the nerve- trunk. The gummatous tumour some- times grows right round a nerve and compresses it, or it squeezes it against the bone, or an exostosis may occur in the osseous canal through which the nerve has to pass. It is quite true that a nerve is occasionally discovered passing right through a syphiloma at the base without having lost its function or structure, but such cases are exceptional. The general sequence of events is neuritis followed by atrophy. The nerve appears at first reddish and softened, its sheath is thickened, and at a later period it is wasted and changed into a thin thread. Sometimes the sheath of the nerve appears perfectly normal, but on opening it the nervous substance is seen to have disappeared and to be replaced by a reddish or yellow mass, corresponding in structure to the soft and hard syphiloma. In other instances the syphiloma grows directly from the pia mater along the bloodvessels into the nervous substance, more particularly into the chiasma of the optic nerves, causing atrophy of the same. Finally there may be no structural lesion, although symptoms of paralysis, anaesthesia and neuralgia may have been present during life. Dr. H. Jackson ^ is therefore incorrect in stating that the pathogenesis of these cases is nothing but ' squeezing of nerve-fibres by over- growth of the connective tissue element of the nerve-trunk.' This is only one of several causes. Amongst the cranial nerves the third is most frequently affected by syphilis ; and the most common symptoms are ptosis, external strabismus and paralytic dilatation of the pupil. Vertigo is occasionally a symptom of paralysis of this nerve. ' 'Journal of Mental Science,' Jiily, 1875, p. 6. SYPHILIS OF THE BRAIN. 355 SyphiKtic neuro-retinitis and simple retinitis are also common. There is efifusion of serum into the layers of the retina, which is sometimes slight and sometimes considerable, and is generally preceded by hyperaemia. The outline of the disc is rendered indistinct and hazy, and the neighbourhood of the yellow spot is particularly affected. Sometimes the vitreous humour be- comes turbid and prevents a thorough ophthalmoscopic exami- nation. Where the effusion takes place rapidly, the sight may be quickly destroyed ; but in most cases it occurs slowly. It is not unfrequently associated with irido-choroiditis. Dr. Jackson has pointed out that double optic neuritis may often be recog- nised by the ophthalmoscope before vision suffers, and that it may be for some time the only symptom, or be accompanied with such slight symptoms as to be hardly noticed. The portio dura and the fifth and sixth nerve may likewise suffer ; there is then inability to close the eye, neuralgia of the face, with lachrymation, paralysis of mastication, and internal strabismus. 7. The third and last form of cerebral syphilis is disease of the arteries, which affects with preference the carotids, the circle of Willis, the sylvian artery, and that of the corpus cal- losum. The first symptom of disease is, that the artery becomes less transparent, and loses its pink colour, assuming instead of it a white greyish appearance. At the same time the vessel loses its cylindrical shape and becomes quite round, while its coat is hardened and gives a cartilaginous sensation to the finger. The diameter of the vessel is very much reduced by the deposi- tion of a moist gray substance, which later on becomes hard and dry ; and what remains of a free canal is often blocked up by thrombosis, so that ultimately the whole artery is changed into a solid cord. This deposit takes place chiefly between the endothelium and the elastic fibres of the vessel. At first it appears to consist of endothelial cells, which multiply consider- ably and develope into connective tissue. This growth goes on in a longitudinal as well as in a transverse direction, and the degeneration is therefore apt to spread to the branches of the artery. I have already spoken of the two spheres of cerebral nutri- tion of Heubner and Cohnheim (p. 148), viz., of the basal and A A 2 356 DISEASES OF THE NERVOUS SYSTEM. cortical sphere. In syphilitic disease of. the cerebral arteries this distinction becomes of paramount importance. The basal sphere comprises the vertebral, basilar, and carotid arteries, the circle of Willis, and the commencement of the anterior, middle, and posterior cerebral arteries. All these vessels give off small branches vertically, which penetrate directly into the cerebral matter, become divided and terminal, and then proceed through the capillary vessels into the smaller veins. It is particularly in this basal sphere, which supplies the central ganglia, that plugging of the arteries from deposit and sub- sequent thrombosis becomes so dangerous to the nutrition of the parts ; for as there is no anastomosis, the various forms of necro- biosis, such as red, yellow, and white softening, are easily pro- duced, the result being generally syphilitic hemiplegia. In the cortical sphere of nutrition, on the other hand, the plugging of arteries is not of the same vital importance, because the peripheral part of the bloodvessel may still be supplied with blood by anastomosis in the pia mater. The cortical arteries run for a long time in the pia mater without giving off any branches to the cerebral substance ; they divide in the pia, become constantly smaller, and anastomose so thoroughly with their fellows that a kind of network is established, by means of which not only the smaller branches but also the principal arteries are made to communicate with each other. The cere- bral matter only receives small capillary vessels from this large vascular net after it has been allowed to spread over a consider- able surface. Although, therefore, the danger of starvation is much less in the cortex than in the central ganglia, nevertheless, a rapid plugging cannot pass without causing mischief, inasmuch as it decreases the pressure in those vessels ; while if collateral circulation is established, the pressure may be suddenly increased above the normal standard. The cineritious substance is thus exposed to considerable vicissitudes of circulation, and the temporary apoplectic seizures, which are so common in this form of syphilis, find in them a satisfactory explanation. ^ In both spheres of nutrition, however, the basal as well as the cortical, simple narrowing of the arterial tubes, without actual plugging of the same, must have a deleterious influence on the nutrition of the entire brain. It increases the resistance SYPHILIS OF THE BRAIN. 357 offered to the current of blood, which becomes further retcarded by the rigidity of the tube, which has lost its elasticity. The interchange of oxygen and nutritive material is therefore considerably lessened, which explains the loss of energy, the impairment of the mental faculties, and the somnolence which is found in a number of these cases. "VSTiere the basal sphere of nutrition suffers, the symptoms are generally rapidly developed. It is not by any means rare that, after a few insignificant premonitory symptoms, there is a sudden stroke of apoplexy which proves fatal. The symptoms of this form of apoplexy are in all respects similar to those which have been described as ordinary apoplexy from cerebral haemorrhage. Multiple thrombosis of several important basal arteries is discovered post Tnortem. In other cases there are premonitory symptoms chiefly on the part of the cranial nerves. There is ptosis, double vision, weakness of sight from optic neuritis, anaesthesia, and neuralgia in certain branches of the fifth nerve, spasm in the portio dura and sixth nerve, etc. These symptoms may come on, as it were, spontaneously, or after mental and physical efforts, excitement, and indulgence in alcohol and the sexual appetite. After a time there is a somewhat slowly-produced attack of hemiplegia, with or without aphasia, and without loss of consciousness. If collateral circulation is established the patient may gradually improve ; or he sinks into a somnolent condition, resembling that of typhoid fever. There is headache, confusion, fussiness ; the patient has a staring, absent look, and a morose expression of the countenance ; he sometimes gets out of bed and passes water or faeces in the middle of the room, and does other things which show absence of the feeling of shame ; but on being talked to, he generally becomes more reasonable. He will often refuse food, and die in the first or subsequent attacks; yet where all these symptoms have been present, an immense im- provement may by proper treatment be brought about in the patient's condition. "Where there has been true hemiplegia, recovery is generally imperfect, even under the best treatment. There are, however, temporary kinds of hemiplegia which only persist for a day or two, and where the starvation of cerebral tissue is evidently of 358 DISHASJSS OF THE NERVOUS SYSTEM. too short duration to cause any great degree of softening. In some cases hemiplegia is followed by Tiirck's sclerosis of the lateral columns of the spinal cord, just as after ordinary cerebral hsemorrhage. h. Syphilitic affections of the Spinal Cord, These are much more rare than the corresponding diseases of the brain and cranial nerves, and there are as yet only few post-mortem examinations of such cases on record. The syphiloma occurs in its two forms, viz., as jelly and as cheese, in the pia mater and the subarachnoid space ; and the three membranes are grown together with each other and with the surface of the cord. There are, however, not circum- scribed tumours as in the brain, but we meet rather with a kind of intiltration of the meninges and lymphatic spaces by gumma- tous effusions, which appear small, multiple and disseminated. Where the membranes grow together with the periosteum of the vertebrae and the surface of the cord, there is generally prolifer- ation of the neuroglia and wasting of the white columns. Some cases in which the symptoms of acute ascending spinal paralysis are observed during life, seem to be owing to hypersemia simply, as no structural alterations of the cord have been discovered after death. In this latter case the symptoms generally commence at an early period, viz., in the first year, and are accompanied by the usual early manifestations of constitutional syphilis. The first symptom is sudden paraplegia, with incontinence of the urine and faeces. There is no pain in the spine, and no anaesthesia of the limbs. Decubitus soon becomes developed, and the patient dies within a few weeks from the beginning of these symptoms. More frequently, however, paralysis comes on in the later periods of the disease, after many other symptoms have existed for a long time. There is muddy pallor of the skin, and a disagreeable smell about the patient, who is generally feeble and in a state of constant malaise. He experiences pain at different points of the spine, which is increased by pressure ; and also pain, ' pins and needles,' numbness and stiffness in the lower extremities. These symptoms come and go, and then there is all of a sudden an attack of paraplegia or hemi-para- SYPHILIS OF THE SPIJVAL CORD. 359 plegia. Where the seat of the disease is in the lower portion of the dorsal cord, there is also paralysis of the sphincters. If the case is not well treated, the paralysis remains stationary, and ultimately decubitus is developed, which shortly leads to a fatal result. By proper treatment, however, the patient may get well in a very short time. Some years a;go I was consulted by a patient of this kind only two days after the paraplegia had become developed. He was carried into my consulting-room on the back of a cabman, and had completely lost the power over the lower extremities, but only slightly over the sphincters. There was no anaesthesia. Under full doses of iodide of potassium the patient improved most rapidly, and walked briskly into my room a week after I had first seen him. He did not, however, perfectly recover, as a slight degree of weakness in the left leg has remained up to this day. "Where the cervical spine is affected, matters are more serious. There is then not only paraplegia and paralysis of the sphincters, but also of the thoracic and abdominal muscles, the upper extremities, and the diaphragm. Asphyxia from paralysis of the phrenic nerve, or pneumonia, generally carries the patients off in a short time, unless, as we have seen it, the remedy proves stronger than the disease. But in cases of this class we cannot look forward to perfect recovery, as the posterior columns of the cord generally become disorganised beyond a thorough repair, and a state resembling locomotor ataxy may then remain for life. INDEX. ABE ABERCROMBIE, Dr., on meningitis, 186 ; tabes dorsalis, 308 Abscess of the brain, 202 Active hypersemia of the brain, 124 Age, influence of, on nervous diseases, 16 ; on convulsions, 66 ; apoplexy, 83 ; paralysis, 141 ; cephalitis, 182 ; epilepsy, 223 ; hysteria, 253 ; cata- lepsy, 264 ; delirium tremens, 273 ; insanity, 267 ; tetanus, 280 ; chorea, 295 Agraphia, 161 Aitken, Dr., on delirium tremens, 276 Alalia, 175 Alcohol, influence of, on apoplexy, 87, 89 ; on meningeal haemorrhage, 124 ; on cerebral hypersemia, 125 ; acute intoxication by, 132; influence on hsematoma of the dura mater, 189 ; - preservative against nervous diseases, 278 Alison, Dr. Scott, on trophic distur- bances after apoplexy, 114 Allbutt, Dr. Clifford, on optic neuritis, 344 Amimia, 162 Anaemia of the brain, 64 Anarthria, 175 Andral, M., on apoplexy, 94 ; menin- gitis, 186 Aneurism of cerebral arteries, 89, 346 Angular gyrus, 51 Annuske, Dr., on optic neuritis, 343 Anstie, Dr., on neuralgia, 229 Aphasia, 40, 155 Aphemfa, 155 Aphonia, 176 Aplasia of the brain, 228 Apoplectic habit, 93 ; cyst, 95 Apoplexy, 18; nervous, 69; sanguine- ous, 82 ; mortality from, 82 ; fou- BRA droyante, 96; of the retina, 97 ; from cerebral hypersemia, 130 Arachnitis, 184 Aran, M., on progressive muscular atrophy, 320 Articulate speech, 39 Ascending myelitis, 209 Ataxy, progressive locomotor, 307 Atrophy, progressive muscular, 320 ; of the brain, 337 Auditory centre, 51 Auerbaeh, Dr., on muscular hyper- trophy, 330 Aura epileptica, 233 BASTIAN, Dr. Charlton, on chorea, 301 Bedsores in apoplexy, 104 ; in myelitis, 215 Behier, M., on aphasia, 166 Benedict, Professor, on epilepsy, 229 ; tetanus, 286 Berthold, Dr., on apoplexy of the retina, 98 Betz, M., on the anatomy of the cortex, 46 Bladder, influence of spinal cord on, 29 ; paralysis of in myelitis, 214 Body-heat, regulation of by spinal cord. , on miliary aneurisms, 91 , on the seat of language. Bouchard, M., Bouillaud, M., 166 Bourneville, M., on eclampsia, 79; on softening of the brain, 152 Brachial diplegia, 211 Brain, physiology of, 40 ; inflammation of, 201 ; hypertrophy of, 337 ; atro- phy of, 337 ; tumours of, 340 ; sy- philis of, 348 362 INDEX. BRA Braun, Prof., on puerperal eclampsia, 78 Bretonnean, M., on diphtheritic para- lysis, 178 Briquet, M., on hysteria, 249 Broadbent, Dr., on the cerebral hemi- spheres, 48; on apoplexy, 91, 106, 120; the thalamus opticus, 118; chorea, 301 Broca, M., on aphasia, 53, 157 Broca's region, 51 Brown-Sequard, M., on epilepsy, 26, 212, 246; on the spinal cord, 36, 118; on the brain, 44, 53; on Duchenne's disease, 174 Budge, on the spinal cord, 29, 39 Buhl, Dr., on diphtheritic paralysis, 180 Burrows, Sir George, on apoplexy, 1 Buzzard, Dr., on nerve-syphilis, 348 CANCER of the brain, 342 Carbonic oxide, cause of eclampsia, 81 Carville, M., on chorea, 301 Celtic race prone to nervous diseases, 14 Cephalitis, 182 Cerebellum, physiology of, 40 Cerebral hsemorrhage, 88 ; fever, 103 ; macula, 104 ; paralysis, 143 ; tu- mours, 146 ; meningitis, 185 Cervical meningitis, 198; paraplegia, 211 Championniire, M., on trephining, 54 Charcot, Prof., on apoplexy, 91 ; cere- bral macula, 104; on sclerosis after apoplexy, 113; on trophic distur- bances, 115; hemi-aneesthesia, 117; aphasia, 167; progressive bulbar paralysis, 172, 174; pachy- menin- gitis spinalis, 191 ; sclerosis, 330 Charcot's disease, 330 Chauveau, M., on chorea, 301 Cheadle, Dr., on Duchenne's disease, 178 Choked disc, 344 Cholesteatoma of the brain, 342 Chorea, 19, 293 Cilio-spinal centre, 34, 218 Clarke, Dr. Lockhart, on paralysis, 165; microscopic method, 172; on the olivary bodies, 173 ; tetanus, 285 ; ataxy, 308 ; muscular atrophy, 322 Classification of nervous diseases, 18 Claude Bernard, M., on salivation, 174 Cohnheim, Prof., on'embolism, 145, 149 Cold, influence of, on eclampsia, 74 ; apoplexy, 92 ECK Coniine, cause of eclampsia, 81 Conjoint deviation of head in apoplexy, 102 Convulsions, 18, 55 ; direct or local, 61 ; reflex, 62 ; central, 63 Cooper, Sir A., on cerebral circulation, 65 Co-ordination of movements, 28 Corpora quadrigemina, 41 Corpus striatum, physiology of, 43 ; hsemorrhage into, 93 Cortex of the brain, physiology of, 43 Cortical epilepsy, 47, 248 Goste, M., on muscular hypertrophy, 327 Cruveilhier, M., on ataxy, 317 ; pro- gressive muscular atrophy, 321 Curling, Mr., on tetanus, 282, 284 Cystitis, 214 Cysts of the brain, 342 DAX, M., on aphasia, 166 Decubitus in apoplexy, 104 ; mye- litis, 215 Deglutition, physiology of, 39 Delasiauve, M., on epilepsy, 240 Delirium tremens, 19, 273 Demeaux, M., on hemi-ansesthesia, 118 Dementia paralytica, 164 Demme, Dr., on tetanus, 285 Descending neuritis, 213 Determination of blood to the head, 124 Dickinson, Dr., on tetanus, 286 ; chorea, 302 Digestive organs, influence of spinal cord on, 32 Diphtheritic paralysis, 178 Disease of the brain, 19 Disseminated insular sclerosis, 330 Donders, Prof., on cerebral circulation, 65 Dorsal meningitis, 198 Dowse, Dr. Stretch, on chorea, 301 Drunkenness, 132 Dnchenne, M., on ataxy, 309 ; pro- gressive muscular atrophy, 318 Duchenne's disease, 171 Dura mater, inflammation of, 185 Durand-Fardel, M., on apoplexy, 1 1 2 Dysarthria, 178 ECHEVEERIA, M., on epilepsy, 231, 247 Eckhard, M., on the spinal cord, 36; the brain, 45 INDEX. 363 ECL Eclampsia of children, 71 ; puerperal, 76 ; from poisoning, 80 Eiohhorn, M., on the spinal cord. Ejaculation, physiology of, 32 Elischer, Dr., on chorea, 301 Embolism, 146 Emotional centres, 64 Emprosthotonus, 287 Encephalitis, 201 Endocarditis in chorea, 303 Epilepsy, 19, 222 ; saturnine, 80 ; gra- rior, 232 ; niitior, 241 ; saltatoria, 293 Epilepticism, 241 Epileptic fit, 232 ; vertigo, 242 ; mania, 24d Epileptoid, 245 Epileptogenic zone, 26 Erb, Prof., on Unterschenkel-Phaeno- men, 27 Erection, physiology of, 32 Etat de mal epileptique, 241 Eulenburg, Prof., on the pulse in apo- plexy, 119; on muscular atrophy, 325 FALLING SICKNESS, 232 Ealret, M., on apoplexy, 2 Faradic exploration of nerves and muscles in myelitis, 213 Ferrier, Dr., on the cerebellum, 40 ; on psychomotor centres, 44, 47, 51 ; hemi-anaesthesia, 117. 233 Fibroma of the brain, 341 Flourens, M., on the vital knot, 37 ; on the brain, 43 Folie paralytique, 164 Freusberg, M., on the spinal cord, 37 Friedreich, Prof., on progressive mus- cular atrophy, 320 ; pseudo-muscular hypertrophy, 328 Friedrich, Dr., on tetanus, 282 Fritsch, on the brain, 44 Frommann, Dr., on sclerosis, 330 Fungus durse matris, 342 aALABIN, Dr., on puerperal eclamp- sia, 78 Gall, on the seat of language, 156 Galvanic exploration of nerves and muscles in myelitis, 213 Ganglia of the pes pedunculi, 42 ; teg- mentum, 41 General paralysis of the insane, 164 Gioja, M., on muscular hypertrophy, 327 Glioma of the brain, 341 Goltz, Prof., on the spinal cord, 29, 32, 37 ; on the brain, 46, 47, 49, 60 Gosselln, M., on trephining, 54 Gray, Dr., on chorea, 301 Griesinger, Prof., on epileptoid, 245 Grotzner, Dr., on tetanus, 287 Gull, Sir W., on tabes dorsalis, 308 ; progressive muscular atrophy, 322 Gummatous tumour of the brain, 351 HEMATOMA of the dura mater, 186 Hall, Marshall, on reflex action, 27 ; on cerebral circulation, 66 ; hyJrocephaloid, 68 ; epilepsy, 227 Hammond, Dr., on apoplexy, 2 Haut mal, 232 Heart's action, influence of nervous system on, 35, 38 Heart-disease, influence of, on apoplexy, 91 Heat, influence of, on eclampsia, 74 Heat-stroke, 137 Helmholtz, Prof, on reflex action, 27; on language, 176 Hemi-ansesthesia, cerebral, 117 ; hys- terical, 262 Hemi-chorea, 298 Hemi-paraplegia, 211 Hemiplegia, 106, 151 Hemptenmaeher, Dr., on muscular atrophy, 324 Hermann, M., on the brain, 46 Herodotus' case of aphasia, 164 Heubner, Prof., on cerebral circulation, 148, 355 Hicks, Dr. Braxton, on infantile mor- tality, 122 Hippocampal region, 51 Hitzig, Prof., on apoplexy, 27 ; on the brain, 44, 233 Homicidal mania, 167 Huguenin, Prof., on haematoma of the dura mater, 187 Hydrooephaloid, 68 Hydrocephalus, 18 ; senilis, 340 Hydrocyanic acid, cause of eclampsia, 81; of apoplexy, 136 Hypersemia of the brain, 124 Hypertrophy of the muscles, 327, 330 ; of the brain, 335 Hysteria, 248 FIOCY, 338 Idiopathic epilepsy, 226; tetanus, 284 Infantile mortality in England, 68 — eclampsia, 71 364 INDEX. INF Inflammation of the brain, 201 ; of its membranes, 184 ; of the spinal cord, 206 ; of its membranes, 190 Inhibitory action, 28, 41 Insanity, 19, 267 Intelligent language, 61 Intemperance leading to apoplexy, 90 Internal capsule, 42 Iris, influence of spinal cord on, 34 Isohaemia papillae, 344 Island of Keil, structure of, 46, 5 1 JACCOUD, M., on aphasia, 159; mus- cular atrophy, 322 Jackson, Dr. H., on discharging lesions, 45 ; on aphasia, 155; diphtheritic paralysis, 180 ; regional spasm, 233 ; cortical epilepsy, 248 ; optic neuritis, 343; nerre-syphilis, 348, 354; cho- rea, 301 Joffroy, M., on Duchenne's disease, 172 Johnson, Dr. George, on apoplexy, 90 TT'ELLIE, Dr., on cerebral circulation, JX 64 Kirkes, Dr., on apoplexy, 90 ; on chorea, 303 Kremiansky, M., on artificial produc- tion of hsematoma, 189 Kussmaul, Prof., on cerebral anaemia, 65 ; aphasia, 163, 164 ; on Duchenne's disease, 172 LAB 1 - GLOSSO - PHAEYNGEAL paralysis, 171 Lanceraux, M., on alcohol, 190 ; on nerve-syphilis, 348 Landouzy, M., on hysteria, 249 Laryngismus, 227 Lasfegue, M., on diphtheritic paralysis, 178 Law of occurrence of nervous diseases, 4 Law of substitution, 36, 44 Lead, influence of, on eclampsia, 80 Lecomte's case, 321 Lemoigne, M., on psychomotor centres, 45, 50 LepeUetier, M., on tetanus, 286 Lepto-meningitis cerebralis, 193; spi- nalis, 196 Lesser evil, 241 Leyden, Prof., on myelitis, 207 ; teta- nus, 285 ; ataxy, 308, 318 Lidell, Dr., on apoplexy, 83, 87 ODI Line of Rolando, 54 Lipomatosis of the muscles, 321 Localisation of cerebral faculties, 44 Locked jaw, 19, 287 London, prevalence of delirium tremens in, 276 Lordat's case of aphasia, 161 Lumbar meningitis, 198 Lussana, M., on psycho-motor centres, 45, 60 Luys, M„ on progressive muscular atrophy, 321 MACGEEGOE, Mr., on tetanus, 292 Mackenzie, Dr. Morell, on aphasia, 158 ; Dr. Stephen, on chorea, 301 Magnan, M., on epilepsy, 239, 247 Major, Dr. H. C, on the Island of Eeil, 46 Marantic thrombosis, 147 Masius, M., on the spinal cord, 36 Medulla oblongata, physiology of, 37 Melanoma of the brain, 341 Meningeal haemorrhage, 121 Meningitis, 184 Meryon, Dr., on pseudo-hypertrophy of the muscles, 327 Meyer, Prof. L., on epilepsy, 231 Meynert, on the ganglia of the brain, 41 ; on epilepsy, 230 Miliary aneurisms, 91 Monro, Dr., on cerebral circulation, 64 Morbus sacer, 222 Moreau, M., on aphasia, 158 Moxon, Dr., on chorea, 302 Myelitis, 206 Myositis, 213, 321 Muscular atrophy, 320; hypertrophy, 327, 330 Myxoma of the brain, 341 VTAITNYN, M., on the spinal cord, 36 jjy Nephritis, influence of, on eclamp- sia, 77 ; on apoplexy, 89 Nervous apoplexy, 69 Neuroma of the brain, 341 Neuropathic constitution, 63 Nightmare, 232 Nceud-vital, 37, 174 Nose-bleeding previous to apoplexy, 97 Nothnagel, Prof., on the cortex, 47 ; on epilepsy, 66 OCCIPITAL lobes of the brain, 52 ; anifmia of, 70 Odier, M., on epilepsy, 235 INDEX. 365 OER Oertel, Dr., on diphtheriticparalysis, 1 80 Ogle, Dr. John, on apoplexy, 94 ; apha- sia, loS Ogle, Dr. William, on aphasia, 157, 160 ; on agraphia, 161 Olivary bodies, 173 Opisthotonus, 287 Opium-poisoning, 134 Optic neuritis, 343 Ord, Dr., on pseudj-hypertrophy of the muscles, 329 Orthotonus, 287 Osborne, Dr., on aphasia, 163 Otitis, 154, 'Ma PACHY-MEN"INGITIS,externalcere- bral, 185; internal hsemorrhagic, 186 ; external spinal, 190 ; internal spinal, 191 Pagenstecher, Dr., on intracranial pres- sure, 156 Paragraphia, 164 Paralysis, 19 ; from apoplexy, 106 ; mortality from, 140 ; of the insane, 164; agitans, 168; of the sphincters, 214 ; diphtheritic, 178 Paramimia, 164 Paraphasia, 163 Parkes, Dr., on chorea, 301 Parkinson's disease, 168 Passive hypersemia of the brain, 125 Petit mal, 241 Pfliiger, Prof., on reflex action, 27 Pia mater, inflammation of, 193 Pleurosthotonus, 287 Poisons, influence of, on eclampsia, 80 Pons Varolii, physiology of, 40, 41 ; haemorrhage into, 1 00, 116 Priapism, 32, 40; in myelitis, 219 Progressive bulbar paralysis, 39, 171, 323; locomotor ataxy, 307; muscular atrophy, 320 Prussic acid, poisoning by, 136 Psammoma of the brain, 341 Pseudo-hypertrophy of the muscles, 327 Pulse, in apoplexy, 119 Pupil, in apoplexy, 100 QUINCKE, Dr., on puerperal eclamp- sia, 79 "DACE, influence of, on nervous Xt diseases, 13, 252 Eadcliffe, Dr., on epilepsy, 246 Eectum, influence of spinal cord on, 31 SPI Eed softening, of the brain, 149 ; of the spinal cord, 207 Eeflex action, 27 Eegistrar-General's Eeports on disease and death, 3 Respiratory diseases, mortality from, 8 Respiration, influence of nervous sys-, tem on, 35, 37 Retina, apoplexy of, 97 Reynolds, Dr. Russell, on epilepsy, 1 ; on chorea, 301 Rheumatic tetanus, 284 Rigidity of muscles in apoplexy, 115 Eindfleisch, Prof., on sclerosis, 330 Eoberts, Dr., on progressive muscular atrophy, 325 Eokitansky, Prof., on the spinal cord, 35 ; tetanus, 285 ; chorea, 301 Romberg, Prof., on hysteria, 249 ; teta- nus, 286 ; ataxy, 308, 320 Royal College of Physicians, nomencla- ture of, 19 Euge, Dr., on alcohol, 189 OALKOWSKI, M., on the spinal cord, Samuel, on trophic nerves, 35 Sarcoma of the brain, 341 Scanzoni, Prof, on puerperal eclampsia, 77 Sohiff, Prof., on the spinal cord, 25, 36 Schneevogt, Dr., on muscular atrophy, 322 Schroder van der Kolck, on the olivary bodies, 173 ; in epilepsy, 230 Sclerosis, 145, 309 ; en plaques, 330 Secretions, influence of nervous system on, 36 See, M., on chorea, 295 Seguiu, Dr., on aphasia, 159 Setschenow, M., on inhibitory action, 41 Sex, influence of, on nervous diseases, 14 ; on convulsions, 59 ; apoplexy, 86 ; paralysis, 140 ; cephalitis, 184 ; epilepsy, 223 ; hysteria, 251 ; cata- lepsy, 266 , insanity, 268 ; delirium tremens, 275 ; tetanus, 282 ; chorea, 295 Shaking palsy, 168 Sieveking, Dr., on epilepsy, 1 Silver, Dr., on Duchenne's disease, 178 Skull, peculiarities of, in epilepsy, 228 Softening of the brain, 145 ; of the spinal cord, 207 Spermatorrhosa, in ataxy, 314 Spinal cord, physiology of, 24 ; inflam- 366 INDEX. SPI mation of. 206; sclerosis o.f, 113; syphilis of, 358 Spinal epilepsy, 212, 226, 334 Spinal hemiplegia, 211 St. Vitus's dance, 293 Sutieulum cornu ammonis, 51 Sunstroke, 137 Sympathetic epilepsy, 226 Syphilis of the nervous system, 348 Syphiloma of the brain, 351 TABES dorsalis, 307 Temperature, in infantile ecUmp- sia, 73 ; in nrsemic eclampsia, 79 ; apoplexy, 102, 105, 119; softening of the brain, 152; meningitis, 196; encephalitis, 203 ; myelitis, 210 Tenner, M., on cerebral anaemia, 65 Tetanus, 19, 280 Thalamus opticus, physiology of, 42 ; hsemorrhage into, 94 Todd, Dr., on epilepsy, 231 ; ataxy, 308 ; chorea, 300 Tongue, deviation of, in apoplexy, 108 Topinard, M., on ataxy, 318 Toxic tetanus, 285 Trachelismus, 227 Traumatic tetanus, 283 Trismus, 19, 287 Thrombosis, 146 Trophic centres, 35 Trousseau, Prof., on aphasia, 155 ; on Duchenne's disease, 172 ; diphtheritic paralysis, 178 ; ataxy, 309 Tubercle of the brain, 342 Tubercular diseases, mortality from, 8 Tuekwell, Dr., on chorea, 301 Tiirck, Prof., on sclerosis, 113, 330 Tumours of the brain, 145, 340 YASOMOTOR CENTRES, 33, 38; anaemia, 69 ; epilepsy, 226 ZTM Vaulair, M., on the spinal cord, 36 Verbal deafness and blindness, 163 Veyseiere, M., on hemi-ansesthesia, 117 Virchow, Prof., on miliary aneurisms, 91 ; on embolism and thrombosis, 145; hsematoma of the dura mater, 186; epilepsy, 228 ; tumours of the brain 341 Viscera, influence of spinal cord on, 29 Vivisection, its importance for practical medicine, 153 Voisin, M., on epilepsy, 239 Von Graefe, on diphtheritic paralysis, 180 ; choked disc, 344 Von Gudden, on the cortex in animals, 47 Vulpian, M., on sclerosis after apo- plexy, 113 WALES, prevalence of nervous diseases in, 13 ; of delirium tre- mens in, 276 Waller, Prof., on nerve-syphilis, 348 Westphal,, Prof., on epilepsy, 26 ; on Unterschenkol-Phaenomen, 27 ; on granular myelitis, 165 White softening of the brain, 150 Wilks, Dr., on chorea, 302 ; on nerve- syphilis, 348 Womb, influence of spinal cord on, 32 WoroschiloflT, M., on the spinal cord, 25 YELLOW softening of the brain, 149, 150; of the spinal cord, 207 ZEKCKEE, Prof., on sclerosis, 330 Ziemssen, Prof. Von, on chorea, 297 Zymotic diseases, mortality from, 8