54-1 % CORNELL UNIVERSITY. THE THE GIFT OF ROSWELL p. FLOWER FOR THE USE OF THE N. Y. STATE VETERINARY COLLEGE. 1897 CORNELL UNIVERSITY LIBRARY 3 1924 104 225 093 Cornell University Library The original of tiiis bool< 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/cu31924104225093 THE NERVOUS SYSTEM AND ITS DISEASES. A PRACTICAL TREATISE ON NEUROLOGY FOR THE USE OF PHYSICIANS AND STUDEJ^TS. BY CHAELES K. MILLS, M.D. PROFESSOR OF MENTAL DISEASES AND OF MEDICAL JTTRISPRUDENCE IN THE UNIVERSITY OF PENNSYLVANIA; CLINICAL PROFESSOR OF NECROLOGY IN THE WOMAN'S MEDICAL COLLEGE OF PENNSYLVANIA J PROFESSOR OF DISEASES OF THE NERVOUS SYSTEM IN THE PHILADELPHIA POLYCLINIC; NEUROLOGIST TO THE PHILADELPHIA HOSPITAL; HONORARY FELLOW OF THE PITTSBURG ACADEMY OF MEDICINE, ETC. DISEASES OF THE BRAIN AND CRANIAL NERVES, WITH A GENERAL INTRODUCTION ON THE STUDY AND TREATMENT OF NERVOUS DISEASES. WITH FOUR HUNDRED AND FIFTY-NINE ILLUSTRATIONS. PHILADELPHIA : J. B. LIPPINCOTT COMPANY. London: 6 Henrietta Street, Covent Garden. 1898. COPYKIGHT, 1897, BY J. B. LippiNCOTT Company. 34-/ t- TO S. WEIR MITCHELL, M.D., LL.D., IN RECOGNITION OF HIS GREAT SERVICES TO NEUROLOGY AND TO MEDICAL AND GENERAL LITERATURE, AND AS A MARK OF HIGH PERSONAL ESTEEM, THIS BOOK IS DEDICATED BY THE AUTHOR. PREFACE. The great work of Gowers is the only extensive treatise on ner- vous diseases in the English language, although excellent manuals of moderate size have been written ; and the author has hence been led to believe that a large text-book, including a comparatively full presentation of the many recent additions to the anatomy and pathol- ogy of the nervous system, would be in accord with the needs of the profession. It has been deemed best to make the present volume complete in itself, with bibliographic and general indexes. In addition to an in- troduction on the study and treatment of nervous diseases in general, diseases of the brain and of the cranial nerves are discussed in full. Should circumstances permit, this volume will be followed by an- other, which shall include the remaining diseases of the nervous system, insanity, and the medical jurisprudence of both nervous and mental diseases. The introductory portion of the work comprises a summary of the embryology, anatomy, physiology, and chemistry of the nervous system, and a consideration of the general pathology, etiology, and symptomatology of nervous diseases, with the methods of investi- gating them and the best measures applicable in their treatment. The introductory chapters have been made full because of what are believed to be the necessities of American students and practitioners. While the methods of investigation described and the data found in the clinical and pathological portions of the book are based mainly upon experience in private and hospital practice, it has been the aim to make the volume also representative of the best American and foreign work in neurology. Close attention has been given to the subject of localization with regard to all portions of the encephalon, — the ganglia and other structures at the base of the brain, the cerebellum, the pons, and the oblongata, as well as the cerebrum. Under cerebral localization are given the results of the latest researches and observations, including the discoveries springing from the newer histological methods. Diseases of the membranes, sinuses, and veins of the brain are considered separately from arterial diseases, which are chiefly focal, as the latter are more conveniently discussed with other focal lesions, such as tumor and abscess. Special attention has been paid to the iv PREFACE. subject of encephalitis. As many of the encephalic affections com- monly met with are chronic, and the results of residual lesions or secondary degenerations, it has been thought best to consider these by themselves. The usual order in which the cranial nerves are enumerated is not followed in their discussion, affections of the special senses being considered together. The chapter on these affections includes separate sections on the cochlear and vestibular nerves and their diseases. Affections of taste are discussed at length, because they have as a rule been slighted in other neuro- logical treatises. The nomenclature and terminology advocated by Professor Burt G. Wilder, of Cornell University, have in the main been used, more largely than in any previous practical work on neurology. The reforms advocated by this distinguished anatomist, especially the introduction of mononyms, are deserving of general adoption. The method of reference in the bibliographic index is novel, and it is hoped will commend itself to the student and the general reader. This index makes it unnecessary to speak here separately of the author's obligations to his confreres in this country and abroad. The plan of using captions for each paragraph has been adopted in the hope that it will be of service in the more exact presentation of facts. The author is greatly indebted to Professor Wilder for direct help and suggestions connected with neural terminology. To Dr. A. C. Peale he has been under continuous obligations during the progress of the work for assistance rendered, including the searching for references and their verification, the reading and criticism of proof, and the modification and supervision of illustrations. Dr. William G. Spiller, by furnishing notes on recent literature, by special criticisms, and by valuable aid in the pathological sections, has placed him under great obligations to his colleague. Acknow- ledgments are also due to Dr. J. W. McConnell for assistance in proofreading and in the bibliographic work ; to Dr. Henry Leff- mann for the revision of the section on the chemistry of the nervous system ; and to Dr. F. X. Dercum, Dr. James Hendrie Lloyd, and Dr. Charles W. Burr, of the Philadelphia Hospital staff, for oppor- tunities of studying and using cases in addition to those under his own care. Many of the illustrations are new, and others obtained from dif- ferent sources have been more or less modified for the particular purposes of the book. Grateful acknowledgments are due to those authors and pirblishers, both American and foreign, who have ac- corded the privilege of using their illustrations, either in the original or in modified forms. 1909 CUiESTNUT Steeet, PiiiLADELrHiA, Jiimmry, 1898. CONTENTS. CHAPTEE I. PAGE Sketch of the Nervous System, its Tissues, Develop- ment, Anatomy, Physiolo&y, Nomenclatuke, and Chemistry 1 Sketch of the Nervous System : The neuraxis, 1 ; chief subdivisions of the human brain, 2 ; pons and oblongata, 4 ; the spinal cord and its nerves, 5 ; gangliated system of nerves, or so-called sympathetic nervous system, 7 ; relations of the spinal cord to the limb, trunk, and gangliated nerves, 7 ; somatic and splanchnic nerves . . 8 Nervous Tissues : Elementary tissues, 9 ; the cell, 9 ; nerve cells, 9 ; shapes and sizes of nerve cells, 10 ; structure of the nerve cell, 11 ; types of nerve cells, 11 ; cellular terminology, 12 ; functions of the nerve cell, 13 ; neuroglia, 16 ; nerve fibres, 17 ; characteristics of medul- lated and nonmedullated nerve fibres, 17 ; nerve endings, 18 ; motor and sensory cells, 19 ; nervous structures of the sense organs, 21 ; nerve trunks or peripheral nerves . . .... 22 Development of the Nervous System : The blastodermic layers and the neural canal, 23 ; neuroblasts and spongioblasts, 24 ; development of motor nerve roots, 25 ; development of sensory nerve roots, 26 ; devel- opment of lateral nerve roots, 27 ; all ganglia neuraxial outgrowths, 28 ; development of the spinal cord, 28 ; the cerebral vesicles, 29 ; the neu- raxial cavities, 30 ; the extensions and relations of the paracceles, 32 ; relationships of cerebral vesicles to the parts of the fully developed brain, 33 ; segmental character of the entire nervous system, 33 ; lobes of the cerebrum, 34 ; physiological lobes, 36 ; lobation of the cerebrum during development, 37 ; first appearance of fissures and convolutions, 38 ; fissures and gyres of the brain after full development, 39 ; fissures of the human brain according to Wilder, 41 ; variations in fissural and gyral arrangement, 42 ; ental correlatives of fissures ... . 46 Nomenclatixre and Terminology: General remarks on nomenclature and terminology, 47 ; suggestions as to nomenclature, 47 ; mononyms, 47 ; the naming of fissures and gyres, 51 ; terms descriptive of the posi- tions and relations of parts, 51 ; classification of encephalic parts • 52 General Anatomy : Important ganglia, tracts, and cavities of the brain, 54 ; the striata, 55 ; the caudatum, 55 ; the lenticula, 55 ; the internal, external, and extreme capsules, 56 ; the claustrum, 56 ; the amygdala, 56 ; embryonic relations of the claustrum, caudatum, and lenticula, 57 ; commissural structures of the brain, 58 ; the callosum, 59 ; the fornix, 59 ; the dentate gyre and fasciola cinerea, 60 ; base of the brain, 60 ; albicantia, 60 ; tuber cinereum, 61 ; the infundibulum, 62 ; association fibres of the cerebrum, 62 ; the interbrain or thalamencephalon, 63 ; the geniculate bodies, 63 ; the cavity of the interbrain, 63 ; the conarium, V VI CONTENTS. PAGE 64 ; the hypophysis, 65 ; subthalamic region, 65 ; red nucleus, 67 ; sub- thalamus, 67 ; the quadrigeminal body, 67 ; the cerebellum, 67 ; sub- divisions of the cerebellar surface, 68 ; ganglia and deposits of the cere- bellum, 70 ; cerebellar conducting tracts, 71 ; fibres of the cerebellar peduncles, 72 ; crura, pons, and oblongata, 72 ; external features of the ventral aspect of the oblongata, 73 ; external features of the dorsal as- pect of the oblongata, 74 ; the floor of the fourth ventricle, 75 ; the re- gion of transition from the spinal cord to the oblongata, 76 ; interior structures of the oblongata, 77 ; formatio reticularis, 78 ; interior struc- ture of the pons, 7!» ; cranial nuclei and nerve roots, 79 ; the deep origins of the cranial nerves, 80 ; ascending and descending roots of sen.sory cranial nerves, 80 ; nuclei and root fibres of the acoustic nerve, 81 ; the nuclei of the motor cranial nerves, 82 ; special ganglia and nuclei in the oblongata and pons, 83 ; nerve tracts in the oblongata and pons, 83 ; longitudinal tracts, 83 ; transverse tracts, 85 ; arcuate or arciform tracts, 85 ; the crusta and tegmentum, 86 ; intercalatum, or substantia nigra, 87 ; the lemniscus or fillet, 87 ; chief subdivisions of the spinal cbrd, 88 ; vertical extension of the spinal tracts, 91 ; the structural elements of the spinal cord, 91 ; Lenhoss^k's commissural cell 94 Membranes, Bloodvessels, and Lymphatics of the Nervous Sys- tem : Envelopes of the brain and spinal cord, 95 ; bloodvessels of the central nervous system, 96 ; venous lakes or lacs sanguins, 97 ; arterial supply of nerves, 98 ; lymphatics of the nervous system, 98 ; lymphatics of the interior of the brain, 98 ; subarachnoid lymph spaces, 99 ; Ij-mph vessels to the nerves ... ... . . 99 Architecture and General Physiology : Encephalospinal conducting paths, 100 ; the great sensory path, 101 ; the cortical sensory expanse, 104 ; the paths of the special senses, 104 ; the pyramidal tract, 106 ; connections of the cerebellum, 107 ; connections of the striata, 109 ; connections of the thalamus, 110; reflex arcs. 111 ; compound reflex arcs, 112 ; the projection system, 113 ; levels of the nervous system, 114 ; functions of different levels, 115 ; centres, 115 ; bilateral arrangement of nerve centres, 116 ; oblongatal centres, 116 ; higher cerebral centres, 117 ; inhibition, 117 ; acceleration, 118 ; the dynamics of nervous tis- sues, 118 ; the nature of nervous impulses, 118 ; electric excitation of nerves, 119 ; transmission of nerve impulses, 119 ; the action of simple nerve centres . ... . . 121 Chemistry of the Nervous System : Chemical composition of nervous tissues, 122 ; chemical characteristics of nervous tissues, 122 ; chemical constitution of the brain, 123 ; chemical constituents of the brain, 123 ; typical brain principles, 123 ; pathological changes in the brain viewed chemically, 124 ; nervous action and chemical processes 124 CHAPTER II. General Pathology axd ETIOT.O(3^Y. Sy.^iptomatology and Methods of Invi;sti(;.vtiox, Electricity, axd Gen- eral Therapeutics ... . 125 General Pathology and Etiology: Pathological classification of ner- vous diseases, 12.'> ; developmental malformations, 125; inflammation 126 ; varieties of inflammation, 126 ; menin,>;itis, 126 ; degenerations 127 ; primary and .secondary degenerations, 127 ; Wallerian degenera- CONTENTS. Vll PAGE tion, 128; regeneration, 129; vascular (nigin of spinal degeneration, 129 ; sclerosis, 130 ; gliomatosis, 130 ; senility, 131 ; tumors and adven- titious products, 131 ; vascular diseases and disturbances, 131 ; predis- posing causes, 132 ; exciting causes, 132 ; here4 ; etiology, 265 ; diagnosis, 266 ; pa- thology and morbid anatomy, 2(3(i ; prognosis, 2(37 ; treatment Purulent Internal Pachymeningitis . . Serous Internal Pachymeningitis Dural Hemorrhage : Varieties, 2(39 ; supradural hemorrhage, 270 ; sub- dural hemorrliagc, 270 ; mode of origin and treatment of dural hemor- rhages Dural Tumors Dural Abscesses Dural Epilepsies Leptomeningeal Hyperemia and Anemia . 273 External Leptomeningitis (so-called Arachnitis) 274 262 263 267 268 269 271 272 273 273 CONTENTS. IX PAGE Leptomeningitis : Method of discussion, and varieties, 274 ; general symp- toms common to all types of acute leptomeningitis, 275 ; symptoms of basilar leptomeningitis, 276 ; symptoms of leptomeningitis of the con- vexity, 277 ; acute purulent leptomeningitis, 278 ; serous meningitis, 278 ; acute tubercular leptomeningitis, 280 ; tubercular cerebrospinal meningitis, 281 ; acute hydrocephalus, 282 ; ei)idemic cerebrospinal meningitis, 28o ; general etiology, 285 ; pathogenesis, 287 ; pathological anatomy common to all types of leptomeningitis, 288 ; lesions in special varieties of leptomeningitis, 289; lesions in epidemic cerebrospinal meningitis, 290 ; microscopical appearances in cerebrospinal meningi- tis, 291 ; diagnosis, 292 ; prognosis, 294 ; treatment 295 Chronic Leptomeningitis : General considerations, 297 ; clinical history, 298 ; etiology, 300 ; pathological anatomy, 300 ; diagnosis, 301 ; prog- nosis, 302 ; treatment - . ... 302 Thrombosis of the Intracranial Sinuses : The dural sinuses, 303 ; the interrelations of the veins and sinuses, 304 ; definitions and varieties, 305 ; clinical history of primary or marantic thrombosis, 306 ; clinical history of secondary sinus thrombosis, 306 ; longitudinal sinus throm- bosis, 307 ; cavernous sinus thrombosis, 307 ; lateral sinus thrombosis, 308 ; etiology, 308 ; pathology, 309 ; diagnosis, 309 ; differential diagnosis of primary and secondary thrombosis, 311 ; prognosis, 311 ; treatment . 311 Diseases of the Intracranial Veins . . . 312 Malformations of the Brain and its Envelopes 313 Chronic Hydrocephalus : Definition, 315 ; clinical history, 315 ; eti- ology, 317 ; pathology, 317 ; diagnosis, 318 ; prognosis, 318 ; treatment . 319 Meningocele : General considerations, 319 ; clinical history, 319 ; etiology and pathology, 320 ; diagnosis, 320 ; prognosis, 320 ; treatment . . . 320 CHAPTEE IV. Encephalic Histology and Physiology in their Eela- TiONS to Focal Diseases of the Beain. General Considerations 321 Minute Anatomy of the Cerebral Cortex : General features of the cortex, 322 ; histological studies, 322 ; discoveries of Golgi, 324 ; cor- tical lamination, 324 ; subdivision of the cortex into four layers, 326 ; types of cells in the four cortical layers, 326 ; the molecular layer, 327 ; the ambiguous layer, 328 ; the layer of large pyramidal cells, 329 ; the polymorphic layer, 329 ; cortical termini of the sensory projection system, 330 ; separate sensory and motor localization . . . 331 Cortical Localization : The prefrontal lobes, 332 ; subdivisions of the Eolandic or motor cortex, 334 ; subareas for the lower extremity, 334 ; representation of trunk and spine movements, 335 ; subareas for the upper extremity, 336 ; subareas for face movements, 336 ; subareas for movements of the lower jaw, 336 ; laryngeal and pharyngeal repre- sentation, 337 ; representation of the movements of the head and eyes, 337 ; unilateral and bilateral representation in the cortex, 339 ; border centres and overlapping areas, 340 ; the representation of cutaneous and muscular sensations, 340 ; visual localization, 342 ; subdivisions of retinal representation, 343 ; macular representation, 343 ; auditory lo- calization, 344 ; the naming centre, 345 ; olfactory localization, 347 ; gustatory localization, 348 ; speech centres, 348 ; the graphic centre. X CONTENTS. PAGE 349 ; the insula and retroinsular convolutions, 350 ; latent or undeter- mined cortical regions, 351 ; diflferent classes of localizing symptoms . 351 Functions and Lesions of the Basal Ganglia, Capsules, and Cen- trum Ovale : Functions and lesions of the striatum (caudatuna and lenticula), 352 ; pseudobulbar paralysis from lesions of tlie lenticula, 353 ; functions of the thalamus, 353 ; syniptoms in cases of thalamic disease, 355 ; heat centres and the thermic mechanism, 355 ; heat cen- tres and clinical phenomena, 356 ; lesions of the geniculate bodies (pre- geniculum and postgenieulum), 358 ; subdivisions and lesions of the in- ternal capsule, 358 ; functions of tlie external capsule, extreme capsule, claustrum, and amygdala, 35!) ; lesions of the centrum ovale, 360 ; lesions of the motor projection system in the centrum ovale, 360; lesions of the sensory projection systems in the centrum ovale, 361 ; lesions of intracerebral associating tracts, 362 ; microscoijical localiza- tion in the cortex and subcortex, 363 ; lesions of the callosum, 364 ; lesions of the cerebral commissures and of the fornix, 366 ; lesions of the ventricles, 366 ; lesions of the hypophysis, or pituitary gland, 367 ; lesions of the conarium or pineal gland, 368 ; lesions of the tuber, 369 ; lesions of special foci of the basal cinerea, 369 ; functions and lesions of the quadrigeminal body, 370 ; subthalamic and subgeminal lesions, 371 ; lesions of the crus . 372 Functions and Lesions of the Cerebellum : Anatomical relations of the cerebellum, 373 ; minute anatomy of the cerebellar cortex, 374 ; physiological theories and facts regarding the cerebellum, 376 ; lesions of the middle and of the lateral lobes, 378 ; lesions of the cerebellar peduncles, 379 ; the flocculus, 380 ; the clinical phenomena of cerebel- lar disease, 381 ; cerebellar affections of congenital origin . . 382 Craniocerebral Topography : Definitions, 383 ; the most important craniocerebral determinations, 385 ; craniocerebral variations, 386 ; Anderson and Jlakins's craniometrical lines, 3!^(i ; Lucas-Champion- niSre's method of determining the central fissure, 387 ; Reid's and Agnew's landmarks, 388 ; angle of the central with the longitudinal fissure, 389 ; Poirier's nasolambdoidal line, 391 ; methods of deter- mining the parieto-occipital and other fissures, 391 ; methods of reach- ing the cranial fossae, 392 ; methods of outlining the prefrontal lobe, 392 ; methods of outlining and exposing the temporal lobe, cerebellum, mastoid process, and lateral sinus, 393 ; tapping the ventricles 394 Postmortem Examinations of the Brain especially with Ref- erence to the Localization of Lesions: Removal of the brain from the skull, 395 ; inspection of the brain and the cranial cavity, 396 ; method of making autopsies to sa\'e the brain for subsequent exami- nation, 397 ; methods of entering the brain and making transections of the cerebrum, 398 ; the interior structures of the cerebrum projected on its convex surface, 404 ; examinations of the cerebellum, pons, and oblongata, 404; methods of separating tlie brain into its component parts, 405 ; the separation and weighing of cerebral lobes, 407 ; brain weight, 408 ; brain weights at difti'rent ages, 409 ; l)rain weight in rela- tion to body weight, stature, and mental condition, 409 ; recorded brain weights of eminent men, 411 ; determination of the volume of the brain, 412; determination of cranial capacity, 412 ; specific gravity of the ))rain, 412 ; hardening and transportation of the brain, 413 ; preser- vation of brains as gross specimens, 413; formalin prejiarations, 414; Golgi's and other methods of preparation and staining 415 CONTENTS. XI CHAPTEE V. Diseases of the Encephalic Vessels, and the Vasculae Disturbances and Diseases oe the Brain. PAGE The Bnceptialic Circulation ... , 416 General arrangement and connections of the encephalic arterial sys- tems, 417 ; cortical distribution of the main cerebral arteries, 418 ; sub- divisions of the cortical arteries, 419 ; intercommunication of cortical arterial territories, 420 ; distribution of the central cerebral arteries, 420 ; the large arteries of the pons and oblongatas, 421 ; arterial sup- ply of special regions of the bulb, 422 ; veins of the brain, 424 ; nerves to the bloodvessels, 425 ; character of the cerebrospinal fluid in diifer- ent diseases . . ... 426 Brain Pressure 426 Concussion, Compression, and Special Traumatisms of the Brain : Concussion of the brain, 427 ; compressibility of the brain substance, 428 ; diagnosis of concussion from compression, 428 ; ex- periments and conclusions of Buret, 429 ; conclusions of Phelps . . 429 Hyperemia of the Brain and its Soft Membranes : Definition and general considerations, 431 ; varieties, 431 ; symptoms, 431 ; etiology, 431 ; pathology, 432 ; pathological anatomy, 433 ; diagnosis, 434 ; prog- nosis, 434 ; treatment . . 435 Anemia of the Brain and its Soft Membranes : Definition and va- rieties, 436 ; symptomatology, 436 ; etiology, 436 ; pathological anatomy, 437 ; diagnosis, 437 ; prognosis, 437 ; treatment . 438 Edema of the Brain 438 Varieties, 439 ; clinical history, 439 ; etiology and pathogenesis, 440 ; pathology and morbid anatomj^, 440 ; diagnosis and prognosis, 441 ; treatment . . . . . . . . . 441 Diseases of the "Walls of the Encephalic Bloodvessels .... 441 Varieties of arteritis, 442 ; chronic endarteritis (arterial or arteriocapil- lary fibrosis or sclerosis), 445 ; symptomatology of encephalic endar- teritis . . . . . 446 Encephalic Aneurism : Varieties, 446 ; symptomatology, 447 ; etiology and pathology, 449 ; diagnosis, 449 ; prognosis, 450 ; treatment . 450 Encephalic Hemorrhage : Varieties, 451 ; most common sites of en- cephalic hemorrhage, 452 ; capsuloganglionic hemorrhage, 452 ; clinical history, 452 ; the apoplectic period, 454 ; cortical hemorrhage, 457 ; primary ventricular hemorrhage, 457 ; secondary ventricular hemor- rhage, 458 ; hemorrhage into the subcortex and centrum ovale, 459 ; cerebellar hemorrhage, 459 ; multiple encephalic hemorrhage, 460 ; capillary hemorrhage, 462 ; duration and complications, 462 ; etiology, 463 ; pathological anatomy, 464 ; diagnosis, 466 ; affections to be dif- ferentiated from encephalic hemorrhage, 466 ; differential diagnosis of the varieties of encephalic hemorrhage, 469 ; differentiation of en- cephalic hemorrhage from other acute focal lesions, 471 ; prognosis, 472 ; treatment 474 Acute Encephalic Softening- . . .... 475 Softening from Embolism : Cerebral arteries usually attacked, 476 ; clinical history, 476 ; focal types of encephalic embolism, 478 ; etiology, 479 ; pathogenesis, 480 ; pathological anatomy, 480 ; diagnosis, 481 ; prognosis, 482 ; treatment 483 490 490 491 492 492 493 529 530 xii CONTENTS. Softening from Thrombosis : Definitions, 483 ; patiiological varieties, 484 ; etiological varieties, 484 ; clinical history, 484 ; duration, course, and' complications, 487 ; etiology, 487 ; pathological anatomy, 488 ; diagnosis, 488 ; jirognosis, 489 ; treatment . • ■ • • • Multiple Encephalic Softening Symptomatology of multiple cerebral softening Occlusion of the Encephalic Capillaries . • Encephalic Infarction ... ..... Encephalic Tumors . • • Etiology, 4it4 ; pathological varieties, 494 ; cysts and cystic degenera- tion, 504 ; purusites of the brain, 504 ; common sites of certain varieties of brain 'tumor, 506; clinical history, 506; general symptoms, 508; focal symptoms, 516 ; multiple tumors, 519 ; duration, 519 ; general course and stages, 520 ; termination and mode of death, 520 ; general diagnosis, 521 ; pathological diagnosis, 527 ; prognosis, 527 ; medical treatment, 528 ; surgical treatment . • Encephalitis . . ... ... .... Varieties ^^^ Acute Focal Encephalitis . • .532 Clinical history, 533 ; etiology, 533 ; pathological anatomy, 534 ; diag- nosis, 534 ; prognosis, 534 ; treatment . . • ■ • • .534 Acute Diffuse Nonsuppurative BncephaHtis . . -535 Clinical history, 536 ; duration and course, 537 ; etiology, 537 ; patho- logical anatomy, 537 ; diagnosis, 538 ; prognosis, 539 ; treatment 539 Disseminated Encephalitis .... ... 539 Chronic Encephalitis . .... 540 Diffuse Suppurative Encephalitis .... . . 542 Encephalic Abscess : Clinical history, 543 ; etiology, 548 ; pathogenesis, 550 ; pathological anatomy, 550 ; diagnosis, 551 ; prognosis, 553 ; treat- ment • ... 554 Multiple Encephalic Abscess . . 555 CHAPTEE YI. Eesidual Encephalic Lesions, Degeneeations. and Dis- eases. Secondary Degenerations chiefly as Occurring after Acute Focal Lesions in Adults • . ■ 556 Initiation ami progress of secondary degeneration, 557 ; inflammatory degeneration, 557; distinction between true secondary degeneration and involution, 5.i8 ; secondary defeneration of the crossed pyramidal tracts, 55".l ; secondary bilateral degeneration of motor tracts, 559 ; de- generation following encephalic lesions variously located, 560 ; ascend- ing secondary degeneration, 5(54 ; secondary degenerations after cere- bellar lesions . . 564 Chronic Hemiplegias and Monoplegias — their Clinical Features, Incidents, and Accidents : The most important hemiplegic phe- nomena, 5(i5 ; amount and order of recovery in paralyzed parts, 566 ; relative involvement of different parts, 507 ; clinical types of hemiple- gia, 5(i8 ; facial and lingual paralysis in hemiplegics, 5(i9 ; pathological significance of difl'erent hemiplegic types, 571 ; alternate hemiple,t;ias, 572 ; hemiplegia on the same side as the lesion in the brain, 572 ; dis- CONTENTS. Xm PAGE orders of position and movement in hemiplegics, 573 ; contractures and rigidities, 573 ; associated and substituted movements, 57(i ; forced movements, 577 ; athetosis and atlietoid phenomena, 578 ; tremors, twitchings, and other abnormal movements, 578 ; cutaneous reflexes, 579 ; tendon and muscle phenomena, 579 ; sensory disorders, 580 ; dis- orders of the special senses, 582 ; vasomotor, secretory, and other allied phenomena, 582 ; surface temperature, 583 ; hemiplegic atrophy, 584 ; miscellaneous trophic phenomena, 586 ; joint affections, 586 ; paralysis of the sphincters, 587 ; disorders of mentality, 587 ; phenomena on the nonparalyzed side, 588 ; bilateral or double hemiplegia, 588 ; diagnosis, 589 ; prognosis, 591 ; treatment 591 Hjrpertrophy of the Brain : Symptomatology, 5!)4 ; etiology and pa- thology, 595 ; diagnosis, prognosis, and treatment 596 Heterotopia . . . . 596 Atrophy of the Brain— Atrophy and Sclerosis 597 Etiology and pathology, 599 ; symptomatology 601 Porencephaly . . . 601 The Cerebral Paralyses of Children, and Affections allied in Pathological Causation . 604 Varieties of diplegia, 605 ; varieties of hemiplegia, 606 ; symptoms of the period of onset, 607 ; symptoms and conditions accompanying the residual paralysis, 608 ; epilepsy, 611 ; defects in the visual fields, and mirror writing, 613 ; etiology and pathogenesis, 614 ; pathological anatomy, 617 ; diagnosis, 619 ; prognosis, 624 ; treatment, 625 ; treat- ment of the residual conditions and symptoms . 626 Aphasia and other Defects of Speech due to Disease of the Cerebrum : Cerebral centres and tracts concerned in speech, ()2S ; definitions and synonyms, 630 ; anatomicopathological varieties of aphasia, 630 ; clinical varieties of aphasia, 631 ; verbal deafness, 632 ; mixed sensory and concept aphasia, 633 ; verbal blindness, 634 ; psychic blindness, 635 ; concept aphasia, 636 ; mixed concept and motor aphasia, 636 ; motor aphasias, 637 ; motor agraphia, 639 ; transcortical agraphia, 640 ; conduction aphasia, 640 ; amusia and the aphasia of intonation, 641 ; the nature of aphasic phenomena, 642 ; the separate existence of concept centres, 645 ; the question of a motor graphic centre, 647 ; rela- tive importance of centres and association tracts, 650 ; importance of the distinction between pure aphasias and aphasias due to impairment of the mechanism of interior language, 651 ; disorders of pantomime among aphasics, 651 ; cases with limited speech and limited panto- mime, 654 ; speech disturbances and mental disease, 655 ; mirror writing, 656 ; pathological etiology and etiological diagnosis of aphasia, 658 ; systematic examination of patients for aphasia, 660 ; diagnosis, 661 ; prognosis, 663 ; treatment . 664 CHAPTER YII. Affections of the Special Senses due to Lesions and DiSTXJEBANCBS OF THE NEEVES OF SPECIAL SEIfSB AND OF THEIE COEEELATED OENTEAL STEUCTUEES. Enumeration of the Cranial Nerves . 667 Affections of Smell due to Disease of the Olfactory Nerve and of its related Encephalic Structures : The olfactory apparatus. XIV CONTENTS. PAGE 667 ; historical, 674 ; clinical history, 674 ; etiology, 680 ; pathological anatomy, 681 ; diagnosis, 681 ; prognosis, 682 ; treatment 682 Affections of Taste due to Disease of the Nerves of Taste and of their related Encephalic Structures : Essential and accessory nerves of taste, (iH'i ; peripheral gustatory end organs, iiS3 ; areas in which taste is normally appreciated, 684 ; delicacy of taste, 685 ; elec- trical tastu, 685 ; the course and origin of the nerves of taste, 685 ; physiological and clinical evidence that the chorda tympani is one of the nerves of taste, 686 ; the gustatory division of the glossopharyngeal nerve, 686 ; evidence that the glossopharyngeal is the main nerve of taste, 688 ; the intermediary nei've of Wrisberg, 691 ; supijuseil relations of the fifth nerve to the sense of taste, 69o ; the bulbocerebral gustatory pathway and cortical centres, 6'.)8 ; clinical history, 698 ; etiology and pathological anatomy, 704 ; diagnosis, 705 ; prognosis, 706 ; treatment . 706 Affections of Hearing due to Disease of the Cochlear Nerve and its related Encephalic Structures : Subdivision of the eighth nerve, 707 ; the essential nerve of hearing, 707 ; accessory nerves of hearing, 708 ; peripheral auditory end organs, 709 ; course and terminal nuclei of the cochlear nerve, 710 ; distribution and course of the coch- lear nerve in the brain stem, 711 ; diagrams of the central auditory (cochlear) tract, 712 ; clinical history, 715 ; atrophy of the cochlear nerve, 719 ; acoustic neurasthenia, 720 ; hysterical affections of hearing, 721 ; reflex auditory neuroses, 721 ; etiol(jgy, 721 ; pathological anatomy, 722 ; diagnosis, 723 ; prognosis, 725 ; treatment .... . 726 Affections of Equilibration due to Disease of the Vestibular Nerve and its related Encephalic Structures, and Conjoint Affections of Hearing and Equilibration due to Cochleo- vestibular Disease : Functions of the semicircular canals, 728 ; peripheral vestibular end organs, 729 ; terminal nuclei of the vestibular nerve and their connections, 730 ; cerebral terminus of the vestibular nerve, 731 ; clinical history, 732 ; tabetic atrophy of the vestibular nerve, 734 ; vertigoes not directly the result of disease of the apparatus of equilibration, 735 ; cochleovestibular disease, 739 ; Voltolini's laby- rinthitis, 739 ; JMeniere's disease, 740 ; etiology and pathology of ves- tibular and cochleovestibular disease, 742 ; diagnosis, 743 ; prognosis, 744 ; treatment . 744 Affections of Sight due to Disease of the Optic Nerve and of the Encephalic Visual Apparatus : The optic nerve a part of the central nervous system, 746 ; end sheathing of the optic nerve, 746 ; structure of the retina, 747 ; general course and connections of the optic nerves and tracts, 749 ; separate fasciculi of the optic nerves and tracts, 750 ; fibres of the optic ner\e of central origin, 751 ; partial and total decussation of the optic tracts, 752 : commissural fasciculi (Gud- den's commissure and Meynert'.^^ commissure), 753 ; the basal centres for vision and the optic reflexes, 75:! ; the optic radiations, 755 ; cortical termini of the visual tracts, 755 ; focal lesions of the visual pathway, 757 ; diagnosis, prognosis, and treatment of hemianopsia, 772 ; diff'use diseases of the visual apparatus, 774 ; tlie normal eye ground (fundus oculi), 774 ; liypercmia of the retina and optic nerve, 777 ; anemia of the retina and optic disk, 779 ; optic neuritis or papillitis, 779 ; toxic amblyopias, 782 ; atrophy of the optic ner\-e, 786 ; primary optic atrophy, 787 ; postneuritic atrophy, 781) ; noninflammatory secondary atrophy, 791 ; miscellaneous visual affections . . . .' 792 COKTENTS. XV CHAPTEE VIII. PAGE Disturbances of Ocular Movement due to Lesions of THE Nerves, Nuclei, and Central Apparatus op THE Ocular Muscles 795 Anatomical and Physiological Considerations relating to the Ocular Nerves : Homologies between the spinal nerves and the cranial nerves from the third to the twelfth inclusive, 795 ; origin and course of the sensory and the motor cranial nerves compared, 796 ; the musculature of the eye, 796 ; the nerves of the ocular muscles, 797 ; connections of the optic nerve with the nidi of the nerves of the ocular muscles, 798 ; the oculomotor neurons from the cortex to the periphery, 799 ; end organs of the oculomotor nerves, 799 ; the nuclei of the third nerve, 799 ; general course of the third or common oculomotor nerve, 803 ; structures adjoining and closely connected with the third nerve, 804 ; the nucleus and the root fibres of the fourth nerve, 804 ; peripheral course of the fourth nerve, 805 ; the nucleus and the root fibres of the abducens nerve, 806 ; peripheral course of the abducens nerve, 807 ; scheme of the nuclei for ocular movements, 807 ; the ciliospinal centre, 807 ; physiological action of the ocular muscles 809 Disturbances of Ocular Movements : Terminology and symptoma- tology, 809 ; methods of examination, 812 ; ocular paralysis as studied by the diplopia tests, 813 ; infrequency of affections of single ocular nerves, 815 ; symptomatology of paralyses of the third nerve, 815 ; affections of the intraocular muscles supplied by the third nerve, 821 ; affections of ocular movements due to disease limited to the fourth nerve or its nucleus, 826 ; affections of ocular movements due to disease limited to the sixth nerve or its nucleus, 827 ; general remarks on the focal diagnosis of disturbances of ocular movements, 828 ; disorders of ocular movements due to cortical lesions, 829 ; disorders of ocular movements due to limited subcortical (cerebral) lesions, 830 ; ptosis from lesions of the striatum, 830 ; cerebral coordinations of ocular movements, 830 ; some of the varieties of conjugate deviation and their mechanism, 831 ; nuclear ophthalmoplegia, 834 ; radicular or fascicular oculomotor paral- ysis, 836 ; alternate hemiplegias of the ocular type, 836 ; hemiplegia with irregular varieties of oculomotor paralysis, 837 ; pareses or paral- yses of ocular muscles associated with forms of hemianesthesia, 838 ; ocular paralyses caused by gross lesions at the base of the brain, 839 ; ocular paralyses due to orbital lesions, 840 ; etiology, 840 ; pathological anatomy, 846 ; diagnosis, 848 ; prognosis, 849 ; treatment 850 CHAPTEE IX. Diseases op the Trigeminal and Facial Nerves, ajstd Small Gross Lesions op the Pons and the Pre- oblongata 852 Anatomical and Physiological Considerations relating to the Trigeminus : General description of the trigeminus, 852 ; sensory xvi CONTENTS. PAGE portion of the trigeminus, 854 ; physiological observations, 858 ; the motor portion of the trigeminal apparatus ■ • 8^" Diseases of the Sensory Portion of the Trigeminus: Varieties of trigeminal sensory disease ; ^"^ Symptomatic Forms of Trigeminal Neuralgia : Significance of tri- geminal pain, 864; irritative focal lesions of the trigeminal sensory apparatus, 864 ; trigeminal neuritis, 864 ; trigeminal neuralgia due to states of the blood, 866 ; diagnosis, prognosis, and treatment of symp- tomatic trigeminal neuralgias 867 Prosopalgia, or Tic Douloureux : Definition and synonyms, 868 ; clinical history, 868 ; etiology, 869 ; pathogenesis, 870 ; pathological anatomy, 870 ; diagnosis, 871 ; prognosis, 871 ; treatment . . .871 Migraine : Definition, synonyms, and varieties, 872 ; symptomatology, 872 ; etiology, 875 ; pathology, 876 ; diagnosis and prognosis, 877 ; treat- ment ... . ... 877 Trigeminal Reflex Neuroses : Trigeminal headaches, 881 ; trigeminal reflex cough . ... . 882 Anesthesia from Disease of the Trigeminus : Trigeminal anesthesia due to focal lesions, 882 ; trigeminal anesthesia in chronic degenerative and retrogressive diseases 885 Hemifacial Atrophy 885 Hemifacial Hypertrophy . . . 888 Paralysis of the Motor Portion of the Trigeminus (Masticatory Paralysis) : Definition and varieties of motor trigeminal disease, 889 ; symptomatology, 889 ; etiology and pathogenesis, 891 ; diagnosis, 891 ; prognosis, 892 ; treatment . . . 892 Spasm of the Muscles supplied' by the Motor Division of the Trigeminus : Synonyms and varieties, 892 ; clinical history, 892 ; asso- ciated paralysis and spasm of the trigeminus, 894 ; etiology, 896 ; diag- nosis and prognosis, 896 ; treatment 896 Cephalic Tetanus . 898 Diseases of the Seventh or Facial Nerve : General description of the facial nerve and its central apparatus, 899 ; nucleus and root fibres, 900 ; peripheral course of the facial nerve . ... 901 Paralysis in the Distribution of the Facial Nerve : Definition, synonyms, and varieties, 904 ; clinical history of difierent types of facial paralysis, 904 ; etiology, 914 ; pathological anatomy, 916 ; diag- nosis, 916 ; prognosis, 917 ; treatment . . ... ... 918 Facial Spasm : Definition and synonyms, 919 ; symptomatology, 920 ; etiology, 923 ; pathology and morbid anatomy, 924 ; diagnosis, 924 ; prognosis, 924 ; treatment .... 925 Small Gross Lesions of the Pons and Preoblongata : Structures of the pons and preoblongata, 926 ; ventral, lateral, and dorsal vi,ews of the pons and preoblongata, 926 ; relative positions of the nerve nuclei and course of the root fibres, 928 ; structures shown in transections of the pons and preoblongata, 929 ; lesions of the pyramidal tract in the pons, 930 ; functions and lesions of the superficial and the deep trans- verse fibres of the pons, 930 ; functions and lesions of the lemniscus, or fillet, 931 ; functions and Icsionsof the superior olive, 931 ; lesions con- fined to the preoblongata, 931 ; cases illustrating segmental localization in the pons and preoblongata 932 CONTENTS. XVII PAGE CHAPTBE X. Diseases oe the G-lossophaeyngeal Neeve (Motoe and Sensoey Divisions), and op the Pneumogasteio, Spinal Accessoey, and Hypoglossal Neeves ; Small Geoss Lesions of the Postoblongata and ObLONGATA-SpINAL TeANSITION ; AND SOME POEMS OF BULBAE PaEALYSIS. Anatomy and Physiology of the G-lossopharyngeal, Pneumo- gastric, and Accessory Nerves: Interrelations of the glosso- pharyngeal, pneumogastric, and accessory nerves, 935 ; subdivisions of the glossopharyngeal nerve, 935 ; summary of the functions of the glossopharyngeus, 936 ; ventral and dorsal subdivisions of the nuclei of the glossopharyngeal and pneumogastric nerves, 937 ; dorsal vago- glossopharyngeal nucleus, 937 ; nucleus ambiguus, 938 ; central neu- rons of the motor portion of the glossopharyngeus and vagus, 939 ; peripheral course of the vagus, 939 ; nucleus of the accessorius, 942 ; peripheral course of the spinal accessory nerve . . 943 Aflfections of Common Sensibility due to Disease of the Glos- sopharyngeus ... . ... 944 Paralysis in the Distribution of the Glossopharyngeus .... 944 Diseases of the Vagus : Diseases of the vagus as a whole, 946 ; vagal neuritis . . 947 Disease of the Sensory Portion of the Vagus : Varieties of pneumo- gastric sensory disease, 948 ; pneumogastric neuralgias, 948 ; angina pectoris of neural origin, 949 ; laryngeal hyperesthesia, 949 ; laryngeal anesthesia, 949 ; gastric anesthesia, 950 ; pneumogastric paresthesia, 950 ; treatment of vagal neuritis and sensory diseases of the vagus . . 950 Disorders of the Palatal and Pharyngeal Muscles supplied by the Vagus . . . 951 Laryngeal Paralyses : Varieties, 954 ; paralysis of the inferior (recur- rent) laryngeal nerve, 955 ; paralysis of the arytenoids, 958 ; paralysis of the thyroarytenoid muscles (paralysis of the external tensors), 958 ; paralysis of the superior laryngeal nerve, 958 ; laryngeal paralysis asso- ciated with hemiplegia, 959 ; association of laryngeal paralyses with tabes and other degenerative diseases, 960 ; association of laryngeal disorders with functional neuroses, 960 ; etiology and pathogenesis, 961 ; pathological anatomy, 962 ; diagnosis, 962 ; prognosis, 963 ; treatment . 964 Spasm of the Laryngeal Muscles : Varieties and clinical history, 965 ; etiology and pathogenesis, 967 ; diagnosis, prognosis, and treatment . . 968 Respiratory Disturbances due to Disease of the Vagus: The nervous mechanism of respiration, 969 ; varieties of respiratory neu- roses, 969 ; tachypnea, 970 ; brachypnea, 970 ; nervous asthma, 971 ; lesions of the pneumogastric and pulmonary consumption . . . 971 Cardiac Disturbances due to Disease of the Vagus : Physiology of the cardiac nerves, 972 ; tachycardia, 972 ; brachycardia, 974 ; car- diac arhythmia, 975 ; irritable heart, 975 ; nervous palpitations . . • 976 Disturbances of the Digestive Organs due to Disease of the Vagus 976 Pneumogastric Disorders involving Different Viscera 978 Diseases of the Spinal Accessory Nerve : Varieties 979 XVIU CONTENTS. PAGE Accessorius Paralysis : Symptomatology of accessorius paralysis, 979 ; etiology and pathogenesis, 982 ; diagnosis, prognosis, and treatment . . 982 Spasm in the Muscles supplied by the Spinal Accessory Nerve (Spasmodic Torticollis) : Varieties of spasmodic torticollis, 983 ; symptomatology, 983 ; etiology and pathogenesis, 985 ; diagnosis, 986 ; prognosis, 987 ; treatment 988 Diseases of the Hypoglossal Nerve : The hypoglossal nucleus, 990 ; peripheral course of the hypoglossal nerve 990 Hypoglossal Paralysis 993 Hypoglossal Spasm 994 Lingual Atrophy 995 Gross Lesions of the Postoblongata and Oblongata-Spinal Transition 997 General remarks on the diagnosis of lesions of the postoblongata, 997 ; topographical subdivisions of the postoblongata, 998 ; effects of limited lesions of the postoblongata, 998 ; lesions of the sensory and motor decussations, 1001 ; cases showing the effects of lesions of the post- oblongata and oblongata-spinal transition 1002 Bulbar Paralysis : Synonyms and varieties 1006 Acute Bulbar Paralysis 1006 Chronic Progressive Bulbar Paralysis : Symptomatology, 1007 ; pathology, 1008 ; diagnosis, 1009 ; prognosis, 1009 ; treatment .... 1009 Asthenic Bulbar Paralysis : Definition and synonyms, 1010 ; symp- tomatology, 1010 ; etiology and pathogenesis, 1011 ; diagnosis, 1011 ; prognosis, 1012 ; treatment 1012 Bibliographic Index 1013 General Index 1033 LIST OF ILLUSTRATIONS. 6 9 10 12 12 FIG. PAGE 1. The neuraxis. (Quain's Anatomy, after Bourgery.) 1 2. The brain as seen from the right side 3. Mesal aspect of the brain 4. Ventral aspect of the pons and oblongata. (Sappey.) 5. Dorsal aspect of the pons and oblongata. (Sappey, after Hirschfeld.) 6. Chief nerve nuclei in oblongata. (Quain's Anatomy.) 7. Relations of the spinal nerves to the bodies and spinous processes of the vertebrae. (After Gowers.) 8. Encephalospinal and gangliated nerves. (Ferrier, after Quain.) . 9. Typical cell, — ovum of cat. (Piersol. ) . . 10. Nerve cell from the spinal cord. (Piersol.) ... .... 11. Nerve cell from a, " sympathetic" ganglion of the frog. (Retzius.) 12. A projection cell of the cerebral cortex. (Schafer. ) ... 13. A bipolar nerve cell invested by the primitive sheath. (Quain's Anatomy, from Key and Retzius.) . 12 14. An intermediary nerve cell. (Ramon y Cajal.) 13 15. " Psychic" cell in different vertebrates. (Ramon y Cajal.) 14 16. The simplest form of connection of cortical cells. (Ramon y Cajal.) . 15 17. Connection of a cortical cell with more than one intermediary cell. (Ramon y Cajal. )..... 15 18. Connection of cells with each other by means of their collateral pro- cesses. (Ramon y Cajal.) . . . 16 19. Neuroglia cells. (Piersol.) 16 20. Silvered nerve fibres. (Piersol.) 17 21. NonmeduUated nerve fibres. (Piersol.) 17 22. Special nerve endings within the epidermis. (Ranvier.) 18 23. Nerve ending in muscular fibre of lizard, seen edgeways. (Quain's Anatomy, from Kiihne.) . .... .... 19 24. Nerve ending in muscular fibre of lizard, seen from the surface. (Quain's Anatomy, from Kiihne.) 19 25. Golgi's corpuscle or tendon spindle from the human tendo Achillis. (After Ciaccio.) ■ 20 26. Nerve cells of special sense. (Schafer, modified from Retzius.) .... 21 27. Section of portion of a nerve trunk. (Piersol.) 22 28. Blastodermic vesicle. (Quain's Anatomy, after E. v. Beneden.) .... 23 29. Blastodermic layers of rabbit embryo. (Piersol. ) 23 30. Section of nine-day rabbit embryo, showing open neural tube. (Piersol.) 24 31. Section of ten-day rabbit embryo, showing closed neural tube. (Pier- sol.) 24 32. Development of neuroblasts. (His. ) 24 XX LIST OP ILLUSTRATIONS. PAGE 33. Neuroblasts. (His.) ^'^ 34. Neuroblasts from the spinal cord of an eleven-day chick. (Lenhoss6k.) 25 35. Neuroblasts from the spinal cord of a five-day chick. (After Lenhoss6k.) 25 36. The spongioblastic framework of the spinal cord. (Lenhossek.) . . ■ • 26 37. The formation of nerve roots. (Edinger, after His.) . . 26 38. Transection of the cervical spinal cord of a human embryo of six weeks. (Quain's Anatomy, from Koelliker.) . • • • • • ■'" 39. Brain and spinal cord exposed from behind in a fetus of three months. (Quain's Anatomy, from Koelliker.) ... . 29 40. Head of embryo chick of thirty-eight hours. (After Duval. ) 30 41. Diagram of the five brain vesicles. (After Edinger-Mihalkovics.) . • 30 42. Scheme of the cavities of the brain. (After Wilder.) 31 43. Horizontal section of the cerebral hemispheres. (Leidy. ) 32 44. Human embryo, showing the peripheral nerves. (His.) 34 45. Lobes of the cerebrum as usually given by anatomists, lateral aspect. (Modified from Morris's Anatomy.) . 35 46. Lobes of the cerebrum, mesal aspect. (Modified from Morris's Anatomy.) 35 47. Physiological lobes of the cerebrum, lateral aspect 36 48. Physiological lobes of the cerebrum, mesal aspect 37 49. Diagram showing the lobation of the cerebrum. (Hill, in the translation of Obersteiner's Anatomy.) .... 38 50. Surface of the fetal brain at six months, viewed from the left side. (Quain's Anatomy, after R. Wagner.) .... . . . ■ 38 51. Surface of the fetal brain at six months, viewed from above. (Quain's Anatomy, after R. Wagner.) . . . 38 52. Lateral view of the brain. (Ecker.) ... .... 39 53. View of the right hemisphere on the mesal aspect. (Ecker.) 40 54. View of the brain from above. (Ecker.) ... . 41 55. View of the brain from below. (Ecker.) 42 56. Lateral aspect of the left hemicerebrum. (Wilder.) 43 57. Mesal aspect of the right hemicerebrum. (Wilder.) 43 58. Lateral aspect of right hemicerebrum of a Chinaman 44 59. Mesal aspect of right hemicerebrum of a Chinaman 44 60. Left hemicerebrum of a white man. (Leidy.) 45 61. Lateral aspect of right hemicerebrum of a criminal paranoiac 45 62. Mesal aspect of right hemicerebrum of a criminal paranoiac 46 63. Mesal aspect of the right hemiencephal of an adult. (Wilder.) .... 48 64. Horizontal section of the cerebrum. (Morris's 'Anatomy, after Landois and Sterling.) ... . . . 54 65. Microscopic frontal section showing the basal ganglia 55 66. Microscopic frontal section anterior to the one in Fig. 65 56 67. Frontal section through the forebrain. (After Edinger.) 57 68. Horizontal transection of the hemispheres of the cerebrum on a level with the callosum. (Leidy.) 58 69. Scheme of the fornix 58 70. Ventral surface of the fornix and callosum and its intermediate surround- ings. (After Rauber.) ... . . 59 71. Mesal surface of tlie left hemicerebrum of a fetus. (After Rauber.) . 60 72. Base of the brain. (After Hirschfeld-Sappey.) . . .... 61 73. Diagram of association fibres of cerebrum. (After Schiifer-Meynert. ) . . 62 74. View of the base of the interbrain and midbrain. (After Rauber.) . . 63 75. Striata, thalami, quadrigeminal body, and cerebellum. (Hirschfeld and Sappey.) g4 LIST OF ILLTJSTEATIONS. XXI FIG. PAGE 76. Diagram of a section through the vicinity of the postcommissure. (After Edinger.) 66 77. Transection showing the subthalamic region from a child four weeks old. (Edinger.) .66 78. View of the upper surface of the cerebellum, natural size. (Schiifer, in Quain's Anatomy.) 68 79. View of the lower surface of the cerebellum, natural size. (Schiifer, in Quain's Anatomy.) . . 69 80. Cerebellum seen on its anterior surface. (Van Gehuchten.) 70 81. Section across the cerebellum and oblongata. (Quain's Anatomy, after Stilling.) 71 82. View of the oblongata, pons, crura, and central parts of the encepha- lon from the right side. (Quain's Anatomy.) 73 83. Dorsal part of oblongata and floor of fourth ventricle. (Leidy.) ... 74 84. View of the dorsal surface of the oblongata. (After Erb.) .... 75 85. Section of the lower end of oblongata at level of decussation of anterior pyramids 76 86. Section of oblongata at level of sensory decussation ... 77 87. Section of oblongata of child through olivary bodies. (Piersol.) . . 78 88. Profile view of the right half of the oblongata and pons. (Quain's Anatomy.) .79 89. Transection showing the structure of the oblongata at the caudal border of the pons. (After Edinger.) . . 81 90. Transection through the pons in the region of the genufacials. (Modi- fied from Koelliker.) 82 91. Transection through the cms and pregeminum. (After Koelliker.) . . 84 92. Longitudinal section of the entire brain through the cortex, alba, striata, etc 85 93. Longitudinal section through the basal ganglia, etc 86 94. Diagram to show the constituents of the fillet. (Bruce.) 87 95. Transection of spinal cord in lower cervical region. (SchJifer, in Quain's Anatomy.) . ... 88 96. Transection of spinal cord in lower thoracic or dorsal region. (Schafer, in Quain's Anatomy.) .... 88 97. Section of spinal cord in lower lumbar region. (Schafer, in Quain's Anatomy.) 89 98. Transection of cervical spinal cord, showing its chief subdivisions . . 90 99. Diagram showing tautomeral, heteromeral, and hecatomeral cells . . 92 100. Golgi's commissural cell. (Lenhoss^k.) 92 101. Diagram illustrating the chief cellular elements of the spinal cord. (Piersol, after Lenhoss^k.) 93 102. Commissural cells. (Lenhoss6k.) 94 103. Section of membranes from brain of child. (Piersol.) . 95 104. Transection of the spinal cord and its membranes. (Morris's Anat- omy, from Key and Eetzius.) 95 105. Section across a cerebral convolution, exhibiting the arterial arrange- ment. (Leidy, after Duret.) 96 106. Section of injected spinal cord of child. (Piersol. ) 97 107. Diagrammatic figure showing the course of a Pacchionian granulation. (Van Gehuchten, after Schwalbe.) 97 108. Arteries of the median nerve. (Qu6nu and Lejars.) 98 109. Diagram showing the paths between the gray masses of the spinal cord and brain. (After Flechsig.) 100 Xxii LIST OF ILLUSTfiATlONS. FIG. '^"^ 110. Diagram showing the probable relations of some of the principal cells and fibres of the cerebrospinal system to one another. (Schafer, in Quain's Anatomy.) .... . . 111. Diagram of the sensory path. (Van Gehuchten.) ^'^^ 112. Diagram of the pyramidal path. (Van Gehuchten.) 10° 113. Diagram showing the connections of the cerebellum. (Van Gehuchten.) 107 114. Origins and terminations of the various constituents of the restiform body. (Bruce.) 108 115. Connections of the striata with other parts of the neuraxis 109 116. Diagram of a sagittal section through the thalamus, etc. (After Edinger.) HO 117. Reflex paths of spinal cord. (After Baker.) 112 118. Scheme showing the origin and probable course of the fibres of the central sensory path. (Modified from Van Gehuchten. ) 113 119. Scheme showing the origin and probable course of the fibres of the central motor path. (Van Gehuchten.) 114 120. Scheme of a simple nerve centre in the spinal cord. (Horsley.) . . 120 121. Diagram illustrating experiment to show time taken by a nerve cell to convert a sensory into a motor impulse. (Horsley. ) . . . 121 122. Cell of anterior horn with ten vacuoles in myelitis. (Obersteiner. ) . . 126 123. Section from the spinal cord of a case of myelitis 127 124. Degeneration and regeneration of nerve fibres in the rabbit. (Quain's Anatomy, after Ranvier.) 128 125. Section from the thoracic region in a case of syringomyeha 131 126. Miliary aneurism of very small vessels partly filled with blood. (Ober- steiner.) 132 127. Beaded enlargement of a large artery in the brain. (Obersteiner.). . 132 128. Annual pain barometer and temperature curves, 1875-1882 inclusive. (Mitchell and Catlin.) 136 129. Relation of pain area to rain area. (Mitchell.) 137 130. Section from the cornu ammonis showing perivascular and pericellular spaces. (Obersteiner.) . . . 141 131. Normal gait compared with the gait of disseminated sclerosis. (JIarie, after Gilles de la Tourette.) 145 132. Benedikt's calipers . ... 146 133. Broca's median facial goniometer in position for taking the facial angle, whose apex is at the subnasal point. (Topinard.) 146 134. Skull landmarks as given by Broca 147 135. Craniometrical diafrram. (After Benedikt.) 148 136. Outlines of heads of idiuts, imbecile, and insane. (Beach and Clap- ham, in Tuke's Dictionary.) . . . . 150 137. Morton's apparatus for the determination and measurement of asym- metry in the lower limbs : shortening of left leg shown 151 138. Morton's apparatus for the determination and measurement of asym- metry in the lower limbs : limbs symmetrized . ... 151 139. Outline of the human back, showing normal base vertical lines and normal base horizontal lines. (Morton.) 152 140. Sieveking's esthesiometer . . . ... I54 141. Carroll's esthesiometer ... . ... . 154 142. Beard and Rockwell's piesmeter . . . ... 158 143. Diagram of the origin, course, and distribution of the nerve fibres of the optic nerve. (Moore.) IgQ 144. Perimeter of Emerson igQ LIST OP ILLUSTRATIONS. XXUl FIG. PAGE 145. Diagram illustrative of the test for hemiopic pupillary inaction. (Seguin.) 161 146. Pupillometer 162 147. Diagram illustrating the binaural reflex. (GelW.) 164 148. The Mathieu dynamometer 167 149. Hamilton's dynamometer 168 150. Krauss's pedodynamometer 169 151. Method of taking muscle jerk 172 152. Taylor's percussion hammer 173 153. Method of taking knee jerk with reinforcement 173 154. Krauss's combination hammer and esthesiometer 174 155. Scheme of the patellar reflex path. (Marie.) 175 156. Seguin' s surface thermometer 177 157. Mattson's surface thermometer 177 158. Diagrams of normal cranial temperatures ... . 178 159. Diagram showing course of currents when two small electrodes are used . . . 180 160. Diagram showing course of currents when one small and one Urge electrode are used 180 161. Galvanic cell, showing position of negative plates and poles 181 162. Gravity cell 181 163. Grenetcell 182 164. Leclanch^ cell 182 165. Silver chloride dry interchangeable cell 182 166. Galvanic battery, with silver chloride dry interchangeable cells . . . 183 167. Electrotherapeutic wall cabinet 184 168. The Vetter incandescent current tap 185 169. The Massey current controller 186 170. The Vetter carbon current controller 187 171. The de Watteville current combiner and commutator 187 172. The Flemming milliamperemetre 188 173. Erb's electrodes of regulated dimensions 189 174. The Du Bois-Eeymond induction coil 189 175. Faradic apparatus for office table 190 176. Mcintosh's faradic battery 190 177. The Kennelly therapeutic alternator 191 178. Interrupting hand electrode 192 179. Putnam's head electrodes 192 180. Erb's diagram, showing the relations between the motor and assumed trophic centres and the nervous and muscular fibres. (De Watte- ville.) 195 181. Leszynsky's diagnostic electrode 197 182. Brush electrode 198 183. Motor points of trunk and limbs. (Lincoln.) 199 184. Points for muscles and motor nerves of the face 200 185. Method of holding electrodes in one hand • 202 186. The Ayres-Adamkiewicz electrode 203 187. Peterson's improved cataphoric electrode 203 188. Toepler-Holtz electrical machine 206 189. The Kanney improved static machine, with charger attached .... 207 190. Morton's electrode for applying the franklinic interrupted current . . 209 191. Morton's method of applying the static induced current 209 192. Friction of the fingers in massage treatment 215 XXIV LIST OF ILLUSTEATIONS. FIG. I"*G» 193. Position of the hands in friction of broad surfaces 216 194. Position of the hands in compression or deep massage 216 195. Cabinet gymnasium 218 196. Mortimer Granville's clockwork percuteur, showing the method of using it . 219 197. Mortimer Granville's flat disk electrical percuteur 219 198. Mortimer Granville's wire brush electrical percuteur 219 199. The Charcot-Motchoukowski suspension apparatus . . . 223 200. Application of the chin neck band of the Charcot-Motchoukowski sus- pension apparatus 223 201. Mitchell's suspension apparatus ... .... 224 202. Hamilton's hot and cold revulsor . ... 226 203. Junod's boot 227 204. Pseudomembrane formed on the dura after a small hemorrhage. (Obersteiner.) . 266 205. Neomembrane of the dura resulting from pachymeningitis hemor- rhagica. (Obersteiner.) . . . . 267 206. Sites of the most common varieties of meningeal hemorrhages. (Elliot, after Kronlein.) .... ... ... 270 207. Meningeal hemorrhage in a newborn child. (^IcNutt. ) 271 208. Hydrocephalus in a case of subacute tubercular meningitis 282 209. Convulsion in a case of cerebrospinal meningitis. (J. Lewis Smith.) . 283 210. Some of the microorganisms of leptomeningitis 287 211. Pia from a case of tubercular meningitis. (Obersteiner.) 289 212. Myotonia and athetoid spasm in a case of convexity meningitis, with cortical and subcortical softening . . 299 213. Basal cranial sinuses, showing also the right orbit. (Leidy.) . . . . 303 214. Vertical view of the dural sinuses. (Leidy.) . . 304 215. Scheme showing some of the most important relations of the intra- cranial sinuses and veins. (After Mace wen. ) 305 216. Anencephalus. (Hirst and Piersol.) . . . ." 313 217. Exencephalus. (Hirst and Piersol. ) 313 218. Encephalocele. (Hirst and Piersol. ) . 314 219. Chronic hydrocephalus with mental deficiency and epileptiform at- tacks . . . . 316 220. Chronic hydrocephalus with imbecility 316 221. Skull of a hydrocephalic infant. (Agnew.) 318 222. Meningocele. (Graham.) .319 223. Diagrams indicating the views of Vicq d'Azyr and Baillarger and the earlier views of Koelliker as to cortical lamination. (After Pejerine. ) 323 224. Section of human ciTebral cortex. (Piersol.) . 324 225. Perpendicular section of the gray substance of a cerebral convolution. (Ramon y Cajal.) 325 226. Section of cerebral cortex. (Piersol.) . 326 227. Cortex of human brain, showing the nerve fibre systems and plexuses. (W. Lloyd Andriezen.) 328 228. Zones and centres of the lateral aspect of the human cerebrum ... 333 229. Zones and centres of the mcsal aspect of the human cerebrum . . 333 230. Lateral surface of the brain of a monkey. (Ferrier.) 334 231. Mesal aspect of the human cerebrum, showing areas of representation for movements ... . . 335 232. Lesions of the superior temporal convolutions of both hemicere- brums oao LIST OF ILLUSTRATIONS. XXV FIG. PAGE 233. Tumor of the meditemporal convolution, indicating the position of the naming centre ... .... . 347 234. The three thermic mechanisms of the nervous system. (W. Hale White.) . . 356 235. Horizontal section through the internal capsule. (Obersteiner.) . . . 359 236. Scheme of the arrangement of the motor fibres in the internal cap- sule. (Beevor and Horsley.) 360 237. Section of human pituitary body. (Piersol.) 368 238. Section of human pineal body. (Piersol.) . . . . .... 369 239. Section across the pregeminum and the adjacent part of the thalamus. (Quain-Meynert. ) 372 240. Section of human cerebellum. (Piersol.) 375 241. Skeleton drawing of half a cerebellar leaflet. (Berkley.) 376 242. Diagram showing the connection of the flocculus and the roof nuclei of the cerebellum with the sixth nerve, etc. (Bruce.) 380 243. Drawing of a cast of the head of a newborn infant. (Cunningham, in Morris's Anatomy.) ... . . 383 244. Drawing of a cast of the head of an adult male. (Cunningham, in Morris's Anatomy.) . . . ... 384 245. Craniocerebral guiding lines. (After Anderson and Makins.) .... 386 246. Lucas-Championniere's method of determining the central fissure. (Lanphear.) .... 387 247. Agnew's diagram showing the cranial lines for cerebral localization . . 388 248. Diagram of craniocerebral relations. (Eeid.) . ... ... 389 249. Horsley' s meter for determining the position of the central or Rolandic fissure . . ... . 390 250. Horsley' s fissure meter applied to the head 390 251. Wilson's cyrtometer ... 391 252. External lines and circles indicating the positions for applying the trephine in operations. (Ballance. ) . . 393 253. Incision through the pons in Dejerine's method of making an autopsy 397 254. Lines of incision into the brain when an autopsy is made with a view of completing the examination after hardening of the specimen . . 398 255. Method of making transections from within outward of the ganglia, capsules, and hemispheres .... . . . 399 256. Diagram showing the lines of the Pitres-Blackburn and Hamilton tran- sections .... . . . 400 257- Transections of the brain according to Pitres and Blackburn 401 258. Transections of the brain according to Pitres and Blackburn . . . 402 259. Appearances presented by Hamilton's transections of a hardened brain 403 260. Diagram showing the relations of the internal capsule and other struc- tures of the interior of the cerebrum to the convolutions of its con- vex surface. (After Stacey Wilson.) . ... . 405 261. Brain stem and cerebellum separated from the brain mantle by Mey- nert's method. (Hektoen, after Siemerling.) 407 262. Arteries of the interior of the cranium. (Bourgery.) 417 263. Diagram of the circle of Willis 418 264. Anomaly of the circle of Willis. (Lloyd.) 418 265. Diagram showing the distribution of the medicerebral artery. (After Duret.) 419 266. An artery from the cortex cerebri in longitudinal section. (Ober- steiner.) . ■ 420 267. Transection of the cerebral hemispheres. (After Duret.) 421 XXvi LIST OF ILLUSTRATIONS. FIG. ^"^^^ 268. Horizontal section of the oblongata, showing the distribution of the arteries. (Leidy.) 423 269. Nerve fibres accompanying a small artery. (Piersol.) 425 270. Syphilitic obUterative endarteritis of the basilar artery. (Weber.) . . 443 271. Section showing endarteritis and dissecting aneurism of a branch of the left medicerebral artery. (Herter.) 443 272. Microscopical section through a vessel in a case of cerebral syphilis. (Bramwell.) 444 273. Aneurism of the medicerebral artery . . .... 447 274. Miliary aneurism in the cortical substance of the brain. (Porter.) . . 447 275. Aneurism of the vertebral and basilar arteries. (Porter.) 448 276. Aneurism of the medicerebral artery. (Blackburn.) 449 277. Scheme of the ganglionic arteries. (After Testut. ) 452 278. Cyst the result of embolic softening .... 479 279. Old cyst, probably embolic, involving the left third frontal gyre and operculum . . .... . .... 479 280. Diagram illustrative of the effects of embolic plugging. (Bevan Lewis, after Rindfleisch.) 480 281. Multiple foci of softening. (Herter.) . . 491 282. Areas of old and recent embolic softening . . 491 283. Gumma of the striatum, showing gummatous infiltration, etc. (Porter. ) 496 284. Transection through the left hemicerebrum in a case of gummatous syphilis. (Bramwell.) ... . 497 285. Microscopical section through a gumma of the brain. (Bramwell.). 498 286. Large sarcoma of the left frontal lobe. (Morrison.) 498 287. Microscopical section of an endothelioma of the left hemicerebrum. (McDowall and Bramwell.) .... . . . 499 288. Microscopic appearances of the superficial part of a sarcoma. (Gibson.) 500 289. Adenomatous tumor of the pituitary body. (Blackburn.). . . . 502 290. Microscopical section of a tumor of the brain. (Dercum.) . 503 291. Cysticercus cellulosse of the central region of the base of the brain. (Herdman.) .... . 505 292. Dorsal view of a tumor involving the oblongata, pons, and cerebellar peduncles . • . . . 508 293. Ventral view of gliomatous tumor .... . . . . 509 294. Fundus oculi in papillitis. (Bramwell.). 511 295. Regressive neuroretinitis of intracranial tumor. (Gowers.) . . . . 512 296. Thinning of the calvarium in a case of cerebral tumor. (W. Hale White.) ... 515 297. Fundus oculi in a case of albuminuric retinitis. (Bramwell.) . . . 522 298. Longitudinal section of right hemicerebrum in encephalitis. (Knaggs and Brown.) .... . ... 538 299. Longitudinal section of left hemicerebrum in encephalitis. (Knaggs and Brown.) . 538 300. Transverse section of an abscess, and track of the ball. (Porter. ) . . 549 301. Section of the spinal cord in the cervical region in a case of left hemi- plegia accompanied by amyotrophy. (Marie, after Pitres.1 .... 561 302. Section at the level of the j lostgeminum showing secondary degenera- tion of the pyramidal tract and other structures of the same side . . 561 303. Section of the oblongata, showing secondary degeneration of the pyra- midal tract . . ... 5g2 304. Section through the pyramidal decussation, showing degeneration . . 562 305. Section just below the decussation, showing degeneration 562 LIST OP ILLUSTRATIONS. XXvii ™- PAGE 306. Hemiparesis with slight contractures of the hands 569 307. Diagram showing the arrangement of the motor tracts for both sides of the face, left arm, left leg, etc. (Bramwell.) . . .... 570 308. Hemiplegia with strong contractures 574 309. Hemiplegia with partial aphasia .... 574 310. Hemiplegia with marked contracture at elbow and wrist 575 311. Position of the hand and lingers in one of the forma of athetosis . 578 S12. Diagram showing the area of retained sensation on the face in a patient otherwise totally hemianesthetic ... .... . 581 313. Hemiplegia with aphasia, contractures, and marked atrophy on the paralyzed side. (Dercum.) . . . ... 584 314. Hemiplegia and aphasia, with atrophy of right arm 585 315. Coronal aspect of the brain, showing marked atrophy of the right hemisphere. (Shaw.) 598 316. Basal aspect of the brain shown in Fig. 315. (Shaw.) 599 317. Coronal aspect of the brain in a case of extreme atrophy of the right hemicerebrum. (Shaw.) 600 318. Infantile cerebral hemiplegia, with marked atrophy of the limbs and trunk. (Shaw.) 601 319. Lateral aspect of the right hemicerebrum from a case of porencephaly. (Brush.) ... . . 602 320. Mesal aspect of the right hemicerebrum in a case of porencephaly. (Brush.) 603 321. Infantile spastic paraplegia. (Willard.) 605 322. Idiocy with spastic diplegia 606 323. Irregular type of diplegia 607 324. Spastic hemiplegia with imbecility 608 325. Spastic monoplegia dating from six years of age 609 326. Irregular type of diplegia in a low grade demi-microcephalic idiot . . 610 327. Diplegia showing cross-legged progression 611 328. Bilateral chorea and double athetosis. (Dercum.) 612 329. Hemiplegia with atrophy and athetosis 613 330. Infantile cerebral hemiplegia with feeble-mindedness in mirror writer 614 331. Cerebral centres concerned in speech 628 332. Diagram of cerebral centres concerned in speech 629 333. Lichtheim's diagram showing the position of lesions of different tracts and centres producing some of the most important forms of aphasia 637 334. The zone of language according to Dejerine 643 335. The zone of language according to the author 645 336. Eight hemiplegia with marked contractures and almost complete aphasia 653 337. Right hemiplegia with marked contractures and complete aphasia . . 654 338. Illustration of mirror writing 659 339. The left hemisphere of the brain, showing situation of clots causing motor aphasia. (Starr.) . 665 340. View of the sphenopalatine ganglia, the outer wall of the left nasal cavity, and the olfactory nerve. (Leidy, after Hirschfeld-Sappey.) . 669 341. A sagittal section of the brain of a rabbit, a little to the left of the mesal line. (After Edinger and Koelliker. ) 671 342. Diagram of the falciform lobe of Schwalbe (limbic lobe of Schafer). (Schafer, in Quain's Anatomy.) 673 343. Glioma of the anterior and inferior portions of the right temporal lobe (lateral surface) with parosmia as a prominent symptom. (Coupland. ) 677 XXviii LIST OF ILLUSTRATIONS. PIG. . ^^"^ 344. Glioma of the anterior and inferior portions of the right temporal lobe (mesal view). (Coupland.) . .... ■■■.■" ^'^'' 345. Eflfect on taste and common sensibility of stretching of the lingual branch of the fifth nerve. (Walsh.) .... 689 346. Diagrams showing usual distribution of the glossopharyngeal and chorda tympani nerves in the tongue and palate - ■ • ■ ... 690 347. Diagram of the geniculate ganglion. (Modified from Lenhossek.) . . 692 348. Peripheral gustatory apparatus . . . ■ 693 349. Diagram of the cochlear and vestibular nerves 710 350. Diagram of the central auditory tract (direct or root fibre system). (Rauber, after Held.) 713 351. Diagram of the central auditory tract (system of second order). (Rauber, after Held.) . . 714 352. Diagram of the central auditory tract (recurrent system). (Rauber, after Held.) . . . • • 715 353. Cross-section of healthy optic nerve. (Wilder.) 747 354. Layers of the retina. (After Van Gehuchten.) 748 355. Section of the retina of a dog. (Ramon y Cajal.) 749 356. Scheme of the general course and relations and separate fasciculi of the optic nerves and tracts, etc. (Hill.) . . .... 751 357. Diagram of the optic nerve and tract, showing macular and other bundles . . 752 358. Scheme of the optic tracts and visual centres. (Ferrier.) ... . 756 359. Visual fields in binasal hemianopsia. (Bramwell.) 761 360. Chiasm hemianopsia. (Seguin.) .... 762 361. Chiasm hemianopsia. (Seguin.) 762 362. Frontal section of gumma overlying chiasm. (Oppenheim.) . . . . 763 363. Right homonymous lateral hemianopsia 764 364. Visual fields in a case of left homonymous lateral hemianopsia. (Starr. ) 765 365. Visual fields in a case of left lateral hemianopsia . ... 765 366. Visual fields in a case of right lateral quadrant anopsia 766 367. Visual fields in a case of double hemiplegia with double hemianopsia. (Dunn.) 767 368. Visual fields in a case of verbal amnesia . . 770 369. Lesion in a case of homonymous lateral hemianopsia with word deaf- ness. (Mills and Spiller.) . . 771 370. Radiation of the optic nerve fibres upon the retina. (Michel.). . 775 371. Normal eye ground of an individual with light brown hair. (Jaeger.) 776 372. Longitudinal section through the head of the optic nerve, showing choked disk. (Wilder.) . . 780 373. Average general size of scotoma in toxic amblyopia 783 374. Large scotoma (left eye) in a case of nontoxic retrobulbar neuritis . . 784 375. Scotoma (right eye) in a case of tobacco-alcohol amblyopia 784 376. Cross-section of the optic nerve, showing marked atrophy. (Wilder.). 786 377. Partial postneuritic atrophy. (Gowers. ) 790 378. Position of eyeball in the orbit, showing the insertions of the most im- portant intraocular muscles. (Merkel.) ... . . 797 379. Oculomotor and abducent nerves, upper part of right orbit removed. (After Hirschfeld-Sappey.) . . . .798 380. Longitudinal vertical section through the human brain, showing posi- tion of ocular nerve nuclei. (Bramwell.) 800 381. A partly diagrammatic view of the floor of the aqueduct, looking up- ward (dorsally). (Edinger.) 803 LIST OF ILLUSTRATIONS. xxix FIG. PAGE 382. Microscopical section through the decussation of the fourth nerve . . 805 383. Scheme of the nuclei of the nerves of ocular movement and of their central and peripheral tracts . 808 384. Diagram showing the difference between homonymous and heterony- mous images. (Hotz.) 814 385. Oculomotor paralysis, showing ptosis 815 386. Oculomotor paralysis (the eye held open) 816 387. Drawing showing the lesions present in the case illustrated in Figs. 385 and 386 .. . 817 388. Right oculomotor paralysis, facial paresis, and meningocortical disease . 818 389. Nearly isolated paralysis of the left internal rectus (left external stra- bismus without ptosis) 819 390. Bilateral oculomotor paralysis 820 391. Bilateral paralysis of the extraocular muscles supplied by the third nerve. (Davidson.) ... .... 821 392. Photograph of case shown in Fig. 391, taken five months after re- covery. (Davidson.) 821 393. Right iridoplegia (dilatation of the right pupil), etc. ... . 822 394. Diagram showing the probable position of lesion in the case shown in Fig. 393 . . , . ... 823 395. Paralysis of the left external rectus and paresis of the right external rectus 827 . 396. Bleuler's diagram in explanation of the mechanism of conjugate paralysis. (Jeffries.) 832 397. Complete paralysis of the right third nerve . 837 398. Microscopical section of right oculomotor nerve, showing complete de- generation and almost total disappearance of the nerve fibres. High magnification .... 846 399. Microscopical section of right oculomotor nerve, showing complete de- generation and almost total disappearance of the nerve fibres. Low magnification . . . . 846 400. Microscopical section of right optic nerve, from case of third nerve paralysis shown in Figs. 385 and 386 ... . , ... 847 401. Microscopical section showing gummatous formation and caseation, etc. , from case shown in Figs. 385 and 386 848 402. Scheme of trigeminal apparatus 853 403. Section of the pons at the point where the descending (spinal) root of the trigeminus bends outward. (Edinger.) . . ... 855 404. Frontal section of the preoblongata and pons of man. (Koelliker.) 856 405. Branches of the fifth or trigeminal nerve. (Hughes. ) 857 406. Cutaneous sensory areas of the trigeminal nerve 858 407. Normal distribution of the trigeminal nerve to the face. (Flower.) 859 408. Microscopical preparation from the descending (mesencephalic) root of the fifth nerve. (Koelliker.) 862 409. Enlarged view of one bipolar cell of the descending (mesencephalic) branch of the fifth nerve. (Koelliker.) 862 410. Case of tic douloureux ; appearance of face in paroxysms 869 411. Paralysis of the third nerve, with anaesthesia in distribution of fifth nerve 883 412. Hemifacial atrophy. (Hirt.) 886 413. Hemifacial hypertrophy. (Montgomery.) 888 414. Hypertrophied gum of upper jaw in a case of hemifacial hypertrophy. (Montgomery.) 889 XXX LIST OF ILLUSTKATIONS. FIG. "'^"'^ 415. Trigeminal paralysis and spasm in the same case °95 416. Scheme of the apparatus of the facial nerve 900 417. The facial nerve. (Hirschfeld-Sappey.) 903 418. Paralysis in the upper distribution of the seventh nerve 908 419. Typical facial paralysis, or Bell's palsy 909 420. Facial and trigeminal paralysis, with atrophy 914 421. Diagram showing the relations of the pons, preoblongata, and post- oblongata to the fourth ventricle, iter, quadrigeminum, and cerebellum 926 422. Subdivision of the ventral aspect of the pons into thirds .... 927 423. Subdivisions of the lateral aspect of the pons and preoblongata . . . 927 424. Subdivisions of the dorsal surface of the preoblongata 927 425. Subdivisions of the dorsal aspect of the pons and preoblongata . . . 927 426. Course of the cranial nerve roots from the third to the eighth .... 928 427. 1 428. [ Transections of the pons and preoblongata 929 429. J 430. Position and apparent size of a pontile lesion in the fresh specimen . 932 431. Microscopical appearances of the lesion shown in Fig. 430 932 432. Diagram showing the anteroposterior dimensions of a pontile lesion . 933 433 "1 I Transections showing appearances in the fresh state of a pontile ^gg J lesion 933 436. Microscopical view of a transection near the middle of the pons . . . 934 437. Section through the bulb of a four-day old mouse. (Ramon y Cajal.) . 938 438. Apparent origins of the spinal accessory, pneumogastric, and glosso- pharyngeal nerves. (After Van Gehuchten.) ... 940 439. The last four cerebral nerves, the facial nerve, the sympathetic, and the upper two cervical nerves. (After Hirschfeld-Sappey.) 941 440. Distortion of the uvula in a case of peripheral paralysis of the right side of the face. (After Sanders.) 953 441. Muscles of the larynx. (Leidy.) 954 442. Drawing of the larynx showing the position of the left vocal cord in left recurrent laryngeal paralysis. (Stewart and Major.) . ... 957 443. Bilateral abductor paralysis. (Porcher.) 957 444. Unilateral adductor paralysis. (Porcher.) . . 957 445. Paralysis of the arytenoideus muscle. (Porcher.) 958 446. Unilateral paralysis of the superior laryngeal nerve 959 447. Posterior view of peripheral paralysis of trapezius. (Eichhorst.) ... 981 448. Spasmodic torticollis, showing prominence of the sternomastoid muscle. (Walton.) 984 449. The usual attitude in the so-called congenital cases of spasmodic torti- collis. (Bradford and Brackett.) 985 450. Diagram of the hypoglossal nerve and its connections. (Ross.) ... 991 451. Unilateral paralysis of the tongue 993 452. Unilateral atrophy of the tongue in a case of syringomyelia 996 453. Subdivision of the ventral aspect, of the postoblongata into fourths . . 998 454. Subdivisions of the dorsal aspect of the postoblongata 998 455. Transection of the postoblongata in its upper fourth 999 456. Transection of the postoblongata in its second fourth 999 457. Transection of the postoblongata in its third fourth 999 458. Transection of the postoblongata at the sensory decussation 1001 459. Transection at the level of the pyramidal (motor) decussation .... 1001 THE NERVOUS SYSTEM AND ITS DISEASES. CHAPTER I. SKETCH OF THE NEETOUS SYSTEM, ITS TISSUES, DEVELOPMENT, ANATOMY, PHYSIOLOGY, NOMENCLATUEE, AND CHEMISTEY. SKETCH OP THE NERVOUS SYSTEM. The Neuraxis. — Figure 1 shows the general appearance of the neuraxis or encephalospiual axis, half of the skull and trunk being removed. It consists of two united central portions, called respec- tively the brain or encephalon and the spi- nal cord or myelon. The cranial and spinal nerves, the roots of which are shown, come to these encephalospiual centres and go from them, carrying, some outward and others in- ward, the messages which bring man into re- lation with his environment. The nerves in general constitute the peripheral nervous sys- tem, which is represented here only in its beginnings and even in these only partially ; it is composed mainly of nerve fibres or con- ductors which, starting or ending in the neur- axis, ramify to every tissue and organ of the body. Scattered along some of these nerves are small gray masses of nervous matter called ganglia, some at least of which are also centres of energy : so that the central nervous system, while largely within the cranial and spinal cavities, is not strictly confined to them, but exists wherever nervous centres are found ; and the peripheral nerves, while chiefly out- side, sometimes run a considerable distance within these cavities. The lettering on Fig. 1 indicates some of the most prominent sub- divisions of the neuraxis, as follows : F, T, O, frontal, temporal, and occipital lobes of The neuraxis. (Qualn'sAnat- the cerebrum ; C, cerebellum ; P, pons ; mo, °™^' ^ '^^ ourgery.) oblongata ; ms, nis, point to the upper and lower extremities of the 2 THE NERVOUS SYSTEM. spinal cord ; ce, on the last Inmbar vertebral spine, marks the cauda equina ; v, the three principal branches of the trigeminal nerve, the largest of the cranial nerves ; Ci, the suboccipital or first cervical nerve ; Cviii, the eighth or lowest cervical nerve ; Di, the first tho- racic or dorsal nerve ; Dxii, the last thoracic or dorsal nerve ; Li, the first lumbar nerve ; Lv, the last lumbar nerve ; Si, the first sacral nerve ; Sv, the fifth sacral nerve ; Coi, the coccygeal nerve ; s, the left sacral plexus. Chief Subdivisions of the Human Brain.— The chief subdi- visions of the fully developed brain are the cerebrum or great brain, the cerebellum or little brain, the pons, and the oblongata as shown Fig. 2. The brain as seen from the right side. in Fig. 2. The pons and oblongata are more spinal than encephalic in their functions and relations, but from custom and because of their intracranial position arc usually regarded as belonging to the brain. In Fig. 3 it will be observed that the oblongata is divided into two portions, the postoblougata and the preoblongata (Wilder), the latter situated mainly between the pons and the cavity of the brain known as the fourth ventricle. The pons, therefore, does not extend through the entire thickuess of the neuraxis as repi'esented in most books. Both portions of the oblongata are composed largely of gray deposits or cell nests, while the pons is mainly constituted of nerve fibres or tracts, facts important to remember in connection SKETCH OF THE NERVOUS SYSTEM. with many points to be hereafter considered. The cerebrum and cerebellum are both divided into halves, the hemispheres of the former being separated by a large fissure, and those of the latter by a narrow lobe. If by way of the great fissure which separates the cerebral hemispheres a medisection is made through the callosum, and through the middle lobe of the cerebellum, other parts of the brain can be seen, as in Fig. 3, the most important of them — in ad- dition to the cerebrum, cerebellum, pons, and oblongata — being the callosum, fornix, quadrigeminal body, thalamus, and the iter or aqueduct of Sylvius. The solid bridge of white substance, called the callosum, is the chief connecting link between the two hemispheres. Fig. 3. Mesal aspect of the brain : Q, quadrigeminal body ; V, fourth ventricle. The other parts need here only be named. If the brain is cut across it will be found that a gray rind or cortex extends to a slight depth, but that the interior is largely white matter. If sections are made in some positions, as through the prefrontal and occipital regions, or anywhere just below the convolutions, only white matter will be seen. Horizontal sections made more deeply reveal gray masses or deposits, and vertical cuts which divide the cerebral hemispheres, either across or from before backward in their middle portions, show striking gray outlines and contours separated by straits and spaces filled with white matter. These indicate the positions of ganglia and small deposits of gray matter in the brain interior, and also the paths by which some of these bodies are connected with 4 THE NERVOUS SYSTEM. one another, withi the convolutions, and with lower levels of the nervous system. Pons and Oblongata.— The pons and oblongata are intermediate between the spinal cord and both the cerebrum and the cerebellum. Bulb is another name for the oblongata, and hence the phenomena and diseases of this portion of the nervous system are often spoken of as bulbar. Pig. 4 is a representation of the ventral or inferior aspect of these bodies, from which the cranial nerves from the third to the last take their superficial origin. Bifurcating above from the Fig. 4. Ventral aspect of the pons and oblongata: 1, pons ; 2, oblongata ; 3, medipeduncle ; 4, crus ; 5, tuber cinereum ; 6, infnndibulum ; 7, albi- cantia, and behind them the posterior perfo- rated spaeu ; 8, optic tract ; 9, chiasm ; 10, oculo- motor nerve ; 11, trochlear nerve ; 12, trifacial nerve, the small or motor root Internal ; 13, ab- ducent nerve ; ,14, facial nerve : 15, intermediate portion ; 16, auditory nerve ; 17, glossopharyn- geal nerve ; 18, vagus nerve : 19, accessory nerve ; 20, hypoglossal nerve ; 21, first spinal or sub- occipital nerve. (Sappey.) Dorsal aspect of the pons and oblongata, the cerebellum removed : 1, conarium or pineal body turned forward, showing the posteommis- sure, 2 ; 3, thalamus ; 4, quadrigeminal body ; 5, postgeuiculum (internal geniculate body) ; 6, yalvula (valve of Vieussens) ; 7, fillet ; 8, lingule ; 9, oblongata ; 10, postpyramid ; 11, restis or res- tiform body ; 12, floor of fourth ventricle ; 13, prepeduncle (superior peduncle of the cerebel- lum) cut through ; 14, medipeduncle (middle peduncle of the cerebellum) cut through ; 1.5, postpeduncle (inferior peduncle of the cerebel- lum) cut through. (Sappey, after Hirschfeld.) pons are seen the crura, large white cylinders which connect the pons with the cerebrum. Between the crura is a space bounded in front by the chiasm or crossing of the optic nerves ; within this space are a gray eminence, the tuber cinereum, prolonged into a hol- low funnel-shaped ])rocess, tlie infuudibulum, and two white rounded bodies, the albicantia or mammillaiy eminences ; and behind these is a narrow triangular space, the posterior perforated space — to be described later. Looking at the dorsal or superior surface of the oblongata, as in Pig. 5, the fourth ventricle is seen, overhung, when SKETCH OF THE NERVOUS SYSTEM. Fig. 6. all parts of tlie brain are in position, by the cerebellum, as is sliown in Fig. 3, page 3. Two pairs of eminences which taken together constitute the quadrigeminal body are also seen ; on each side of them the postgeniculum or internal ge- niculate body ; and in front the couarium or pineal body, with por- tions of the thalami, connected by a band of fibres called the post- commissure. Other parts in the illustration are the valve of Vieus- sens, a lamina of white matter form- ing a roof to the upper portion of the fourth ventricle ; the fillet, a white band constituting one of the important tracts between the spinal cord and the brain ; the lingule, a small process of gray matter in the cortex of the cerebellum ; the pre- peduncle, the medipeduncle, and the postpeduncle, stout bundles of fibres which connect the cerebellum with the brain above and with the oblongata and the cord below ; and the posterior pyramids and resti- form bodies, columns uniting the spinal cord and oblongata with the parts above. If transections were made through the pons and oblon- gata, an intricate arrangement of gray and white matter would be re- vealed, indicating important nerve centres and fibres. If a horizontal section is made lengthwise, close to the floor of the fourth ventricle, the situation of the nuclei or sources of most of the great cranial nerves will be shown, as in Fig. 6. The Spinal Cord and its Nerves. — The adult spinal cord reaches from the oblongata down- ward to a thread of nerve substance called the fllum terminale ; from the upper boundary of the first cervical to the second lumbar vertebra, as shown in Fig. 7. It averages about seventeen to eighteen inches in length, while the spinal canal to the last lumbar vertebra is about Chief nerve nuclei in olilongata, motor nuclei on the ri^ht side only, sensory on the left : twice the natural size, seen from hehind. The numbers indicate correspond- ing nen'es. V and Vil, spinal and mesen- cephalic roots of the filth nevxe ; Vs, its sensory, and Vm, its motor nucleus ; Vin' is the outer or ventral nucleus of VIII ; n. a. is the nucleus arabiguus, an accessory nucleus to IX and X. These nuclei will he considered under cranial nerves. Str, the acoustic striEe. (Quain's Anatomy.) THE NERVOUS SYSTEM. Fig. 7. Fig. icM C.K J>.U ^^m 1^ 10 1 11 [ 12 1 X.l{ im Relations of the spinal nerves to the bodies Encephalospinal and gangllated nerves. (Fer- and spinous prot'osses of the vertebrce. Tlie posi- rier, after Quain.) tions of the letters and numbers clearly indi- cate the parts. (After Gowers.) twenty-three inches, and if the sacral portion and the coccyx are included, four inches more should be added. In general it is cylin- SKETCH OP THE NERVOUS SYSTEM. 7 drical iu shape, but in two places, at the cervical and lumbar enlarge- ments, where arise the great nerves which go to the limbs, its size is much increased. Below it has a tapering extremity, which is called the conns. Nerves are given off at all levels, and pass through fora- mens to go to various parts of the body, nearly all descending more or less to these foramens, so that the lower the segment of the cord the longer is the intramural course of the nerves. The lowest spinal nerves form a bundle or leash, named the cauda equina, ar(jund and below the conns. Thirty-one pairs of spinal nerves are given off in all — eight cervical, twelve thoracic or dorsal, five lumbar, and six sacral. On transection, the spinal cord, like the brain, reveals an arrangement of gray and white matter, the relative amounts of gray and white substance varying according to the position at which the cut is made, and corresponding differences in the general bulk and form of the cord are also seen. Fibres isolated or in groups in various places cross the white matter to reach the gray. In this gray matter are situated the centres for important functions. Gangliated System of Nerves, or So-Called Sympathetic Nervous System. — Erroneous views long prevailed as to the gan- gliated nerves, or so-called sympathetic nervous system, which is simply an arrangement of true spinal nerves connected with a series of ganglia through which they sometimes pass, and which are sub- divided according to location. On each side of the ventral aspect of the spinal column is a chain of them united by a longitudinal cord, constituting the lateral ganglia or the vertebral portion of the sympa- thetic ; they are in number, three cervical, twelve thoracic, and four lumbar. Within the cranium are numerous special ganglia all having branches of communication with the cranial nerves. The cervical spinal ganglia also have cranial prolongations. On or near the great viscera of the chest, abdomen, and pelvis is another series of col- lateral ganglia or plexuses, sometimes called the prevertebral portion of the sympathetic. Besides these are numerous special plexuses, as the cardiac, pharyngeal, laryngeal, pulmonary, coronary, suprarenal, renal, mesenteric, ovarian, and vesical ; and the ganglia on the pos- terior spinal roots really belong to this system of nerves, although they are not usually so regarded. Even if, as held by Paterson, the gangliated nerves are developed from a continuous rod of mesoblast, lying on either side of the aorta, and are only secondarily united with the cerebrospinal nerves, they become parts of one great whole, not an independent system. Relations of the Spinal Cord to the Limb, Trunk, and Gan- gliated Nerves. — The relations of the spinal cord to the nerves which go to the trunk and limbs, and to the gangliated nerves, are well represented in Fig. 8. On the left side of the diagram is shown the manner in which the nerves come together to form the brachial or arm plexus or network, and the lumbar and sacral plexuses for 8 THE NERVOUS SYSTEM. the lower limbs. On the right of the figure is seen the gangliated cord, a series of ganglia united together, and also, an important fact, joined to the spinal cord. The letters indicate certain special ganglia. The spinal nerves are indicated by the Eoman numerals. Those below not specially numbered are the sacral nerves. The brachial plexus is composed of branches from Cv to Di, with some communicating branches from Civ and Dii ; the lumbosacral plexus derives its branches from Li to the fourth sacral nerve inclusi\'e. The individual branches of these plexuses are indicated by letters and small numerals, but need not here be named in detail. The gangliated cord is seen on the right side, with its junction with the spinal nerves : a, the superior cervical ganglion ; b, the middle cer- vical ganglion ; cd, the inferior cervical ganglion, united with d, the first thoracic or dorsal ganglion ; sp„ the great splanchnic nerve ; spj, the lesser splanchnic nerve ; d', the eleventh thoracic or dorsal ganglion ; ss, the upper sacral ganglion. Somatic and Splanchnic Nerves. — Gaskell has proposed the terms somatic and splanchnic in describing the two great varieties of nerves to which reference has just been made. The somatic are the sensory and motor nerves from the dorsal and ventral roots. They supply the chief body or skeletal structures, such as the skin, subcutaneous tissues, muscles, and bones. The term splanchnic is commonly used to describe the great splanchnics, the lesser, and the smallest or renal splanchnic of the ordinary anatomical textbooks ; but Gaskell uses it in a more general sense. The .term is derived from a Greek word meaning "entrail," and everything pertaining to the viscera is in a generic sense splanch- nic. The splanchnic nerves go to the bloodvessels and viscera. Gaskell divides the efferent splanchnics into nerves of the vascu- lar muscles, both vasomotor and inhibitory ; nerves of the visceral muscles, both visceromotor and inhibitory ; and glandular nerves. Vasomotor nerves for all parts of the body arise in the central ner- vous system, and are controlled from a centre in the oblongata. In the ventral roots of all the spinal nerves from the second thoracic to the second lumbar, they can l)e traced as fine medullated fibres, and outward to the visceral ganglia, wliere they lose their medidla, and are distributed to the heart and vessels, some being reflected to the membranes and vessels of the cord itself. The spinal accessory, or eleventh cranial nerve, acts partly as a somatic and partly as a splanchnic nerve for parts not sujiplied by the thoracic nerves. The afferent or sensory splanchnic nerves follow closely the efferent distributions, entering the neuraxis in three groups— the highest in the head and neck, the middle lietween the first thoracic and first lumbar segments, and the lowest from the fifth lumbar to the fourth sacral segment. NERVOUS TISSUES. NERVOUS TISSUES. Elementary Tissues. — The elementary tissues of the human body are the epithelial, the connective, the muscular, and the ner- vous. Our concern is chiefly with the last. The ultimate elements of nervous tissues are called cells, but between the nerve cells and their processes, and separating them from other tissues, are inter- cellular substances. The Cell. — An animal cell is nearly always of microscopic dimen- sions. Every cell consists of protoplasm and a kernel or nucleus ; and the nucleus often contains one or several smaller bodies called nucleoli. Sometimes the cell is bounded by a limit- ^^'^' ^' ing membrane called the cell wall ; the nucleus is surrounded by a nuclear membrane. Even the pro- toplasm of the cell has been shown to be far from simple in composition, containing at least two especially im- portant substances, the spongioplasm and the hyalo- plasm. A typical cell is shown in Pig. 9. Nerve Cells. — Nerve cells are found everywhere in the masses of gray ner- vous matter, small or large. It is important to have a clear idea of their shape, size, composition, varieties, and inter- relations ; of the tissues which surround them and divide them from one another ; of their method of development ; of the manner in which they receive, store, reshape, and transmit impressions ; of the plan on which they are grouped for special purposes in x^articular localities ; of the extrinsic and intrinsic lesions to which they are liable ; and of the possibility of their regeneration after complete or partial destruction. Every nerve cell is to be regarded anatomically and physiologically as a separate unit, in the sense that each with its prolongations has a distinct individuality ; that each has a certain work to do in originating, transferring, or using force, although many may act together towards some general end, or one cell or set of cells may even to a certain extent compensate for the destruction of others. It has usually been taught that nerve cells and nerve fibres are different structurally. Strictly speaking, this is not true ; they are parts of the same histological unit, as has been especially shown Typical cell, — ovum of cat : a, protoplasm ; 6, nu- cleus ; c, nuclear membrane ; d, nucleolus ; e, true cell wall. (Piersol.) 10 THE NERVOUS SYSTEM. by recent investigations ; but it is necessary for practical purposes to consider separately many of the facts relating to them. Shapes and Sizes of Nerve Cells.— The shapes and appear- ances of nerve cells under the microscope differ according to the magnifying power used, the special variety of the cell, the age of the individual, and the disease if a lesion is present. Methods of preparing and staining also cause differences in appearance. The cells of the cerebral cortex, and of other parts, vary according to the region and function subserved ; some are ovoid, others of sphe- roidal or of a nearly round shape ; some are angular ; others are irregular ; some are with and others without visible processes or prolongations, some are spindle-shaped and some flask-shaped. Cells Fig. 10. Nerve cell from the spinal cord, isolated by maceration and teasing ; the numerous branched protoplasmic processes are somewhat displaced and distorted, owing to manipulation: a, axis cylinder process. (Piersol.) vary widely in size. The nerve cells of some lower animals can be seen even without the microscope. In the lobus nervi vagi of the torpedo, in the oblongata of the river lamprey, and in the spinal cord of the electric eel, are enormous ganglion cells which can be seen with the naked eye (Edinger). As studied in the human body, nerve cells usually range in size between one three hundredth and one three thousandth of an inch. Doubtless large and small cells have differences in function which ai(> to some extent indicated by their size. Of the cells in the motor regions Hughlings .Tackson has sug- gested that small muscles are represented by small cells, or more properly, in his own language, movements which require little energy for the displacements the>' have to effect are represented by small cells. In the motor subcortex the axis cylinders differ greatly in NERVOUS TISSUES. 11 size. In the regions of tlie brain and spinal cord now universally regarded as motor, ganglion cells of large size and pyramidal shape abound. Structure of the Nerve Cell. — Each nerve cell (Pig. 10) has its distinct kernel or nucleus and within this a smaller kernel or nucle- olus. Every nerve cell has one or more processes or prolongations, although these may be broken otf or not apparent in some prepa- rations. Views regarding nerve cells have undergone great modifi- cations within a few years, owing chiefly to the investigations of Golgi, His, Eamon y Cajal, Eetzius, Koelliker, Nansen, Biederman, Waldeyer, Lenhoss6k, Marchi, Obersteiner, Van Gehuchten, Sala, Schafer, Piersol, and Baker. The processes of nerve cells are of at least two kinds. The chief prolongation, and the one first to appear in the development of the nerve cell, is called the axis cylinder, and if but one process is present it is always this. It is continuous with the nerve fibre ; the process becomes the fibre or the fibre the pro- cess, according to the point of view. The nerve cell has, although not invariably, other short free projections, which have most fre- quently been called protoplasmic processes. Golgi regarded them as rootlets by means of which the cells were fed from the neighbor- ing gray matter. It is now believed that they are not solely if at all concerned with nutrition, but transmit impulses of some descrip- tion. Axis cylinders have usually been regarded as composed of fine threads embedded in a clear substance having the appearance of protoplasm, but new views are appearing with reference to these ultimate fibrils. According to Schafer, it is not improbable that they are excessively fine-walled tubules filled with fluid. In a sec- tion of nerve fibre studied by him, the fibrils appeared distinct from one another and tubular In structure, and each showed a minute circular area bounded by a definite line, which he interpreted to represent a minute tubule ; and he holds that this theory accounts for the varicosities which appear in broken axis cylinders treated with osmic acid and other reagents. This question is important with regard to the manner in which nerve impulses are conducted. Types of Nerve Cells. — A plain distinction between nerve cells is into two types, one possessing long axis cylinder processes, and the other short axis cylinders. The long process cells may send their processes from the central organ to the i^eriphery as motor, sensory, or secretory fibres, or as long commissural or association fibres. The cells with short or local processes reach only as far as gray deposits or masses in their immediate neighborhood. Golgi believed that the cells with long processes were motor, and that the smaller cells, with relatively short processes, were sensory or receptive, but this distinction has not been confirmed. The process sometimes as- sumes an exceptional form, as where it becomes spiral in shape as shown in Pis:. 11. 12 FlQ. 11. THE NERVOUS SYSTEM. Fig. 12. Nerve cell from a "sympathetic" gan- glion of the frog, show- ing the tortuous course and terminal network of the spiral fibre : n, neurilemma con- tinued as a delicate sheath. (Eetzius.) A projection cell of the cerebral cortex (Schafer). Cellular Terminology. — The axis cylinders have been designated by various names, as neuraxons, ax- ons, and neurons (Schafer) ; the short free projections, or so-called protoplasmic processes, are called dendrons (Schafer), from the Greek oi'^il/xn, a tree. The latter were designated by His as dendrites. Sometimes an axis cylinder process or neuraxon unites with a dendron, and for such combination the name neuro- dendron is used. All nerve cell processes have, at a longer or shorter distance from their origin, a tree- like or tuft-like termination, although, this arbori- zation is sometimes difficult to determine. In the cortex dendrons or protoplasmic processes pass up- ward from the apex of the pyramidal cells through the superficial layers and form a plume-like expan- sion ov panicle (Fig. 15), so called because it has the appearance of a pyramidal inflorescence. N^erve cells Fig. 13. mm A bipolar nerve cell invested by the prim- itive sheath : R, R, nodes of Ranvier. (Qualn's Anatomy, from Key and Ret- zius.) NERVOUS TISSUES. 13 Fig. 14. are iisually named according to the number of their processes, as uni- polar, bipolar, multipolar, etc. ; but it has been suggested by Schafer to distinguish them as dendric and adcndrk; according as they have or have not dendrons, and according to the number of their neuraxons, as mononeuric, di- neuric, trineuric, xwlyneuric, etc. Some of these varieties of cells are seen in Pigs. 10, 11, 12, 13, and 14. The term neuron has unfortunately been used with several meanings. Wilder, in 1884, proposed it as a designation for the cerebrospinal axis, but has since abandoned it in favor of neuraxis ; Waldeyer, in 1891, suggested that it be used to express the idea of a complete nervous unit consisting of the - nerve cell, the nerve process, its collaterals, and its termination or end branchings. This use of the word is attractive and has some ad- vantages in teaching, but it seems to me best, following Schafer, to include under the general term nerve cell not only the body of the cell, but also its processes, collaterals, and end- ings. As employed by Waldeyer, neurons are spoken of as of the first order and of the second order, but for these designations the . . , ^. ^ ^ An intermediary nerve cell terms projection cell and intermediary cell (Fig. from the posterior' hom of the 14) can be substituted. The axis cylinders ^pinaicord: ^, dendrons; s, ^ neuraxon, soon ramifying, and show a branching network of fibres; their its branches ending either first branches at right angles, which have ''^p^^ or in bifurcations, as at been particularly demonstrated by Eamon y Cajal and Koelliker as everywhere present in the nervous system, are called collaterals. The nerve process or fibre ends in a tuft or brush- like arrangement called the end brush. The term nerve tree has been aptly applied to the entire branching system of fibres, well shown in Pigs. 12, 15, 16, 17, and 18. Oelhdipetal and cellid.ifugal have been suggested by Eamon y Cajal as expressive of the method of trans- mission of nerve impulses.* Functions of the Nerve Cell.^The most important function of * The suggestion of Waldeyer has found so much favor that it should be understood by the student that the word "neuron" is now most commonly used to mean the cell unit. Neuraxon, first proposed by Koelliker, is now largely used for axis cylinder process. Neuriie is another term for it, suggested by Fish and Rauber. Cellular terminology is still undergoing modifications. Baker has recently suggested neure for the nerve cell, including all its appen- dages ; rhizoneures, for the cells which form nerve roots, etc. Instead of neuron or neure, Fish has proposed for the cell with its appendages the term neurocyte, and spongiocyie for the glia or neuroglia cells. 14 THE NERVOUS SYSTEM. the body or corpus of the cell is to preside over the nutrition of the cell and all its processes. If a cell process be separated from the corpus it will eventually die. A nerve cell may originate im- pulses, but this is probably always by stimulation either from within or from without. The cell and its processes are undoubtedly con- ductors of impulses ; but the connection of nerve cells with each other is physiological and not anatomical ; it is by means of processes with processes or of processes with cells. The gray color of the granular looking substance which forms a large part of the central nervous system, and which has been called by Leydig the punktsubstanz, or dotted substance, is due to the interblending and interlacing of in- numerable nerve cells with their ramifying processes. The isolated Fig. 15. The upper series of cells shows the " psychic" cell in different vertebrates : A, frog ; B, newt ; C, mouse ; D, man. The lower series shows the stages of growth of a single cell : a, neuroblast with axis cylinder process just commencing ; b, panicle commencing ; c, panicle and axis cylinder pro- cess more advanced ; d, collaterals of axis cylinder appearing ; e, collaterals of the cell body appearing. (Ram6n y Cajal.) anatomical elements form chains which may be either simple, as in some of the lower forms of animal life, or extremely compli- cated, as in the central nervous system of man (Schafer). In Fig. 15 the lower series shows the stages of growth from a cell with a short single process to the full nerve tree. All nervous conduction is from nerve cell to nerve cell by contact. The crossing and recross- ing of sensory and motor impulses in the cord and elsewhere are by means of commissural cells, and not by continuous iibres, these cells having short cylindrical processes by which connections are made with other cells. Even the white columns of the cord, although composed largely of vertical fibres, give off at short intervals col- laterals with their tree-like formations, and these communicate by NERVOUS TISSUES. 15 contact with other cells and fibres. Although always fundamentally the same, the process of transmission by nerve cells is often over a long distance and may be elaborate and complicated. A series of intermediary cells may be interposed between the nerve cell which receives the impression and the final destination of the impulse. In Pigs. 16, 17, and 18 are representations of the method in which the cells of the cerebral cortex, to which Eamon y Cajal has gi\en the name of psychic cells, are united with lower levels of the nervous system and with each other. Pig. 16 shows the chain from the cell and its panicle on the surface of the brain to the musculature. The axis cylinder of the cortical cell extends through the pji^ramidal tract to a cell in the anterior horn in the spinal cord, embracing the latter with its terminal tufts, the spinal cell with its process and end brush Fig. 16. Fig. 17. a c^ij^c The simplest form of connection of cor- tical cells : a, cell with its processes, b, c,d; b, cortical panicle, cellulipetal -, c, c, lateral processes ; d, axis cylinder process forming a portion of the pyramidal tract ; e, terminal iilaments embracing /, a cell of the spinal cord which forms an inter- mediary cell, sending an axis cylinder process, g, in the anterior root of the spinal cord to break into terminal fila- ments within the motorial plates of a muscle, ft. {Ram6n y Cajal.) Connection of a cortical cell with more than one intermediary cell (secondary neuron of Waldeyer) by means of the collaterals of its axis cylinder process. (Ram6n y Cajal.) then reaching out to the muscle. In Pig. 17 another method of con- nection is shown ; a lateral and its collaterals from the neuron or axis cylinder process are brought in con- tact with the branches of another nerve tree. Pig. 18 shows several "psychic" cells connected with each other by the contact of their collaterals. At i is represented 16 THE NERVOUS SYSTEM. the mode by which stimuli are carried by cellulifugal process to the panicle of the cell. Neuroglia.— Nerve cells are embedded in a substance, usually called neuroglia, found everywhere in the central nervous system, existing in abundance in the brain and spinal cord, among the nerve elements. It is composed of cells and their processes, and is not a true connective tissue, as is indicated by its development from the epiblast and not the mesoblast, although to a certain extent it serves to bind together and shield the more important nervous matter. While essen- tially a cellular tissue, its cells (Pig. 19) differ from true nerve cells. Fig. 18. Fig. 19. Neuroglia cells, one of which is seen in pro- file (s). (Jolgi staining. They have received various names, as glia cells, spider cells, or Deiters's cells. The neuro- gliar network is really composed of branchings of these cells loosely or compactly arranged. In the spinal cord they accom- modate themselves closely to the nerve fibres, and have been compared to packing material between parallel glass tubes. In other places they have a dense brush-like arrangement. The epithelial cells which line the cavities of the nervous system send out prolongations which blend with the neurogliar tissue, and proc(\sses of the pia pass into the brain and cord in various places, these together constituting the supporting or sustentacular tissue of the nervous system. Many of the so-called degenerations of the nervous system, as the scleroses, are usually regarded as primarily affections of the neuroglia, a subject which will be hereafter con- sidcicd. Bevan Lewis and others have attached great importance to the lymph connective system and the neuroglia in the pathogenesis of mental and nervous diseases ; calling the cells of the neuroglia sca^'enger ctdls, becans(^ they assist in carrying off effete, irritative, and destructive material, disease interfering with their cleansing and Connection of cells with each other by means of their collateral processes. Communication of stimuli by means of cellulifugal process i, coming up from the zona radiata. (Ram6n y Cajal.) NERVOUS TISSUES. 17 purifying work. They may be overdeveloped or underdeveloped ; they may be inflamed or destroyed ; or they may insidiously de- generate. Nerve Fibres. — I^erve fibres, as has been shown, have their origin in nerve cells, usually directly from a ganglion cell the axis cylinder of which passes straightway into the fibre. They vary widely in size, the figures as usually given being from one twelve thousandth to one fifteen hundredth of an inch, and at least three distinct sets are recognized by their differences in size. Most of the somatic cerebrospinal nerves are of large diameter ; the gangliated spinal nerves are comparatively much smaller ; while fibres of inter- mediate size are present in large numbers in several of the cranial nerves and in the anterior roots of the spinal nerves. Two princi- pal varieties of nerve fibres are described, the meduUated, double bordered or white fibred (Pigs. 13 and 20) ; and the pale gray, non- FiG. 21. Fig. 20. Silvered nerve fibres : A, small bundle of NonmeduUated nerve fibres from the gan- meduUated fibres displaying the silver crosses gliated system, the nucleated fibres joining to at several nodes; £, node of Ranvlerimder high form a plexus. (Piersol.) power ; C, silvered axis cylinder, showing a bi- conical enlargement and transverse markings or lines. (Piersol.) meduUated fibres, sometimes called the fibres of Eemak (Fig. 21). The meduUated fibres are found everywhere in the brain and spinal cord ; the nonmeduUated chiefly in the gangliated nerves, but both are to some extent present in all parts of the nervous system. Characteristics of MeduUated and NonmeduUated Nerve Fibres. — The meduUated nerve fibres differ somewhat in different situations, but usually consist of three distinct parts or structures, a central axis cylinder or axial fibre, a soft inner medullary sheath called myelin, and a firmer outer sheath, the primitive sheath or sheath of Scliwann, called the neurolemma or neurilemma. In the brain and spinal cord this latter sheath is usually absent, the medul- lated fibre here consisting simply of axis cylinder and myelin. The sheath of Schwann is present in the peripheral nerves. The axis 2 18 THE NERVOUS SYSTEM. cylinder is enclosed in a tougli envelope, wMch Kiihne and Ewald call the keratoid sheath. In peripheral nerves this sheath not only surrounds the axis cylinder but is reflected on the inner aspect of the sheath of Schwann, thus serving also to enclose the myelin. In the peripheral medullated nerves Eanvier discovered here and there dents or breaks in the continuity of the white substance or myelin, which are called nodes, and the subdivisions of the nerve fibre formed by them internodes, or interannular segments (Fig. 20). These ap- pearances are made very plain by certain methods of preparing and staining. Osmic acid makes clear the segmentation, and the con- stricting bauds are readily stained by nitrate of silver. An impor- tant point to remember is that the subdivision of a nerve fibre always takes place at a node. The inner nodes vary in length, in the large nerves averaging about one millimetre. NonmeduUated fibres, or the fibres of Eemak, are pale, transparent, and faintly striated. They have nuclei believed to be part of a delicate homogeneous sheath which is difficult to make out and is similar to the sheath of the medullated fibres. Unlike medullated fibres, the nonmeduUated divide and anastomose, forming a network, although their continua- tions are similar. Nerve Endings. — Sensory nerve endings are grouped into tactile cells, tactile corpuscles, and end bulbs (Piersol). Fig. 22 is a repre- sentation of a special method of ^^'^- "^' nerve ending within the epider- 1^^^^-H_ -^ y mis. A compound tactile cell or '~r)''f^>^ (/7}]'^ ^^^^^^^^u corpuscle results from the union ( V -ry^^ ^ ':^''Q>^ o^ ^^"^ «i°^P^« ^'I'^'^il® cells- 'Til® ■<<*-«-^'0^ "^^^iJ (^"tOy end bulbs are a special group ^)jK-^;Li^^J^\'^^ ■<^2^/ of nerve terminations generally cylindrical in type, and usually composed of three parts, a cap- sule, an inner bulb, and the nerve fibre. They are of various forms, „ . , ^. which of course cannot be fully Special nerve endmgs within the epidermis ; gold . . . preparation : N, nerve fibre entering the epithelium Considered in a UCUrolOgical and dividing into the fibrils which are connected textbook. The nCrveS Of VOlUU- with the tactile disks (m) ; upon these latter rest the tactile cells, u (Ranvier.) tary niusclcs usuallv temunate in a special form of nerve expan- sion to which the name motorial end plate has been applied. These nerves form plexuses in the muscles, and their fibres divide and sub- divide very minutely, passing finally to the sarcolemma. Figui'es 23 and 24 re])rescnt the muscular ending of the nerve fibre of a lizard. Tendons have a nerv(> supply, although this is not as complete as that to the skin and to the muscles. These nerves to tendons will be of interest in the subsequent discussion of the tendon phenomena, such as knee jerk and ankle clonus. Thus it has been found that a NERVOUS TISSUES. 19 nerve is distributed to the patella and that this has its origin in a certain segment of the lumbar spinal cord. In Kg. 25 is shown the organ of Golgi in the tendo Achillis. Where the tendons unite with the muscles are spindle-shaped bundles into which medullated fibres pass, their axis cylinders dividing and spreading out between the smaller tendon bundles and forming a branched expansion. Various obscure peripheral nervous affections will probably ultimately find their explanation through a more intimate knowledge of the nerve terminal structures, their functions, and the methods by which they «an be morbidly influenced. Wedenski makes a suggestion which may prove fruitful, namely, that the rhythmical variations in mus- cular contractions may be due to the storing of energy in nerve endings. Nerves end differently in different organs, as in the skin, Fig. 24. Nerve ending: in muscular fibre of a lizard. (Highly magnified.) End organ seen edgeways : s, sarcolemma ; p, p, expansion of axis cylinder. Beneath this is granular protoplasm containing a number of large clear nuclei and constituting the " bed" or " sole" of the end organ. (Quain's Anatomy, from Kiihne.) Nerve ending in muscular fibre of a lizard. (Highly magnified.) End organ seen from the surface. The expansion of tlie axis cylinder appears as a clear network, branching from the divisions of the medullated fibre. (Quain's Anatomy, from Kiihne'.) muscles, connective tissues, tendons, bones, vessels, tongue, stomach, uterus, and genital apparatus, according as they are sensory, motor, vasomotor, secretory, inhibitory, etc. ; and they connect or anasto- mose with each other in varying degree according to their peculiar functions and the parts to which they are distributed. Motor and Sensory Cells. — In the spinal cord in the anterior horns are found cells of very large and of smaller size, ending in a single process which gives off lateral branches ; also cells of the anterior and lateral columns, some with few but others with many branches ; and cells in the posterior horn, whose axis cylinders do not extend beyond the gray matter but form in it delicate ramifica- tions. In the cerebrum and in the cerebellum at least six varieties of nerve cells have been described. Under appropriate headings, the various properties and peculiarities and the greater abundance of 20 THE NERVOUS SYSTEM. certain types of cells in different portions of the nervous system will be considered. Nerve cells Fig- 25. have been differentiated into at least two great classes according as their work is sensory or receptive or is motor or emissive; and subdivisions of sensory and motor cells have been made according to the manner in which these functions are specialized. According to Golgi, Marchi, and other investigators, the multi- polar cells which have been considered can be divided into two types, one mo- tor, in which the neuraxon or axis cylinder becomes a fibre directly ; the other sensory, in which the pro- cess has a shorter course and passes into a network or complex ramification of processes out of which the ner^e fibre seems to arise. It is universally admitted that cells of the first class are motor in function, al- though they may also have other functions, but the question of the sensory type may be regarded as unset- tled. Ramon y Cajal, for instanoo, believes that the so-called sensory cells of Golgi, ■which are found in all the layers of the cortex, but chiefly in the fourth, are associati^'e rather than sensory in function. Triie sensory nerve cells are found in the spinal gan- glia, their processes reach- ing to the integument. It is worthy of consideration whether the cortical termination of the (rolRi's oorpiisolo or tendon spindle from the human tendo AchiUis ; j^'old pivpiirnlioii : V, nerve fibres sur- rounded by the perineuria! sheath (Fs) spreading out into tlie reticular ramifieations i7;i') of the axis cylinder ; A, the tendon bundles, one of which is separated at b : Mf, the muscle fibres; R, node of Eanvier, (After Ciaccio.) NERVOUS TISSUES. 21 sensory apparatus is not by processes rather than by cells ; but it seems necessary to have separate sensory areas with special cells in the higher levels of the brain. Nervous Structures of the Sense Organs. — The universally admitted senses are those of touch, hearing, sight, smell, and taste. Lenhoss6k and Eetzius have shown that in the earthworm all sen- sory nerve cells are situated in the epidermis, and that these cells have neuraxons and dendrons which ramify after the manner of such processes in the nervous system of higher animals. It has been demonstrated that the earthworm responds to touch, sound, and light, and probably to odors, although it has no differentiated special sense organs. The different sense organs of the higher animals are there- fore probably all modifications of one fundamental ancestral struc- ture. Sensations of touch, hearing, and smell are received by per- ipheral processes. The peripheral process of the tactile cell passes to a special end organ between the elements of the skin and other structures, and thus the centripetal transmission begins and proceeds. The nerve endings for the auditory and gustatory organs originate from bipolar or unipolar cells placed somewhere along the course of the nerves as shown in the figures. These peripheral nerve cells Fig.' 26. Auditory. Gustatory. Tactile. Olfactory. Visual. Nerve cells of special sense: gl, olfactory glomerules; g, ganglion cell of retina; gr. i., inner granules of retina ; m. L, inner molecular layer of retina. iSchafer, modified from Eetzius.) are essentially the same as all other nerve cells. Visual and olfactory impressions are received either directly by the body of the cell or by its very short process, and from the other end fibres pass off to ter- minate in a tree-like arrangement whose branches interlace with other arborizations, and thus from cell to cell the impulse is con- veyed brainward. From morphological standpoints the retina and olfactory bulb are really parts of the brain, in some lower animals the latter forming a large projection from the hemisphere. In the embryo, the retina has the appearance of a stalklike outgrowth 22 THE NERVOUS SYSTEM. Fig. 27. turned inward from the older part of the forebrain. The nervous apparatus of the retina is of a highly specialized character. Some of its great cells correspond to the projection cells of the cortex, with long axis cylinder processes. Eetzius has shown with regard to the terminations of the auditory nerve in the semicircular canals and in the organs of Corti, that the true nerve terminals are between the epithelial elements as in other regions. In Pig. 26 are diagrammatic representations of the nerves of special senses, showing their origin, course, and peculiar methtjds of termination. These in some details bear a striking resemblance to the cells and processes both of the cerebrum and of the cerebellum. Nerve Trunks or Peripheral Nerves. — What is usually spoken of as a nerve trunk, a nerve, or a peripheral nerve, consists of a collection of cylindrical fasciculi or bundles of white filjres. The entire nerve, as the facial or sciatic, is en- closed in a sheath of connective tissue, which is known as the epineurium. Each of the constituent bundles of the nerve is enveloped by its own membranous sheath, t\xe perineurium, a more compact mass of connective tissue than the ej)ineurium. Even the nerve fibres which form the separate strands or fasciculi of the nerve are each surrounded bv a fine envelope of connective tissue, the endoneurium (Fig. 27). These enclosing and sepa- rating constituents of the peripheral nerve, although not essential parts of the nerve fibres, must be constantly borne in mind in considering diseases of the nerves ; as in some instances these affections are jointly of the con- nective sheaths and partitions, and of the nerve tissue, or they maj^ be of either one or the other. Nerves are either afferent, incoming, or centripetal ; or efferent, outgoing, or centrifugal. Tlie incoming or afferent nerves convey to the centres impressions of Aarious sorts, as of pain, touch, heat, cold, location, pressure, weight, space, sight, hearing, smell, or taste. Some of them simply awaken the latent forces of the spinal cord or other nerve centres, and are hence sometimes calh^d excitoreflex nerves. The ciferciit or outgoing nerves may be purely motor or muscular; or they may be vasomotor, going to vessels; secretory, supplying glands; or trophic, regulating nutrition. Section of portion of a nerve trunk, in- cluding three bundles, or funiculi, sur- rounded by the perineurium (p) ; the funiculi, together with the bloodvessels and adipose tissue, are united by the more general epineurium (e) ; the sections of the individual nerve fibres are lield in place by the endoneurium ; /, fat cells, near which are the sections of bloodvessels. (Piersol.) DEVELOPMENT OF THE NERVOUS SYSTEM. 23 DEVELOPMENT OP THE NERVOUS SYSTEM. The Blastodermic Layers and the Neural Canal. — After the earliest changes in the fertilized ovum, the blastoderm (Pig. 28), which accumulates over the in- ner surface of the vesicle, is at first composed of two layers, but eventually of three, which are known as (1) the epiblast, ecto- derm, or outer layer ; (2) the mesoblast, mesoderm, or middle layer ; and (3) the hypoblast, en- toderm, or inner layer (Fig. 29). The entire nervous system — brain, spinal cord, peripheral nerves, and ganglia — is derived from the epiblastic layer, which *** is epithelial, and from which are derived also numerous epithelial structures, and the muscular fibres of the sweat glands. The components of the nervous sys- tem are in fact modified epithelial cells. We need only concern our- selves further with that portion of this subject which relates to the neural canal. After the ovum has assumed its hollow spherical shape, a groove or furrow forms on its surface near the primitive groove. This is the first faint streak of the nervous system, the neural or medullary groove, which slowly deepens, and then coming Fig. 29. Blastodemiic vesicle, its wall formed of a layer of flattened cells, ect, with a patch of dark granu- lar cells, ent, adhering to it at one part ; z.p., zona pellucida. (Quain's Anatomy, after E. v. Beneden.) Blastodermic layers of rabbit embryo : a, ectoderm ; b, entoderm ; c, entodermal cells ; m., meso- derm. (Plersol.) together at its edges forms the medullary canal. Pig. 30 and Pig. 31, from the embryo of a rabbit, show the groove just before and just after it has closed. The neural canal is really formed by an infolding of the exterior surface. It begins to close in the pos- terior cephalic region. It is lined at first with a single layer of columnar epithelial cells ; but after a time large round cells, called the germ cells of His, appear. 24 THE NERVOUS SYSTEM. Neuroblasts and Spongioblasts. — It has been shown that the two chief tissues of the nerve centres are the nerve cells and the neuroglia ; also that the two main sets of nerve fibres are those of the ventral, anterior, or motor roots and those of the dorsal, posterior, or sensory roots. The development of these tissues and of these roots will now be briefly ^'"^- ^^- considered. The germ cells of His actively develop, soon be- coming pointed and then pyri- form (Fig. 32) ; and after a time an extended process starts out, giving each cell a tadpole appear- ance (Pig. 33). In these young cells, called neuroblasts, various changes take place, and soon they become towards their centres rod- like, and in contact at their ex- tremities, at the periphery form- ing a dense network. The cells thus shaped and arranged are known as spongioblasts (Fig. 34), the entire reticulated or lattice-like tissue now present being sponge-like in appearance and hence called the myelospongium ; and in this myelospongium three distinct zones may Section of nine-day rabbit embryo, showing open neural tube : e, ectoderm invaginatfid and thickened witliin neural canal (n) ; m, meso- derm ; 6, body cavity ; g, still open gut, lined by entoderm (h). (Piersol.) Fig. Fig. 31. Section of ten-day rabbit embryo, showing closed neural tube: n, neural canal; s, area from which segmental ganglia develop ; m, mesodermie tissue ; <7, gut tube; v, v, primitive aortse; p. pleuro-iicri- cardial cavity. (Piersol.) Development of neuroblasts. Epithelium from the medullarj- canal of the rabbit soon after it has closed. Between the epithelial cells lies a germ cell (a) which has 1 lecome pyriform. (His.) be made out, an iniKM- towards the central canal, an outside network, and an intermediate zone of nuclei. From the internal or limiting menihrane afterwards (l<'vel(i])s the substantia gelatinosa centralis, the zone of clear ground substance surrounding the central canal ; from the intermediate zone, known as the columnar or mantle lauer the DEVELOPMENT OF THE NERVOUS SYSTEM. 25 neuroglia of tlie gray matter ; and from the outside reticulum or velum confine, the neuroglia of the white matter. Fig. 33. Fig. 34. C, neuroblast from the em- bryo of a salamander ; D, neu- roblast from an embryo trout. (His.) Neuroblasts from the spinal cord of an eleven-day chick. Some of the cells show the first formation of the dendritic pro- cesses directed towards the central canal. Lenhoss6k, who at one time regarded this as primary, now looks upon it as a sec- ondary formation. (After Lenhossek.) -The neuroblast at- FiG. 35. Development of Motor Nerve Roots. tempting to pass outward between the reticulations of the myelospongium is stopped by the velum confine or external network, and its process is turned aside inward or ventrally ; but eventually it succeeds in piercing the external layer, then to become the ru- diment of an anterior or motor spinal nerve, which soon gets close to the rudi- ments of the posterior or sensory roots which have been first formed. The neu- roblast remains within, and becomes a true nerve cell. It is thus seen that the nerve fibre and the nerve cell are embi-yologically and histologically the same unit. The cell nuclei of the columnar cells are arranged in rows, but their ends reach to the surface of the medullary plate. When the closed neural tube or canal is formed, the axes of these cells become disposed round it in a radial manner, as shown in Pig. 36. Neuroblasts from the spinal cord of a five-day chick : a, pyriform cell ; 6, cell with first dendrite directed centrally : c, cell showing development of the dendrites ; ri, growth cone of a motor fibre. (After Lenhossfik.) 26 THE KERVOUS SYSTEM. Fig. 36. Posteriiyr nglion The spongioblastic framework of the spinal cord. Cord of a human embryo, fourteen centimetres long-, impregnated by the Golgl method. (Lenhossi51i.) Development of Sensory Nerve Roots. — The sensory nerve roots do not arise in the central nervous system, but in the pos- terior spinal ganglia which ^i'5- 37. in the spinal region lie along the courses of the spinal nerves and are present also in some instances along the cranial nerves. When the medullary groove closes to become the neural canal, just at the seam appears an epithelial band or ridge, known as the neural crest, which becomes segmented, moves outward, and forms the spinal ganglia. The cells of these ganglia are bipolar, their prolongations being opposite, and pass- ing as fibres, one towards the spinal cord and the other towards the periphery. For these cells, which are desig- nated by Lenhoss^k as gangliohlasts, Baker has proposed the name cesthesioblasts. The roots of all sensory spinal nerves and sensory interior Root ---JMl.-'^ The formntion of nerve roots. Section through spinal cord of a human embryo. (Edinger, after His.) DEVELOPMENT OP THE NERVOUS SYSTEM. 27 cranial nerves grow from these ganglia into the central organs. The method of the formation of both motor and sensory nerve roots is shown in Fig. 37. The size of the posterior spinal ganglia is in the main proportionate to that of the nerves upon which they are formed. Most of these ganglia occupy the intervertebral foramens externally to the points where the nerves pass througli the dura ; but the ganglia iipon the iirst and second cervical nerves are exceptions, being placed in the arches of the vertebrae o\'er which the nerves pass ; while the ganglia of the sacral nerves are placed within the spinal canal, and the ganglion on the coccygeal nerve in the canal about the middle of the posterior root. Each ganglion gives origin internally to a posterior root and receives an anterior root, the two portions being united into a single mass externally. Careful examinations made on adults show that about as many fibres pass through the posterior root to the sijinal cord as have entered the ganglia from the nerves, and therefore it would seem as though a single cell were intercalated in the course of each fibre. A few sensory fibres probably originate in the spinal cord. That practically all the sensory nerves originate in the cells of the spinal ganglia has been settled by the experiments of Waller, Joseph, and others. If a sensory nerve is divided just in front of the spinal ganglion, all its fibres degenerate, the ganglion itself and the root originating in it remaining normal ; but if the posterior root is cut just back of the ganglion, only a few fibres of the sensory nerve de- generate. The nerve must, therefore, consist of fibres which origi- nate in the spinal ganglion cells, for the connection between these is unbroken, while the fibres which are destroyed must have come from the spinal cord itself, for they are severed from the latter only and not from the ganglion. Experiments have shown that the cell pro- cesses pass out of the ganglion in two directions, and that the fibres which originate in the spinal cord alone pass through it (Edinger). Development of Lateral Nerve Roots. — "We commonly speak of only two sets of nerve roots— Sir Charles Bell's anterior or motor and posterior or sensory ; but Bell really divided the nerve roots throiighout the central nervous system into three sets, ■ the third being a lateral or respiratory set and containing nerves which excite motions which depend on or are related to the act of respiration. Gaskell says that physiologists have failed to follow this, because the triple arrangement of these nerve roots was not immediately evident, like the separation into the anterior and posterior roots. Every seg- ment of the spinal cord, according to Gaskell, gives origin to two series of roots, a somatic and a splanchnic— the latter being the roots of the nerves supplied to the viscera and bloodvessels ; the former of the nerves to the muscles and skin, and to the tissues which are not vascular and visceral. The somatic roots are, in other words, the motor and sensory roots, and in the main are connected re- 28 THE NERVOUS SYSTEM. spectively with the cells of the anterior horns and of the posterior spinal regions— ganglia and horns. The lateral roots arise from two columns of nerve cells, namely, the column of Clarke and a column of the lateral hoi'n. The splanchnic roots arising from the column of Clarke bcctmie gangliated, their nerves going to vessels, viscera, and glands chiefly, and those arising from the lateral horn are non- gangliated, their nerves going mainly to muscles. These lateral roots are found in greatest number in the region from the second thoracic to the first lumbar segment. The distinction into a ventral or somatic and a lateral or splanchnic group of fibres is, according to His, well marked in the embryo. All Ganglia Neuraxial Outgrowths. — All the ganglia lying outside of the great neural canal are best regarded as encephalospinal offshoots and outgrowths ; and from this point of view it is certainly best to include the posterior spinal and intracranial ganglia in the same system which includes the lateral and collateral chains, and the cardiac, vascular, and other distal ganglia. Every fibre of the gan- gliated system before it reaches its final destination fuses more or less with other fibres from the neuraxis. The Gasserian ganglion and other intracranial ganglia, as well as the posterior spinal ganglia, have developed as offshoots of the encephalospinal nerves or nerve roots close to their central terminations. Even some of the cranial nerves which are recognized as not now having ganglia have prob- ably at one time had at least traces of these structures. Motor nerves in the adult are wanting in such ganglia, the groups of great cells in the cord and oblongata being sufficient for their inner- vation, and yet some nerves which are recognized as almost purely motor show traces of sensory ganglia. Thonisen has found even in the adult traces of preexistent ganglionic structure in the root of the third nerve, and Gaskell finds similar traces in the roots of the fourth, the seventh, and the motor roots of the fifth ; these indicate the preexistence of sensory elements in the root, and it is there- fore probable that these nerves and ganglia have all been originally developed as outgrowtlis from the neural crest. Development of the Spinal Cord. — A transection of the cer- vical cord of a human embryo of six weeks, after Koelliker, is seen in Pig. 38, and shows the manner in which the horns and ct>lumns of the cord first appear. At about this time can be seen the beginning of the anterior white column, and to a less extent the posterior, with their roots, the former on the Aciitral and the latter on the dorsal aspect of the neural canal. Only a few neuroblasts representing gray matter sejiarate at this stage the posterior white columns from the neurogliaT' lining of the canal, but a little later the gray horns grow outward, and the anterior and posterior fissures appear. The cord changes somewhat in shajie from stage to stage in its develop- ment. The allerent or sensory nerve fibres become united with the DEVELOPMENT OF THE NERVOUS SYSTEM. 29 dorsolateral portion, and the efferent or motor take origin from the ventrolateral. Lateral nerve roots also appear. The cylindrical form of the spinal cord is assumed after the development of the Fig. 38. Fig. .39. Transection of the cervical spinal cord of a human embryo of six weeks : c, central canal ; «, its epithelial lining ; e' (superiorly), the origi- nal place of closure of the canal ; a, ventral or anterior columns ; g, gray substance of antero- lateral horn ; p, dorsal or posterior column ; ar, ventral or anterior roots ; pr, dorsal or posterior roots. (Quain's Anatomy, from Koelliker.) Brain and spinal cord exposed from behind in a fetus of three months : h, the hemispheres ; m, the mesencephalic vesicle (quadrigeminal body) ; c, the cerebellum ; below this are the oblongata (mo) and fourth ventricle, with re- mains of the membrana obturatoria. The spinal cord (s) extends to the lower end of the sacral canal, and shows brachial and crural enlarge- ments. (Quain's Anatomy, from Koelliker.) lateral columns. At first the cord and its canal are of nearly equal length (Pig. 39) ; but aft«r about the fourth month the vertebral column begins to grow more rapidly than the cord, giving eventually the well known relations of the spinal cord and its nerves to the canal, as seen in Pig. 7, page 6. The Cerebral Vesicles. — After the neural groove has reached a certain stage of development its cephalic or anterior end enlarges, bends downward, and shows three dilatations which are called pri- mary cerebral vesicles. Soon the anterior and posterior vesicles each subdivide into two, one at each side ; the middle remains single. These five vesicles give rise to the five rudimentary divisions of the brain — the forebrain, hindbrain, midbrain, interbrain, andafterbrain. The rudiments of the optic nerve and retina grow from the sides of the forebrain. In Fig. 40 these vesicles as in an embryo chick thirty-eight hours old, and also some structures connected AAith the cranial nerves, are seen. Pig. 41 is a diagrammatic representation, modified from Mihalkovics and Edinger, of these five cerebi'al vesi- cles. The figure also shows a fold of the interbrain wliich afterwards becomes the conarium or pineal body ; a depression of its roof in the position of the posterior commissure ; and a pushing upward of the epithelium of the pharynx, which is the rudiment of a portion of 30 THE NERVOUS SYSTEM. the hypophysis or pituitary body. From time to time flexures occur at various places, the general trend being forward and down- ward : the first flexure is opposite the base of the midbrain ; the Fig. 40. Fig. 41. Posterior commissure Cerebellum Head of embryo chick of thirty-eight hours, viewed from above : \\, first cerebral vesi- cle ^ third vei>tricle ; op, optic vesicle ; Vo, second cerebral vesicle ; F3, third cerebral vesi- cle = fourth ventricle ; g, facial ganglion ; au, auditory vesicle ; gl, glossopharyngeal ganglion. Enlarged about twenty times. (After Duval.) Diagram of the five brain vesicles indicating the subsequent great subdivisions of the brain. (After Edinger-Mihalkovics.) second in the region of the hindbrain or pons, in this case the concavity being di- rected dorsally ; and a third rentrad at the junction of the hindbrain with the spinal cord. The brain thus gradually assumes curious crooks and twists, developmental addi- tions constantly taking place. The Neuraxial Cavities. — The cavities of the neuraxis, the relics of the neural groove and cerebral vesicles, may be regarded as parts of one great whole, for which the term ccele or calia has been pro- posed by Wilder, who by appropriate prefixes has also correlated the names of the several divisions of the coelia with one another, and with the special segments of the nervous system. These cavi- ties are the so-called ventricles of the brain, with their horns, their connecting foramens and canals, and the central spinal canal, although the last is usually so reduced in size iu the adult as to be scarcely recognizable as a cavity. Figure 42 has been com- bined and slightly modified from two diagrams by Wilder, com- posed by him to express his morphological ideas respecting the seg- mentation of the braiu and the continuity of all the neuraxial cavities.' The cephalic or anterior boundary of the cavities is the ' In a letter to the author, dated March IS, 1804, Prof. Wilder calls atten- tion to the ncitc on p. 114 of the Reference Handbook of the IMedical Sciences, Vol. VIII., — the note referring to whether or not the olfactory bulbs, their crura, part of the precommissure, and a corresponding portion of the aula, should be regarded as a sixth segment, — and adds, " Certain facts of development and DEVELOPMENT OF THE NERVOUS SYSTEM. 31 terma or lamina cinerea, the thin layer of gray matter immediately in front of the recess formed by the chiasm. The prosoccele repre- sents the cavity of the prosencephalon or forebrain ; the paracceles, its lateral extensions, corresponding to the lateral ventricles ; while the rhinocwle, an imperfectly developed extension of the latter, corre- sponds to the olfactory bulb. The third ventricle of the brain, as Fig. 42. Scheme of the cavities of the brain (and five encephalic vesicles), and of the myelio cavity or central spinal canal. (After Wilder.) usually described, is subdivided in this diagram into two segments, a larger, or diacoele, between the thalami ; and a smaller, the aula or hall, which constitutes the middle portion of the prosoccele, with which it connects at either side by the 2^orta or foramen of Monro. The optic nerve and retina are represented as lateral extensions of the diacoele, because they are originally hollow outgrowths of the diencephalic vesicle prior to the formation of the second cerebral vesicle. The mesocoele corresponds to the iter or Sylvian aqueduct, which is also represented with lateral extensions (hylas and paraque- comparative anatomy indicate that the olfactory portion of the brain is primary, and morphologically principal, the cerebral portion secondary and subordinate. Probably there should be recognized a segment, the rhinencephal, not in the Owenian sense, but as composed of one pair of olfactory bulbs and their cavities united across the meson by part of the precommissure, and part of the aula." 32 THE NERVOUS SYSTEM. Fig, ducts), some adult human brains presenting a slight groove at each side of this aqueduct, and the mesencephalic cavity of frogs, some reptiles, and all birds being distinctly in three parts. Wilder prefer- ably subdivides the cavity of the fourth ventricle into two parts, the epicmle and the metacoele, corresponding respectively to the hind- brain and the afterbrain ; but it is usually more convenient for descriptive purposes to use the term iiwtepicwJc, which includes both epiccele and metacoele, as synonymous with fourth ventricle. The correlations of these cavities to the five cerebral vesicles are as follows : prosoccele to the first ; diacoele to the second ; mesocoele to the third ; epiccele to the fourth ; and metacoele to the fifth. The anatomical textbooks usually speak of a fifth ventricle, a cleft in the septum between the lateral ventricles or paracoeles ; but this is not a true brain cavity, and is properly designated by Wilder as the pseudo- coele, or false ventricle. As the brain develops, this appears first as a part of the great longitudinal fissure, from which in man it subsecxuently becomes isolated bj' the formation of the callosum. Each of its sides consists of an outer lajer of white matter continuous with the callo- sum, and a thinner internal lam- ina of gray substance. The central spinal canal, or myelocosJe, is divided into its main length, or syringocceJe, and a lower dilated portion, the rhomboccele, which is usually called the inferior rhomboidal sinus or terminal ventricle. This method of representing the neuraxial cavi- ties gives a bird's eye view of the brain as a series of mesal segments, and shows the relations of these to the cavity of the spinal cord. The Extensions and Relations of the Paracoeles. — In Fig. 43 is represented a horizontal transec- tion of the cerebrum, so made as to expose the paracojles or lateral ven- tricles, and to show their extensions or horns, and some of their most important related solid structures. The third ventricle or diacoele is not shown, but it is situated between the thalami, and chiefly beneath the fornix and its attachments at 12 Horizontal section of the cerebral hemi- spheres, the callosum removed, and the lat- eral ventricles exposed : 1, white substance of the interior of the cerebral hemispheres ; 2, gray cortex of the convolutions ; 3, 4, ex- tremities of the callosum ; 5, precornu (an- terior horn) of the left lateral ventricle or paraca?le ; 6, medicornu (middle or descend- ing- horn) ; 7, postcornu (posterior horn) ; S, striatum ; 9, septum ; 10, pseudoc.vle (fifth ventricle) ; 11, fornix ; 12, posterior cms of the fornix ; 13, attachment of the fornix to the under part of the callosum ; 14, hippocamp ; 15, fimbria; 10, calcar; 17, tenia (ta;nia semicirciilaris) i 18. choroid plexus ; 19, edge of the thalamus ; 2(1, arrow through the porta or foramen of Monro. (Leidy.) DEVELOPMENT OF THE NEUVOUS SYSTEM. 33 and 13. The fimbria, one of the parts seen in the figure, is a white band along the inner side of the hippocamp. The tenia or tieuia semicircularis is a whitish streak between the caudatum or caudate nucleus and the thalamus. The extensions of the paracceles called the anterior, middle, and posterior horns— or the precornu, medi- cornu, and postcornu — are shown at 5, 6, and 7 ; the septum and the pseudoccele, at 9 and 10. The caudatum appears as a gray eminence tapering behind, external to the thalamus, only a small portion of which is seen at 19. The hippocamp and calcar are white eminences or ridges which correspond to the infoldings of two great fissures, the hippocampal and the calcarine. The position and appearance of the fourth ventricle or metepicoele have been indicated in Pigs. 3, 5, and 6. Relationships of Cerebral Vesicles to the Parts of the Fully Developed Brain. — The subjoined table, modified from Quain's Anatomy, shows the relationships which the cerebral vesicles subse- quently bear to the subdivisions of the brain, both cavities and solid structures : Aula (cephalic end of third ventricle) ; porta (foramen of Monro) ; paracceles (lat- eral ventricles) ; cerebral hemispheres ; olfactory bulbs and tracts ; striata ; callo- sum ; fornix. Diacojle (third ventricle) ; op- tic nerve and retina ; thal- aa i ; hypophysis ; conarium. I. Anterior primary vesicle or fore- brain. First secondary vesicle (prosencephalon) . II. Middle vesicle brain. primary or mid- Second secondary vesi- cle (diencephalon or thalamencephalon) . Third secondary vesi- cle (mesencephalon). Mesoccele ; iter ; num ; crura. quadrigemi- III. Posterior pri- mary vesicle or ■ hindbrain. Fourth secondary vesi- cle (epencephalon). Fifth secondary vesicle (metencephalon) . Epicoele ; cere- bellum ; pons. Metacoele ; ob- longata. Metepicoele (fourth ventricle). Segmental Character of the Entire Nervous System.— The central nervous system is to be regarded as a series of segments. The segmental character of the brain has been illustrated in the consideration of the brain vesicles and neural cavities. The spinal cord may be considered as a series of organs vertically linked to- gether—a chain of segments placed one above another. In many lower animals, as in fishes and snakes, this arrangement is obvious, and the spinal cord becomes a series of alternating swellings and con- strictions. Each segment may be viewed as a distinct spinal cord for a definite area of the body, namely, that muscular area to which its ventral or anterior roots proceed, and that sensitive area— skin, tendon, muscle, mucous membrane, or viscus— to which the fibres 34 THE NERVOUS SYSTEM. of the uition of the Lectui brain, in the dorsal roots are distributed. According to Hill, the recog- of the segmental snccession in the arrangement of the nuclei nerves in the spinal cord is due to Aeby. In the Hunterian •es, in 1885, Hill applied this principle of segmentation to the or at least to the cranial nerves, attempting to fix the position cerebral axis of the nuclei of these nerves by a consideration Fig. 44. Human embryo, showing the peripherfil nerves : III to XTI, the cranial nerves in order from the third to the twelfth ; ( fi, developing cerebral hemispheres ; m, midbrain ; 4, fourth ventricle ; b, commencement of oblongata ; C (I to .s), the cervical nerves and ganglia on their dorsal or poste- rior roots ; D (1 to 12), the thoracic nerves and ganglia on their dorsal roots ; i (1 to 5), the limibar nerves and ganglia on their dorsal roots; .s' (1 to 5), the sacral nerves and ganglia on their dorsal roots ; Co (1 to 2), the coccygeal nerves and gauRlia on their dorsal roots ; Ht, ventricle of heart ; i, intestine ; (S, sciatic nerve cut at its origin. (His.) of their segiiicnial distribution in the head. The spinal nerves and the cranial nerves from tlie third to the twelfth, as observed in the human emlnyo, are shown in Fig. 44, as are also the relations which these ucM'ves bear to one another, and to the development of the head and of the spinal column. Lobes of the Cerebrum. — The lobes as usually given are, on the lateral aspect of the cerebrum, the frontal, j)arietal, temporal or DEVELOPMENT OF THE NERVOUS SYSTEM. 35 temporo-sphenoidal, and occipital, as shown in Fig. 45. The frontal lobe reaches backward to the central fissure or fissure of Eolando, and below to the horizontal limb of the fissure of Sj'lvius ; the paiie- tal in front to the central fissure, and behind to the parieto-occipital Fig. 45. LolDes of the cerebrum as usually given by anatomists, lateral aspect : C, central fissure or fissure of Rolando ; Po, parieto-occipital fissure. (Modified from Morris's Anatomy.) fissure ; in front below to the posterior arm of the Sylvian fissure ; below and behind it is not usually fully separated from the temporal and occipital lobes by any anatomical landmarks, although it is at times by a short but well defined vertical fissure corresponding to Fig. 46. Lobes of the cerebrum, mesal aspect ; .S', Sylvian fissure ; Om, ealloso-marginal fissure ; Po, parieto- occipital fissure ; Ca, calcarine fissure. (Modified from Morris's Anatomy.) one of the "ape fissures." The boundaries of the temporal and of the occipital lobe are sufficiently indicated liy the description of the limitations of the frontal and parietal. On the mesal surface of the hemicerebrum the continuations over the edge of the hemisphere 36 THE NERVOUS SYSTEM. of the frontal, parietal, and temporal lobes are seen in Fig. 46. A faleiform lobe lias been suggested by Schwalbe ; it cannot well be located with any other of the lobes of the brain surface, and embry- ology and comparative anatomy sustain this lobation. Its outer seg- ment, sometimes spoken of as the limbic lobe of Broca, is that shown curving around the callosum ; it has an inner segment composed of parts hidden in the view, namely, the septum, the fascia dentata, and a portion of the fornix. Physiological Lobes. — Instead of the usual anatomical subdi- vision the brain may be divided, as the result of functional devel- opment, into physiological lobes, as shown in Fig. 47 and Fig. 48. Fifi. 47. Physiological lobes of the cerebrum, lateral aspect : .?. Sylvian Assure ; C, central fissure or fissure of Rolando ; Po, parieto-occipital fissure. These lobes may be regarded as (1) a higher psychical ; (2) a motor ; (3) a sensory, meaning by this a lobe of general or common sensa- tion ; (4) a visual; (5) an auditory ; (6) an olfactory ; and (7) a gusta- tory. The insula, or island of Eeil, constitutes a separate lobe of the brain whose functions have not yet been fully determined. Accord- ing to some authorities, in the middle portion of the temporal lobe, or possibly in the insula, is an ideational or naming region, where converge the recepts of various kinds as the result of which object and word images arise in the mind. The designation of the pre- frontal region as a higher psycliical lobe is not unobjectionable, and some would oppose altogether the use of the tei'in psychical in such a coniieclioii ; but it peiliups <'xpresses as well as any other the physiological views whicli liave the most support. It is not in- tended to indicate that it is the only portion of the brain wliich is psychical ; but only that it is related to the highest mental processes, its lesions causing, when suificieiitly extensi\e, a mental deterioration DEVELOPMENT OF THE NERVOUS SYSTEM. 37 which is essentially or mainly a defect of the faculty of attention. It is Hughlings Jackson's third or highest level of the nervous system, the acme of human evolution, containing centres of re- representation of the most complex movements of all parts of the body. It might perhaps be designated as tlie lobe of re-repre- sentation or of complex coordinations. The physiological lobes are in the main well demarcated by prominent fissures. Lobation of the Cerebrum during Development. — Hill has shown that the brain during its growth exhibits a well maiked tendency to bulge into lobes ; and he believes that these have a dis- tinct morphological and also a distinct physiological significance. Pig. 49 shows this lobation of the cerebrum. The cephalic end of the cerebrum has the appearance of greatest stability. The appear- FiG. 48. Physiological lobes of the cerebrum, mesal aspect ; S, Sylvian fissure ; Cm, calloso-marginal Assure ; Po, parieto-occipital Assure ; Ca, calcarine Assure. ance of the Sylvian fossa is owing to an intimate relation which exists between the lenticula and the overlying cortex, whereby the island of Eeil is fixed and prevented from taking part in the free growth of the rest of the hemisphere. The general surface bulges over the fossa, and soon that portion of the brain which is known as the oper- culum or Eolandic lobe (B) becomes and remains the most distinct of all the lobes of the brain. The ventral and caudal part of the hemisphere bulges forward as the temporal lobe ; while the prolonga- tion backward of its caudal and dorsal portion is obvious in many animals. These prominent frontal, opercular, oceijiifal, and temporal bulgings include others which are less obvious. Hill is unable to assign to any of the lobes mentioned, that portion of the surface which lies behind the Eolandic and temporal and in front of the 38 THE NERVOUS SYSTEM. occipital lobe, although he finds sufacieut indications of the exist- ence upon it of other less pronounced swellings. In the main this method of lobation shown during fetal life corresponds to the physi- ological lobes as given in Fig. 47. Fig. 49. Diagram showing the lobation of the cerebrum : _F, frontal lobe ; R, central or Rolandic lobe ; 0, occipital lobe ; T, temporal lobe ; I, insula (Island of Reil) ; Py, pyriform lobe (uncinate gyre) ; OB, olfactory bulb. (Hill, in the translation of Obersteiner's Anatomy.) First Appearance of Fissures and Convolutions. — At first the surface of the brain is perfectly smooth, but soon, the enlargement of the cranium not keeping pace with that of the brain, the latter Fig. 50. Fig. 51. Surface of the fetal brain at six months, viewed from the left side, showing the forma- tion of the principal fissures : F, frontal lobe ; P, iBirietal ; O, occipital; T, temporal; n, n. a, slight appearance of sulci in the frontal Pilie ; s, Sylvian fissure; ,s'', its anterior divisinn ; witliin it <', the central lobe; r, Rolnndic sul- cus ; ]i. parirtiMicci]iital fissure. (Quain's .Vnat- omy, after R. W'a.tincr.) Surface of the fetal brain at six months, viewed from al lovo : F, frontal lobe ; P, parie- tal ; O, occipital ; T, temporal ; a, a, n, slight appearance of sulci in the frontal lobe ; s. Syl- vian ti.'^siirc ; r, Rolandic sulcus ; p, parieto- occipital fissure. ((Juain's Anatomy, after K. Wa,i,nicr.) liogiiis to be thrown into folds and furrows. The primary infoldings are mo.stly tra.ns\-ci-S(', although (luc or two on the ines;il surface are i)ai;illel witli tlie brain axis. These temporary or primitive sulci, with the exception of three, disappear during the fourth month. DEVELOPMENT OF THE NERVOUS SYSTEM. 39 The permanent primitive sulci are, the hip])()campa], correspond- ing with the projection of the cornu ammonis or hippocamp ; the parieto- occipital (occipital of AViklcr), corresponding with the bend of the postcornu ; the calcarine, corresponding with the projection of the calcar ; and the Syh'iau fissure, corresponding with the cur\'e of the lateral ventricle. The formation of the principal fissures in the fetal brain is shown in Pigs. 50 and 51. According to Jelgeisma and Cunningham, convolutions form on account of the tendency of the superficial layer or cortex to increase by surface extension, and because of the effort at accommodation as regards space between the gray substance and the white coudu.cting j)aths ; but many interest- ing theories have beeu advanced with reference to the origination and multiplication of cerebral fissures and convolutions which cannot be considered in a eampal g>rus ; U, imcinate gyms ; Oh, chiasm ; cc, albicantia ; KK, crura ; C, callosum. (Ecker ) names of a single word each. The outlines and locations of the principal fissures shown in these diagrams are derived from photo- graphs of the ccicbium of a mulatto. The differences in nomen- clature will be sufficiently clear from a comjnirison of the two sets of diagrams. Variations in Fissural and Gyral Arrangement. — All published schemes ol' fissures and gyres must l>e consitlered more or less imper- fect, as they liaAc been basi'd upon in\'estigations of lower animals andoftlii^ liuman brains most frequently accessilile, which commonly have been instances of arrested or irregular development — the brains DEVELOPMEXT OF THE NERVOUS SYSTEM. Fig. 5(;. injiectcd /. 43 basisyh Lateral aspect of the left hemicerebnira : A, angular gyrus ; M, marginal (or supramarginal) giTus ; /, fissure ; G, gyrus ; preop., preoperculum. The interrogation points near the caudal end indicate Professor Wilder's doubts as to the existence of constant fissures in these places, or as to what they should be called if they do exist. (Wilder.) of criminals, idiots, paranoiacs, and others belonging to the ignorant, vicious, or insane classes. Comparatively few studies have been made of the brains of the intelligent and educated, although much more is promised, through the formation of societies the members of Fig. 57. '^"'Jffdalaic / Mesal aspect of the right hemicerebrum : G, gyrus ; /, fissure ; ocdc, /., oecalcariiie fissure, for occipito-calcarine, the common stem of the fissures demarcating the cuneus. (Wilder.) 44 THE NERVOUS SYSTEM. which have willed their brains to their associates for scientific pur- poses. Simplicity of structure, particularly of the frontal fissures and gyres, seems to indicate an inferior order of brain ; but such indications are not to be accepted without reserve, as in a few in- FiG. 58. Lateral aspect of right hemicerebrum of a Chinaman. stances the brains of the highly intellectual have shown unusual simplicity of the cerebral surface. Considerable variations from the schemes usually given are to be expected. In Figs. 58 and 59 are shown the lateral and mesal aspects of a Chinese brain, and in Fig. .59. Mesal aspect of ri^ht beraicerebnim of a Chinaman; Fig. 60 the left hemicerebrum of a white man showing unusual elab- orations and confluences of fissures. The great extent of the super- temporal fissure in the hemisphere shown is a striking peculiarity of the Chinese brain. Figs. 61 and 62 are rei^roduced from photo- graphs of the right hemicerebrum of a delusional paranoiac of the criminal type. The right hemisphere Mas shorter and higher than the left, and the whole brain was reinarkal)le for its ape-like and DEVELOPMENT OF THE NERVOUS SYSTEM. 45 fetal conditions. A nearly vertical fissure, described in Wilder' s dia- gram as the exoccipital, and termed by Benedikt Wernicke's fissure, Fig. 60. Left hemicerebrum of a white man, outer view, one fourth size r F, frontal lobe ; P, parietal lobe ; O, occipital lobe ; T, temporal lobe ; 1, Sylvian Assure ; 2, anterior brancli ; 3, posterior branch ; 4, central fissure ; 5, 6, superior and inferior frontal fissures ; 7, precentral fissure ; 8, interparietal fis- sure ; 9, 10, superior and inferior temporal fissures ; 11, 12, superior and inferior occipital fissures ; 13, occipito-parietal fissure ; 14, calloso-marginal fissure ; a, b, c, superior, middle, and inferior frontal convolutions ; d, e, anterior and posterior central convolutions ; /, g, superior and inferior parietal convolutions ; g, k, angular convolution ; i, k, I, superior, middle, and inferior temporal convolutions ; m, n, o, superior, middle, and inferior occipital convolutions ; x, x, x, x, annectant (bridging) convolutions. (Leidy.) was better defined in tliis tlian in any other human brain that I have ever seen, easily demarcating the parietal and temporal lobes from Fig. 61. Lateral aspect of right hemicerebrum of a criminal paranoiac. the occipital upon the lateral aspect of the hemispheres ; it corre- sponded to the inferior portion of the external perpendicular fissure in the ape. These figures illustrating arrested and aberrant de- velopment are given, in connection with the diagrams of Ecker 46 THE NERVOUS SYSTEM. and "Wilder, to impress the importance of keeping in mind atypical and irregular fissural and gyral arrangements. By a study of the brains of primates, of fetal brains, and of postnatal brains supposed to be normal, from individuals of different ages, we can obtain a good working knowledge; of the average arrangement of the hills and valleys of the cereljral surface. While we have not as yet what might lie termed a standard average adult brain, what can be hoped for is that the observer, even the practitioner of medicine of ordi- nary attainments in cerebral anatomy, shall have a fair idea of brains of different tyi^es or degrees of inferiority or superiority of develop- ment. Some authorities deny that the fissures and gyres of the human brain can be elucidated by a study of the lower animals, and perhaps in some respects it would be Ijest always to describe and figure what is found without reference to any A'iews as to afiinities Fig. 62. Mesal aspect of right liemicerebrum of a criminal paranoiac. with other animals or differences from them ; but even so high an authority as Meyneit takes as his starting-point the brain of a monkey. Bischoff held that the monkey brain was not a miniature model of the human brain, but represented arrested stages in the development of tlie latter. Ental Correlatives of Fissures.— The student should always have in mind the internal elevations which correspond to external fissures— their ental correlatives (Wilder), as such knowledge not only gives a clearer comprehension of the fiicts of brain development and conformation, hut is of direct practical benefit in making autopsies and even in performing surgical operations on the brain. The most striking of these correlations aic the calcar to the calcarine fissure, the collateial eminence to the collateral fissure, and the hippocamp to the hippocampal fissure. The caudatum has been suggested as the correlative of the Sylvian fissure, but on grounds not entirely clear. NOMENCLATUEE AND TERMINOLOGY. 47 NOMENCLATURE AND TERMINOLOGY. General Remarks on Nomenclature and Terminology. — In a textbook on neurology, a section on nomenclature and terminology may at first seem out of place, but anatomical nomenclature is under- going rapid changes, and this is particularly true of terms used in describing the nervous system. It would be a great gain if general conformity on the part of writers and teachers could be obtained, but, while this is impracticable, the impossibility of bringing about a full reform and of securing a perfect system is not a reasonable excuse for neglecting the subject altogether. Although confusion has occasionally followed attempts at the introduction of new ana- tomical terms, much practical good has already resulted from the earnest labors of men like "Wilder and Gage, whose suggestions as to nomenclature I have to a considerable extent followed, aiming to adopt improved names when this could be done without causing uncertainty or making too much explanation necessaiy, remembering that the book is for students and general practitioners rather than for anatomists and neurologists.* Suggestions as to Nomenclature. — Two of the most important suggestions of Wilder, which are gradually becoming more and more appreciated, are the use of appropriate and if possible preexisting mononyms for all parts, and the employment not of heteronyms but of paronyms of these Latin terms formed in accordance with the genius of each language.f He advocates "that, as far as possilile, for each part of the central nervous system there be found a name con- sisting of a single Latin word ; that for each such Latin name there be found an English equivalent — not a translation, but a paronym ; and that in obtaining these names, Latin and English, due regard be had both to existing nomenclatures and to the establishment of etymological conversion." Mononyms. — Fig. 63, drawn by Wilder from an actual specimen, represents various parts of the brain as seen in hemisection. It ex- hibits the manner in which the dura, or outer membrane of the brain, and many of its vessels are related to different parts, showing un- usually well the sickle shape of that portion of the dura which is be- * The material for this section has been drawn chiefly from the writings of Wilder and Gage, and particularly from their contributions to the Reference Handbook of the Medical Sciences, Vols. VIII and IX. t A homonym is a word having the same sound as another, but differing from it in meaning ; a heteronym is a vernacular term which is a more or less precise translation of a name in Latin or any other language ; paronyms are words having the same derivation as others to which they are radically allied ; they have similar sounds, although sometimes similar and at other times different spellings and meanings. A mononym is a term composed of a single word. 48 THE NERVOUS SYSTEM. tween the two hemicerebrums and is called the falx. The numerous descriptive names upon the figure are mononyms, while the common terms for these parts are nearly all polynyms : thus, terma is lamina cinerea ; pseudoccele, the fifth ventricle ; fornicommissure, the an- terior pillars of the fornix ; porta, the foramen of Monro ; aqueduct, the iter e tertio ad (iiiartum ventriculum ; metapore, the foramen of Magendie ; postcribrum, the posterior perforated space, etc. The Fig. 03. porr.i pseudocoele rostrum I genu, ) : fonilcommis.siire I mtdicomniisstire ^ aulix. terraatic a. Iiabena supracommissure conaniun spieniirni Mesal aspect of the right hemiencephal of an adult : 1, auliplexus ; 2, subfalcial sinus ; 3, right velar vein ; 4, orifice of vein nf Galen ; 5, faliicula Unix cerebelli) ; 6, straight sinus ; 7, uvula (of cerebellum) ; S, tuber einereum ; 9, falx ; 10, arachnoid ; 11. longitudinal sinus. (Wilder.) diagram is anatomically very valuable, and reference will be made to it again for purposes of description. In the table which follows illustrations are given of some of the mononyms adopted. In each of llicsc and in otliers which may be used the evident meaning of the word, or the fact tliat it is cleiiiiy a part of a descriptive term long in use, will usually guide the reader, even if he is not familiar with the cliaiiged nomenclature. Tlie mononyms arbor, calcar, rallosum, caudatum, Iciiticula, pims, dura, and pia, will be at once recognized as NOMENCLATURE AND TERMINOLOGY. 49 standing respectively for arbor vitce, calear avis, corpus callosum, caudate nucleus, lenticular nucleus, pons Varolii, dura mater, and jj(« mater. In the table, tlie Latin mononym, in the nominative singular, is used. In many instances the English vernacular has the same form, and when it has not the change is slight : thus, diacceUa and diaccele ; myelon and myel; medicommissura and medicommissure ; postpeduncidus and postpeduncle ; prapedancuhcs and prepcduncle. Ala for ala cinerea. Alba " white (nervous) matter. Ansa ' ' ansa lenticularis. Arbor " arbor vitse cerebelli. Aula " cephalic part of third ventricle. Calcar " calcar avis, or hippocampus minor. Callosum ' ' corpus callosum. Caudatum " caudate nucleus. Cinerea " gray matter. Conarium " pineal body. Crus " cerebral crus or cerebral peduncle. Diaccelia " third ventricle less the aula. Diaplexus " plexus of third ventricle. Diatela " membranous roof of third ventricle. Diencephalon " thalamencephalon or interbrain. Dura " dura mater. Fimbria " corpus flmbriatum. Geniculum " geniculate body. Habena " peduncle of the pineal body. Hippocampus " hippocampus major. Hypophysis " pituitary body. Insula " island of Eeil. Lenticula ' ' lenticular nucleus, or corpus lentiforme. Medicommissura " middle commissure. Medipedunculus " middle peduncle of cerebellum. Metaporus " foramen of Magendie. Myelon " spinal cord. Neuraxis " cerebrospinal axis. Oblongata " medulla oblongata. Oliva " olivary body. Pallidum " globus pallidus. Paracoelia " lateral ventricle. Pons " pons Varolii. Porta " foramen of Monro. Postbrachium " brachium conjunctivum posterius. Postcribrum ' ' posterior perforated space. Postpedunculus " inferior peduncle of cerebellum. Praecornu " anterior horn of lateral ventricle. Prsepedunculus " superior peduncle of cerebellum. Quadrigeminum " corpus quadrigeminum. Terma " lamina terminalis or lamina cinerea. Thalamus ' ' optic thalamus. Tuber " tuber cinereum. Velum " velum interpositum. 4 50 THE NERVOUS SYSTEM. Table of Synonyms of Gyres or Convolutions and Lobules. Wilder. Superfrontal. Medifrontal. Subfrontal. Precentral. Supertemporal. Meditemporal. Subtemporal. Subcollateral. Subcalcarine. Postcentral. Parietal. Subparietal. Supramargi- nal. Angular. Precuneus. Callosal. Uncus. Hippocampal. Dentate. Cuneus. P'aroccipital. Medioccipital. Suboccipital. TUENEE. Superior frontal. Middle frontal. Inferior frontal. Ascending frontal. Superior temporo- sphenoidal. Middle external temporo -sphenoi- dal. Inferior external temporo-sphenoi- dal. Inferior internal temporo-sphenoi- dal. Middle internal temporo- sphenoi- dal. Ascending parietal. Postero-parietal . Supra-marginal. Angular. Quadrilateral. Callosal. Uncinate. Hippocampal. Dentate. Cuneus. Superior occipital and first external annectant. Huxley. Supero-frontal. Medio-frontal. Infero-frontal. Antero-parietal. Antero - tempo- ral. Medio ral. tempo- Postero - tempo- ral. Postero-parietal gyrus. Postero -parietal lobule. Angular. Quadrate. Callosal. Uncinate. Dentate. Internal occip- ital. Supero- occi]3ital and flviJt exter- nal annectant. Middle occi]iital jMedio - occipital and .second annec- and second an- tant. nectant. Inferior occipital, third and fourth annectants. Infero -occipital and tliird an- nectant. EcKER, Cunningham, aud Others. First or superior frontal. Second or middle frontal. Third or inferior frontal. Anterior central. First or superior temporal. Second or middle tempo- ral. Third or inferior tempo- ral. Lateral occipito-temporal or fusiform. ^Median occipito-temporal or lingual. Posterior central. Superior parietal. Inferior parietal. Supramarginal. Angular. Precuneus. Gyrus fornicatus. Uncinate. Hippocampal. Dentate. Cuneus. First or superior occipital. Second or middle occipi- tal. Third or inferior occipital. NOMENCLATURE AND TERMINOLOGY. 51 The Naming of Fissures and Gyres.— Wilder' s names for fissures and gyres are shown in Figs. 56 and 57. As the methods of naming these parts used by different writers vary so much, it may serve a good purpose to give in a table the English gyral synonyms in most general use, to which fissural names closely correspond. The terms most commonly met with are given in the fourth column of the table, although those of Wilder are coming more and more into favor, and anatomists and morphologists are gradually approach- ing uniformity in their terminology. Only those gyres are tabulated which are most frequently referred to in practical work. Huxley and Turner sometimes use interchangeably " supero-frontaV and " superior frontal,' ^ " mid- occipital," " medio- occijntal,'' or "middle occipital," etc. The angular convolution of Huxley does not exactly correspond to the "angular" convolutions of others. Huxley' sj)os- tero-parietal convolutions and postero-parietal lobule designate two ad- joining but separate regions, and very wisely these terms have been generally discarded. The supramarginal and angular convolutions together constitute the suhparietal of Wilder {inferior parietal of Ecker). 'WHAbv' s, paroccipital gyre, which practically corresponds to Ecker's first or superior occipital, is named from his paroccipital fissure, which has been given an independent footing because in a large number of brains examined by him it appeared as a distinct fissure. The annectant or bridging gyres connect lobes across great fissures, like the human parieto-occipital, and the perpendicular fis- sures in simian brains. Their annectant character is more apparent in the brains of apes and other lower animals than in man, although sometimes it is evident in low type human brains, such as the one shown in Pigs. 61 and 62. Both the annectant and the adjacent occipital convolutions of Turner and Huxley correspond to Ecker's first, second, and third occipital convolutions. Operculum, meaning a "cover" or "lid," is a term applied to a brain region which covers other parts. The operculum shown in Wilder' s diagram. Pig. 56, includes at least portions of the precentral and subfrontal gyres, and overhangs the insula. The pf-eoperculum, suboperculum, andpost- operculum receive their names from their relations to the operculum. Terms descriptive of the Positions and Relations of Parts. — In describing the positions and relations of parts of the nervous system to each other, and to other structures, it is important to use terms which apply equally to man and the lower animals, as those based upon the normal position of a vertebrate animal, which has six aspects — cephalic, caudal, dorsal, ventral, dextral, and sinistral. Terms derived from these words should be used in x^reference to common but sometimes ambiguous expressions such as anteiior, superior, inferior, external, internal, etc.; although it is difficult for medical writers, students, and practitioners, consistently to dis- regard them. Cephalic and cephalad are used to designate posi 62 THE NERVOUS SYSTEM. tion in or direction towards the head end of the body ; caudal and caudad, the same with reference to the tail end of the body ; dorsal and dorsad refer to the back, or the part containing the central nervous system ; ventral and ventrad, to the belly, or digestive part of the body ; while dextral and sinistral are used for right and left, as in everyday life. These terms have much to commend them, and have been largely adopted in this work ; their adoption in all cases might prove confusing to the average reader. For the particular uses of cephalic, caudal, ventral, dorsal, etc., as applied to the limbs, the student must be referred t(j special works or articles, as Gage and Wilder' s article in the Eeference Handbook of the Medical Sciences ; but attention may be called to a few expressions which require to be used with comparative frequency. Preaxial, which means situ- ated in front of any transverse axis of the body of an animal, refers to the cephalic or anterior side of the axis of a limb ; postaxial, to a position behind any transverse axis of the body of an animal, as the caudal or posterior (ulnar or fibular) side of the axis of a verte- brate limb. Edal and entcd have been introduced to take the place of such terms as external and internal, outward and inward, super- ficial and profound. They indicate position on or direction towards an aspect or surface farther from an actual or supposed centre than some other part with which it is compared. Proximal indicates position or direction near, distal, position or direction away from, the attached end of a limb. Classification of Encephalic Parts. — The table on page 53, which gives, with a few changes. Wilder' s provisional classification of encephalic parts according to segments, relations to cavities, and other chai'acteristics, will be found useful not only for gaining familiarity with newly introduced terms, but also as a compact presentation of important embryological and anatomical facts re- lating to the nervous system.* * With a few exceptions the structures described in this tal)le are discussed in more or less detail in the present chapter, so that brief references to a few of the terms will be all that is necessary to make the table clear. The aulix is a slight furrow, sometimes called the sii/.rus of Monro, which runs from the porta to the aqueduct on the mesal surface of the thalamus, which it divides into a doreal and a ventral area, the hahena being a slight convexity situated at the doreal margin of this sulcus. The pala is a thin structure shaped like a turf cutter connecting the fimltria and tenia in the medicornu. Trio is applied to the prolongations of pia found within the encephalic cavities : thus, the aulatdo is a pial layer which constitutes a ]>ortion of the root of the aula, the dialda a similar structure for the diac(cle, and the mdaiehi for the metactelc. Pro.mjilr.tiis, diajilc.riis, e})iple.nis, and mcUriili'.riia indicate respectively the folds of the pia with their network of vessels found within the prosoc(eIc', diaccrle, etc. Eiiocincrea is descriptive of external or peripheral, and ciitncinrnn of internal or central gray matter. The cappa is a superficial layer of gray matter, or cctoanere(d lamina of the quadrigeminal body, situated just beneath the expansion of the optic tracts. Rimidx are the crevices between the cerebellar folia or leaves. NOMENCLATURE AND TERMINOLOGY. 53 o T) M TIH W r^ 3 o >~t e-*- ^ o s-g 1 o 5' o 1 CD o' a> H » CO S i B 2 P W Z- *^ §-' 2 ■ ■ CK Pj ?D O m 3 ■ m B on ^1 ^ ETX 1= *^ 5=aE £-5 °2 r o. fs 3 c a; t; CO m C:. fro rt- ED pl ff E^ tfi rt s I — ' >- ^ ^ ^ ^ " T ° B g 3 ^ d TJ a 'X' •-' S-S ;'3' o o H ^ B Kt r^ ^:, Eo gfl 1^ m ^ B3 -I 3^0 ►d a; err" S " S C ^ a P 2. So- o a- 3 p (re 3 o' S ^ i^ 8 CO p ■ t— I S' 3 5' 3 5-w B 2- J2 CD C 3 so a- e f= " o p SB ^ ^ CD r+- -•3- 3 era 3 3 ^-; CD BBSs P -^ 3 B. ■^ 3 C B CD c^ CT'C->73 ^ ^ ^ p ?o ^ h3 ,0.00 o < 2.2 • B E-CTQ CTq' Bp CD CD CO !-• >-• CO as ^ 3 3 CD B 3 p 3 a. B^ a B o o ff. &§- == s j» 5 CD CO -a 3 03 o ^ P 3 3 3= » E 3 ' o CD 3 S &5.3g.!?8 p ^ 3 ii.p,£. P 3 cf CD C B o o < 2m f? 54 THE NERVOUS SYSTEM. GENERAL ANATOMY. Important Ganglia, Tracts, and Cavities of the Brain.— lu Fig. 64 are shown some of the most important ganglia, tracts, Fig. 64. ,16 / / 1 '^m itf r k '?F1 1 ^r 1 5-j W" Wl" : I fifii jMf ' 'm V f A ■'^- / - ' V 1 \^^ ,-a^ /■»- ■^ ^ ^^ V /m 1 ^*=»^ " f ' W ^/ 11 \ ' '^r 1 m ■'•■i i^ .i\^ dii 15 Horizontal section of the luivlinim : 1, precornu (anterior horn) ; 2, eaudatum (caudate nucleus) ; 3, anterior limti of internal i-ai>suU' ; 4. external capsule ; Ti, leuticula (lenticular nucleus) ; 6, claus- trum ; 7, jiostcriur limb of internal capsule: s, thalamus; 9. postgeniculum (internal geniculate body) ; 10, eaudatum ; 11, hippoeampus (hippocampus major) ; VI, ealcar (hippocampus minor) ; 13, clava ; 14, funiculus cuneatus ; 1'), funiculus ;.,q-ncilis ; IG, callosal i^yrc (t^yrus ciuguli or gyrus for- nicatus) ; 17, callosum ; is, septum (septum lucidum) ; W, eaudatum; a), fornieolumn (anterior pillar of the fornix) ; 21, tenia (ticnia semieircularis) ; 22, thalamus; 2:^, gemina (quadrigeminal body) ; 21, prcpedunclc (superior cerebellar peduncle) ; 2r>, postpeduncle (inferior cerebellar pedtm- cle) ; 2(1, medipeiliuu'le (middle cerebellar peduncle) ; 27. ala (ala einerea) ; 2s, obe.x ; IV, fourth or y)alhetie ner\'e. (Morris's Anatomy, after Landois and ^terhn,u.i and cavities of the brain. On the right the appearances are those observed wlicii the lateral veiitiieles are just uncovered by a horizon- GENERAL ANATOMY. 55 tal section of the liemieerebium ; on the left, when a section is made through the basal ganglia and adjacent parts. These sections reveal the gyres of the ut^nthi, the alba or white matter of the hemisphere, the extreme eajhsule, chmstrum, external capsule, lentieula, internal cap- sule, caudatiun, thalamus, callosal gyre or gyrus foruicatus, known also as thQ gyrus cinguU, eallosum, preeornu, fornicolumns or anterior pillars of the fornix, tenia, gemina or quadrigeminal body, postgeniculum or in- ternal geniculate body, hippoeamp, calcar, ala cinerea, obex, clava, funi- culus cuneatxis, and funiculus gracilis. In Figs. 65 and 66 are shown vertical transections of the left and of the right hemicerebrum, show- ing some of the structures above men- tioned in different planes, and other im- portant parts, as the precommissure, optic tract, tuber cinereum, amygdala, the sub- division of the thalamus into three nu- clei, and the nucleus of the pregeniculum or external geniculate body ; also the gyres of portions of the fronted, parietal, cen- tral, and occipital lobes. The Striata. — Formerly under the designation corpus striatum, or in the plural corpora striata, two great ganglia in the basal portion of the cerebrum were described as one, the term being given because of the streaked or mixed gray and white appearance, now known to be due to the presence of separate deposits and tracts. The great subdi- visions of each striatum are the cauda- tum, or nucleus caudatus, and the len- tieula, or nucleus lenticularis. The Caudatum. — Each caudatum, caudate nucleus, or intraventricular portion of the striatum, appears, when the lateral ventricles are exposed from above, as a large rounded mass, of pyriform shape, the larger end directed forward so as to project into the frontal lobe, the caudal extremity tapering steadily and passing around the thalamus downward along the roof of the medicornu or descending horn, and then forward again nearly to the cephalic extremity of this horn. This tail-like extension of the caudatum has been described by Dalton as making a surcingle to the thalamus. It ends at the amygdala of the temporal lobe. The caudatum and the lentieula usually merge in front for a short dis- tance, and are in close relation below with the cinerea of the pre- cribrum, or anterior perforated space, at the base of the brain. The Lentieula. — The lentieula, lenticular nucleus, or extraven- Microscopio frontal section showing the basal ganglia and adjacent struc- tures and parts. The section is stained hy the method of Weigert-Pal. The fasciculus of Meynert is seen passing downward from the hahenula. A little posterior to the plane of this section the third ventricle passes into the aqueduct of Sylvius : o, thalamus ; f, pineal body ; g, third ventricle ; h, internal capsule ; i, precommissure ; k, putamen ; n, pallidum (globus pal- lidus). 56 THE NERVOUS SYSTEM. Fig. 66. tricular portion of tlie striatum, does not, like the caudatum and the thalamus, appear upon laying open the paracceles, but is revealed by making deeper sections into the hemispheres. Below it is con- tinuous with the claustrum, as well as with the caudatum and the postcribrum. It is large, extending between the claustrum and both the caudatum and the thalamus for nearly their entire length. In horizontal section it is shaped like a biconvex lens, one curve directed outward and the other inward, the outer having a larger radius than the inner ; and in sagittal section it is also approximately lens shaped. A transection, as in Fig. 65, indicates the interrelations of the lenticula, cauda- tum, thalamus, and other parts, and also shows that the lenticula is composed of at least three distinct subdivisions sepa- rated from each other by thin white layers, which can readily be made out in a fresh brain. The outer larger segment, which is more distinctly separated from the middle than are the middle and inner from each other, is of a dark reddish color, and is called the putamen, while the middle and inner segments taken together are known as the pallid ion (or globus pallidas). The Internal, External, and Ex- treme Capsules.— The internal capsule is a broad band of white matter to the inner side of the lenticula, and between it and both the caudatum and the thala- mus. It is shown in various illustra- tions, as in Figs. 64, 65, and 66. It presents two limbs, an anterior and a pos- terior, which are demarcated by a I'nee or bend. The external capsule is a narrower white band between the lenticula and the claustrum. Between the claustrum and the insula is a third band or sheet of alba, usually unnamed, but which has been called the e.rfmne rapsnh' or lawiiui of the 8i/lrian fossa. The Claustrum.— The claustrum, shown in Figs. 64, 65, and 66, is a thin sheet of cinerea — an elongated layer or expansion of ganglion cells lying laterally to the external capsule. At its cephalic end it fuses at one point with the amygdala, and it sends small projections outward into the extreme capsule towards the gyres of the insula. The Amygdala.— The amygdala, shown in Figs. 65 and 67, is a nodular mass uf cortical ciuerea at the apex of the temporal lobe, just at the termination of the medicornu, into which it bulges as a Microscopic frontal section some- what more anteriorly situated than the one represented in Fig. 65. The cornu ammonis, external and ex- treme capsule, and claustrum are represented in the drawing, but are not designated by letter: e, optic nerve ; f, fibres from the internal capsule ; g, pallidum ; h, putamen ; i, caudatum ; k, fibres to callosum. GENERAL ANATOMY. 57 tubercle, sometimes called the amygdaloid tubercle. It lies ventrally to the lenticula, and is in contact at one place with both the lenticula and the caudatum. Embryonic Relations of the Claustrum, Caudatum, and Lenticula. — A transection through the forebrain of a human em- bryo of about ten or twelve weeks shows the rudiments of the stri- atum projecting upward into the still large forebrain vesicle ; also a rim of cortical matter near the free border of the striate body, and connected at one of its extremities with a narrow layer of the cortex proper. Sections made later show enlargements of these layers of gray matter both in the cortex and in the striatum, and white fibres beginning to separate the latter into two parts, the caudatum and the lenticula. Both, in like manner, are soon separated from the Fig. 67. Frontal section through the forebrain. (After Edinger.) cortex, except at one point at the base of the brain (Edinger). It is thus seen that these great masses of gray matter, which in the adult brain appear to be interior and separate deposits, are in origin re- lated to the cortex, from which they are pushed out in the process of development ; and it is probable that they are cortical in function as in genesis. The student without some knowledge of brain de- velopment tends wrongly to regard the thalamus and the striata, because of their juxtaposition, as having functions on the same level 58 THE NERVOUS SYSTEM. or plaae. The claustrum even more evidently than the striata is related genetically to the cortex. The relations of the various parts described are beautifully shown in one of Edinger's diagrams, Pig. 67. Commissural Structures of the Brain. — The chief structures uniting the hemicerebrums are the callosum, precommissure, niedicom- missure, and postcommissure. The fornix is sometimes spoken of as a commissural structure, but it is rather, on each side, a great tract, the hemifornix, the bodies of the hemifornices coming together in the median line. The distinction between a true commissure, or part uniting related portions of the two sides of the ueuraxis, and a decussation, or tract crossing the median line and joining different regions or levels, should be re- membered. According to some authorities, the postcommissure is not a true commissure, but in part at least a decussation of the fibres of the fillet. The precom- missure appears as a rounded band crossing the forepart of the third ventricle, and is traceable into the temj)oral lobes in two parts. The medicommissure, which consists mainly of cells, unites the thalami at the narrowest part of the diacoele at about the level of the aqueduct. The postcommissure is seen in the caudal jiortion of the dia- coele just above the entrance to the aqueduct, to which it forms a curved roof. After ]iassiug through the thalami, its di\-ergiug fibres continue into the white substance of the hemi- spheres. Some are supposed to be connected with the pineal roots and with the nut'leus of the third nerve, others with the (luadrigeminal body. A commissure called the unprda^iniiismii-e unites the known as the habena on the mesal surfaces of the thalami. Horizontal transection of the hemispheres of the cerebrum on a level with the callosum : 1. white substance of the hemispheres, dotted with divided bloodvessels ; '2, gray cortex of the convolutions ; 3, callosum, with the di- rection of its fibres indicated by transverse striee ; 4, longitudinal median stride ; 5, cephalic and caudal portions of the great longitudinal fissure. (Leidy.) Scheme of the fornix : A, A, alblcan- tia ; PPP, precommissure ; F, fimbria ; L, lyre or psalterium ; r, V, bundles of Vicq d'Azyr (so-called descending roots). slight ridges GENERAL ANATOMY. 59 The Callosum. — The callosuin is the great white commissural structure uniting the two cerebral hemispheres. It has been usu- ally taught that its fibres associate identical areas of the two hemiecre- brums ; but late researches seem to show that this is not altogether true, although they certainly do this in part. In the process of brain develop- ment the callosum begins in front of the fifth ventricle, and later reaches backward as the hemispheres develop over the midbrain. The caudal or i^os- terior extremity of the callosum is the splenium; its anterior end is the genu, and this after it has curved downward and backward is called the rostrum or beak. The body of the callosum is the part between the splenium and the rostrum. Its free portion forms the roof of the lateral ventricles. A hori- zontal transection of the cerebrum on a level with the callosum, as in Fig. 68, shows a well marked transverse striation ; a striation is also present on its ventral surface. Obersteiner has given the name indusium griseum, rendered by Wilder simply as the mononym indusium, to this thin layer of gray substance above the callosum. This indusium, which is a continu- ation of the cortex of the callosal gyre (gyrus cinguli or gyrus fornicatus), was first recorded by Giacomini, although it was recognized in 1880 by Wilder, who failed to note and publish his ob- servation. The researches indicating the transmission of nervous impulses by cell contact give to these as to other commissural striations a new significance. The Fornix. — The fornix is a body of complicated construction. Cephalad are its fornicolumiis or anterior pillars ; its two portions coming together in the middle line constitute its body ; and these caudal portions, which soon sejiarate from each other, passing to the right and the left, are its posterior pillars. The anterior pillars curve downward slightly, diverging in front of the porta, and pass- Ventral surface of the fornix and cal- losum and its intermediate surround- ings ; the brain trunk (or peduncle) haa been removed from the base ; the plane of section of the brain trunk is towards the left hemisphere : 1, body of for- nix ; 2, fornicolumn ; 3, posterior pillar of the fornix ; 4, exposed transverse fibres of the callosum ; 5, precommis- sure ; 6, anterior notch of the pallium or forebrain mantle ; 7, posterior notch of the pallium ; 8, olfactory tract ; 9, trigonum (olfactory triangle) ; 10, pre- cribrum (anterior perforated space) ; 11, basal view of the uncus ; 12, cephalic part of the hippocampal gyre. (After Rauher.) 60 THE NERVOUS SYSTEM. ing through the tuber cinereum end in the albicantia at the base of the brain. The posterior pillars curve outward and downward over the thalami, and pass along the hippocamps, as narrow flat bands of white substance known as the fimbrice. Sometimes the under or ventral surface of the fornix is designated as the lyre or psalteriim, because of some fancied resemblance to harp strings ; but this, as Wilder points out, is not a part, but merely a surface. Fig. 69 is a schematic representation of the fornix. The bundles of Vicq d' Azyr were formerly supposed to be direct continuations of the reflected anterior pillars, but this view is now regarded as doubtful. The Dentate Gyre and Fasciola Cinerea. — The dentate gyre, or fascia dentata, is a notched or dentated gray cord at the inner side of the dentate or hippocampal fissure, in the bottom of which it is almost hidden — a low serrated ridge of gray in a narrow white valley. It follows the fissure or valley upward towards the sple- FiG. 71. CallosuiTL. .. Pre- '.Commiisure Albicans ^'Giacorninis Band Dentate fascia fimbria. ^"■"'^ Mesal surface of the left hemicerebram of a fetus. (After Rauber.) nium of the callosum, where it becomes continuous with the fasciola cinerea, a similar gray layer, but one having a smooth margin : these together represent a rudimentary gyre. These parts and various aspects of the commissures, callosum, fornix and related structures, notches, fissures, foramens, surfaces, and lobes, are well shown in Pigs. 69, 70, and 71. Base of the Brain. — In Fig. 72 are represented all the impor- tant structures seen at the base of the brain after the removal of the mejnbranes, including portions of every great embryonal sub- division of the encephalon — forebrain, iuterbrain, midbrain, hind- brain, and afterbraiii. Albicantia.— Tlie albicantia, knowu also as the corpora mam- millaria, eandicantia, and pisciformes, are two small, round, white bodies squeezed in between the crura behind the tuber cinereum. They are sometimes called the bulbs of the fornix, being formed by GENERAL ANATOMY. 61 its anterior pillars after desceuding to the base of the brain. While these bodies are in the main composed externally of white, internally they are made up of gray substance ; and they are connected by a gray transverse commissure. Gudden has divided each albicans into a mesal ganglion of small cells and a lateral ganglion containing large cells. Edinger regards the albicantia as the place of separation between the forebrain and the interbrain. They have connections with the pons, and also with the anterior tubercle of the thalamus ; and they also have a tegmental bundle, which can be traced back of the gemina to the aqueductal cinerea. Fig. 72. 4''^ ^ 3 — 3 Base of the brain : 1, frontal lobes of the cerebrum ; 2, temporal lobes ; 3, occipital lobes ; 4, 5, cephalic and caudal extremities of the great longitudinal fissure ; 6, Sylvian fissure ; 7, precribrum ; 8, infundibulum ; 9, albicantia; 10, postcribrum ; 11, crura; 12, pons; 13, oblongata; 14, pyra- mid ; 14', decussation of the pyramids ; 15, olive ; 16, restiform body ; 17, lateral lobes (hemi- spheres) of the cerebellum ; 18, vermis at the bottom of the valley separating the latter ; 19, medi- peduncle ; 20, floccule ; 21, fissure which accommodates the olfactory lobe, 22 ; 23, bulb of the olfactory lobe ; 24, chiasm ; 25, oculomotor nerve ; 26, trochlear nerve ; 27, trifacial nerve ; 28, ab- ducent nerve ; 29, facial nerve ; 30, auditory nerve ; 31, glossopharyngeal nerve ; 32, vagus nerve ; 33, accessory nerve ; 34, hypoglossal nerve. (After Hirschfeld-Sappey.) Tuber Cinereum. —The tube}\ or tuber cinereum, in the interior of which is the cavity of the infundibulum, is a projection at the base of the skull, lying between the chiasm and the albicantia. Close examination shows on its outer side a tract of gray matter, which Meynert termed the basal optic ganglion, but this ganglion does not appear to be connected with the optic nerve, as was sup- 62 THE NERVOUS SYSTEM. posed by Meynert. From it on each side a small tract issues which after crossing the middle line passes backward to the subthalamic body ; by some this is supposed eventually to join the upper fillet, while in front it may be connected with the lenticula. The Infundibulum. — The infundibulum appears as a conical hollow process, a continuation of the tuber cinereum, descending from the third ventricle behind the chiasm, to end in the posterior lobe of the hypophysis, in the process of brain development having grown downward from the floor of the forebrain or second cerebral vesicle. Fig. 73. LOSE Diagram of association fibres of cerebrum : s. short fibres connecting adjacent gyres; f.l.s., su- perior longitudinal, f.l.L, inferior longitudinal, /.'(., uncinate (to the uncinate gyre), and /.p., per- pendicular fasciculus ; ci, cingulum ; fo, fornix ; fl, fimbria ; v.d'A., bundle of Vieq d'Azyr. (After Schafer-lMeynert. ) Association Fibres of the Cerebrum. — Various regions of the cortex of the hemispheres are associated functionally and of course anatomically : a general idea of the cerebral association fibres can be obtained from Fig. 73. Association fibres, called arcuate, which connect parts of the same hemisphere, are very numerous, and pass in many directions, uniting adjacent or near convolutions of the same lobe, or more distant parts of the same hemisphere. The subfrontal gyre, for example, is joined with portions of the temporal lobe ; parts of the temporal and the occipital, of the frontal and the occipital, and of the parietal and the temporal, are connected. The fornix in part of its course connects a portion of the hippocampal convolution with the thalamus. Commis.viral association fibres which pass from one side of the brain to the other chiefly in the callosum or in the prccommissure lunc already been considered. Some arcuate fil)res associating areas of the same hemisphere pass in the cingulum, wliich lies within the cingulate convolution (callosal gyre or gyrus GENERAL ANATOMY. 63 fornicatusV The bundle of Vicq d'Azyr is a collection of nerve fibres whicb pass between the thalamus and the albicantia, while the fimbria or fringe has already been described as a prolongation of the posterior pillar of the fornix. The Interbrain or Thalamencephalon. — The thalamencepha- lon, called also the interbrain or 'tweenbrain, includes the thalami, the genicula or geniculate bodies, the optic tracts, and the albicantia, although the entire thalamus is not always included. The thalamus is in many respects the most important ganglion of the nervous system, although its functions are still wrapped in considerable ob- scurity. Its surface is on the whole wedge shaped, with the blunt edge of the wedge in front. It presents several prominences, de- pressions, and bands or striae, and is subdivided into at least three parts, the anterior tubercle, the posterior tubercle or put viiiar, and below and external to the pulvinar a lateral or external tubercle or nucleus. The anterior tubercle is compared by Bdinger to a wedge driven in between the other two with its broad end in front. Other prom- inences, known as the Jmbenulas or pineal peduncles, are connected on both sides with the pineal region. The trigonum habenuhe is a small triangular area in this part of the thalamus between the pulvinar, habeuula, and midbiain. A thin layer of white matter covering the ventricular surface of the thalamus is called the stratum zonule, which consists of fine nerve fibres derived from the optic tract and retina, being in fact a thin expansion of the optic tract. The Geniculate Bodies. — On the posterior inferior face of the pulvinar are seen two small rounded protuberances, called the post- geniculum and pregeniculum, or the corpus geniculatum internum and corpus geniculatum externum. The post- geniculum, or internal geniculate body, ^'<'- "^■ which is regarded by Obersteiner and others as part of the acoustic tract, is an oval eminence to which run fibres which have been traced as the hindermost layer of the chiasm into the corresponding bundle of the opposite optic tract. The *^^ pregeniculum, or external geniculate ViewofthebaseoftheinterlDrain -, ^ -..-,, . ^ Tj_j_i and midbrain : Th, thalamus ; Po, body, a slight eminence placed to the postgemculum {internal geniculate outer side of the pulvinar, also COntrib- body) ; Pr, pregeniculum (external utes fibres to the optic tract. These fX C'' (AftS Eftib^r'r'"™" bodies are sometimes discussed as belong- ing to the thalamus, but may be regarded with the quadrigeminal body as parts of the mesencephalon or midbrain. They are con- nected by a loop or band of fibres. Their positions with reference to the pulvinar and to near structures are shown in Fig. 74. The Cavity of the Interbrain. — Between the thalami lies the third ventricle, or diaccele, the special cavity or chamber of the inter- 64 THE NERVOUS SYSTEM. brain. The thalami are close together and trend inward somewhat towards the middle line, to some extent fusing, and thus forming the gray medicommissure. The aqueduct of Sylvius passes from this cavity to the metepicoele, or fourth ventricle ; and its floor opens out, as already described, into a funnel-like depression which forms the entrance to the iufundibulum. The Conarium.— The conarium, or pineal body (Fig. 75), is in- cluded in the thalamencephalon, forming with its peduncles a portion of its roof. It has been shown that in the development of the roof of Fig. 75. Striata, thalami, quadrigeminal body, and cereliellum: 1, quadrigeminal body; 2, valvula (anterior velum) ; 3, prepeduncle ; 4, upper portion of the medipeduncle ; o, upper portion of tlie cms ; 6, pulvinar of the thalamus ; 7, anterior tubercle ; S, vermis ; 9, lingule ; 10, postcommissure ; 11, medicommissure; 12, precommissure ; 13, conarium (pineal I'tidy) turned forward; 14, pineal peduncle; 15, thalamus; 16, hemispheres of the cerebellum; 17, dentatum (dentate nucleus); 18, tenia (semicircular band) ; 19, vein of the caudntum ; 20. fornicolumn (anterior pUlar of the fornix); 21, caudatum ; 22, ventricular septum. (Hirschfeld and Sappey.) the second cerebral vesicle a hollow median pi-ocess is formed which becomes the conarivim or epiphysis cerebri, which in some reptiles is a rudimentary eye occupying an opening in the middle of the skull. It is about the size of a clierrystone, usually of a reddish color, and is situated between tlie caudal xjortious of the thalami, its inferior surface resting in the mesal groove of the pregeminum, the spleuium of the eallosum having the under part of its curvature jnst above it and the cephalic end of the cerebellum abutting against it. While the conarium has little functional importance, its position is GENERAL ANATOMY. 65 such that a lesion of any size involving it might include three of the most important regions of the brain, — the interbrain, of which it is a part, and the cerebellum and the cerebrum, by which it is en- compassed. The ancients attributed to the conarium, probably be- cause of its central position, fanciful powers and virtues, even desig- nating it as the seat of the soul. Its peduncles are flattened stalks of white fibres, each of which is separated by the pineal recess into a ventral and a dorsal portion, the former going to the postcommis- sure, and the latter, along the thalamus in the form of strife, merging into the trigonum habenulae. In the main the conarium is composed of epithelial tubules, but its peduncles contain a few nerve fibres ; its follicles often contain gritty matter which is called brain sand. The Hypophysis. — The hypophj^sis, pituitary body, or pituitary gland is a small reddish gray or reddish yellow mass, situated in the sella turcica of the sphenoid bone at the base of the brain. It was formerly described as a gland because it was supposed to secrete the pitnita or mucus of the nose. It is composed of two distinct structures, a posterior or caudal lobe, in the walls of which are found nerve cells and fibres aud neuroglia, and which is directly continu- ous with the infundibulum, and contains a cavity which was origi- nally a part of the third ^'eutricle. In lower animals at least it may be regarded as a true subdi-^isiou of the brain. In higher verte- brates and in man the nervous structures l>ecome almost obliterated. The anterior or cephalic lobe is not a nervous structure, but has developed as an epithelial prolongation of the cavity of the mouth. In adult man it contains epithelial tubes, connecti\e tissue, and bloodvessels from the pia, and here and there the tubules are cut in two so as to form vesicles. Microscopically this portion of the hypophysis resembles the thyroid body ; and in its alveoli or tubules are found a colloid material and also a special pigment. Subthalamic Region. — A transection of the brain through the pulvinar at the postcomniissure, as shown diagrammatically in Pig. 76, will bring into view several gray or dark masses and various re- lated tracts. The structures of this subthalamic region have been studied by Luys, Porel, Flechsig, Wernicke, and Edinger, among others, who have determined many facts with reference to their anat- omy, their histology, and their relations to other structures, although their functions still remain practically unknown. The two chief structures are the red nucleus and mhtJudamus ; and a little posterior to these a transection reveals the intercalatum or substantia nigra, shown in the diagram as if in the same plane. Other parts shown are the postcommissure, the iter, or aqueduct, the anterior nucleus of the third nerve, the caudatum, lenticula, and internal capsule, the pes pedunculi, the optic tract, and the ansa or lenticular bundle (ansa lenticularis or lenticular loop). Various names have been applied to the masses of fibres or to portions of them in this region, as the 66 THE NERVOUS SYSTEM. Fig. 76 Diagram of a section tlirough the I'icinity of the postcommissure, showing the ganglia and the course of some of the fibres of the subthalamic region. (After Edinger.) stratum intermedium, the substantia imunniruita, tie zona incerta, terms whicli simply indicate the uncertainty and paucity of our knowledge. Fig. 77. Transection showing the subthalamic region from a child four weeks old. (Edmger.) In Pig. 77 are shown some details of a section from a child four weeks old, which gives a more correct idea of the natural appearances GENERAL ANATOMY. 67 than is obtained from the diagram, which is not quite accurate in details and arrangements. The red nucleus and subthalamic body are exposed by this section. Red Nucleus. — The red nucleus, nucleus ruber, or tegmental nu- cleus, is an ovoid, brownish gray mass, extending backward and just below the thalamus into the midbrain below the aqueduct. It is round in transections and of an elongated oval shape in sagittal sections. Fibres of the coronal radiation surround about one third of this nucleus, which contains numerous multipolar angular cells. Subthalamus. — The subthalamus, subthalamic ganglion, or body of Luys, is a small mass of yellowish gray color in the fresh brain, situated just below the thalamus. On transection it appears as a spindle with the greater convexity placed dorsally. It lies just between the tegmentum and the crusta. It is composed of a net- work of fine medullated fibres throughout which multipolar nerve cells of moderate size are distributed. The Quadrigeminal Body.— The qiTadrigeminal body (quadri- geminum), the chief constituent of the midbrain, is conspicuous early in embryonic life. Considered as a whole it is quadrate in shape, and is subdivided on its dorsal surface into four rounded white masses. It is situated beneath the splenium of the callosum in the interval between the cerebrum and the cerebellum. Its cavity is the meso- coele, or aqueduct of Sylvius, the four elevations of which it is com- posed constituting the main roof of the mesoccele. The quadrigemi- nal body has most important connections with the optic, auditory, and other cranial nerves, with the cerebellum, and with other parts. The Cerebellum. — The cerebellum consists of two lateral lobes, usually called hemispheres, joined by a narrow lobe, the ivomi or vermis, which is subdivided into an upper, superior, or cephalic portion, the prevermis, and a lower, inferior, or caudal portion, the postvermis (Pigs. 78, 79, and 80). In several figures already given, profile and other partial views of the cerebellum have been shown. It is situated dorsally to the fourth ventricle and both Ijehind and below the quadrigeminal body. By its three sets of peduncles it is connected directly with the quadrigeminal body, with the oblongata, and with the pons. Between its peduncles, dorsally to the cephalic portion of the fourth ventricle, a white lamina, the valvida (valve of Vieussens, anterior or superior medullary velum), extends from the vermis to the postgeminum, or testes ; while the more caudal por- tion of the ventricle is roofed by another smaller semilunar lamina, ihe. posterior ox inferior medullary velum, or valve of Tarini — sometimes called the commissure of the flocculus — which is continued downward to the upper extremities of the posterior columns of the spinal cord. The fissures of the surface of the cerebellum are closer, more regu- lar, and more parallel than those of the cerebrum, giving a foliated appearance. The largest fissure {f.h-, in Figs. 78 and 79), known as 68 THE NERVOUS SYSTEM. the fireat horizontal fissure ov peduncular sulcus (Wilder), divides the surface into an upper and a lower portion. The cerebellar lobes or hemispheres are separated l>y anterior and posterior notches. Sec- tions across the direction of the lamina reveal an arrangement of gray and white matter which has a tree-like appearance and is known as the arbor or a)-bor vitir. This appearance is due to the subdivision of the lamina into smaller and these into still smaller branchings. The central white matter of the vermis, regarded as a whole, is some- times called the corpua fnipezoides, or trapezoid body, which is also applied to an important structure iu the oblongata i^referalily desig- nated the trapezium. Fig. 78. s.p.-cL i:^ ^ View of the upper surfiice of the cerebelhun, natural size, from a photograph : I.e., lohulus cen- tralis (central lobule) ; a.l.c, ala lobuli centralis (ala or lateral portion of central lobe) ; 77!,, culmen monticuli (monticulus) : l.m., lobus culminls (culmen); c.L, clivis (declivity): l.d., lobus clivi (quadrangular lobe) ; l.cac, lobus cacuminis (presemilunar lobe) ; l.t., lobus tuberis (piostsemilunar lobe) ; s.p.-c, sulcus postcentralls (postcentral fissure) : s.pr.-cl, sulcus preclivalis (preclival fissure) ; s.p.-cl., sulcus postolivalis (postcliTal fissure) ; /.h., f.li., flssura horizontalis magna (great horizontal fissure, peduncular sulcus). (Schafer, in Quain's Anatomy.) Subdivisions of the Cerebellar Surface.' — The upper surface of the cerebellum is less complex than the lower, the vermis merging into the lateral lobes or hemispheres. The prevermis, or superior vermiform process, is usually divided from the anterior to the pos- terior notch into a succession of lobes, namely, the central lobe, aud the monticulus, subdivitled into two parts, an anterior elevation, called the culmen, and a ]>osterior slope, the deelire (decliris or clirin). A subdivision called the caeumen is sometimes present below the decli\e, and the part connecting the hemispheres in the posterior ' Cerebellar tenniiinldLry illustrates forcibly the confusion caused by a mul- tijjlication of synonyms for tl)e same part, and it is to he hoped that soon a uniform systt-m of names — mononyms whenever possible — will be generally adopted. GENERAL, ANATOMY. 69 notcli is spoken of as the co)nmissura simplex or simple commi.s,m)-e. The lobes or lobules of the hemisphere on this aspect correspond closely to the subdi^'isions of the vermis ; and the names given in the illustration have reference to these relations, as lobus cidiniHis, lohus clivi, lobus caeuiiiinis, and lubus tuberis. Fissures of similar names bound and separate these lobes. While on the upper surface of the cerebellum but little demarcation exists between the vermis and the lateral lobes, on the lower these lobes or hemispheres are sepai'ated by a broad depression, the eulleeitlu or ndleij, which extends from before backward along the postvermis. The subdivisions of the Fig. 79. pJi. S.J>.-C. p.SjC. Vfl. S.pr-gr. View of the lower surface of the cerebellum, natural size, from a photograph : I., lingula : I.e., lobulus centralis (central lobule) ; a.l.c, ala lobuli centralis (ala or lateral portion of the cerebral lobe) ; s.p.-c, sulcus postcentralis (postcentral fissure) ; v.m.s., velum meduUare superius (valvula) ; ji.^.c., pedunculus cerebelli superior (prepeduncle) ; p.f., pedunculi cerebelli medius et inferior (medipeduncle and postpeduncle) ; n., nodulus ; v.m.i., reltim medullare inferius (valve of Tarini); p.fi., pedunculus flocculi (peduncle of the flocculus) ; ft., flocculus ; «., uvula ; am., amygdala (ton- silla) ; py., pyramis ; l.biv., lobus biventralis (cuneiform or digastric lobe) ; t.v., tuber valvute seu posticum (tuber) ; It., lobus postero-inferior (inferior semilunar or postsemilunar lobe) ; l.gr.'^, lobus gracilis anterior (anterior slender lobe) ; l.gr.^, lobus gracilis posterior (posterior slender lobe) ; s.pr.-gr., sulcus pregracilis (pregracile fissure): s.i.-ffr., sulcus intragracilis (intragracile fissure): s.p.~gr., sulcus postgractlis (postgracUe fissure) ; f.h., fissura horizontalis magna (great horizontal fissure, peduncular sulcus). The vallecula has been somewhat opened, to display the parts of the lower worm. (Schiifer, in Quain's Anatomy.) postvermis or inferior worm are the central lobe, lingula, nodule, uvula, pyramid, and tuber (tuber valvulw sen posticum) ; those of the lateral lobes or hemispheres are the flocculus (pneumogastric lobe), tonsil (amygdala), biventrcd lobe (digastric or eimeiforni lobe), slender lobe (lobus gracilis), — which last may be subdivided into the lobulus gracilis anterior and lobulus gracilis posterior, with their fissures of similar name, — and finally the jiostero-inferior lobe (inferior semilunar or post- semilunar lobe). The continuity of the ^'ermis with the hemispheres is not as obvious upon the lower as upon the upper aspect of the 70 THE NERVOUS SYSTEM. cerebellum ; still the mesal and lateral parts can be related to each other with but little difficulty, — the nodule to the flocculi, the uvula to the tonsils, the pyramid to the biventral lobes, the tuber to both the slender and the postero-iuferior lobe ; while the lateral or hemi- spheric portions of the lingula and central lobe are rudimentary. Besides the lobar divisions j ast given, the upper surface of the hemi- spheres is sometimes divided into an anterior square, or quadrangular lobe, which extends from the anterior notch backward as far as the posterior limits of the vermis, and a f)osterior or presemilunar lobe {superior semilwiiar lobe), which lies between the quadrangular lobe and the great horizontal fissure. The quadrangular and semilunar lobes appear in the views on both surfaces of th(' cerebellum, but the latter on its lower or caudal asj^ect is called by Wilder the j^ost- semilunar lobe. In studying the cerebellum confusion may be caused Fig. 80. vv s. fixrc Cerebellum seen on its anterior surface : vs, anterior extremity of the prevermls (superior vermis) ; VV, valvula ; pes, section of the prepeduncle ; vi, anterior extremity of the postvermis (Inferior vermis) ; pern, section of the medipeduncle ; [icl, section of the postpeduncle ; IT, posterior medul- lary velum (valve of Tarlni) ; lob, flocculus (pneumogastric lobule or lobe) ; s. circ, circumferential border. (Van Gehuchten.) through consulting different books, not only because of terminology, but also because of the different plaues in which the views are pre- sented. In some of the illustrations the tuber does not appear as a part of the upper surface. In Fig. 79 it is represented below the pyramid, in the view of the lower surface, white in the figures of Edinger and Wilder it appears on the dorsal or upper surface. In Fig. 80 is a view by Van Gehuchten of the anterior surface of the cerebellum which differs from those usually given, presenting in the mesal line, above and below, the anterior extremity of the prevermls TO, resting on a tliin wliite layer. The valvula is seen extending transversely between the piepeduncles, and under this structure is a sort of cul de sac of the fourth ventricle. Ganglia and Deposits of the Cerebellum.— The most impor- GENERAL ANATOMY. 71 tant nuclei of the cerebellum (shown in Pig. 81, with some struc- tures of the oblongata) are the dentafum (mideus tJenUdm, corpus ciliure, cei-ehellar olive), the embolus (nucleus emboliforinis), the globulus (nucleus globosus), and the fastuialum (nucleus fastigii, nucleus of the roof, or tegmental nucleus). The position of the dentate nucleus, the largest ganglion of the cerebellum, is shown at nd. The embolus lies close to the mesal side of the dentatum, and probably belongs to it, while the globulus is a small distinct deposit internal to the embolus. The fastigatum is an important collection of cells which lies close to the median line in the white matter of the postvermis. Fig. 81. 7Z-. emBolifi/r/ni-s 72- cfZobcsua jjZeicus Section across the cerebellum and oblongata, showing the position of the nuclei in the medullary centre of the cerebellum : n.d., dentatum (nucleus dentatus) ; s, band of fibres derived from the restiform body, partly covering the dentatum; sx.p., commencement of prepeduncle (superior cerebellar peduncle) ; com,', com", commissural fibres crossing in the median white matter. (Quain's Anatomy, after Stilling.) The epieoelian portion of the fourth ventricle is shaped somewhat like a tent or gable roof, as can be seen in several profile views already given, and the fastigatum is in the wall of the roof of this extension ; hence one of its names, roof n ucJens. These cerebellar deposits are here and there united imperfectly with one another. The dentate and emboliform nuclei have much the same microscoijic structure, while the roof and globose nuclei are similar in structure, having larger cells than the two former. Cerebellar Conducting Tracts. — Persevering efforts have been made to trace the course of the fibres which pass to and from and 72 THE NEEVOUS SYSTEM. through the cerebellum. Stilling, and more recently Edinger, Marchi, Bruce, and others, have devoted much laljor to the study of this and other problems connected witlL tlie cerebellum. Several sets of fibres which have Ijeen well traced are the intrnciJiari/, which pass from the anterior peduncles into the dentatum, or ciliary body ; the extraeiU- nnj, which pass external to the dentatum and converge towards it, partly entering and partly passing through its gray matter ; and the deii'liitic trarts, sets of fibres which, arising from all parts of the cortex and diA-erging from each other like the limbs of a tree, pass into the white substance. The mass of fibres which constitutes the ejira- ciJiary tracts is sometimes called the fleece, because of its resemblance tu wool. The restiform l)odies are in large part connected with the fleece. A band or tract called the direct sensory tract of the cere- bellum arises near the globose nucleus and xjasses to the outer wall of the fourth ventricle, some of its fibres ijassing out with fibres of sensory cranial nerves, and others .uoing to the posterior columns of the oblongata and spinal cord. In the cephalic portion of the alba of the vermis is a most important encephalic decussation, the anterior decussating co)ninissHrc of the cerel)ellum ; a posterior commissure also passes through the pf)Sterior extremity of the vermis, connecting the hemispheres ; and a loncjitiidinnl commissure is present in the vermis. Fibres of the Cerebellar Peduncles. — With reference to the fibres of the cerebellar peduncles and their relation to the rest of the nervous system, ilarchi concludes that the prepeduncles do not cr( iss completely, but give some fibres to the thalamus of the same side; most of their fibres go to Stilling' s nucleus of the opposite side ; and no fibres go either to the optic tract or to the bundle of Eeil. The medipeduncles are not solely commissural, but contain fibres which join the gray matter on both sides. The fibres in the postpeduncle for the opposite olive are both afferent and efferent. The dorsal longitudinal bundle and the fillet receive fibres from the cerebellum, chiefly in the vermis, and connect the nuclei of the cranial nerves with the cerebellum. The fillet connects the cere- bellum with the pons, the quadrigeminum, and perhaps the striatum. The dorsal longitudinal bundle joins the fillet about the level of the olive, and both go into the anterolateral tracts, and proliably are thus connected directly with the ventral horn and indirectly with the ventral roots. The origin of all these peduncles is spread over the whole gray matter, but the prepeduncles are connected chiefly with the dentate nucleus, the medipeduncles with the vermis. Schemes by Flechsig. Van Gehuchten, and Bruce, showing the most important tracts of the cerel)ellum, will be given later. Crura, Pons, and Oblongata.— The crura, the great highways to the cerebrum, with the iter and quadrigeminal body, are con- stituents of the midbrain or mesencephalon, as has been already shown, but, for practical reasons, in the study of local diagnosis GENERAL ANATOMY. 73 Fig. 82. and of various encephalic associations it is sometimes desirable to consider the crura, pons, and oblongata together. In Fig. 82 is an excellent view of these important structures and central parts of the cerebrum, as seen from the right side ; and in other illustra- tions already given various aspects of these structures have been shown. The description accompanying the figure is sufficient to make clear all that is necessary regarding superficial aiapearances. The pons and oblongata, which serve to join together the fore- brain, inter brain, hindbrain, and spinal cord, were often termed by older writers the isthtii/us. MeduUa oblongata in the days of Willis included not only what is now known as the oblongata, but also the pons and the crura. The pons is made to include the entire thickness of the mass between the crura and a section through the well defined cephalic extremity of the ventral face of the oblongata ; but it is more correct to regard all the dorsal portion of this segment as belonging to the oblongata — with Wilder designating it the preoblongata — calling all the more caudal portion of the isthmus the postoblongata. External Features of the Ventral Aspect of the Oblon- gata. — The length of the ventral surface of the oblongata (the post- oblongata) is nearly an inch ; its greatest breadth is about three fourths of an inch, and its thick- ness is a little less. On this sur- face the chief superficial struc- tures are the pyramids or anterior pyramids, the lateral columns, and the olives. The anterior pyramids, prominences on each side of the mesal fissure, are largely com- posed of fibres which cross below at the decussation of the pyramids. The lateral columns are continuations of the anterior and to a small extent of the lateral columns of the cord, the main bulk of the fibres View of the oblongata, pons, crura, and cen- tral parts of the encephalon from the right side : St. uppLT surface of the striatum ; Th, pulvinar of the thalamus ; C Insula ; Sy, fissure of Syl- vius, in whicli are seen the white striee of the olfactory tract ; I, the olfactory tract : II, optic nerves a little in front of the chiasm ; a, allii- cans with the tuber cinereum and infundibu- lum in front of it ; It, hypophysis ; e, pregenicu- lum, and i, postgeniculum ; P, peduncle or crus of the cerebrum ; III, right oculomotor nerve ; p, epiphysis ; q, quadrigeminum (quadrigemi- nal body) ; IV, trochlear nerve arising from V, the valve of Vieussens ; V, placed on the pons above the right trigeminal nerye : s, the superior, m, the middle, and in, the inferior peduncle of the cerebellum cut short ; VI, the sixth nerve ; VII, facial nerve ; VIII, auditory nerve ; IX, glossopharyngeal nerve ; X, pneu- mogastric nerve : XI, the uppermost fibres of the spinal accessory ; XII, hypoglossal nerve ; pa, pyramid ; o, olive ; ar, arciform fibres : r, resti- form body ; tr, tubercle of Rolando ; ca, ven- tral or anterior, cp, dorsal or posterior, and d, lateral columns of the spinal cord ; CI, Ci, ven- tral and dorsal roots of the first cervical nerve. (Quain's Anatomy, after Allen Thompson.) 74 THE NERVOUS SYSTEM. Fig. 83. of the latter crossing and becoming continuous with the anterior pyramids ; so that, in the main, anterior and lateral and lateral and anterior change places in the spinal cord and oblongata. The ante- rior pyramids are frequently crossed by arched fibres, constituting the pontkidus (little bridge) of Arnold. The olives, known also as the lower olives or olivarij bodies, appear externally as longitudinal oval eminences projecting from the lateral columns close to the pons and extending longitudinally about half the length of the oblongata. In the longitudinal grooves between the different structures of the ventral and lateral surfaces of the oblongata, and in the transverse furrow between the latter and the pons, the cranial nerves from the sixth to the twelfth have their origins, most of them by numerous roots. External Features of the Dorsal Aspect of the Oblongata. — On its dorsal aspect the oblon- gata includes both the postob- longata and the preoblongata — the latter lying dorsally to the pons — the length of the entire structure being about two inches, and the depth of the preoblongata being about half that of the post- oblongata at the latter' s greatest thickness. This aspect of the ob- longata presents the floor of the fourth ventricle or mefejnccelian floor, and two important pro- longations of the columns of the spinal cord, the postpyramids and restes (posterior pyramids and res- tiform bodies). When the columns of GoU or posteromedian tracts of the spinal cord reach the ob- longata, they become demarcated by the median fissure and a slight lateral groove, as narrow cylin- ders, the gracile funicles (funiculi graeiles), ^hich cephalad expand into elevations known as the claiHi, the two together consti- tuting the postpyramids of the postoblongata. Between the fu- niculi graeiles and posterolateral grooves are other distinct col- umns, known as the cuneate fimielcs {funiculi cuneati), which are pro- longations of the posterolateral columns of Burdach : and still more laterally are the funiculi of Rolando or external cuneate funicles, with Dorsal part of oblongata and floor of fourth ventricle ; magnified one and a half times : 1, prepeduncle of the cerebellum, cut surface ; 2, medipeduncle and postpeduncle ; 3, lingula lying on the valvula or velum ; 4, anterior or ventral median Assure ; 5, gracile funicle ; 6, clava tapering away at 7 ; 8, internal cuneate funicle ; 9, external cuneate funicle ; 10, lateral funicle; 11, cuneate eminence; 12, obex; 13, ponticulus ; 14, inferior velum ; l.s, prefovea (superior fovea) ; 16, postfovea (inferior fovea) ; 17, ala (ala cinerea) ; 18, terete funicle ; 19, auditory eminence cnissed by auditory stria; ; 20, root of auditory nerve. (Leidy.) GENERAL ANATOMY. 75 Fig. 84. their tubercles, wMcli are prolongations and projections of the sub- stantia gelatinosa of the cord. Another narrow dorsolateral st rand, the direct cerebellar tract, appears on each side just above the tubercle of Rolando. Arched fibres course OAer the pyramids, oli\'es, and cuneate fuuicles from the ventral median fissure. The restiform body is formed by the coming together of these columns and bands —the cuneate funicles, funicle of Eolando, direct cerebellar tract, and external arched fibres— with the addition of other fibres coming from the opposite side of the oblongata ; and these restiform bodies become the postpeduncles or inferior peduncles of the cerebellum. The Floor of the Fourth Ventricle.— The dorsal aspect of the oblongatas is largely constituted by the floor of the fourth ventricle, which is rhomboidal, lozenge shaped, or diamond shaped, as shown in several views. The fourth ventricle as a cavity has already been described ; but it is of practical ad- vantage to be fa- miliar with the ap- pearances presented by the floor of this space, and to know the meaning of its eminences, depres- sions, grooves, stria- tions, and colora- tions. In the first place, this metepicce- lian floor presents a shallow mesal groove or sulcus ; and ivMte acoustic or medullary strice, which divide it into a cephalic or up- per and a caudal or lower portion. By a comparison of Figs. 83 and 84 with the description in the text and with the legends, the landmarks can be learned. Because it has the shape of a pen, the most caudal portion of the ventricle has been called the calamus View of the dorsal surface of the oblongata. The left half of the figure represents : Cn, funiculus cuneatus, and g, funiculus gracilis : 0, obex ; sp, nucleus of the spinal accessory ; p, nucleus of the pneumogastric ; p + sp, ala (ala cinerea) ; iJ, restis (resti- form body) ; XII', nucleus of the hypoglossal ; t, funiculus teres ; a, nucleus of the acusticus ; in, strife medullares ; 1, '2, and 3, cere- bellar pedimeles ; /, prefovea ; 4, eminentia teres ; 5, ceruleum (locus ceruleus). The right half of the figure represents the nerve nuclei diagrammatically : V, motor trigeminal nucleus ; V, median and V", inferior sensory trigeminal nuclei ; VI, nucleus of abducens ; VII, facial nucleus ; VIII, posterior median acoustic nucleus ; Vlir, anterior median, VIII", posterior lateral, VIII'", anterior lateral acoustic nuclei ; IX, glossopharyngeal nucleus ; X, XI, and Xn, nuclei of vagus, spinal accessory, and hypoglossal nerves respectively. The Roman numerals at the side of the figure, from V to XII, represent corresponding nerve roots. (After Erb.) 76 THE NEEVOITS SYSTEM. h - scriptorius ; while its pointed lateral extremities, at the position of the medipeduncles, are the lateral recesses. In the upper segment or triangle of the floor, near the aqueduct, on both sides of the median line is a slate-blue area, the locus cendeus, corresponding to the sub- jacent .substantia ferrur/inea, which contains pigmented cells from which it is supposed that the trophic fibres of the trigeminal nerve are derived. On each side of the mesal sulcus run slightly promi- nent columns, the funiculi teres or terete funicles, fasciculi or bundles which are dorsad to the dorsal or posterior longUudinal bundles of the tegmens. In the lower portion of the superior triangle these rounded columns become slight elevations, the eminentia teres, which are in relation with the nuclei of the abducens nerve and the curved rootlets from the facial cell nest which pass over the abducens nuclei and form what is known as the geaufaciaUs. External to the terete emi- nence is a small angular depression, the prefovea or superior fovea. Below the medullary strife, in the lower triangle of the ventricular floor, a little laterad of the mesal groove, is another small triangular depression, the postfovea or inferior fovea. A triangular area of a gray or ash color in the lower portion of the caudal sub- division of the ventricular floor is known as the ala or ala cinerea. This area is the darkest portion of the floor ; it corre- sponds in part to the nuclei of the pneu- mogastric and of the glossopharyngeal ner\e. At each lateral extremity of the medullary strife is a thin grayish ridge, the teniola cinerea, which has been shown by Spitzka and others to correspond to the tuberculum acustieum in lower mam- mals. Between the medullary strife, the mesal groove, and the ala cinerea is a white field, the ala alba medi- alis, which is relfited to the hypoglossfil nucleus! It will thus be seen how these and other landmfirks serve to fix the positions of structures in the interior of the oblongata, and therefore constitute important aids and guides in making either gross or microscopical examinations of these parts. The Region of Transition from the Spinal Cord to the Ob- longata.— The griiy matter of the spinfil cord retains the same gen- eral shfipe and appearance from the conns until the oblongata is nearly reached ; but the gray substance of the posterior horns, as seen in sections, increases considerably as it is followed upward, and at about the le\el of the first, and sometimes even of the second Section of the lower end of ob- longata at level of decussation of anterior pyramids: a, anterior pyramidal tracts ; b, posterior me- dian septum; c, fibres of crossed pyramidal tracts crossing (d) to an- terior pyramid of opposite side ; e, ventral horn of gray matter iso- lated by decussating fibres; f, re- mains of bases of ventral horns; g, nucleus gracilis; h, enlarged and displaced posterior horns. GENERAL ANATOMY. 77 Fig. 86. cervical nerve, these horns become club-shaped gray masses united with the central ciuerea by only a thin stalk. A little higher, pro- jections or tubercles are formed and bundles of white fibres begin to penetrate and pass through these gray masses. Two separate nuclei are here formed, known respectively as the Hurleus f/ivciUs and the nuck'iis cuneatiis, which are in fact simply extensions ujjward of the spinal ciuerea. These masses cephalad form the distinct ele- vations or eminences known as the davate or gracile tiihrrcJe and the citneate tubercle or eminence. The clavate nucleus is nearer than the cuneate to the posterior median groove. Eemains of the pos- terior horns are still seen, and are known at this position as the substantia gelatinosa of Rolando. External to the cuneate nucleus is a small gray mass called the external or accessory cuneate nucleus, which probably represents a continuation of Clarke's column. Interior Structures of the Oblongata. — In Pigs. 85 and 86, the interior structures of most of the parts in the transitional region above mentioned are shown, and also two great decussations — one motor, composed of fibres of the anterior pyramidal tracts, and the other sensory, of fibres emerging from the cuneate and clavate nuclei. The oblongata is a complex structure, on the unravelling of which much labor has been spent, and not unfruitfully, although much still remains to be done. In the first place, all the nuclei or cell nests of the cranial nerves from the third to the last are located in the preoblongata and postoblongata, near their dorsal surfaces. The oblongatas also contain certain spe- cial ganglia, numerous intranuclear and intraganglionic tracts, and other long nerve tracts, which connect the spinal cord with the midbrain, the interbrain, the cerebrum, and the cerebellum. In all essential features the oblong ciuerea corresponds with the gray matter of the spinal cord. Cell masses and eminences take the place of horns and elongated prominences of isolated columns. Motor nidi contain multipolar cells like those found in the ventral horns of the cord, and the nuclei of the sen- sory cranial nerves have a structure similar to that of the dorsal ganglia and dorsal spinal horns. It is only by studying many trans- verse, longitudinal, and horizontal sections that a familiarity with the internal structure of the oblongata and pons can be obtained. Fig. 87 is an illustration of the interior appearances seen in a tran- section of oblongata at level of sensory decussation : it, anterior pyramidal tracts ; b, posterior me- dian septum ; c, gray matter repre- senting bases of ventral or anterior and dorsal or posterior cornua ; e, pyramidal nucleas ; f, sensory fibres displacing posterior horn ; g, nu- cleus gracilis ; i, posterior horn, sub- stantia gelatinosa of Rolando; k, nucleus cuneatus ; 1, decussating sensory fibres. The decussation of the motor fibres is here complete. 78 THE NEEVOUS SYSTEM. section of the oblongata through the olives. Within each olive is an olivary nucleus, a lamina of gray matter of ovoid shape and of cor- rugated outline, having the appearance of a pouch with its mouth directed inward. In this zigzag zone of gray matter which forms the outer boundary of the open pouch are found numerous small multipolar cells mixed with neuroglia. Besides the olives the most important structure is the formatio reticularis ; the other nuclei, fibres, grooves, and Imndles have been or will be explained in other ■=■) to connections, Fig. 87. Section of oblongata of child through olivary bodies : a, anterior median groove ; b, raphe ; c, formatio reticularis ; d, gray matter of nucleus dentatus of olive ; e, dorsal accessory olivary body ; /, root ilbres of hypoglossal nerve ; g, nucleus arciformis ; h, external arcuate fibres ; /, anterior pyramidal tract ; k, remains of nucleus lateralis ; /, substantia gelatinosa of Rolando and fibres of descending trifacial root ; m, n, gray matter of posterior (cuneate) funiculus ; o, funiculus solitarius ; p, nucleus ambiguus; q, root fibres of pneumogastric nerve; r, s, hypoglossal and vagus nuclei; t, nerve cells of funiculus gracilis ; u, posterior medullary velum closing in fourth ventricle, IV. (Piersol.) Formatio Reticularis. — The formatio reticularis, or reticular field, consists of numerous interlacing fibres of different lengths interspersed with multipolar cells, and can be readily followed as a structure of peculiar appearance in the central regions of the oblongata and pons from the top of the posterior columns cephalad all the way into the midbrain. The reticular field is shown in several transections, and its great longitudinal extent in Flechsig's diagram of the encephalo- spiual conducting paths. In the oblougata it lies just dorsad of the pyramids and olives, and iu the pons ventrad of most of the nerve nuclei, although some of these, as the nucleus of the facial and of a portion of the trigeminal, lie within its bounds ; it also contains GENERAL ANATOMY. 79 a considerable collection of cells, called the superior olive. Just at the dorsal border of this formation, close to the raphe, an impor- tant angular tract known as the dor- sal ov posterior longitudinal bundle is isolated, and extends the whole distance from the spinal cord to the quadrigemiual body. Interior Structure of the Pons. — The pons, as it has been delimited in this chapter, contains numerous small aggregations of gray matter, the nuelei pontis : but it is composed chiefly of masses of fibres, longitudinal and transverse. The longitudinal are mainly continua- tions of the pyramidal tract from the cerebrum to the spinal cord ; but at least three sets of transverse fibres are easily recognizable, one commis- sural, uniting the lateral lobes of the cerebellum, the other two decussat- ing ; of the latter the first set comes from the cerebellum and crosses to the opposite side, thence to pass onward to the cerebrum, while the second, which also decussates, prob- ably goes chiefly to the cerebrum, but its fibres originate mainly in the pontile nuclei. These transverse fibres pass both before and behind the pyramidal bundles, those which are dorsad to the pyramid consti- tuting a special tract known as the trapezium, or corpus trapezoides, many of the fibres of which pass around the superior olivary nucleus. Cranial Nuclei and Nerve Roots. — rig. 88 is a profile view of the right half of the oblongata and pons, supposed to be transparent, giving a fair idea of the course of the nerve roots and of the relative positions of the deep and superficial origins of the nerves. In several other illustrations the superficial or apparent origins of these nerves have been indicated, all being on the lateral and ventral aspects of the pons and oblongata : their Profile view of the right half of the ob- longata and pons, shelving the chief cranial nerve nuclei and the course of their root fibres. The numbers indicate nerves of cor- respondlBg number : Va, mesencephalic root of the fifth nerve, probably passing to the motor root ; V, descending (spinal) root of the fltth nerve (formerly called the ascend- ing) ; Vs, its sensory, and Vm, its motor nu- cleus : VIII' is the outer or ventral nucleus of the eighth nerve ; n.a is the nucleus am- biguus. (Quain's Anatomy.) 80 THE NERVOUS SYSTEM. deep or true origins are in the preoblongata and postoblongata, and have been indicated when describing the floor of the fourth ventricle and its internal correlatives. It is important for diag- nostic purposes to know not only the exact locations of the deep and apparent origins of these nerves, but also the manner in which the root fibres traverse both oblongata and pons to reach the ven- tral or lateial surfaces. In order to involve the cell nests of the cranial nerves, lesions must be situated in the extreme dorsal por- tions of the oblongatas, but root fibres may be attacked by lesions which affect any of the formations of the pons or oblongata. "When treating of affections of the cranial nerves and of the substance of the pons and oblongata, this important subject will be more particu- larly discussed. The Deep Origins of the Cranial Nerves. — It will be necessary here, however, to direct attention a little more fuUy to some points connected with the cranial nerves, and the other structures of the pons and oblongata, in order to understand their relations to each other and to certain tracts entering into the architecture and general physiology of the nervous system. Of the twelve pairs of cranial nerves, the olfactory issues from the forebrain ; the optic from the iuterbrain ; the common oculomotor and pathetic spring from the midbrain ; the trigeminal, abducens or external oculomotor, facial, aud acoustic from the hindbrain ; and the glossopharyngeal, pneumo- gastric, accessory, and hypoglossal from the afterbrain. The deep as well as the superficial origins of the motor nerves are in the parts of the brain just indicated; but the nerves of common and of special sensibility originate in ganglia situated on their diirsal or posterior roots or tracts. The spinal and cranial nerves, both sensory and motor, are usually described as originating in regions of the spinal c(n'd, oblongata, and other more cephalic structures at the base of the brain ; but the intra-axial cell nests of the sensory nerves are best regarded as terminal nuclei for the peripheral elements of the sensory tract or path — as masses which link together the peripheral and the central elements of this tract. Their real origins are in the dorsal spinal ganglia, and in certain cranial ganglia, as the jugular, petrous, plexiform, and Gasserian. Axis cylinder prolongations from the ganglia of these sensory cranial nei\es pass into the neuraxis, processes for the glossopharyngeal and the vagus going to the da ciiwrca in the postolilongata, and those for the trigeminal nerve proceeding to its great terminal sensory nuclei in the substantia ffelathwsa. Ascending and Descending Roots of Sensory Cranial Nerves. — After entering the spinal cord the dorsal or posterior root fibres divide into T-shapes, or dichotomously, one branch running upward and the other downward, these branches forming the bulk of the posterior coluiinis, and collaterals passing from them into the gray GENERAL ANATOMY. 81 substance, there to break up into nerve trees. The sensory subdi- visions of the mixed cranial nerves — pneumogastric, glossopharyn- geal, and trigeminal — follow the same course ; that is, after entering the oblongata they bifurcate into ascending and descending branches. In various illustrations the location and course of the root fibres of the fifth nerve have been shown, as in Fig. 87, where they are seen closely related to the substantia gelatinosa of Eolando, or in the profile view. Fig. !SS, where a long root is seen extending towards the spinal cord, and a shorter one towards the midbrain. This long root has until recently been regarded, and in most books is still designated, as the ascending ; but this root is I'eally a descending portion of the main sensory root, and with our present knowledge should be called descending or spinal. In a similar manner the funiculus or fascicuJus solitarius (Fig. 87), or solitary huntlle of Meynert (respiratory bundle of Krause), represents the descending roots of the sensory portions of the pneumogastric and glossopharyngeal nerves. Nuclei and Root Fibres of the Acoustic Nerve. — The acous- tic or auditory nerve, which arises superficially by lateral and mesal roots from the lower border of the pons, is subdivided into two parts. The lateral, dorsal, or posterior root is continuous with the cochlear nerve, and is the true nerve of hearing ; while the mesal, ventral, or anterior root Fig. 89. becomes the vestibular nerve, which is con- cerned especially with equilibration. The spi- ral ganglion, an arrange- ment of nerve cells also ■called ganglion ofCorti, corresponds for the cochlear nerve to a pos- terior spinal ganglion, and the ganglion of Scarpa in the depths of the internal auditory canal, to the same for the vestibular division of the nerve. The ob- longata! nuclei (Fig. 89) related to these nerves are usually regarded as three in number, the ventral or accessory acoustic nucleus or auditory ganglion (Bruce), on the outer side of the restiform body ; the dorsal or internal nucleus, sometimes called the chief nucleus, lying beneath the floor of the fourth ventricle, and reaching the whole distance from the clavate 6 Transection showing the structure of the oblongata at the caudal border of the pons : 0, inferior olive (olivary body) ; S, restis (restiform body) ; S.g., substantia gelatinosa of Eolando; D.s.c.t, direct cerebellar sensory tract, including Deiteis's nucleus ; Alt, anterior lateral tract (lateral medullary tract)); Ctt, central tegmental tract; D.t./., dorsal or posterior lon- gitudinal bundle; Y.a.n., ventral acoustic nucleus; B.a.n., dorsal acoustic nucleus ; G.n., glossopharyngeal nucleus ; F.n., facial nucleus ; F.r./., facial root fibres. (After Eduiger.) 82 THE NERVOUS SYSTEM. nucleus to the nucleus of the sixth nerve ; and the so-called external or superior nucleus or nucleus of Deiters, on the inner side of the resti- form body, although by some the acoustic connections of these two nuclei are regarded as doubtful. The cuneate nucleus has also relations of importance to the auditory nerve. In the courses taken by them after entering the neuraxis, the cochlear and vestib- ular branches of the auditory nerve show striking homologies with the spinal sensory and with other cranial sensory nerves ; and the optic and olfactory iier\'^es have similar homologies, all of which will be considered when the great sensory path is described. The Nuclei of the Motor Cranial Nerves. — Through nearly the entire length of the oblongata, and seen therefore in numerous transections, is a large collection of ciuerea, known as the nucleus Fig. 90. Transection through the pons In the region of the genufacialis : ^^. abducens roots ; Gf, facial knee (genufacialis) ; VH, emerging root of the facial nerve ; V, descending (spinal) root of the trigeminal nerve ; O, superior or minor olive. (Modified from KoelUker.) ambif/uus (Pigs. 87 and 88) or common nucleus, which is practically a continuation of the ventral spinal horns, and from which arise the motor branches of the glossopharyngeal, pueumogastric, and spinal accessory nerves. The liypoglossus arises from a separate large nucleus. The nuclei of the se\euth or facial nerve are situated in the r(>ticular field, dorsad to the sui)erior olive and somewhat deeply placed below the floor of the fourth ventricle. The positions and cor- relations of this nerve are shown in several illustrations. Its root fibres in their course form a curious double bend which is called the genufacialis (Pig. 90). Spitzka describes the facial bundle as curving over the abducens nidus and overlying it like a bent horseshoe over a ball. The nucleus of the sixth or abducens nerve is the ental GENERAL ANATOMY. 83 correlative of that portion of tlie terete fasciculus which lies just cephalad of the acoustic strife. The motor nucleus of the trigeminal nerve, much smaller than its great terminal sensory nucleus, is situ- ated a little more mesad and ventrad than the latter, l^eueath the cephalic portion of the metepicoelian floor. The nucleus of the fourth or pathetic nerve lies in front of the gray matter dorsad of the aqueduct, about midway between the pregeminum and the post- geminum, close to the lower end of the third nucleus. The cell nests of the third or common oculomotor nerve are in the ventral portion of the central cinerea of the aqueduct, close to the middle line, in several separate segments or groups of cells, which extend longitudinally from the postcommissure to a point nearly midway between the pregeminum and the postgeminum. Special Ganglia and Nuclei in the Oblongata and Pons. — Besides the cell masses which are clearly related to the roots of the cranial nerves, other special nuclei and ganglionic masses are found in the oblongata and pons, some of known and some of unknown functions and relations. The largest of these is the inferior olive (oliva, olivary body), already described, which has near it two small nuclei, a dorsal or outer and a mesal or inner olivary nucleus. Other deposits or cell masses are the superior olive, the centred nucleus, and the lateral nucleus. The superior olive (Pig. 90) is an ovoid mass which extends through the entire length of the pons in the ventral portion of the tegmentum, close to the trapezium, and has numer- ous connections with the nuclei of the cranial nerves and of the cerebellum, also with the postgeminum, and even with the spinal cord. The central nucleus is an accumulation of gray matter in the higher levels of the oblongata. The lateral nucleus, in the periphery of the oblongata, under the groove between the inferior olive and the restiform body, is composed of a ventral and dorsal group of cells, and probably represents the continuation of the lateral horns of the cord. Nerve Tracts in the Oblongata and Pons. — The intricate nerve tracts in the oblongata and pons might perhaps be separated into numerous groups according to the directions taken by their constitu- ent fibres, but, as shown in several illustrations in the near context, they are chiefly : 1, longitudinal ; 2, transverse — including those which run an almost straight course and those which are more or less oblique in direction ; and, 3, arcuate or curving. Two sets of fibres, which have been especially studied, cross the middle line near the pregeminum, one beneath the dorsal longitudinal bundle, called Mey- nej-t' s fountain-like tegmented decussation, the other on the ventral side of the red nucleus, known as Forel's ventral tegmental decussation. Longitudinal Tracts. — Some of the great nerve root tracts, as the descending branch of the trigeminus and the solitary bundle of Meynert, constitute longitudinal fibre tracts in the oblongata and 84 THE NERVOUS SYSTEM. pons ; but the longitudinal tracts of this region, as usually given, are : 1, the pyramidal tract ; 2, the lemniscus or fillet ; 3, the lateral medullary tract ; 4, the central tegmental tract ; 5, the dorsal or poste- rior longitudinal bundle. The pyramidal tract is the great cortico- mu3cular or motor pathway, and will be described in its entirety when considering the architecture of the nervous system. It occu- pies a large place in the crustal portion of the crura and pons, as shown in several figures ; and in the oblongata it gets to the sur- face as the anterior pyramid. The lemniscus or fillet will be pres- ently described in detail. The lateral medullary tract is a distinct strand or bundle in the most lateral portion of the reticular field, passing outward to the periphery of the oblongata. It lies just ven- trad of the direct cerebellar tract, for which it has been mistaken. Fig. 91. Transection through the eras and pres;eniinum : A, iter or aqueduct ; B, brachlum conjunctivum ; Fl, dorsal longitudinal bundle : Illn, oculomotor nucleus ; ///, roots of the oculomotor cut longi- tudinally and transversely ; M, Meynert's fonntain-like tegmental crossing ; F, Forel's ventral teg- mental crossing; Sn, longitudinal bundle on the edge of the substantia nigra (intercalatum) ; Y, descending root of fifth nerve. (After Koelliker.) It contains Gowers's tract, and, according to Bruce, terminates in the lateral nuclei of the oblongata, in the lower pole of the supe- rior olive, and bj' a special bundle which crosses the trapezium to enter the lateral fillet. Bechterew, Edinger, and others have de- monstrated a central tegmental trad, beginning near the dorsal acces- sory nucleus and passing cephalad in the mid-tegmeutum. In one of my cases of thalamic disease witli involvement of the posterior limb of the internal capsule, this tract with the inferior olive was found to be markedly degenerated, showing that it probably reaches to the iutcrbrain. According to Bechterew, it terminates in the lenticula. The dorsal longitudinal bundle already indicated GENERAL ANATOMY. 85 is a compact fasciculus which can be traced throughout the oblon- gata and pons as far cephalad as the nucleus of the third uer\'c. Transverse Tracts.— The most important transverse fibres are the superficial and the deep transverse fibres of the pons, the latter in- cluding the trapezium or trapezoid body. These bundles are found respectively on the ventral and dorsal aspects of the pyramidal tracts. Arcuate or Arciform Tracts.— Arcuate or curved fibres are to be seen in many transections of the oblongata or pons, and their arching course shows clearly in the planes of several of the trans- verse sections. These arcuate fibres are conveniently subdivided Fig. 92. .,VV .1 ■ M [V Longitudinal section of the entire brain througli the cortex, alba, striata, thalamus, pons, oblon- gata, and cerebellum : 0, occipital lobe ; P, putamen ; G.P., pallidum (globus pallidus) ; Pc, pre- commissure ; 0. T., optic tract; Pi\ preoblongata ; Po, postoblongata ; D, dentatum (dentate nucleus). into a superficial or external and a deep or internal set. Internal arcuate fibres constitute the decussation of the fillet ; others frojn the clavate and cuneate nuclei pass through tlie dorsal longitudinal bundle and inferior olive to the fillet and restiform body of the op- posite side ; and still others pass from the inferior oli\'e to the opijo- site restiform bodies. Many of these curving strands run from the nuclei of the motor cranial nerves, partly to the opposite dorsal longitudinal bundle and partly to this fasciculus on the same side. Others from the nuclei of sensory and sensorial nerves pass into the reticular field of either the opposite or the same side, probably into the central tegmental tract, which may serve to correlate the cell nests of the sensory cranial nerves, as the dorsal longitudinal fas- 86 THE NERVOUS SYSTEM. ciculus does those of the motor. It is owing to the correlations which many of these tracts are intended to accomplish that their fibres take a curved or arciform course, some passing from longitu- dinal tracts to nuclei situated at different levels and in different longitudinal planes ; some leaving nuclei and decussating to enter important longitudinal tracts either ascending or descending ; some serving to connect ganglionic masses with others widely separated in the midbrain, hindbrain, or afterbrain. The Crusta and the Tegmentum. — The crura and pons are con- veniently subdivided into a ventral or anterior portion, the crusta, and a dorsal or posterior, the tegmentum. The former is also known as the pes or fuss, the lattei' term being commonly used by the Ger- mans. These subdivisions in the cerebrum pass among the basal ganglia — the crusta in the main piiramldal tract, which comes from the motor cortex, and tlie tegmentum as the tegmental radiation, which probably goes chiefly to the limbic lobe and the postparietal region. Below the pons the crusta and tegmentum blend with less definition with the ventral and dorsal structures of the oblongata. Thej^ appear most Fi's- 93. distinctly as separate formations in a tran- section through the crura just above the pons. The tegmen- tum is much darker in appearance be- cause it has in it many nerve cells, which in some places Subthalamus K-f * \ Oi •^ are arranged in well defined nests, de- posits, or ganglia. At the cephalic ex- tremity of the crura, close to the pulvinar, the crusta contains fibres from the motor cortex and from both the frontal lobe and the temporal lobe to the pons. Fig. 92 represents a longitudinal section through the entire right half of the brain, close to the raphe of the callosum, showing the relations of the crusta and tegmentum to the more cephalic structui'cs aiid also to the oblongata and cerebellum. Sev- eral of the subthalamic structures are shown in Fig. 93, the section being made in a slightly diff'erent plane. Longitudinal section through the basal ganglia, subtlialamus, substantia nigra (mteroalatum), pons, and oblongata: Im. ante- rior limb of internal ca]isule ; Icp, posterior limb of internal cap- sule ; G, genu or knee of internal capsule. GENERAL ANATOMY. 87 ^/f/: Intercalatum, or Substantia Nigra. — Sometimes the tegmen- tum and crusta are described as separated by the substantia nigra or locus niger, names which have been given because ^'^- ^■*- of the dark color of the mass, which is due to pig- mented cells. Spitzka has proposed the name inter- calatum, referring to its constant intercalation be- tween the tegmentum and the crusta. The inter- calatum is a collection of nerve cells and fibres the functions of which are as yet unknown. It can be demonstrated from the subthalamic region down- ward to the midbrain. The Lemniscus or Fillet. — The lemniscus or fillet (Fig. 94) is best studied by a series of transections beginning at the crura and passing downward to the junction of the oblongata and the cord. It is divided into three parts : a division which probably goes to the parietal and limbic cortex and hence has been called the cortex "'^c. lemniscus tract ; another subdivision, which goes to the pregeminum and to the thalamus ; and a lower lateral division, which passes to the post- geminum. It is a part of the great sensory tract, which is in the most ven- tral portion of the teg- VIIIACCNUGL. Diagram to show the constituents of the fillet: N.F.O., nucleas funiculi gracilis (gracile or clavate nucleus); X.F. C, nucleus funiculi cuneati (cuneate nucleus) ; F.A.I., inter- nal arcuate fibres crossing the raphe ; a, fibres to pons ; b, fibres from pons ; M.F., median fillet ; L.F., lateral fillet ; P.C.Q., postgeminum; A.C.Q., pregeminum; Opt. Thai., thalamus; L.X., lenticula ; S.O., superior olive; N.C.S.. nucleus centralis superior. Jjateral fillet : ] , fibres from median fillet to postgeminum ; 2, fibres from superior olive to postgeminum ; 3, lateral medullary tract ; 4, fibres from nu- cleus centralis superior to lateral fillet; VIII.Acc.Nml., ac- cessory nucleus of auditory nerve ; 5/, Flechsig's tract from accessory nucleus to lateral fillet by way of trapezium (corpus trapezoides) ; 56, Baginsky's tract from accessory nucleus of opposite side to lateral fillet by trapezium. (Bruce.) mentum. On its way brainward it gathers in the fibres which come from or go to the cell nests of those cranial nerves which have sensory functions. 88 THE NERVOUS SYSTEM. Chief Subdivisions of the Spinal Cord. — The appearance, di- mensions, and some of the relations of the spinal cord to its nerves and to other parts have already been briefly described, and, as has been stated, transections of the spinal cord reveal a peculiar arrange- Fro. 95. Transection of spinal cord in lower cervical region. (Schafer, in Quain's Anatomy.) Fig. ment of gray and white matter differing somewhat in bulk and ap- pearance at different heights. It is necessary at this point to study the main divisions of the spinal cord, as re^-ealed by tliese sections, in order to understand its relations to other portions of the nervous system. In Figs. 9.5, 96, and 97 are shown semi- diagrammatic view.s of tran- sections in the lower cer- vical, thoracic, and lumbar regions. The spinal cord is composed of symmetrical halves, sei^arated dorsally by a septum and ventrally by a fissure. Its gray mat- ter forms au H-like mass, the bar of the H being com- posed of a gray and a white or whitish commissure. The bulk of the gray matter is divided into a ventral or anterior horn and a dorsal or posterior horn, the former broader aiul more massive than the latter. The ventral horn is placed at a considerable distance from the periphery of the cord ; Transection of spinal cord in lower thoracic or dorsal reyion. (Schilfer, in Ciuain's Anatomy.) GENERAL ANATOMY. 89 while the dorsal horn reaches by its pointed extremity to the sur- face ; and near its tip this horn is capped by a semitransparent substance, the substantia gelatlnosa of Bolando. The gray substance intermediate between the two horns has been named by Gowers the intermediate gray substance. In the thoracic region is a projection about the position of the intermediate gray substance, sometimes spoken of as the lateral horn, and sometimes as the intermediate 2)rocess of Gowers, or the intermediolateral tract of Lockhart Clarke. What is known as Clarke's column or the posterovesicidar column of Clarke is a column of nerve cells (/) grouped in the inner portion of the neck of the dorsal horn, principally between the eighth cervical and third lumbar segments. Nerve cells are arranged in groups in the sub- FiQ. 97. POSTERIOR 3T- BUNDLES Section of spinal cord In lower lumbar region. fSchafer, in Quain's Anatomy.) divisions of the gray matter at all levels, and these superimposed groups form cell columns or longitudinal tracts of cells. The best defined of these groups are indicated in the illustrations at a, b, V, c, d, e, f and g, in Figs. 95, 96, and 97. A general division of the white matter of the spinal cord is made into a ventral or anterior, a dorsal or posterim^, and a lateral region, and these have important subdivisions which have been determined by anatomical, pathologi- cal, and physiological investigations. They need in this connection to be little more than named : when the diseases of the spinal cord are considered they will demand more attention. The columns or tracts of the ventral region are TilrcW sdireci pyramidal tract, descend- ing and motor ; and the ventral or anterior ground, bundle or anterior root zone, which is crossed by many nerve fibres from the anterior 90 THE NERVOUS SYSTEM. horns. The two most prominent tracts of the dorsal or posterior region are the posteromedian tract, or column of Goll, and the pos- terolateral tract, or column of Burdock, which latter is in part a root zone. At the end of the posterior horn is a small but well de- fined bundle of nerve fi)»e,s, known as the zone, tract, or column of Linsaaer, described by Lissauer, and also by Spitzka, Bechterew, and others. These tracts are almost exclusively ascending and sensory, but not far from the centre of the column of Burdach is a narrow zone, wliich has been described as the descending comma tract, in which filtres are constantly observed to degenerate downward. Of the tracts of the lateral columns some are ascending and some descending ; some are sensory or afferent paths, and some are motor Fia. 98. Transection of cervical spinal cord, showing its chief subdivisions. or efferent, facts which arc in the main indicated in the diagrams. The crossed pyramidal tract is motor, and of course descending. The dorsolateral or direct cerebellar trad or hnndle, sometimes called the direct lateral eerelxllar tract of Fleeimif/, is ascending and sensory. (ioivers's tract is ascending and sensory, and Lowenthars is descend- ing or motor, and is connected with the cerebellar cortex. In some diagrams tlic separation of tliese into two tlivisious is not made, because the precise limitations of cacli have not been fully made out. It is probal>l(' tliat in the mi.red laterid tract the dorsal or pos- terioi' division contains sensory, and the ventral or anterior motor fibres. Pig. its, drawn l>y Dr. J. C. McConnell, from a study of sections and of various diagrams, shows some parts just described, but not indicated in the other illustrations. GENERAL ANATOMY. 91 Vertical Extension of the Spinal Tracts.— The columns of GoU and Burdaoh are distinctly separated in tlie cer\'ical region and less so in the lower tlioracic, but in the lumbar portions of the coid the distinction cannot be clearly made. The descending comma tract is best defined in the upper thoracic and lower cervical regions. The zone of Lissauer is present at all levels. The direct cerebellar tract reaches only from the level of the first lumbar nerve upward. The crossed pyramidal tract extends through the length of the cord ; so also do the anterolateral column and lateral limiting layer, both of which are largely composed of fibres which have only a short course within the cord. The anterolateral ascending tract of Gowers prob- ably begins at a lower level than the direct cerebellar tract. Tiirck's column is usually considered as present only in the cervical and upper thoracic regions, but it has been traced to a much lower level. Ill considering a level below the upper thoracic region, the diagnostician would not usually take into account the column of Tiirck. The direct cerebellar column would also in large measure not be regarded in lesions of the lumbosacral cord and the cauda equina, even although in the lesions of the lower lumbar region the tract of Gowers might be involved. On the other hand, the crossed pyramidal tract and anterolateral columns would receive consideration at any and all heights. The Structural Elements of the Spinal Cord. — The structural elements of the spinal cord, and their relations to each other, to the periphery of the body, and to the higher levels of the nervous sys- tem, have been elucidated by the labors of Golgi, Ramon y Cajal, Koelliker, Edinger, Van Gehuchten, and Lenhossek. Fibres from the dorsal or posterior ganglia enter the white substance, and, di- viding into ascending and descending branches, give off, at right angles to their course, twigs which pass into the gray matter, there breaking into tufts or ending in free fibrils. These may be in con- tact with the nerve cells, but are not structurally continuous with them. Cells of the ventral or anterior horns send out axis cylinder processes, which become true nerve fibres of the motor nerves or of the ventral or lateral columns of the cord. That fibres originate in the cells of the gray substance has been jiroved by actually tracing their courses, and also by experiments like those of Singer and Miinzer, who found that destruction of the lumbar cinerea was followed by extensive degeneration of fibres of the anterolateral columns. The gray substance of the spinal cord, as of the entire neuraxis, is constituted chiefly of cells, or rather of cell bodies, between which ramify innumerable collateral and terminal fibres. Golgi discovered that some of these cells have short and some long axis cylinders ; and to those with short processes the name Golgi' s commissural cells has been given. They have been observed especially in the dorsal horns. Van Gehuchten divides the cells of the spinal 92 THE NERVOUS SYSTEM. cord into root cells and column cells, and the former into cells of ths anterior or ventral and the latter into cells of the posterior or dorsal Fig. 99. Diagram showing a, tautomeral ; b, heteromeral ; and c, hecatomeral cells. roots. The column cells have been subdivided by him into three groups : (1) cells the axis cylinders of which pass into the white Fig. 100. Golgi's commissural cull (from tlie ctTvical iv^non of an eighteen millimetre long human em- bryo) : Q, Golgi's commissural cell ; A, anteriur longitudiual fissure ; C, central canal. (Len- hossSk.) substance of the side on which they originate, or tautomeral cells; (2) cells the axis cylinders of which proceed by way of the ventral GENERAL ANATOMY. 93 or anterior commissure to the wliite substance of the opposite side, or heteromeraZ cells ; and (3) cells the axis cylinder processes of which bifurcate in the gray substance, one branch passing into the white substance of the same side, and the others by the anterior commis- sure to the anterolateral columns of the opposite side, or liecatom- eral cells.^ These are shown diagrammatically in Pig. 99. Fig. 100 represents a so-called Golgi's commissural cell, — here a hecatomeral cell whose axis cylinder process passes by way of the anterior com- FiG. 101. Diagram illustrating the chief cellular elemeuts of the spinal cord, and the probable relations between the cells and the fibres and the principal tracts ; the left half of the figure exhibits the communications of the several varieties of nerve cells ; A, P, ventral or anterior and dorsal or posterior horns ; PM, postericjr root bundles ; DP, direct pyramidal tract ; CP, crossed pjTamidal tract ; DC, direct cerebellar tract ; GB, Gowers's tract ; a, motor cells passing directly into fibres of ventral roots ; 6, various cells of the anterolateral column ; some give oif collateral branches of remarkable size ; c, commissural (heteromeral) cells ; d, cells to dorsal column (tautomeral) ; e, Golgi cells of dorsal horn. The right half of the diagram shows the comm.unications established by means of the collateral fibres. (Piersol, after LenhosstJk.) missure to the opposite side of the cord. Fig. 101 shows the chief cellular elements of the spinal cord and their probable relations to each other and to the horns and principal columns. Ventral motor root cells are shown at a, and dorsal root bundles at PB ; at h are cells of the anterolateral columns with fibres going only to the side on which the cells originate ; at d cells going to the posterior col- umns of the same side ; at c commissural cells of the heteromeral variety. Hecatomeral cells are not shown in the figure. At e are ' These words are derived from the Greek to avro f^^po^, the same part or side ; hepov nepoi;, the other side ; and cKdrepov jxepog, both sides. 94 THE NEKVOUS SYSTEM. seen the cells with short processes peculiar to the dorsal horus. The diagram also represents on one side the methods of communication by means of collaterals, and on the other by different forms of nerve cells. At one point is seen a long reflected collateral. Collaterals of the dorsal portion of the lateral columns cross by way of the dorsal or posterior commissure ; and protoplasmic processes of the cells of the dorsal horns are also said to decussate. Lenhossek's Commissural Cell. — Lenhossek has described a special form of commissural cell (Fig. 102), which, passing from the ventral horn, leaves the white substance between the ventral and lateral columns, and sometimes reaches the surface of the spinal cord, where it becomes flattened out like a scale through loss of its dendritic processes. On transverse section, as in a, these cells Fig. 102. Commissural cells reaching the circumference of the spinal cord (from a nine days' old chicken) ; a, b, c, d, various forms of these commissural cells ; e, motor cell ; /, commissural cell Avlth pecu- liar dendritic processes : g, ependyma cell ; ft, glla cell ; A, anterior ventral longitudinal fissure; C, central canal. (Lenhoss6k.) appear as thin lines which can hardly be recognized as cells ; in 6 the cell body is coarser, more defined, and has a short process pass- ing into the white substance, and giving also au unbranched proto- plasmic process ; in c the cell approaches closely the common type, having many dendritic processes, exee])t at its free border ; while at d is seen a cell much less displaced, and in the innermost part of the anterior cfilumn the cell is spindle shaped, its axis being directed towards the x>crii>hery. The real dendritic processes spring from the outer, the axis cylinder prolongations from the inner point. Near the anterior commissure one of these spindle shaped commissural cells is seen lying obliquely at f, and this differs from the ordinary type, having on its point a coarse protoplasmic process which passes through the gray and white substance to the surface of the cord, to end there in a large bulb. Glia cells are also shown. MKMBRANES OF THE NERVOUS SYSTEM. 95 Fig. 103. MEMBRANES, BLOODVESSELS, AND LYMPHATICS OF THE NERVOUS SYSTEM. Envelopes of the Brain and Spinal Cord.— The brain is in- vested by three membranes, called respectively the diim, the j^hi, and the arachnoid, although the last two are often so united as practically to form one membrane. The dura lines the interior of the skull and also supports and protects the brain. A great process of the dura, called the faJx, passes between the two hemispheres of the cerebrum into the great longitudinal fissure ; another, the ientor'nim, separates the cerebrum and the cerebellum, and the falcula or cerebellar falx dips between the two cerebellar hemispheres. The pia closely in- vests the brain, everywhere follow- ing the contours of its surface and dipping into its fissures, e\'en i)uss- ing by way of the great transverse fissure into the ventricles. The arachnoid closely envelops the pia, but does not pass into the fis- sures, except those, like the longitudinal, which contain processes of the dura. In Pig. 103 are shown the microscopical appearances of a section of the membranes from the brain of a child. The Section of membranes from brain of child. : D, A, P, respectively the dura, the arachnoid, and the pia ; a, subdural space ; 6, meshes of subarachnoidean space ; c, bloodvessel within the pia sending branch into cerebral cortex, d. (Piersol.) Fig. 104. Dura. Subarachnoid space. Ventral nerve roots (in section). Ligameutum dentic- ulatum. Subarachnoid tra- beculte with bun- dies of posterior nerve roots. Dorsal septum. Transection of the spinal cord and its membranes. (Morris's Anatomy, from Key and Retzius.) spinal cord, like the brain, is invested with three membranes. The dura is a loose sheath around the cord and the Cauda equina. 96 THE NERVOUS SYSTEM. Externally it is loosely connected with the periosteum and ligaments of the spinal canal, and a narrow subdural space separates it from the pia-arachnoid. Processes of the pia, called the ligamentum denticulatum, pass across the subdural space between the two mem- branes. The spinal arachnoid is a thin membrane continuous with the cereljral arachnoid. The spinal pia has an outer and an inner layer, the latter being continuous with the pia of the brain. Fig. 104 shows the spinal cord and its membranes in transection. Bloodvessels of the Central Nervous System. — The functions of nervdus tissue being in a high degree specialized, and requiring abundant blood, and yet a supply which often changes abruptly, its vessels are adapted to do their work with the greatest facility and with the least danger of rupture. Both in the brain and in the spinal cord are two vascular systems, one cortical or circumferential and the other central. From the cerebral and cerebellar arteries cer- tain branches dip into the central region of the brain ; other dis- tinct branches pass to the brain cortex. The branches from the anterior, middle, and posterior cerebral arteries which pass to the various convolutions of the brain, in their course send off innumer- able small vessels which anas- tomose and then go down through the cortex to termi- nate almost straight in the alba or centrum ovale. The terminations of the central and of the cortical vessels are near ti ) each other, but they do not communicate. Even between different cortical systems hut little communication exists. Some of the cortical ^•essels are short and some are long, and the latter alone penetrate to a considerable depth. A section acro^is a cerebral convolution (Fig. 105) exhibits the arrange- ment of cortical arteries. The blood supply to the spinal cord is by numerous vessels, and is ventral and dorsal, the central supply being chiefly \'entral, by way of the Acntral or anterior mesal fissure from the anterior spinal artery. Its arterial supply is well shown in Fig. 106. The veins divide and subdivide and "are dis- tributed to different portions of the nervous system in much the same manner as the arteries. Like the arteries, they subdivide dichotomously, that is, by bisecting in pairs. Within both the Section across a cerebral convolution, exhibiting the iirteriiil arrangement : 1, the gray cortex ; 2, interior white matter ; 3, medullary arteries pcne- Iruting the cortex to the white matter ; 4, cortical arteries ihstrib\itca to the cortex. (Leidy, after Duret.) BLOODVESSELS OF THE NERVOUS SYSTEM. 97 Fig. 106. Section of injected spinal cord of cliild : s, sulcal branch of anterior spinal artery occupying ventral or anterior median fissure ; c, c, sulco-commissural \es.'sels from sulcal artery passing to gray matter to form dense network ; p, posterior spinal artery, sending oif twigs to white matter ; around margin of cord numerous peripheral vessels enter white substance to form open network. (Piersol.) cranium aiicl the spinal canal the arrangement of veins and sinuses is such as to guard against serious accidents from disturbances of the circulation. Communication be- tween the different sinuses of the brain is free ; it is also com- paratively free between the in- tracranial and the extracranial sinuses and veins, and between these and the spinal sinus system. The cerebral veins and sinuses have no valves. Venous Lakes or Lacs San- guins. — Besides the venous si- nuses of the brain, small irregu- lar cavities are found on each side of the superior longitudinal sinus. These were discovered in 1853 by Paivre, and were described in 1868 by Trolard, who called them lacs sanguins. They are intradural cavities which communicate with the superior longitudinal sinus, with the meningeal veins, and Diagrammatic figure showing the course of a Pacchionian granulation with the lac sanguin of the dura : p, villosity of the arachnoid ; dm, dura ; dm', deep fold or lining of the dura ; dm", superior lining or fold of the dura ; Is, lac sanguin ; arack, arachnoid ; tss, subarachnoid tissue ; pm, pia ; ec, gray matter of the brain. (Van Gehuchten, after Schwalbe.) with the cerebral veins. Trolard considered them reservoirs to re- ceive momentarily the overflow of venous blood when the cranial 7 98 THE NERVOUS SYSTEM. Fig. 108. circulation was congested. These little cavities or lakes are found just at the level where the small granular white masses on the ex- ternal surfaces of the dura, known as Pacchionian granulations, are most abundant (Van Gehuchten). Pig. 107 shows a Pacchionian granulation with the lac sanguin. Arterial Supply of Nerves. — As an artery approaches the nerve sheath it divides into pairs, one branch going upward and one down- ward, sometimes on the outside and sometimes ou the inner side of the sheath or epineurium. These branches divide and subdivide again and again. They pierce the perineurium at an oblique angle, and when they reach the interior of the nerve bundles they break up into fine capillary networks. The arrangement of vessels in the ner\'es, as in the brain and in the cord, is such as to prevent bad effects from sudden changes in circulation. Fig. 108 shows the dis- tribution of the arteries to the median nerve. Lymphatics of the Nervous System. — As the part played bj' the lymphatics in nervous dis- ease is one of increasing importance, the student and physician should have some knowledge of the arrangement and distribution of this system in the neuraxis and nerves. The interior of the skull is rich in lymph tracts, which, according to Eauber, are divided into .six groups : 1, adventi- tious, perivascular lymphatic sheaths which sur- round the bloodvessels down to the capillaries, and open on the exterior of the brain into the sub- arachnoid space ; 2, epicerebral lymph tracts, which lie between the pia and the surface of the brain ; 3, the interpial lymph space, between the two layers of the pia ; 4, the subarachnoid lymph space, between the pia and the arachnoid ; 5, the subdural lymph space, an extensive although cap- illary lymph I'left or slit, between the dura and the arachnoid ; G, the epidural lymph space, a system of lymph clefts or slits on the outer sur- face of the dura. The choroid plexuses have rich lym]diatic networks which belong to the system of interpial lymph clefts. The same lymphatic clefts occur in the spinal cord. A sjiecial epidural lymph space of the spinal cord has not been proved, but probably exists. Lymphatics of the Interior of the Brain.— Eossbach and Sehrwald described lymphatics in the brain substance: but their presence in the brain has been denied by Sappey and others, and the evidence indicates that they do not exist as independent vessels in Arteries of the median nerve : A, A, A, branches to the nerves ; B, brachial artery ; C, anHstomotiea ; E, radial ; U, ulnar ; U', anterior ulnar recurrent ; P, superficial palmar arch ; M, median nerve. (C;u6nu and Lejars.) LYMPHATICS OP THE NERVOUS SYSTEM. 99 the tissues of the nervous system, but that, as above described, around the bloodvessels of the brain and cord are loose adventitial lymph spaces which open into the subarachnoid space. The peri- vascular spaces of His are supposed by Eetzius to be artefacts. Ac- cording to Bevan Lewis, a system of lymph connective elements or scavenger cells with numerous prolongations drains the areas be- tween the minute branching vessels. Subarachnoid Lymph Spaces. — The subarachnoid lymph space extends everywhere beneath the arachnoid, and has numerous sub- divisions of greater or less size, these in some positions forming cisterns or reservoirs. The largest, situated between the oblongata and cerebellum and adjacent portions of the cranium, the jwsterior subarachnoid space of the older anatomists, has been described as the cisterna magna cerebeUo-ineditUaris by Key and Eetzius, and as the postcisUrna by Wilder. The intracrural cistern or ventricisterna of Wilder — between the crura, pons, tuber, iufundibulum, and hypophysis — has been usually described as the anterior subarachnoid space. Su^barachnoid spaces, large and small, communicate with one another, and with the neurocoele, or connected ventricular cavi- ties, at various places, as by the foramen of Magendie, by a cleft in the pia along the descending horn, and by lateral apertures in the fourth ventricle. That the ventricles of the brain constituted a great lymph cavity was correctly asserted by Willis in the seven- teenth century. The central spinal canal and the brain ventricles are to be regarded as primitive lymph spaces which at a certain stage of fetal development get into direct communication with the subarachnoid lymph spaces. The discharge ways of the lymph of the brain, the spinal cord, and its membranes are through all the openings in the skull and spinal column : even microscopic blood- vessels and canals take part in this process. Of the large cranial openings, the carotid canal, the jugular foramen, and the tract of the vertebral artery deserve especial attention. The existence of lymphatics in the dura is by some regarded as doubtful, although it shows numerous clefts, probably lymph channels. Lymph Vessels to the Nerves. — The subdural and subarach- noid lymph spaces are continuous with the spinal lymph spaces out- ward and along the nerves, and in an especially complete manner with the olfactory and auditory nerves. Along the nerves in general the subdural and subarachnoid spaces merge, the arachnoid disap- pearing. Flatau believes that in the rabbit and cat it is possible to inject lymphatics of the nose from the subarachnoid space, and holds that a number of "reflex nasal neuroses," so called, may be due to a derangement of the lymphatic circulation in these channels. The injection follows the olfactory nerve fibrils in perineural channels. Key and Eetzius had already made experiments on this point, al- though they were not free from error. 100 THE NERVOUS SYSTEM. ARCHITEOTUBE AND GENERAL PHYSIOLOGY. Encephalospinal Conducting Paths.— While some of the views now held differ somewhat in their details from those indicated in Pig. 109, this diagram serves an admirable purpose in showing some Diagram showing the paths between the gray masses of the spinal uurd and brain : E, central fissure or fissure of Rolando ; P", P, T, and PI, course of the pyramidal tract from the central con- volutions to the ventral or anterior horns {a, a') ; /, //, III, first, second, and third portions of the lenticula (lenticular nucleus) (NL) ; NC, eaudatum ; Tli, thaliunus ; D, C, B, A, points from which fibres issue connecting the cortex of the brain and basal ganglia, and also the gray substance of the pons (PO) ; Bil, fibres connecting the rerebellum and thalamus ; Cap, fibres connecting the cerebellum and gray substance of the pons ; ai/, pregeminum, and pq, postgeminum ; J, upper, and x', Iftwer fibres connecting the olive and tlie (inareseutation of common sensibility will be more fully discussed hereafter. The Paths of the Special Senses. — In order to complete the survey of the sensory side of the mechanism of the nervous system, it is necessary to consider the acoustic, optic, and olfactory path- ways, — to compare them with each other and with the paths for the various forms of common sensibility. This can be done by a study of Van Gehuchteu's \'ery instructive table showing the constitution of the various sensory tracts and their homologous portions, which I have somewhat moditicd. The tracts for the special senses, accord- ing to the views there summarized, are homologous throughout with the sensory spinal patlis of the cranial and mixed nerves ; and while future investigations may lead to modifications of some of the views presented by the table, in tlie main its teachings will stand. ARCHITECTURE AND GENERAL PHYSIOLOGY. 105 '*' O " — 5 5'CD O i— "^ '^ X ^ !^ s p ^ £.;. >fJ5 3 i. s oq J o - i.ac r^ E ■ 01 o ^+ "? a' 5' g' " S ■< S-H m p ^ a T ^ !2 ^ j — ^ P - 2. °a 2 ^ if? ^r" pu, 305 EJ-.Pa?*' =iS >I^O fci« 0^ ==.3 Cr^ ^5 o^i S'^ S" tip- *?; n a ^ ^ B^^ ' Is -LCD as -^0 Si OS pS ys iS f;-o a)cr5 tl ?,B s-s- too ■1 rt P X ^£l ?l ga ^' PJ «Ei p a-n FTP =0 s = 3f^ ^?^ IS p p 003 dp IP S2 a'S go ^3 ■"JUS'S' L,cb ft ,'- M a> CD C - p "■3 Q « p a h2i -i tr § >- « ^ H « H w2? <0qCfq g3.B B- ^^^5 s"gf So g. a pose's 'S oV o Q u as M-i-J. p is- i 5-3. P ;1. p- tr^ p f-ii o o a -o "el a o -a o a c8iS2.os^ e-w p S 2: 2 B o p p I-3P P-o o3 g-B g w .^ O O fl! P P ^ ^2 352I lEi ^ fD Pss Sr. S &M ■ „o p Gp-ft ■^.0 ft ?3- = ^ p "a a- p ^. a ;■ ;i a p -■ a a 2 ^o &^[^.^ o g' ■"^ c? r K a' p ig §■§' «-o ■3- & Be. p^B c; pi3^ O oi 3 P P P P [l-O p en OT P-S ^^ P- •to ft ^ ;^ p 3 p- f? '-2 "^ i^ p -1 ::; P CD r+ OT M m Co O O-P Oi ^ r+5 aft 2 'stem of Marshall Hall, including the cord, oblongata, and pons, or rather certain centres in these parts ; and from it pass all the nerves of the body. The middle or second ARCHITECTURE AND GENERAL PHYSIOLOGY. 115 level in its motor province is located in the motor region of the cerebral cortex, and possibly in the striata. The highest or third level is situated in the prefrontal lobe, which Jackson regards as containing centres of representation of the most complex movements of all parts of the body. Functions of Different Levels. — The cortex of the brain is the seat of the representation of numerous manifestations associated with consciousness ; its different portions subserve highly specialized func- tions ; in it are stored the memories of past events ; and in it occur the last and highest bodily processes concerned with sensations re- ceived from without, and with the setting free of impulses which are projected to lower centres and to the outside world. The thalamus and smaller masses of gray matter in the interior of the brain have functions of importance, but they are not so high as those of the cortex ; part of their work at least is to collect, rearrange, and dis- tribute the impulses and impressions which pass from the cortex downward or from the periphery cortexward. Beginning in the gray deposits at the base of the brain and reaching downward through the spinal cord to its tapering conus are successive areas of gray matter close to the median line in the cord, forming a closed tube. The centres or nuclei in the oblongata, pons, and the more cephalic basal deposits haA'e functions of sensation, motion, and nu- trition manifested through the cranial nerves. The spinal centres are preeminently concerned with reiiex actions. The cerebellum, like the cerebrum, has surface layers of gray matter, and also interior ganglia which doubtless constitute special levels of nervous activity. Cerebellar centres are correlated with cerebral centres, and both with those of the pons, oblongata, and spinal system. According to the generalization of Spencer and Jackson, the cerebellum regulates the muscular contractions necessary to the maintenance of attitudes in space, and the cerebrum those necessary to effect the changes of attitudes made in response to the successive impressions made upon the organism in time. The functions of special organs and parts will be considered when their lesions are discussed. Centres. — In neurology the word centre frequently occurs. By "centre," as commonly used, is meant simply a collection of gray and white matter — of cells and their processes— of greater or less bulk and complexity, an aggregation which represents physiologi- cally some action. Groupings of centres are spoken of as zones, areas, regions, or districts. Destruction of a centre or zone causes loss or impairment of function ; irritation of it may give rise to abnormal functional activity ; and in numerous ways interference with normal processes is brought about by disturbances of these centres or of the tracts which connect them with each other, with different levels of the nervous system, and with the outside world. The use of the term centre in the description of function and of 116 THE NERVOUS SYSTEM. disease is largely a matter of convenience. The three things neces- sary to make of a certain spot a centre are — (1) that its abolition causes certain phenomena to disappear ; (2) that its irritation- mechanical, chemical, or electrical — causes the phenomena to be present ; and (3) that the part of the nervous system exhibiting these peculiarities is circumscribed in extent. (Ott.) A cortical motor centre in some way represents a definite movement appar- ently performed volitionally ; in a cortical visual centre is the rep- resentation of some part of the function of seeing. In studying brain centres, we are, in the language of Hughlings Jackson, inves- tigating the anatomical substrata of visual, tactual, motor, and other ideas, the parts in which occur the most special and widely associated nervous processes which represent impressions of sight, of touch, of movement, and other functions. Lower centres differ from higher in accordance with the simplicity or the complexity of the processes which they subserve. Bilateral Arrangement of Nerve Centres. — In the higher ani- mals each half of the body is represented and regulated by half of the nervous systejn. Centres — sensory, motor, vasomotor, and trophic — are in close relation with the origin of every spinal nerve. Sen- sory and motor nerve centres are arranged in pairs up and down the whole lengtli of the spinal cord with great uniformity, although differing in size and development according to their work. They form a complete series, one for each segment of the cord. The vaso- motor and visceral centres lie chiefly between the second thoracic and second lumbar segments. The centres on both sides are more or less intimately connected with each other, in accordance with the greater or less necessity for mutual or reciprocal action. In highly organized parts of the spinal cord, as in the cervical enlarge- ment, the upper thoracic region, and the lumbar enlargement, are centres with special functions. A phrenic centre of great impor- tance to respiration is situated in the upper cervical cord ; a pupillary centre or region between the fourth cervical and second thoracic segments ; a cremasteric centre in the first lumbar segment ; a centre for the patella about the third lumbar ; and sexual, vesical, and anal centres in sacral segments. Oblongatal Centres.— The centres in the oblongata are more important to life than those either in the higher regions of the brain or in the spinal cord, and hence they are sometimes spoken of as vifuJ. The three most important of these are the respiratory, the rardUic, and tlie iiio)iarchic(d ra.soDiotor centre. The respiratory and cardiac centres arc located in the terminal nuclei of the vagus nerve, as it is by way of this nerve that the lungs, the heart, and also a large extent of the alimentary canal are supplied. Exactly how the cardiac and respiratory centres are separated from each other is not known. The monarchical vasomotor centre, a group of nerve ARCHITECTURE AND GENERAL PHYSIOLOGY. 117 cells in the same general locality as tlie respiratory and cardiac cen- tres, is so called because it exercises a controlling influence o\er the lower spinal centres. Other centres of less and yet of large importance are a space centre for receiving impressions from the semicircular canals, and centres for deglutUion or sivdllotciiit/ and for phonation. The various sensations and mo\'ements of the head and face are also represented in this region of the glossopharyngeal, facial, auditory, oculomotor, and trigeminal nerves. The respira- tory, cardiac, and monarchical vasomotor centres are sometimes spoken of as automatic. In a proper sense this automatic action, and even higher activities, are simply more elaborated forms of reflex action. The oblongatal centres are stimulated by the blood passing through them. Even the ganglia above the oblongata contain cen- tres which show apparent automatism, but the nearer the cortex or brain mantle is approached, the more does voluntary or semivolun- tary regulation appear to enter into nervous mechanism. Higher Cerebral Centres. — Certain centres on the surface of the brain, on its motor or emissive side, are sometimes spoken of as volitional or psychomotor. Stimulation of the areas around the fissure of Eolando gives rise to movement, destruction to loss of movement ; but these movements may be reflex or associated, the result of stimulation of sensory centres, and their nature has been variously interpreted. Some of the facts which bear out the view that they are volitional are their definite and purposive character ; that they can be reproduced in every detail by ordinary volition ; that the paralysis which results from their destruction is that of voluntary motion, in many cases a certain amount of automatic or reflex movement being possible in the paralyzed limbs (Ferrier). Even above and beyond these so-called voluntary motor centres are others of re- representation which exercise such functions as inhi- bition and attention and the controlling of centres at lower levels. Inhibition. — Inhibition, by which is meant the checking, stop- ping, or restraining of function, plays a part of vast importance in the nervous system in health and in disease. If the pneumogastric nerve is cut and a weak electrical current is applied to the cut end farthest from its centre, the beat of the heart will be arrested ; in the superior laryngeal branch of this nerve are certain fibres stimulation of which will arrest respiration ; and again, if under certain con- ditions the splanchnic nerve is stimulated, the action of the small intestine will be diminished or stopped. Many reflexes can be sup- pressed or inhibited through nerve impulses from more or less dis- tant centres or from peripheral parts ; but reflex movements which can never be performed voluntarily can never be inhibited. In gen- eral terms, most of the phenomena of nervous disease are due either to irritation or destruction of centres or conductors, or to the removal of these from inhibition normally exercised. When restraint is sud- 118 THE NERVOUS SYSTEM. denly removed, as when a stimulus is suddenly applied or stopped, the resulting overactiou or abnormal function is the most intense. The doctrine of inhibition affords an explanation both of some forms of insanity which depend upon disease of the highest regions of the nervous system, and also of some of the simplest forms of nerve dis- ease depending upon changes in nerve endings and nerve fibres. Lauder Brunton believes that inhibition is not dependent upon the existence of special inhibitory centres, but that stimulation and in- hibition are different phases of excitement, the two being simply relative conditions depending on the length of the path along which the impulse has to travel and the rate of transmission. The hierar- chy of nerve centres, or system of centre-levels, which has been described, is subject to the laws of inhibition. Each set of nerve centres is to a greater or less extent under the inhibitory influence of higher centres ; the highest level of the nervous system, supposed to be in the prefrontal region, exercises an inhibitory influence over all the rest, and this can be influenced only by afferent or incoming currents. Acceleration. — Acceleration of nerve function is under certain circumstances produced by acting upon nerve centres or fibres. It is supposed, for example, that in the oblongata are situated centres which send accelerating fibres to the heart. If the pneumogastric nerves of an animal be divided, stimulation of the oblongata, of the lower end of the divided cervical spinal cord, and of the lower cervical or the upper thoracic ganglion of the sympathetic, will cause acceleration of the heart beat. Exactly what this acceleration means and its relation to inhibitory action are not yet thoroughly understood. The Dynamics of Nervous Tissues. — Some knowledge of the dynamics of nervous tissues is of fundamental importance to the student of nervous phenomena and nervous disease, who should know something of the stimuli to which nerve cells and fibres react ; of the manner and degree of this reaction ; of the phenomena by which it is attended ; and of the nature of molecular transmission. The Nature of Nervous Impulses. — According to d'Arsonval, the electrical phenomena of the nerve in action are due to variations in fiurfaee tension progressing in a wave-like manner along the nerve fibrils ; and Schiifer's view that these fibrils may be extremely fine tubules filled with fluid, is in accord with this hypothesis. An understanding of this transiiiissiou by variations of surface tension is best obtained liy observing what takes place in semifluid living protoplasm. According to Eyder, free and interfacial surface ten- sion is probably the most important factor in determining the shape of cells, and, I might add, in the transmission of energy along the processes and bodies of these cells. What is meant by surface ten- sion is illustrated by reference to a drop of water falling through a ARCHITECTURE AND GENERAL PHYSIOLOGY. 119 vacuum, which drop will constantly present very nearly the form of a sphere, the molecules of which at every point, being of equal size and having equal powers of attraction, have the same surface tension or reciprocal pull. Any disturbance of this will affect the shape of the drop, but its superficial layers will always form a closed surface. Surface tension is opposed by viscosity, or the friction which is de- veloped between moving molecules, and this viscosity differs accord- ing to structure. According to the correlation between viscosity and surface tension will be the degree of motion or action exhibited. The motions exhibited by nervous tissues and other forms of living matter are probably of the same character as those shown in the simplest organisms, like the ameba, in which these phenomena are best studied. Electric Excitation of Nerves. — When a nerve is excited by electricity, chemical, thermal, and other changes take place. The electrical current does not pass up or down the nerve, but across it, and an impulse developed in the nerve is accompanied by its own electrical change. If a nerve is injured, the damaged part becomes electronegative to the rest, so that a current flows from one part to the other. This is called the negative variaUon or action current. This is the current evoked by nerve impulses which pass down a nerve which has been cut, as can be shown when the cut end and the longitudinal surface of the nerve are connected respectively with a galvanometer. S'erve conductivity is increased by sending aa electrical current through the nerves. Electrotonus, a state of modified neuro-irritability, is produced, and can be spread by con- tact from nerve to nerve. Heat appears to imi:)rove conductivity, that is, to diminish resistance, and cold to do the opposite, except that, according to Gotch, cold directly applied to the nerve trunk has not this effect. When an electrical current not quite sufficient to excite a muscle to contract is sent along the nerve, if a heated bar be brought near the nerve, the muscle will contract. IsTerves are more easily excited by electrical and other stimuli the nearer they are to their centres. The most important of these stimuli, besides the electrical, are mechanical, chemical, and thermal. Transmission of Nerve Impulses. — The average rate at which nervous impulses are conveyed is about one hundred feet or thirty- three metres per second, varying somewhat for different nerves and under special circumstances. It is of great interest to know whether the same nerve can carry different impressions at the same time, which would be in accordance with the transmission of electricity. One of the most valuable commercial discoveries is that of multiplex telegraphy, by which numerous messages can be sent along the same wire simultaneously. The study of questions such as this may eventually lead to important discoveries regarding the so-called forms of sensation. New light has been thrown on nervous impulses by 120 THE NERVOUS SYSTEM. the investigations which have developed the theory of nerve trees, and the transmission by contact from nerve cells to nerve cells, which is analogous to methods of electrical transmission. Horsley with others holds that it is probable that all nerve fibres transmit impulses at the same rate, but this view is by no means universally held. It is supposed by some physiologists that afferent or sensory impulses travel at a quicker rate than efferent or motor impulses. Exner has suggested that the rapidity of transmission in cells and Fig. 120. Sectional Surface of Cord ^ Efferent Side. Di Afferent Side. C Sp.g FieLd Con/, tinctzon . Scheme of a simple nerve centre In the spinal cord : Sp.g, ganglion on the dorsal or pos- terior root ; C, posterior root ; Ex, excitation electrodes applied to the fiosterior root ; iD, indirect nerve sensory or afferent path ; Dl, direct aiferent path ascending cord in posterior column ; CO, small corpuscle of posterior part of gray mutter ; I, internuncial fibre ; P, pyramidal tract fibre from brain ; Co, large corpuscle of \entral or anterior horn of gray matter ; B, anterior root. (Horsley.) fibres of nerve centres is different from that in peripheral nerves. Horsley and Gotch, haA-iug examined this point experimentally, came to the conclusion, provisionally at least, that the fibres in the spinal cord conduct like those of the peripheral nerves. It is important, as Horsley states, to determine the rate of the trans- mission of inipnls(»s in the peripheral nervous system, as otherwise it would not be possil)l(' to measure the amount of time a nerve centre occupies in its work. ARCHITECTURE AND GENERAL PHYSIOLOGY. 121 Fig. 120 is a W\ The Action of Simple Nerve Centres. — The structure of a simple nerve centre such us is present iu the spinal cord may be re- garded, as stated by Horsley, as consisting of three parts : (1) an afferent side for the reception of impressions ; (2) a field of conjunc- tion, which connects the afferent side with (3) an efferent side, through which impulses pass out down the ner\'es. diagrammatic representation l>y Horsley of a simple nerve centre in the spinal cord, and of its relations to the periphery and to the brain ; also of an excita- tion electrode applied to the posterior root. Horsley and Gotch obtained an idea of the amount of nerve energy discharged by a spinal nerve centre by a system of comparative electrical measurements. By exciting directly an afferent or sensory nerve con- nected with the galvanometer, a certain deflection was obtained ; then by means of a stronger current an excitation was conveyed across the field of con- junction through the efferent or motor nerve centre, and this centre was made to discharge through the efferent nerves, which also were connected with the galvanometer. The sensory nerve excited directly gave a deflection of 200 to 300, while tlie discharge of the nerve centre on the ner\'e fibre averaged only 26 on the same scale. This experiment revealed a bloct: to the passage of the current from the afferent to the efferent periphery. The actual time taken in converting a sensory into a motor impulse is approximately arrived at by an extension of this electrical method, which is indicated in Fig. 121. A sensory nerve fibre is stimu- lated at B, and the time between this stimulation and the contraction of the muscle at M is accurately measured. A represents the afferent or sensory side, and E the efferent or motor side, of the simple spinal centre. The time taken to pass from B to A and from E to M is subtracted from the whole time lost in going from A to M, and in addition about one-hundredth of a second as representing the time lost, according to Helmholtz, in the motor nerve ending before the muscle contracts. Horsley and Gotch found as the result of their experiments that the time lost in the nerve centres averaged .006 of a second ; but other observers have found it much longer, Exner making it as much as the six-hundredth of a second : that a definite time is lost is conceded by all. £:x Experiment to show the time taken by a, nerve cell to convert a sensory into a motor Impulse. (Horsley.) 122 THE NERVOUS SYSTEM. CHEMISTRY OF THE ISTERVOUS SYSTEM. Chemical Composition of Nervous Tissues. — It is commonly assumed that the composition of the tissues of the nervous system, especially of the gray matter of the brain, is the most complex within the domain of organic chemistry. The numerous func- tions of the brain, and the great rapidity with which these are ex- ercised, together with the profound mystery that still surrounds the phenomena of mental action, lead to the supposition of high com- plexity of chemical structure ; but it is probable that the chemical character of the tissues of the ovum is equally complicated, and that the processes of transformation involving the action of enzyms, or formless ferments, are as intricate as any in brain structure. While considerable work has been done in the way of extracting definite crystallizable principles from brain structure, we have as yet no positive evidence that such principles are concerned in brain functions. They may be merely products of the breakdown of the proteid structures, and therefore may be of no more significance than the urea and uric acid found in the examination of the tissues of a kidney. Chemical Characteristics of Nervous Tissues. — S^ervous tis- sues in a negative or passive state are feebly alkaline ; when in a condition of activity they become acid in reaction ; and after death also the nervous substance usually rapidly becomes acid. The fresh gray matter of the brain is alkaline. The percentage of water in the nervous system varies according to the portion of the system, whether nerve cells or nerve fibres. The gray substance of the human brain contains about eighty-two per cent, of water, expelled at 95° C. ; the white matter, about sixty-eight per cent. The nerves contain less water than the centres, spinal and cerebral, averaging between sixty- five and seventy per cent. The following table, from Landois and Stirling's Physiology, shows the approximate composition of the two classes of nervous tissue : Chemical Composition. Gray Matter. Water 81.6 per cent. Solids 18.4 " The solids consist of: Proteids Lecithin . . ... Cholcsterin and fats . . (lere)irin Siihstances insoluble in ether Salts 100.0 rM.4 17.2 18.7 0,5 7 1.5 100.0 White Matter. 68.4 per cent. 31.6 100.0 24.7 9.9 52.1 9.5 3.3 0.5 100.0 CHEMISTRY OP THE NERVOUS SYSTEM. 123 Chemical Constitution of the Brain. — We owe a large part of our knowledge of this topic to Thudiehum, according to whom the brain as a whole is an aggregated mass of bioplasm, which derives its peculiarity mainly from specific chemical additions. The stroma of bioplasm is mainly constructed of proteid substances, in which the specific matters are distributed or with which they are combined in such a manner as to produce the living brain tissue or neuroplasm. It contains small quantities of soluble albumin, also fibrin, and a substance termed neuropktstin. The nuclei of the gan- glionic cells are composed of a substance which Thudiehum calls gangliocytin, which, as it contains phosphorus, is also termed eijto- phosphatide ; its congeners in the yeast cells bear the name nudein. The relative weight of the proteid matters of the brain free from its membranes amounts to seven to eight per cent., varying in different parts of the brain. Chemical Constituents of the Brain. — The immediate prin- ciples, organic and inorganic, which have been isolated from the brain may be arranged into (1) nitrogenous phosphorized principles ; (2) nitrogenous non-phosphorized principles ; (3) true proteids or substances closely allied thereto ; (4) principles containing carbon, hydrogen, and oxygen, which include alcohols, carbohydrates, and organic acids ; (5) inorganic bodies, which include acids, bases, and salts, which may either be free or in combination with the foregoing organic principles. Much study has been spent on the phosphatides or phosphorized bodies of the brain ; they are analogous to the phosphates, and may be regarded as complex derivatives of phos- phoric acid. One class of phosphorized principles, the lecithins, is said to be present in every human brain to the extent of at least six- teen grams. Numerous other principles have been isolated, as have also nitrogenized and non-phosphorized substances. Cholesterol, an important constituent of gall stones, in quantity and possibly in function, is also an important constituent of the brain ; it is an alcohol, solid at ordinary temperatures and possessing a distinct crystalline form. Lactic acid is the principal organic acid of the brain. Typical Brain Principles. — It is impossible to present clearly and fully the chemical composition of brain principles without for- mulas, but it will suffice to indicate the nature of a few of the important types of compounds. The lecithins contain the radical phosphoric acid associated with an ammonium derivative partly al- coholic in structure, and also with an incomplete fat. Different leci- thins may be produced by radicals of different acids. It is possible that the character of the fatty food entering into the diet may exer- cise a direct influence on the composition of the lecithin, and thus indirectly upon mental action. The kephalins are analogous to the lecithins in composition, but contain a radical of a peculiar acid, 124 THE NERVOUS SYSTEM. kephalic acid. The principal form, which is present in very large quantity, is the most unstable of all the phosphorized brain princi- ples. The substances consisting of carbon, hydrogen, and oxygen aw doubtless the results of the breaking down of fundamental structures, and are therefore excretory products. Among the nitro- genous principles are phrewmn and eerebrin, from which by the action of dilute acid a true sugar, galactose, is obtained. Pathological Changes in the Brain viewed Chemically. — Glycerophosphoric, oleic, and other fatty acids have been extracted from the softened portions of the brain. In disease, not only do nor- mal constituents and ingredients decompose, l)ut abnormal products accumulate through local action or by way of the blood. In this way poisons such as arsenic, antimonj-, and narcotics affect the nerve centres. In cholera, Thudichum found in the cerebrospinal fluid two per cent, of urea. Blyth has shown that in chronic lead poisoning there is often a substitution of one or more lead atoms for the hydrogen of the kephalin, and it is obvious that the func- tions of such a molecule will be materially altered by this change in composition. As phosphorus and nitrogen, prominent ingre- dients in the brain principles, are analogous in their chemical rela- tionships to arsenic and antimony, the substitution of the latter for the phosphorus and nitrogen of the brain principles might occur in poisoning by their compounds. It has been asserted that the injection of arsenic in large doses produces increased excretion of phosphates, indicating a direct substitution of one element for the other, but the experimental evidence for this view is not entirely satisfactory. That excessive excretion of phosphates in urine is dependent on brain disease is not established. Nervous Action and Chemical Processes. — The actions which take place in nerve cells are known to be accompanied by chemical processes. If the gray matter of nerve centres is stimulated by drugs or by other methods, it becomes acid in reaction. Mosso has shown that activity in nerve cells is accompanied by a rise in temperature. Whether nerve fibres take part in the chemical and thermal changes of nerve cells has been doubted. Fatigue is believed to be due to the accumulation of the products of chemical action : it is held that the results of this action are felt only by the gray matter, because it is thought that nerve fibres cannot be fatigued like nerve cells. Edes, liowe\'er, has shown that the action current which can be studied in nerves after some hours of acti\ity tends to become weakened. Eolleston was unable to obtain any evidence of the dc^-elopment of heat by the jiassage of the nerve impulses along nerve fibres ; but, as suggested liy Schafer, the thermal changes in the excited living nerve may have been too slight to be detected. The vi(^w of Scliiifer, that the same chemical processes go on in the axis cylinders as in the gray substance, is probably correct. CHAPTEE II. GENERAL PATHOLOGY AND ETIOLOGY, SYMPTOMATOLOGY AND METHODS OF INVESTIGATION, ELECTRICITY, AND GENERAL THERAPEUTICS. GENERAL PATHOLOGY AND ETIOLOGY. Pathological Classification of Nervous Diseases. — Diseases of the nervous system can be included under a few general heads, as (1) developmental malformations ; (2) inflammations ; (3) degenera- tions ; (4) tumors and adventitious products ; (5) diseases of blood- vessels ; (6) vascular disturbances ; and (7) functional disorders. Lesions of the nervous system may be macroscopic, microscopic, or invisible to all known methods of investigation. Under coarse macroscoijic disease are embraced inflammation, hemorrhage, soft- ening, abscess, tumors, parasites, and fibrosis. Some of the lesions ordinarily regarded as microscopic, as the scleroses, are determinable by the naked eye, but need microscopic investigation for their full comprehension. Some affections long regarded as undemonstrable have yielded to new methods of research. A helpful method of con- sidering nervous pathology is by relating the special phenomena to their localized lesions. Cerebral and spinal disease give symptoms of local irritation, destruction, pressure, and instability. Developmental Malformations. — The development of the ner- vous system may be arrested, or it may be aberrant, causing agen- esis or aplasia, and giving rise to malformations and monstrosities. Arrests and deviations of growth and development act upon both the physical structure and the psj^chical nature ; so that mental deficiency usually accompanies both arrest and abnormal increase of development. Forms of idiocy and imbecility, dwarfism, gigantism, acromegaly, cretinism, and similar affections are sufficient evidences of the truth of this statement. Arrests of development usually occur during fetal life, but both arrests and deviations may take place at any period. When not fetal they are most likely to occur before adolescence. The entire cerebrum may be undeveloped ; or gyres and lobes may have disappeared, leaving a cavity in the brain ; or the brain and spinal cord may be unusually small. Hy- pertrophy of the brain is a rare condition, and may be total or par- tial. "Normal tissues, sometimes the gray matter and more rarely the white substance, may be misplaced. The cavities of the brain and of the central spinal canal may be dilated. Occasionally the bony encasement of the brain and cord may be undeveloped. 125 126 NERVOUS DISEASES. Inflammation.— Inflammation, tlie response of living tissues to an irritant accompanied by abnormal nutritive processes, may at- tack any part of tlie nervous system or its envelopes. Primarily it is an affair of bloodvessels and lymphatics, but tlie nervous tissues may be affected either rapidly or slowly. Inflammation may be parenchymatous, affecting the specific textures of a part, or interstitial, involving the tissues which intervene between the true structural elements ; or it may be diffused, attacking both parenchyma and non- nervous tissues. When neuritis is parenchymatous nerve fibres are involved, when interstitial the connec- FiG. 122. ^ t,i\'e tissue and nerve sheaths, and when diffused all parts of the nerve bundle. It is sometimes difficult to decide whether well known affections are primarily parenchymatous or in- terstitial inflammations. How far in- flammatory processes play a part in the degenerations of nerves and of the white matter of the spinal cord is a mooted question. Inflammation some- oiesir^^^o™" ^""" t™^« 1«^<1« to degeneration, but it may pass away without this result, and de- generation may arise without preceding inflammation. Vacuolation (Pig. 122) is sometimes a result of inflammation, but may also be due to postmortem changes. Inflammation is commonly of infectious or toxic origin. Varieties of Inflammation. — Inflammation of nervous tissues may be exudative, and according to the nature of the exudate may be subdivided into serous, fibrinous, or purulent. Any of these may or may not be accompanied by a necrosis or death of the tissues. Inflammatory exudates may infiltrate the substance of the brain, spinal cord, or nerves. Inflammation also may 1)e focal, localized to one spot or region ; or it may be multiple or disseminated; or it may be diffused continuously over a large area. A multiple encephahtis is found in some acute insanities, and disseminated myelitis is a not infrequent infectious disorder ; in rare oases patches of inflamma- tion may be scattered everywhere throughout the neuraxis. When inflammation attacks the gray matter of the spinal cord or brain, it is usually acute, and is called iwliomi/rJitis or imlioencephaJitis. In- flammation dependent upon syphilis or other infectious agencies is described as proVifrrativc when new tissue is formed slowly without exudation. Neural inflammation may be acute, subacute, or chronic. Meningitis. — Meningitis, or iuflammation of the membranes which envelop the brain and spinal cord, is usually included under affections of the nervous system. The inflammation may be of the dura, when it is termed pachymeningitis, or it may be of the pia and GENERAL, PATHOLOGY AND ETIOLOGY. 127 arachnoid, wlien it is known as leptomeningitis. Like inflammation of nervous tissues, it may be exudative or proliferative ; focal, disseminated, or diffused ; acute, subacute, or chronic. When sub- jacent nervous texture is involved with the membrane, a meningo- encephalitis or meningomyelitis results. Degenerations. — Degeneration of nervous tissue does not occur spontaneously, but originates either from alteration of the bodies of the nerve cells which are trophic centres, or by separation of these centres from their processes. Fig. 123. As commonly understood, it is a gradual process of decay and death of the nerve cells and fibres ; although the term acute degeneration is some- times applied to rapid processes of necrosis or softening. Degenerations may be colloid, gran- ular or fatty, pigmentary, fibroid, or calcareous. In colloid degeneration minute round or ovoid bodies permeate the nervous textures. Granu- section from the spinai lar or fatty disintegration of nerve cells is ob- """"^ "^ ^ "'^"'^ "^ "pyelitis. ^ The neuraxons are in the served particularly in the brain cortex; cells early stages of aegenera- become displaced or are represented by col- *'™ '^'^^ ^^'^ °^ various 1 ,. „ , T J. J.J. ii 1 ■ si^es, some being greatly lections of granules, much fatty matter being eniargea, others of normal present, and especially around the bloodvessels. ^i^«- In pigmentary degeneration the cells are deeply pigmented, but it must not be forgotten that pigmentation is present in healthy nerve cells. In fibroid degeneration fibrous tissue is sub- stituted for the nerve elements ; and in calcareous degeneration the deposition of insoluble compounds of calcium and magnesium takes place. Primary and Secondary Degenerations. — The most important classification of degeneration of nervous textures is into primary and secondary. Simple atrophy which may attack the gray matter of the cord or brain is a form of primary degeneration. The cell bodies diminish in size and lose their outlines, and their processes dwindle or disappear. Primary degeneration may be due to embryonal arrest, or it may be infectious or toxic. Secondary degeneration is commonly caused by the separation of nerve processes from their cell bodies or trophic centres ; but, according to Vulpian, it may be due to persistent irritation of nerve fibres ; and it may result also from the starvation of the nervous tissue through the cutting off of blood supply. Primary and secondary degeneration show marked histological differences. The lesion in primary degeneration is usually histochemical. The nerve fibres are not always abso- lutely disintegrated, and hence recovery is sometimes possible when the toxic influence is removed. (Vassale.) As usually studied, secondary degeneration follows such focal diseases of the brain or cord as hemorrhage, softening, tumor, or abscess ; or a spinal injury. 128 NERVOUS DISEASES. or a compressing curvature. If a function is interfered with by a focal lesion, degeneration takes place in the nerve tracts along which the impulses which interpret this function are conveyed ; and secondary degenerations are therefore divided into descending and ascending, or centripetal and centrifugal, or, using the terminology of Eamon y Cajal, celhdipetal and celhdifugal. A destructive lesion of the cortical motor centres causes descending degeneration in the pyramidal tract as far as the ventral horns of the cord. Ascending degenerations are chiefly in the line of the sensory tracts in the spinal cord, but any nerve tract, long or short, may secondarily degenerate. Fig. 124. Degeneration and regeneration of nerve fibres in the rabbit : A, part of a nerve fibre in which degeneration is commencing in consequence of section (fifty liours pre^-iously) of tlie trunk of the nerve higiier up ; my, medullary sheath becoming broken up into drops of myelin ; p, granular I.rotoplasmic substance which is replacing the myelin ; », nucleus not yet multiplied ; g, primitive sheath. B, another nerve fllsre in which degeneration is proceeding, the nen-e having been cut four days previously. This specimen is diflcreutly prepared from the others, so as to exhibit the axis cyl- inder (cy) also partly broken up into portions of different lengths enclosed in the myelin, my. C. more advancorl stage of degeneration, tlic medullary sheath having in great measure disappeared, while several nuclei (ji", «") have been formed by division of the single nucleus of the intemode. I), commcncmg regeneration of a uer\-c fibre ; several small nerve fibres ((', (") have sprouted out from tlie enlarged cut end {b) of the nen-e fibre (0 ; «, an axis cvlinder which has not yet ac- quired a medullary shcatli ; s, ,s', primitive sheath. (Quain's Anatomy, after Ranvier.) Wallerian Degeneration.— Waller showed that division of a spinal nerve was followed by degeneration. When the ventral root GENERAL PATHOLOGY AND ETIOLOGY. 129 was divided before it joined the dorsal, only the distal motor fibres underwent degeneration ; while if the ilorsal or posterior rout was cut between the ganglion and the spinal cord, only that portion of the nerve root which passed between the point of section and the spinal cord degenerated. These experiments proved that the trophic centres for the sensory nerves A\ere situated in the posterior ganglia, and those for the motor roots in the multipolar nerve cells of the ventral horns of the cord. Sensory peripheral nerves which spring from cells in the posterior spinal ganglia degenerate down- ward and outward, and conduct upward and inward, an apparent exception to the usual rule, but one explained by the law of Waller. Friedlander, Krause, and Marie record facts regarding degeneration of the nerves and spinal cord following the amputation of a limb which are apparently not in accord with this law. After amputation of the thigh, Marie found that the posterior columns of the cord on the side of the amputation presented the most constant and decided diminution, but the opposite side also showed marked decrease in the posterior spinal columns, and to a less extent of the anterolateral region. He suggested that both ascending Wallerian degeneration and ascending neuritis of septic origin may have occurred, the ampu- tation having taken place before the days of antiseptic surgery. Regeneration. — Nerve cells sometimes appear to regenerate, but the destruction in these cases has not been complete. Even after a long time regeneration in peripheral nerves may occur, the activity and completeness of the process depending on the influence which can be exerted by their trophic centres. Suturing of nerves has resulted in the restoration of function after months and years. The process is largely one of outbudding and outgrowing of the cen- tral portion of the nerve, which is in accordance with the facts of embryology, all nerves being outgrowths from the central nervous system. Nerve tracts in the spinal cord and brain have power to regenerate, but this is not so great as in the peripheral nerves, and yet even old cases of compression of the spinal cord may make great improvement after a long time, largely through the regener- ation of the columns of the coj-d. Vascular Origin of Spinal Degeneration. — Impoverished blood may cause degenerations of the central nervous system, as is de- monstrated by the posterior sclerosis of pernicious anemia. Even momentary arrest of circulation will cause degenerative lesions. When the circulation in the abdominal aorta was temporarily sus- pended and then reestablished, Ehrlich and Brieger found con- siderable degeneration of the gray substance related to the antero- lateral columns. The bloodvessels in spinal sclerosis are decidedly more prominent than in secondary systemic degenerations, and the lesions are most decided in the A'icinity of these altered vessels. (Marie.) Brazzola, in a case of general paralysis of the spinal type. 130 NERVOUS DISEASES. found everywhere decided vascular alterations from which the mis- chief appeared to take its start. The changes in the nervous ele- ments may in some cases be due directly to the action of a specific virus or toxin, and in others to preceding iniiammatory and degen- erative alterations in the bloodvessels. According to Preston, in posterior spinal sclerosis a diminished amount of blood is sent to the spinal cord, owing to arterio-sclerosis, and, as a result of the imperfect supply of nutriment, atrophy and degeneration occur. Sclerosis. — Certain organic nervous diseases are usually classed as scleroses. The term sclerosis comes from a Greek word meaning "hard," and in using it cause and effect are often confused. The word is more applicable to the results of the disease process, the fibroid induration, than to the disease itself, although it is used in both senses. Under the scleroses are included such diseases as pos- terior sclerosis or locomotor ataxia, lateral sclerosis or spastic para- plegia, combined sclerosis or ataxic paraplegia, disseminated and amyotrophic lateral sclerosis. Some regard sclerosis as a chronic inflammatory process affecting the nerve elements, a true paren- chymatous inflammation ; others as a disease in which a proliferation of neuroglia is the primary process. Marie has shown that the lesions of the lateral columns in amyotrophic sclerosis are largely due to alterations of cells situated in the central cinerea of the spinal cord ; and he believes that in other forms of sclerosis, in paretic de- mentia, and in pellagra, the lesions of the white fasciculi of the cord are poliomyelitic in origin. The existence of cells whose prolongations go to both the lateral and the dorsal columns ex- plains the coincidence of lesions in various columns producing the "mixed" or "combined" forms of sclerosis. Tabes is probably primarily an exogenous affection, the cells of the posterior gan- glia being first attacked. Eecent researches by Popoff on the his- tology of disseminated sclerosis led him to the conclusion that the sclerotic tissues are products which result from the destruction of nerve fibres, and that no development of connective tissue takes place ; also that the axis cylinders as well as the medullary sheaths are involved, and that the bloodvessels are the starting points. Gliomatosis. — The process known as gliomatosis or gliosis is of special importance in connection with the disease known as syringomyelia. The development of the neuroglia has already been considered. An undue proliferation of the glia cells of this tissue constitutes gliosis or gliomatosis. The neurogliar lining of the spinal cavity in the embryo may not undergo the usual modi- fication. Gliomatosis, as commonly seen, is practically a neoplastic process, and may be regarded as essentially a chronic inflammation of the gray matter, the cavities and other conditions being sec- ondary. Cavities are not always present in gliomatosis, or the cavity formations may be few and small. In syringomyelia the cavities GENERAL PATHOLOGY AND ETIOLOGY. 131 are often surrounded by gliomatous tissue whlcli contains glia cells in all stages of development and regeneration, and more or less broken down, as shown in the illustration (Pig. 125). Fig. 125. Section from the thoracic region in a case of syringomyelia. The gliomatous tissue is broken down in the centre and has given place to a cavity : a, ventral sulcus. Senility. — In normal old age the nervous system has undergone and is still undergoing a process of slow decay. The brain shrinlfs, the cortical cinerea becoming thinner and the fissures shallower, and the shrinking is compensated for by an increase of ventricular and subarachnoid fluids. In the spinal cord and in nerve trunks many of the medullary sheaths disappear. Nerve conductivity is lowered. Bloodvessels undergo changes. In some of the degenerative affec- tions of old age the pathological conditions present are simply exaggerations of ordinary senility, but the lesions may be most pronounced in certain portions of the neuraxis. In paralysis agi- tans the nervous system tends to early degeneration, — to premature senility, in other words. Tumors and Adventitious Products. — Statistics give somewhat different results as to the relative frequency of different forms of intracranial and intraspinal tumors, but the tuberculous, gliomatous, sarcomatous, and syphilitic are of frequent occurrence. Hydatids and serous and hemorrhagic cysts are comparatively common. True gliomata are simply outgrowths of neuroglia. When carcinoma at- tacks the nervous system it is almost invariably secondary. Many, if not most, of the ueuraxial neoplasms originate in the membranes of the brain and spinal cord. Several varieties of neuromata or tumors connected with the nerves are known. Vascular Diseases and Disturbances. — Hemorrhages, arterial and capillary, show a tendency to select certain parts of the nervous system, and particularly of the brain. In cases of cephalic hemor- 132 NERVOUS DISEASES. Fig. 12(). Miliary aneurism of very small vessels partly filled with blood. (Obersteiuer.) Fig. 127. rliage, enlargements of the arteries called miliary aneurisms are com- mon. Softening is generally due to occlusions of blood^-essels. Vege- tations, detritus, or coagula, carried from the heart or large vessels, plug the arteries of the brain and thus lead to softenings; and sometimes around a hemorrhage, tumor, or exudation, local ischemia and softening take place. Softening is also caused by compression or by contusions and concus- sions of the brain and cord. Either active or passive congestions may occur in the nervous system. The causes of the latter are mainly mechanical. Active congestion may be the result of excitement, fever, or the use of alcohol or other toxic agents. Anemia of the brain or cord may be part of a general condition of anemia, or it may be due to profuse hemorrhage or exhausting dis- ease. Local anemia is sometimes caused by alterations in the calibre of the vessels. Functional disorders include a gradually decreasing list of diseases, the pathology of which is not certainly determined. Predisposing Causes. — The nervous system may be in a con- dition of impaired resistance, and, this predisposition being present, various accidents and incidents may serve as exciting causes of nervous diseases. Among the most important predisposing causes are heredity, developmental influences, age, sex, race, occupation, habits, social condition, climate, poisons, special dia- theses, and infection. A new significance has been given to jjredisposition by bacterial research. It may mean some slight difference in the chemical composition of the body, the excess of some element which is obnoxious to the bacteria, or the deficiency of some substance which is necessary for their vigor- ous growth ; but it may mean only a greater or less vitality and resisting power on the part of the cel- lular and tissue elements. It may l»e local as well as general. (Cheyne.) Among the causes which lower the resistance of the nervous system are heredi- tary weaknesses in special directions, the ])resence of other poisons in the nervous system, the effects of trauma, and a poorly acting vasomotor system. (Putnam.) Exciting Causes. — Souk^ of the causes gi^en as predisposing may also act as exciting influences in the immediate production of ner\'ous diseases ; and additional exciting causes of considerable im- ])ortauce are emotion, fright, mental strain, injuries, and reflex irri- tation. Emotion, fright, and psychical causes in general, as a rule, Beaded enlarge- ment of a lars:o ar- tery in the brain. (Obersteiner.) GENERAL PATHOLOGV AND ETIOLOGY. 133 produce functional nervous affections, Init occasionally may be the starting point of organic disease, as of an attacli of cerclnal conges- tion or hemorrhage. Traumatisms need brief special consideration. Crushing, bruising, laceration, or division of nerves may (jccur ; the brain and spinal cord may suffer from the effects of fracture of their bony encasements, or from hemorrhage on tht'ir surface or within their substance ; vertebral dislocations may compress and crush the spinal cord ; and the nervous system may suffer in A'arious other ways in consequence of injuries. Traumatic nervous aftV^ctions of great medicolegal interest result from railroad and other accidents, and here the influence of fright and general shock is often added to the direct effects of injury, while suggestion and self- concentration may also be etiological factors. Intracranial tumors are frequently ascribed to traumatisms, a contusion or local inflammatory lesion being produced and acting as a nest for the development of the growth. Not a few nervous affections are referred to reflex irrita- tion of nerves in various parts of the body, as to genital, nasal, pharyngeal, oculai', ovarian, and uterine irritation. Heredity. — The influence of dissimilar heredity is seen in func- tional affections, such as hysteria, neurasthenia, mania, and melan- cholia, which often appear in families with a history of alcoholism, epilepsy, syphilis, or tuberculosis. Epileptics and alcoholics have often inherited weak nervous systems from a pathological ancestry, and insanity, deaf- mutism, pauperism, and criminality are frequently results of atavism. Even acquired nervous affections can be in- herited. Brown-Sec[uard produced in guinea pigs an epilepsy which became hereditary in subsequent generations of these animals. The term neuropathk conaiitidion describes a diathesis manifesting itself in nervous and mental instability, which is not infrequently the inheri- tance of a condition acquired in a near generation. Strictly speak- ing, it is often the tendency to nervous disease rather than the disease itself that is inherited ; it is the neurotic defect or neuropathic con- stitution which is handed down. The tendency to a recurrence of particular pathological types may continue through several genera- tions, as is illustrated by the growing list of ' ' family diseases, ' ' such as Friedreich's ataxia, hereditary chorea, muscular atrophy, and forms of spastic disorder. These affections are embryonal. Developmental Influences. — Developmental influences play an important part in the etiology of certain nervous diseases. During the embryonal or fetal period occur arrests and aberrations, which give rise to malformations and monstrosities, and to various forms of idiocy and imbecility. During the rapid growth of the brain between birth and seven years of age, convulsions, night or day terrors, transient delirium, ephemeral fever, meningitis, encephalitis, and poliomyelitis may occur ; chorea, epilepsy, and family forms of disease appear between seven and thirteen ; during 134 NERVOUS DISEASES. puberty and adolescence the same nervous disorders may arise as just before puberty, with the addition of others such as hystero- epilepsy, insanities, and sexual perversions. ' ' A man is as much a part of his ancestry, and his posterity is of him, as the root and stem are parts of one tree. The philosophic view of reproduction is that it is but one incident in a continuous protoplasmic life. Concerning hereditary defects and looking to the influeuce of nerve over nutri- tion, it seems reasonable to attribute early formative failures and the malformation of body and limbs, in some degree, to trophic innerva- tion." The nerve cell develops its function with great slowness after its full bulk has been attained ; and it is a rule with few exceptions that the tissues that are of slow de^'elopment are most influenced by hereditary evil tendencies. (Olouston. ) Age. — The most frequent nervous diseases of infancy and early childhood are those which indicate unstable and irritable conditions of the nerve centres, such as spasms, head-ljanging, night terrors, ephemeral fever, and chorea. Diseases due to destructive central lesions are not common. Eeiiex irritative disorders in young chil- dren occur as the result of teething, and from digestive disturb- ances. Family affections appear at various developmental periods. Functional nervous disorders such as neurasthenia are most preva- lent from adolescence to middle life. Hemorrhages into various parts of the nervous system, and especially into the brain, and degenerative diseases of all parts of the neuraxis, are, from their very nature, likely to occur beyond middle life. When they occur earlier they may be evidences of premature senility ; as age in such cases is not to be measured so much by years as by the condition of the bloodvessels and nerve cells. Sex.— The female sex is more liable than the male to certain functional nervous affections, as hysteria and neurasthenia, and to certain types of sensory disease, as headache, spineache, neuralgias, and migraine. Motor paralyses occur in both sexes, but are of greater frequency among boys and men. Types of disease vary according to the inherent powers and requirements of the two sexes, and according to differences in occupation and exposure. While the uterus and its appendages play a part in the produc- tion of nervous diseases, their influence has been overrated. Race.— Special types of hysteria are determined largely by racial characteristics. Hystevo-epile])sy and other forms of grave hysteria are most common among the Latin races. :Melancholia and a special tendency to suicide are most prevalent in some of the Ger- man nations. Locoiuotoi- ataxia is of infrequent occurrence among negroes, although cases have been reported by Burr and others. The negro i-ace suffers unusually from cerebrospinal meningitis, as has been evidenced in many epidemics in the Southern States in this country. The disease is more severe in the dark races than GENERAL PATHOLOGY AND ETIOLOGY. 135 in tlie white, the ratio of susceptibility being exactly in proportion to the depth of color, the blackest suffering most. Trismus neo- natorum also has a high rate of mortality among negroes ; and it is more common among Jewish and Mohammedan children than among those of other races. The Semitic people are prone to melancholia. (Byers. ) Occupation. — Occupation also influences the development of nervous diseases of certain types. Affections occurring among clerks, telegraphers, typewriters, artists, pianists, and others, have been erected into a class of occupation neuroses. Paralysis, tremor, and spasm are found among -norkers in lead, mercury, or arsenic. Headaches arise from work which causes eyestrain, and sleeplessness from too intense literary labor. Idleness is also a not infrequent cause of functional nervous disorder, and particularly of some types of hysteria and hypochondria. Habits and Social Conditions. — The abuse of alcohol produces special types of acute and chronic nervous disease, and its effects are felt in the weakened nervous system of succeeding generations. The excessive use of tobacco has also an injurious effect upon the nervous system. Bremer holds that the use of tobacco in the young is pro- ductive of both mental and moral deterioration. Sexual abuses and irregularities have depressing psychical and physical eifects, and if excessive may cause functional and organic affections, although their efficiency in the production of the latter has probably been overesti- mated. Vicious habits of x^sychical origin sometimes act as causes of nervous and mental disease : thus, hysterical anorexia may be- come established through the patient having feelings of discomfort which lead to the reduction of diet, and fixed delusions as to food. Muscular twitching, whether of spontaneous origin or the result of imitation, may become a habit chorea. Bad educational methods count for much in the causation of nervous disorders in growing children, and the complicated conditions and harassments of a high civilization, involving great mental strain, have a tendency to affect the nervous system injuriously. Climate. — Valuable data with reference to the influence of cli- mate on nervous disease have been furnished by Eskridge, Solly, Curtin, Loomis, Eeed, Hinsdale, and other members of the American Climatological Association. Some nervous affections, and especially neurasthenia and neuralgia, may be the result of a lack of equa- bility in climate. The effects of altitude upon nervous patients are important. The high altitudes of Colorado, North Carolina, New Mexico, and other regions often resorted to for health, may be a disadvantage or a source of danger. Some affections which have been attributed to high altitudes are hysteria, general nervousness, melancholia, chorea, tachycardia, irregular heart, and apoplectiform attacks. Both blood pressure and the rhythm of the heart may be 136 NERVOUS DISEASES. injuriously influenced through the nervous mechanism of the vas- cular system. Besides the rarefied air, dryness, dust, wind, and an atmosphere highly charged by electricity affect nervous cases un- pleasantly. Careful acclimatization is of the utmost imiiortance. (Eskridge.) A dry climate, by diminishing the water in the blood, acts as a ]30werful stimulant to the nervous system, increasing its functional activity and causing excitement and sleeplessness ; hence the healthy removed tO a dry climate or to one of considerable ele- vation become restless. Nervous affections which are not absolutely initiated by climatic conditions may be aggravated by them. Seasonal Influences.— In the spring, either as the result of severe and prolonged labor or as the effect of cold and exposure, the nervous system becomes lowered in tone, and in the weak and those predisposed by neuropathic constitutions, certain functional nervous diseases, as chorea, hysteria, and neurasthenia, develop. A large proportion of cases of chorea occur in the spring. Weather. — Weir Mitchell and Captain E. Catlin, the latter a suf- ferer from "stump" neuralgia, have made important observations on Fig. 128. --t-Q-d-a - - ^ - '^^ _ 1^:52 S tzaa _^^ -_ _ _ I2S5 i^" ^ ^'f ^ ^JU.'^'^t^e _ _ .:.Z _\ -". ■fli3:''~~'^-. " 5# ~ ^^ ^. "~"^^5^ " V \ 5 M*^ -,' ^u y:i' ^if- c \ ___^^__ 7 _ _ _"", u^ S^^ -m ' '^& *^ 7 -^SSl.-^'v -'-'- t_ ^ > sa__ _ _ _ _ it S 'I &=* - - - -^: iiii :iii:::::^:^. ::::::. U^^SiS ■ j^ "^ 5 "- y9 9(?o-^ Tit rilrJ ^^ "HH~ TrH i: « _ _^, _ \ rft p"'if'^'5. \\ WM 1 1 M 1 > /SSZ - - ~'59!??7> -^^ Annual pain barometer and temperature curves, LST.VISSJ inclusive. (Miteliell and Catlin). the relations of pain to weather. Less than half of the cases studied felt unusual sensations upon the coming of an east wind and during its continuance ; and of these two thirds insisted on their power to predict such change in the weather, while the rest thought that any GENERAL PATHOLOGY AND ETIOLOGY 137 great change was likely to cause them ]3ain. An annual neuralgia curve was constructed on the monthly ordinates of neuralgic dura- tion, as shown in Pig. 128 ; and a large number of neuralgic attacks were seen to be definitely related to storms, but no single element of mischief was discovered, and Mitchell bcslieved that some combina- tion of weather started the pain. At the centre of the ^ast rain area of every storm is a moving space of the greatest barometric depres- sion, known as the storm centre, which the rain usually precedes by five hundred and fifty to six hundred miles, and before and around the rain is a forerunning neuralgic belt. Fig. 129 is a diagram of a storm with its theoretical rain area and neuralgic belt. Fig. 129. Relation of pain area to rain area. (Mitchell.) Metallic and Gaseous Poisons. — Important central and periph- eral nervous diseases result from the ingestion of metallic poisons, such as arsenic, mercury, lead, copper, zinc, and antimony ; or from inhaling gaseous substances, such as carbon disulphide and carbonic acid. In carbonic acid poisoning central lesions are caused by the extreme congestion of the brain, the result of the direct action of the gas upon the vessels, with an undiminished action of the heart. (Schwerin.) Various poisons cause affections much like the scle- roses. The symptoms of alum poisoning, as pointed out by Mayer and Siem, are like those of bulbar paralysis. Diatheses. — Arthritic patients are often neurasthenic, insom- nic, hypochondriac, or melancholic. Eenal work is increased by arthritism, giving rise to toxins which may poison the central or the peripheral nervous system. A great stimulus to the study of the part played by uric acid in the production of various nervous and 138 NERVOUS DISEASES. mental disorders was given by the investigations of Haig, althougli long before his publications Maudsley advocated the theory of auto- intoxication by uric acid as a cause of melancholia. The blood of somti cases of melancholia shows both a relative and an absolute increase in uric acid. Oxaluria is sometimes described as a cause of nervous disease, but how far it is a concomitant and how far a cause has not Ijeen satisfactorily determined. The rheumatic and gouty diathesis, and that form of half gout described by Da Costa as lithemia, produce distressing nervous symptoms, and a distinct type of lithemic neurasthenia has been erected by some authors. Gout in one generation may cause various forms of nervous dis- order in succeeding generations. Microbic Origin of Nervous Disease. — Microorganisms, only a portion of which are definable by the microscope, abound every- where, and diseases of the nervous system are being more and more recognized as of bacterial oi'igin, and particularly as due to certain bacilli and micrococci. Just how these bacteria produce their effects upon the nervous system is a question which has received much con- sideration. They may act directly, but in this case susceptibility must be great and the pathogenic bacterial dose must be large; commonly their effects are indirect, due to the toxins excreted by the bacteria. In some instances the bacteria and the chemical poisons which they excrete act together. In a restricted sense an " infectious disease" is produced by the direct influence of bacteria introduced into the body ; bacterial toxic diseases are caused by the poisons secreted by microorganisms. In tetanus the active poison is gener- ated at the place of its introduction and is gradually carried through the body, causing a general intoxication ; but the toxin artificially manufactured and injected will cause the same phenomena as the direct tetanus infectiim. Even the protozoa, which are not true bacteria, probably play a part in the pathogenesis of a few nervous affections, as when malarial organisms exert their poisonous in- fluence upon the central or tlie peripheral nervous system. Many organic nervous diseases are perhaps best regarded as due to pro- toplasmic poisoning, the toxin or infection having had a special afSnity for nerve protoplasm. Ptomaines and Leucomaines. — The term ptomaine, derived from the Greek word meaning a "corpse," is applied to all the products of the decomposition of organic bodies under the influ- ence of microorganisms. What Gautier first termed Irucomaines are basic alkaloidal substances which occur in living tissues as the result of physiological or pathological processes. It would perhaps be better, as has been ■ suggested by Leflfmann, to disregard both expressions and s|»eak only of hasie nitrogenous bodies. Such bodies are found in plants and animals ; they are constantly produced hy the most minute forms of life. These products are stored in the GENERAL PATHOLOGY AND ETIOLOGY. 139 structure of plants, and often give them their poisonous and their medicinal properties. Microorganisms and the higher animals, owing to the media in which the former live and the excretory organs with which the latter are provided, are largely able to rid themselves of these products, which would otherwise be injurious or even fatal. Chemical and other Effects caused by Microbic and Toxic Agencies. — Some clear general idea should l»e had of the train of physical and chemical processes occurring from infection or poison- ing in an organic affection of the nervous system. As a result of the action of microorganisms, ptomaines are excreted, and by their action upon the protoplasm of nervous tissues, and of other tissues, leucomaines are produced, and these may have a greater or less toxic influence in conditions of the system in which they are not properly excreted, thus giving rise to disease. The physician confronted by chronic, and even in some cases by acute, nervous affections of microbic origin has to deal not with the originating microorganisms, but with their primary or secondary products ; or perhaps not with these, but with their effects ui>on nervous tissue — with the blurs and scars which they have left. The thoughtful neurologist must always bear such facts in mind. The same truths hold good for inorganic poisons, such as mercury, arsenic, and lead, which early give rise to structural nervous disease, which frequently after certain stages have passed does not improve under eliminative therapeutics because the pathological condition is dependent not upon tlie presence of the original toxic bodies, but upon deranged molecular states, resulting from the original agents. Nervous and Mental Diseases due to Infectious Processes. — The infectious diseases admitted to be causes of nervous affections are tetanus, rabies, syphilis, tuberculosis, diphtheria, lepra, gonor- rhea, typhoid fever, erysipelas, infliienza, mumps, the acute exanthe- mata, the pyogenic organisms, the diplococcus lanceolatus, malaria, and actinomycosis. The diseases of the nervous system which are suspected but not fully proved to be of infectious origin are beriberi, poliomyelitis, Landry's disease ; certain forms of myositis, neuritis, and myelitis ; some of the cerebral palsies of children ; chorea, epi- lepsy, disseminated sclerosis, and other cerebrospinal and spinal scleroses ; amputation neuritis and herpes zoster. (Putnam. ) Men- tal manifestations and even special types of insanity may be due to such causes as traumatism, anemia, exhaustion, and emotional shock, but they are also sometimes dependent on the action of infectious intoxication and probably on specific microorganisms, although the last cannot be regarded as absolutely proved. Febrile delirium and postfebrile insanity have been especially considered. A special type of confusional insanity has been suggested as following infectious and diathetic disorders, and this type is probably a toxemia and 140 NERVOUS DISEASES. due to a special poison. (Korsakoff, Hurd.) Numerous cases have been reported. Much negative evidence in favor of the infectious origin of acute mania or acute delirium has been furnished by clinico-pathological observations, autopsies revealing nothing posi- tive. Various microbic agents are apparently capable of producing the same nervous or mental diseases. Syphilis. — As syphilis is one of the most frequent of the infec- tious causes of nervous disease, it requires a few words of special discussion. It affects either the central or the peripheral nervous system, acting both directly and indirectly, both recently and re- motely, and both as an intrinsic and an extrinsic cause. Many so-called syphilitic affections of the nervous system are in reaUty diseases of its envelopes or of its vessels, as meningitis and arteri- tis ; or the effects of such diseases, as when the brain substance is destroyed by hemorrhage or vascular occlusion. One of the most common forms of intracranial syphilis is the diffuse basal gumma- tous meningitis. The degeneration of nerves is often dependent on infiltrations from the epineurium. Tabes and the scleroses in gen- eral usually occur in syphilitic subjects, and syphilis is the most important of the toxic agents which can produce degenerative nervous diseases ; and yet such affections are not curable by anti- syphilitics, because what is present is a degenerative process, not the virus by which it has been initiated. Endarteritis obliterans, an acute or subacute inflammatory process which involves both the intima and the endothelial lining of arteries, is the result of syphi- litic endarteritis, and especially affects the cerebral arteries, more often the vessels of medium size. It gives rise to many of the extrinsic affections of the brain, of the cord, and even of the nerves. Periarteritis, which frequently attacks the small arteries of the brain, causing miliary aneurisms and cerebral hemorrhage, is also often syphilitic. Autoinfection and Autointoxication. — Functional nervous af- fections apparently directly related to gastrointestinal, hepatic, renal, and other conditions are probably due to poisons which are produced in the system by the diseases of these organs. Many processes result in disintegrations and reconstructions of poisonous materials which are carried through the system ; and the retention of substances which, although normal in themselves, should in regular process be largely excreted, gives rise to certain nervous and mental symptoms and forms of disease. According to Albertoni and others, poisons in large quantities are formed by the action on food of the putrefaft- tive bacteria of the intestines. Under most conditions this process is not pathological, but in indigestion excessive quantities of aromatic, albuminoid, and nitrogenous bodies, besides fatty acids, are formed. An old idea has been given a new dress by Klippel, who holds that hepatic disorder may not only maintain and exaggerate a psychosis, GENERAL PATHOLOGY AND ETIOLOGY. 141 Fig. 130. but may be its true cause, a position which he has endeavored to establish both by cliuical and by experimental in\'estigatioiis, ad- ducing as evidence the presence of glycosuria and of certain hepatic coloring matters in the blood, also the decrease of urea and increase of uric acid. Urobilinuria j)reseut in these cases affords a method of testing the question. Numerous ner\ous and mental disorders are present during pregnancy and attend the puerperium. They are usually dependent upon the surroundings of the puerperal woman, or carelessness on the part of the attendants, but auto- infection has been advanced as an explanation in cases which occur when every precaution has been taken. During pregnancy, the production of toxins in the system is sometimes the cause of ner- vous and mental symptoms, such as headache, general nervous- ness, depression, nervous exhaustion, melancholia, and mania. The chorea of pregnancy, with its accompanying mental phenomena, is probably toxic in origin. Phagocytosis. — The phagocytes or leucocytes are groups of cells which have the power of eating or taking into their substance solid particles, as the colorless corpuscles of blood and mucus, and the connective tissue cells. They are scavengers of the human body constantly at work. Metchnikoff, to whom the doctrine of phagocytosis is due, has likened specific inflammation to a warfare in which the invading army is represented by microorganisms, and the resisting force by the leucocytes. In certain conditions of disease of the brain and nervous system Deiters's or spider cells abound ; and, according to Bevan Lewis, these abundant connecti-^e elements of the brain take an active share in the patho- genesis of mental decadence. In paretic dementia, in chronic alcoholism, in senile atrophy of the brain, and in some other mental and nervous affections, the true nerve elements, according to Lewis, are destroyed by these abundant scavenger elements. Sep- tic intoxications are due to the effects pro- duced by nonparasitic bacteria. When such bacteria are injected into the tissues a struggle follows between them and the cellular elements ; and according as the leucocytes or the bacteria obtain the mastery will be the result for the patient. The doctrines of IMetchnikoff and Lewis have not been generally accepted. Nuttall has shown that the destruction of virulent bacteria in the blood by leucocytes is not essential. Others hold that the germicidal power of the blood resides in the serum alone, and that phagocytosis is but a secondary process. Section from the cornu am- monis showing perivascular and pericellular spaces : a, capillary vessel in a perivascular lymph space ; b, pericellular lymph space directly lantinuous with the former : two leucocytes are seen in the pericellular space c, and one in the space b. (Ober- steiner.) 142 NERVOUS DISEASES. SYMPTOMATOLOGY AND METHODS OP INVBSTIG-ATION. General Method of Study. — The same procedures may have their application in numerous affections differing widely in pathol- ogy, but general rules and principles will serve to guide in an inves- tigation of disease of the nervous system. The examination will vary somewhat with the views and habits of the investigator, and some- times according to the special object to be attained. It is a good practical method for most cases to obtain (1) statistical data, such as name, age, birthplace, and occupation ; (2) an account of the onset of the disease ; (3) its etiology, including family history ; (4) a his- tory of the patient from the onset to the time of examination ; and (5) his present condition. The examiner may prefer first to obtain the family history and general etiology ; but, as a rule, it is best to fix accurately the date of the onset of the illness, as other investiga- tions will radiate naturally from this point, and it is not always an easy task to do this. The ataxic may fix as the beginning of his disease the time when symptoms of incoordination were first mani- fested, although he may have had for months and even years lanci- nating pains or affections of the eyes or of the bladder. When the time of onset is settled, inquiries should be made as to heredity ; as to diseases of infancy, childhood, and youth ; as to syphilis, alcohol- ism, exjjosure, injury, overwork, poisoning, or anything else bearing on causation. The i^eriod from the onset to the examination may cover hours or days, or may extend over months and years. Classes of Symptoms. — In studying the present condition it may be necessary to investigate (1) psychical symjitoms ; (2) somatic stigmata ; (3) disturbances of general sensibility ; (4) morbid phe- nomena of the special senses ; (5) motor disturbances ; (6) reflex dis- orders ; (7) electrical conditions of nerve and muscle ; (8) vasomotor, secretory, and trophic symptoms ; (9) symptoms of varying char- acter referable to the great viscera of the body. Only one set of manifestations may be present in a case, while sometimes, as in tabes dorsalis or in dementia paralytica, sooner or later in the progress of the disease a long train of phenomena, covering almost the whole field of symptomatology, mny appear. Mental Examination. — The mental examination of a patient supposed to be insane is of first importance, but in nervous cases in general the study of psychic phenomena is also essential. In hys- teria, neurasthenia, and the traumatic neuroses, the mental condition is often the most important factor ; and in some organic diseases, as the hereditary choi-eas, scleroses, dystrophies, and chronic inflam- matory diseases, mental disease may sooner or later appear. The ])sychical study must include a consideration of depression or exal- tation, of delirium, \iolence, apathy, torpor, stupor, coherence, hal- lucinations, illusions, and delusions ; of special tendencies— suicidal, SYMPTOMATOLOGY AND METHODS OF INVESTIGATION. 143 homicidal, destructive, or criminal ; of automatic or cataleptic phe- nomena; of peculiarities of speech, and of powers of memory, judg- ment, comparison, and all the higher faculties. Instruments for the study of the psychology of the senses have been much added to in recent years, and these vary in number and complexity according to the fineness of the work to be done. It is of course not feasible for the physician in his daily work to use all the apparatus employed in the laboratory of the experimental psychologist, but some of the appliances of experimental psychology will be found practicable. Time Relations of Mental Phenomena. — A fundamental de- termination in psychophysics was that of Helmholtz of the rapid- ity of nerve transmission. Important experiments have been made recently to determine the reaction time for the various senses both in the sane and in the insane. By reaction time is meant the time taken by a sense to respond to a gi\'en stimulus, which, ac- cording to James, is a pure reflex, not a psychic, act. "In the simple time reaction there is a physiological and also a psychologi- cal portion. The physiological elements include : first, the time for the sense reaction to respond to the impression ; second, the time for the passage of the impulse inward along the nerves ; third, the retiirn passage of the motor impulse from the brain to nerve and muscle ; fourth, the time for the contraction of the muscle. The time thus left unaccounted for is taken up by the psychological processes and transformation of the sensory into the motor impulse. The reflex act takes less time than the voluntary one. The reaction time differs for the different senses. Hearing is shortest, touch is intermediate, and sight longest. Eeaction to the sense of tempera- ture is longer than to contact. Reaction to heat is longer than to cold. When the stimulus is intense the reaction time is shortened. When the subject knows the nature of the experiment, and expects certain results, the reaction time is shortened." f Jastrow.) Subjective Symptoms. — To give subjective symptoms their just value will often severely tax the diagnostician. They may consti- tute the entire case, or they may play an important coordinate or subordinate part ; or the assertion of their presence may be indica- tive either of fraud or of self-deception on the part of the patient. It must not be concluded that because symptoms are subjective they are not real. Intellectual conditions often complained of are loss of the power of attention, melancholy, apathy, indifference, irritability, and emotionality ; uncontrollable thoughts, doubts, and fears ; tin- nitus and partial or complete deafness ; photophobia and eye pains ; all sorts of paresis and paresthesia ; twitchings and jerkings ; and feebleness in standing and walking. It is always important to dis- criminate as to the real nature of pain. It may be hallucinatory, hut even when not it may be cerebrally initiated. According to Eaggi, pain reflexes following hallucinations may acquire an inten- 144 NERVOUS DISEASES. sity equal to those of true perceptive origin, and pain due to intel- lectual processes is a phenomenon of insanity. The subconscious pain of the hysterical is fundamentally delusional. Pain of cerebral origin due to organic lesion must be recognized. Mann has recorded a case of localized burning pain apparently caused by a lesion irri- tating the intraencephalic sensory fibres. Edinger has also reported a similar case in which the pain became so intense that the patient committed suicitle. The autopsy showed softening of the external nucleus of the thalamus, the pulvinar, and a small segment of the internal capsule. The character of the pain described by a patient, whether aching, burning, darting, lancinating, fulgurant, intermit- tent, or constant, is often of diagnostic value, and a close cross- examination may be necessary in arri^-ing at a conclusion. Other sensory phenomena besides pain may be of cerebral origin, as the brain itch described by Bremer. Many of the abnormal head sen- sations, such as drawing, compressing, weighing down, and crawl- ing, of which nervous patients complain, are doubtless due to simi- lar cortical processes, and here might also l)e placed the subjective false sensations of cold, described by Mitchell and others. 31any nervous patients suffer from forms of tinnitus, the cause of which must be sought through an examination of the ears and hearing, of the cerebral symptoms, and of the general condition of the patient. Among the subjective visual disturbances are photophobia or fear of light, photopsia or sensations of phosphenes, luminous circles or sheets, sparks, flashes, balls of fire, colored lights, fortification lines, polyopia or multiplied sight, and muscie volitantes or flying bodies. Inspection. — Many signs of nervous disease can be noted by- careful inspection. The gait may be seen to be notably spastic, ataxic, or paretic. A diagnosis can often be made in hemiplegia, sclerosis, or hysteria, by a study of either the carriage or the gait. Fig. 131 compares the normal gait with that of disseminated scle- rosis. The slow, grotesque, mobile spasm of athetosis, and the dif- ferent forms of chorea and tremor, are studied chiefly by sight. Fibrillary tremor may be nbserved in the muscles anywhere, and is sometimes strikingly exhibited in the tongue, ^"asomotor affec- tions reA-eal themseh'es to the eye by flushing, pallor, or irregu- larities of color, as well as by differences of temperature to the hand and to instruments. The complexion and morbid changes in the skin due 1o tiophic disease are to be studied in the same man- ner. The facial e\i)ression in melaneliolia, in mania, in various forms of idiocy and imbecility, and in neurasthenic and hysteric patients is often distinctive. Opposite mental states give opposite facial signs. Stigmata.— Somatic stigmata are the landmarks or body marks of physical degeneration, the evidences of arrested or irregular de- velopment ; they include differences in stature and in the length SYMPTOMATOLOGY AND METHODS OF INVESTIGATION. 145 of limbs ; irregularity, undue symmetry, or abnormal shapes of the skull or face ; deformities of the tongue, palate, ear, eye, or gen- itals : in brief, constitutional deformities in general. Stigmata may i 9 ^ <^ ^ ^ ^ P J) Fig. 131. ^ C3 % ^ 7 P ^ P P \ I y affecting the cardiac centres in the oblongata may caiise either slowness, in- creased frequency, or iri-egularit>' of the pulse. Arteriocapillary sclerosis plays an important iiart in the etiology of many lesions occurring in the nervous system. Headache, vertigo, insomnia, want of concentrating ])o\\'er, gradual mental failure, and general weakness are fre(iuently due to arteriocapillary sclerosis, but are supposed l>y patients or physicians to be evidences of tumor or meningitis, or perhaps only of neurasthenia. ELECTROPHYSICS AND ELECTROMEDICAL APPARATUS. 179 BLECTROPHYSIOS AND ELECTROMEDICAL APPARATUS. Galvanism, Faradism, and Franklinism. — Galvanism as used in medicine always refers to the current obtained directly from a cell or a series of cells ; famdism, to that derived from an induction coil. Synonyms for galvanism are voltaic, dynamic, chemical, ov contact elec- tricity, or the constant, continuous, or direct current; and for fara- dism induction electricity, electroinagnetism, the coil current, and the interrupted current FranMinism is the electricity obtained from a static machine. Galvanism, faradism, and franklinism are not essen- tially different in their nature. A current can be generated by magnetic induction which will produce all the effects of galvanism and franklinism ; with a galvanic battery and suitable changing devices, effects identical with those regarded as peculiar to faradism and franklinism can be obtained ; and it is also possible with suitable electrostatic generators to produce the effects of galvanism and fara- dism. With all three it is simply a question of volts, ohms, and amperes with certain special phenomena. Action of Electricity on Living Tissues. — The electric current contracts protoplasm, and its effects can sometimes be limited to special tissues. It may act by electrolysis, or chemical decomposi- tion of the tissues at the electrodes, and in the circuit ; or by cata- phoresis, — that is, by carrying particles to and through the tissues in the direction of the galvanic current. A modification of nerve ex- citability known as electrotonus occurs in the immediate vicinity of the electrodes or poles and in the interpolar region. At and near the anode the excitability is diminished, producing anelectrotonus ; while at and near the cathode it is increased, the condition being termed cat electrotonus. When catelectrotonus appears by making the circuit with the cathode the nerve is excited by an acti\'e modifi- cation ; when anelectrotonus disappears by breaking at the anode, the diminished excitability is substituted by a negative increase, so that by this procedure also the nerve is thrown into a state of excite- ment. Electrophysics. — The potential of a substance is its power of overcoming resistance. Separation of electricities takes place at the point of contact of the elements of a cell ; the electricity is said to flow from one of higher to one of lower potential, as water flows from a higher to a lower level, or as heat passes from a hot body to one that is cooler. The earth is supposed to be at zero jiotential, and when a body is at low potential, electricity flows to it from the earth, and the reverse. Electromotive force is an imaginary force which causes the difference in potential. Besistance is the obstacle offered to the passage of an electrical current, which latter is simply the action which continues in the electrical circuit as long as the difference of potential is maintained. The current strength is equal 180 NERVOUS DISEASES. to the electromotive force divided by the resistance. A volt is the unit of electr(jmotive force, an ohm the unit of resistance, and an ampere the unit of current strength. These terms have concrete interpretations. An oiim, for example, is the resistance to a cur- rent of electricity offered by a column of mercury one square milli- metre in area of cross section and 106 centimetres long at a tempera- ture of 0° C. or '6'1° P. The electromotive force necessary to over- come this resistance is estimated to be a little less than that of a freshly charged Daniell's cell. The ampere is the current resulting from the action of one volt on one ohm. The term milliampere, introduced by de Watteville, is applied to the resultant of the re- sistance offered by a human l^ody to a current generated by three Daniell's elements. It is the one-tliousandth of an ampere. The density of a current is the amount of electrical charge accumu- lated at any point, and is proportional to the unit area at that point When a current flows between a large and a small conductor the elec- tricity is denser at the latter, a fact which underlies the scientific use of large and small electrodes. Density is greater at projecting points or edges. A current is ten times denser in a wire one millimetre in diameter than in one of a diameter of one centimetre. If two small wet electrodes are firmly applied over a nerve, the two Fig. l.W. Diagram showing course of currents ivlien two small electrodes are used : +p and —p, wetted electrodes ; s, skin. Fio. 160. Diagram shelving course of currents when one small and one large electrode are used : n, nerve. points will receive an eqiial density of current (Fig. 159) ; but if one is large and the other small (Fig. 1(50), the spot under the small electrode will receive the full force of the current, which is diffused in the tissue and over the surface of the other and much larger elec- ELEGTROPHYSICS AND ELECTROMEDICAL APPARATUS. 181 trode. A substance along which electricity passes readily is known as a conductor ; relatively U) other substances it ijreseuts a low resist- ance. An iiiHidatof or nonconductor is a substance which does not allow electricity to pass freely, relatively presenting a high resist- ance. Important conductors are the metals, carbon, flame, linen, cotton, and moist bodies generally, and important insulators are resins, shellac, amber, caoutchouc, dry air, silk, glass, wax, and sul- phur. A dielectric is a nonconducting or insulating material between two charged bodies. Nature of Electricity. — The modern view of the nature of elec- tricity is a return to an old theory qualified by recent scientific discoveries. According to this view, electrical phenomena are dependent upon the vibrations of the subtile, continuous, and incom- pressible ether which pervades all space. "This electrical ocean, in which we and everything else are immersed, has been likened by Sir William Thomson to a mass of jelly which allows all bodies to pass through it without friction, which is perfectly fluid for steady forces, but rigid for infinitesimal vibrations, and, as water is contained in jelly, so is electricity contained in the ether. Electricity thus be- comes a mode or manifestation of the ether, as heat is a mode of motion of material particles. Condu^ctors are bodies whicli allow electricity to flow through them. . . . The insulators or dielectrics are like elastic or impervious partitions, but yielding masses, sub- ject to strains when electricity is moved. As a general definition it may be said that cdl trannparent substances (not fluids) arc insidcdors, and that all opaque bodies are conductors." (McClure.) Galvanic Cells and Batteries. — Theoretically every substance, conductor or insulator, holds a certain elec- trical relation to every other, so that a list Fig. 161. Fig. 162. Galvanic cell, showing position of negative plates and poles. Gravity cell. might be made in which each substance higher in the list than its fellows would be electropositive to all the rest. Zinc and copper, 182 NERVOUS DISEASES. zinc and carbon, or zinc and platinum, are often used in tlie con- struction of batteries, tbe electropositive zinc being separated widely Fig. 163. Fig. 164. "^ i III ?l » Greuet cell. Leclanchg cell. Fig. 165. from tbe other elements named. The two metals are usually placed in a solution. The construction of a cell is seen in Fig. 161. A dry cell, so called, does not contain as much free liquid as a ivet ceJI, moist material being used in- stead of the ordinary fluid. The absence of free liquid permits the cell to be closed. The separate cells of a medical l>attery should not be too powerful ; the cur- rent supplied should be constant, should be compara- ti^ely smooth and regular, and should not flag during applications. Cells with one fluid are inconstant, but in medical praotice some have been found to answer. For portable l)atteiies hard rubber cells are preferable to those of <;lass or porcelain. Among desirable bat- teries are the Grenet (Fig. 163), Edisou-Lalande, Law, Leclanclu' (Fig. 164), Gravity, and Chloride of Silver, The constituents of some of the best known batteries are shown in the following table. A great improvement in the Chloride of Silver battery, as formerly made, is in the use of what is known as the dry interchangeable cell (Fig. 165), the construction of which allows one or any numl)er of exhausted cells to be disconnected and repaired, or new cells attached in their places. Sil\'ur fliiuride dry interchange- able cell. ELECTROPHYSICS AND ELECTROMEDICAL APPARATUS. 183 Constituents of Well Known Batteries. Name of Cell. Positive Element. Negative Element. Exciting Fluid. Depolaeizeh. Daniell. Zinc. Copper. Zinc .sulphate. Cupric sulphate. Edison-Lalande. Zinc. C'upric oxide and carbon. Potassium hy- droxide. Cupric oxide. Gaiflfe. Zinc. Silver. Zinc chloride. Silver chloride. Gravity. Zinc. Cojiper. Zinc sulphate. Cupric sulphate. Grenet. Zinc. Carljon. Sulphuric acid and potassium dichromate. Chromic acid. Lalande-Cliaperone . Zinc. Copper or Caustic potash. Cupric oxide. Law. Zinc. Carbon. Ammonium chloride. None. Leclanche. Zinc. Graphite. Ammonium chloride. Manganese dioxide. Walker. Zinc. Platinized graphite. Sulphuric acid (dilute). None. Fig. 166. Galvanic battery, with silver chloride dry interchangeable cells. Galvanic Apparatus for Medical Purposes. — The well known manufacturers of electromedical instruments all do work of sucli 184 NERVOUS DISEASES. high character that it is difficult to choose among them. Physicians will be well served by such firms as Plemming, Waite & Bartlett, the Chloride of Silver Dry Cell Battery Company, the Edison Manu- facturing Company, the Macintosh Company, the Galvano-Faradic Electrotherapeutic waU cabinet : 1, Mas^L■y current controller ; J. Flemming rnilliamperemetre ; 3, single switch for Including or omitting the rnilliamperemetre in the galvanic circuit; 4, de Watteville current combiner ; S, the ((miimitHtor or pole changer ; 6, Du Bois-Eeymond induction coil ; 7, water rheostat ; s, single switch for omitting or including the water rheostat in the faradic current ; 9, faradic double switch ; Id, single switch for starting or stopping the faradic apparatus ; X, contact screw : y, controlling screw ; <;, liuttun for galvanic current ; F. for faradic current; P, for primary faradic current ; S, for seeoudary faradic current. For letters on milliamperemetre, see Fig. 172. Company, and others. Tllustiaticms are given of some of the best forms of ixtrtablt^ and of permanent galvanic and faradic apparatus. Apparatus for the Adaptation of Street Currents to Medical Use.— Since the general introduction of electric lighting, efforts ELECTEOPHYSICS AND ELECTROMEDICAL APPARATUS. 185 have been made to use street currents for medical work, and specially designed rheostats or adapters have been invented. The Vetter current adapter, which can be attached to a light fixture as readily as changing a lamp, is shown in Pig. •^^®- ■^^^• 168, connected with a current controller and milliamp e r e m e t r e. If connected with a sixteen candle power lamp, the rheostat will control the incan- descent current from to 500 milliamperes. To run a faradic coil, the current adapter is adjusted to a sixteen candle power lamp, and posts 1 and 2 are joined to an ordinary faradic apparatus, or an ordinary faradic battery can be united to the adapter. When the current is in use the lamp acts as re- sistance to the flow, allowing only a limited cxuantity of the current to pass in that circuit. While this and other forms of adapting ap- paratus have been recently much improved, many electricians believe that the street current cannot be safely tapped for medical purposes ; certainly no one should attempt to make use of it without a knowl- edge of the principles involved, and of the possibility of accidents through carelessness or some unexpected defect. Apparatus for the Continuous Application of Weak Cur- rents. — Many forms of electric disks, belts, chains, and girdles have been used, but most of these appliances are useless, as frequently no current is derived from them, or when one can be obtained it is too feeble to be effective. To make long continuous applications of electricity of small dosage, Dana has had constructed a small box apparatus, made by Stammer, of New York, which can be applied for six hours or more daily, and from which a continuous current of one-half to one milliampere may be obtained. Rheotome. — A rheotome is an apparatus for interrupting the current ; it may be a contrivance run by clockwork or electricity, or a special form of hand electrode. Duchenne invented a pedal ov foot rheotome for slow intermissions, and Gowers has improved The Vetter incandescent current tap : A, the current adapter, connected by a cord from post 1 with the milliamperemetre, B, and by a cord from post 2 with the controller D. 186 NEBVOUS DISEASES. Fig. 169. it by having it so constructed that a slight twist of the foot will fix it immovably when required, even when the foot is removed. Rheostats and Current Controllers. — The rheostat is an instru- ment by which the strength of a galvanic current can be regulated with exactness by increasing or decreasing the resistance without opening the circuit. Many forms of -wire rheostat have been used in the arts and in medicine. It is only necessary to remember that the longer the wire through which the electric force is acting the weaker will be the resulting current. Another contrivance for diminish- ing coarse currents is the water rheostat, a glass tube with metallic bottom and top, in which works a movable rod. By the Massey cur- rent controUer (Pig. 169) the current can be varied at will from a frac- tion of a milliampere to the fuU strength of the battery without shock, by rapidly increasing or decreasing the resistance of the cir- cuit. It consists of a porcelain plate provided with a sickle shaped conducting area of graphite (soft pencil), broadening and thickening up to the terminal, where the graphite unites with a metallic surface which is in direct contact with the battery without any material resistance. The construction of the Vetter carbon current controller, shown in Fig. 170, is based upon the effect of the variation in re- sistance taking place in a quantity of carbon subjected to change of pressure. Finely di- vided carbon is placed in a small rubber cyl- inder between two metal plates which form the opposing ends of a circuit. The lower one is fixed to the base of the instru- ment, and the upper can be depressed by a fiue screw, so as to compress the carbon. The government of the circuit is absolutely reliable, ;is the carbon resistance is susceptible to the slightest varia- tion of ]iressurc of the screw, so that any degree from an almost im- perceptible current to the full power of the battery can be obtained. Equal work is imposed on the cells of the battery, and a current of uniform and equal strength can be maintained. Other advantages are the saving of space and the avoidance of annoyance in the The Massey current controller : r, binding post to connect ■n'ith carbon terminal ; Z, binding post to connect with zinc terminal ; N, anode or negative pole ; P, cathode or positive pole ; 1, turning crank ; 2, hard rubber bridge. ELECTROPHYSICS AND ELECTROMEDICAL APPARATUS. 187 absence of a complicated system of wires, and the absence of glass and liquid. Another excellent instrument is Willms's unalterable Fig. 170. r»>-v \^ ^* The Vetter carbon current controller. current controller, in which the resisting material consists of com- mon glue, graphite, and metal filings, the disk having a series of metal contact points with which the turning crank makes connection. Commutators. — By a co)n)iuttator or pole changer not only can the galvanic current be made and broken, but its polarity can be changed Fig. 171. The de Watteville current combiner and coromutator. from moment to moment. A commutator may be a device on the switch board of the battery, or a foot or a hand instrument. In Fig. 171 is shown an apparatus devised by de Watteville, as both current 188 NEEVOUS DISEASES. Fig. 172. combiner and commutator. Both galvanic and faradic currents may- be elicited simultaneously by placing tlie double switch in a parallel position. The faradic apparatus is started with all the switches set for actual work. The two currents are thus regulated each by their own controllers. For using the galvanic current alone, the upper double switch is moved so as to rest one part of the double switch on the flat plate G, and the other on the button in the middle. For the faradic currents alone, the double switch is moved so as to rest on P. The lower double switch is the commutator, with its index, N, always pointing to the cathode or negative pole. Gowers has invented a pedal commutator. Changing the polarity is more under the imme- diate control of the physician when it can be done by means of an apparatus held in the hand, and excellent pole changers of this kind have been invented by Birdsall and by Faught. Electric Dosage. — Eules for electric dosage, applicable to all cases, cannot be formulated. An accurate galvanometer or a miUi- amperemetre (Fig. 172), di- vided according to an ap- proved system, and elec- trodes of certain diameters, should be used. The so called Erb's normal elec- trodes, marked in square centimetres (Fig. 173) so that the current density may be known, have some advantages. With a uni- form current strength the density is inversely propor- tionate to the diameter of the electrodes. The pro- portion which the current bears to its place of entrance and exit should also be considered. If a current strength equalled 6 milli- ampcres. and the electrodes 6X1- centimetres, or 72 square centimetres, the den- sity would be equal to ^ or The Flemming uiiUiamperemetre ; < i and P, binding screws to make connections for circuit. When the metre is being transported, the needle should be arrested by turning the knob K ; if the needle, when released, does not settle at the of the scale upon coining to rest, raise or lower the case by means ot the adjiisting screw, S. until the index is exactly at zero. Tlie scale is diA-ided into ten units from zero in cither direction. When the double switch points to the figure 1 in front of it, the figures of the scale indicate a niilliampere t.'ach. If the switch be moved to button 10. the scale reading is to be multiplied ten times, and if it points to 100^ it is to be multiplied one hundred times. 12 square electrode 1 milliampere of current is spread.* To express the cur- jij, which means that upon ■^ c,,iiii-o centimetres of * These suL'^estions ni'c condeiiscrt from the recommendation made in 1886 by a committee of the .Vmerican NeiirciloL'ical Association, consisting of D"^- G. W. Jacoby, W. F. Birdsall, unj R. ^V. Amidon. ELECTEOPHYSICS AND ELECTROMEDICAL APPARATUS. 189 rent a fraction can be used, of which the numerator represents the number of milliamperes, and the denominator the number of square Fig. 173. ^«l«lllHuiBiml^^ ::t^::?''''!!'":ill!i!iilll||| 1 II "PI . ' liiiiii 1' III il fl (ill' '°- •■■! Mill 1! ^ ' Oil Erb's electrodes of regulated dimensions. centimetres contained in the electrodes. Conclusions drawn from the number of cells employed cannot be depended upon, as the strength of a given number of cells is a varying quantity. Faradic Apparatus. — Some faradic machines are made with several coils, but most of them have two, a primary and a second- ary, as shown in the Du Bois-Eeymond coil (Fig. 174). A faradic battery should be provided with a commutator or polarity changer, Fig. 174. Primary coil. Secondary coi The Du Bois-Reymond induction coil. with a slow and rapid rheotome or current interrupter, with a scale by which the currents may be finely graduated (Fig. 176), and with an enduring form of galvanic cell. In most faradic machines the first or inner coil consists of comparatively coarse insulated cop- per wire, one layer wound over another, and a second or outer coil of ten to fifteen times as much insulated wire of the size of very fine packthread. A standard faradic machine was adopted at the Elec- trical Congress in 1881. The galvanic generator is a single Daniell cell. The resistance in the primary coil is about 1.5 Siemens units ; 190 NERVOUS DISEASES. in the secondary coil the resistance is aboat 300 Siemens units. (Robinson.) To gauge the faradic current, a scale is attached to Fig. 175. Switch to regulate current strengtli Cylinder regulator of current for primary coU. strength. Faradic apparatus for office table. the coil to indicate the strength of the current when the secondary Fig. 176. Mcintosh's faradic battery. coil is made to slide over the primary coil, the distance through which it is jjushed being marked in millimetres ELECTEOPHYSICS AND ELBCTEOMEDICAL APPARATUS. 191 The various parts of the standard machine are as follows : Primary coU. Secondary coil. Length of spool (excluding wooden frame) . . KH.oO mm. 65.00 mm. Diameter of spool 36.00 " 68.00 " Diameter of wire 1.00 " 25 " Number of turns of wire 300.00 " 5000.00 " Layers of wire 4.00 " 28.00 " The best method of marking a faradic current is to have the scale read zero when the secondary coil is removed from the primary. Sinusoidal Current and Therapeutic Alternator. — The sinu- soidal current, so named by d' Arsonval, on account of the sinusoidal form of the curve produced by the current when graphically repre- sented, is obtained from a magnetoelectrical apparatus, like the Ken- FiG. 177. Tlie Kennelly therapeutic alternator. nelly therapeutic alternator* (Fig. 177), which can be driven by a motor from a battery of eight Edison-Lalande cells or from a small motor or Edison incandescent circuit. It has twelve poles, on each of which is a spool with two windings of wires, the inner having eight layers of fine and the outer two of coarse wire. The former are connected in one series constituting the secondary or delivery coil, while the latter, connected in another series, form the primary or field winding of the machine. To transform the battery or con- tinuous primary current into an alternating current wave in the secondary circuit, it is necessary to drive the armature, which is a combination of iron disks. By duly proportioning the grooves and projections in the armature surface the waves are made practically * Manufactured by the Edison Manufacturing Company. 192 NERVOUS DISEASES. sinusoidal. A rheostat of wire for battery circuits, or of lamps when operated from incandescent mains, is included in the primary circuit of the alternator, by which the strength of the Fig. 178. secondary currents can be controlled independently of frequency. Special therapeutic effects can be obtained from using such a rapidly alternating or continuous sinusoidal current. Electrodes. — It will not be necessary to describe in detail the different forms of electrodes, two of whicli are shown in Pigs. 178 and 179. A neat method of cov- ering an electrode is to employ absorbent cotton instead of chamois skin or sponge. (^lassey.) After a time an electrode tends to become encrusted with salt, dirt, or chemical deposits, but one that is not clean should not be used. The deposits may cause local electrical reac- tions, and render the applications unnecessarily pain- ful, and a clean polished electrode is therefore less painful than any other. When a current passes be- tween a metal and a liquid electrolyte, a great apparent resistance occurs, the current becoming weaker, this diminution in the strength of the main current being due t(j a local action, called polarization, which gives rise to secondary currents, which act in an opposite direction to the chief current. Not only may the plates or elements of the battery become polarized, but po- larization may occur at the surface of the electrodes, interfering with their efficacy. Unpolarizable elec- trodes have been invented by Du Bois-Eeymond, but have not come into general use. Electrodes which can , be adjusted to the head, spine, or limbs are often useful in neuro- A good form of head electrode is shown in Pig. 179. Fig. 179. Interrupting hand electrode logical work. Putnam's head electrodes (0, C, C. C, C), held In place firmly by a belt (.1) and spring iH], tha' can be used on the head or any part of the body. ELECTEODIAGNOSIS AND ELBCTROPROGNOSIS. 193 ELECTRODIAGNOSIS AND ELEOTROPROGNOSIS. Diagnostic Uses of Electricity. — As an aid to diagnosis elec- tricity is chiefly used to assist in diflferentiating central from periph- eral paralyses. In malingering it sometimes has a definite value, because of its power to distinguish an organic peripheral paralysis from a simulated loss of power ; but it is not true that the presence of normal response both to galvanism and to faradism indicates that loss of power is not real, for, as will presently be seen, in central palsies the electrical reactions are often practically the same as in health. Both faradic and galvanic currents can be used to assist in determining whether a painful spine is due to organic disease of peri- osteum, bone, cartilage, or membranes of the spinal cord, or whether it is merely assumed or is part of a hysterical or neuromimetic syn- drome. Electricity may aid in the diagnosis of the presence of death through failure of the patient to respond to both sensory and mus- cular tests. Central and Peripheral Paralyses. — A peripheral paralysis may be caused by a lesion situated in the muscles or in the nerve endings in the muscles, in the nerve trunk entirely outside of the cranium or spinal canal, in the root ganglia, in the foramen through which the nerve passes, in the intracranial or intraspinal course of the nerve, or even in the nerve roots and tracts at their nuclei of origin ; and when the lesion is in any of these places the electrical response is peripheral. Similarly a central paralysis may be due to a lesion in at least half a dozen places between the nerve nuclei and the brain surface, as in the upper pons, or in the cms, capsules, alba, or cortex. In the columns of the spinal cord, a lesion which produces paralysis, if situated above the centres in which originate particular nerves which supply the paralyzed muscles, gives a paralysis which is cen- tral for these nerves and muscles, although the same lesion might cause a peripheral palsy of the nerves originating in its immediate vicinity. In peripheral motor paralysis, electrocontractility both to faradism and to galvanism is usually lost wholly or in part, but in some cases, on account of the slightness of the lesion, the electrical changes cannot be recognized. In true central paralyses, whether spinal or cerebral, electrocontractility is not lost, although occasion- ally it is quantitatively depressed. If a lesion is at the same time both central and peripheral the responses to the electric current will be peripheral. Illustrations of central lesions are to be found in cere- bral hemorrhage, embolism or thrombosis, tumors or abscesses, and some forms of sclerosis. Myelitis of various types will give cen- tral or peripheral reactions according to the diffusion of the lesion. Diseases which give diagnostic peripheral reactions are facial paral- ysis, traumatic paralysis, diphtheritic and lead paralysis, and other forms of palsy due to infectious or toxic agents. 13 194 NERVOUS DISEASES. Reaction of Degeneration. — The reaction of degeneration is a marked change iu excitability or contractility observed when neui'o- muscular examinations are made with the faradic and galvanic cur- rents. Coincidently with more or less wasting, faradic contractility may be entirely abolished, while to galvanism certain peculiar changes, which are spoken of technically as modal or serial, may be present. The modal change shows itself to the eye of the investi- gator as a slow, wormlike quivering of the degenerated muscle, even under the influence of a very weak current. Once seen and under- stood it cannot well be forgotten. Serial changes are qualitative also, and the term is used because when the anode or cathode is succes- sively applied on opening or closing the circuit we get a series of differences in the degree of response and, to some extent, in its char- acter. When nerve and muscle are normal this formula takes a cer- tain order, the cathodal closure leading, the anodal closure coming second, and then the anodal and the cathodal opening. This order is changed in degeneration reaction. In forms of disease in which nerve and muscle slowly degenerate, these tissues gradually grow more and more abnormal in their response to both galvanism and faradism. This gives what is called partial degeneration reliction ; it is easily determined when it is remembered that both nerve and muscle con- tinue to respond to galvanism and faradism as long as any nerve fibre or muscular tissue remains. In the complete form of the reac- tion of degeneration the muscles, while showing lost irritability to faradism, may show an increased irritability' to galvanism. In partial degeneration reaction easily recognized modal changes are present, and polar changes can be determined, but may require careful and skilful investigation. The degeneration reactions are dependent upon pathological changes which occur in nerve and muscle. As regen- eration progresses the electrical reactions become more and more those of health. In old cases of paralysis, nerve and muscle sometimes entirely disappear, and no reaction can be obtained with any form of electrical current. Technically, this is not a reaction of degener- ation, but simply an absent reaction. A reaction of degeneration which is at one time ])artial may in the downward progress of the disease become complete, and the same muscle, when large and com- posed of separate bundles, may even show diftVrences of reaction in different parts. Symbols and Formulas. — The following symbols are sometimes employed in studying these reactions : An, anofU'. Ca, cathode. De R or RD, reaction of degeneration. C, contraction. CI, closure. O, opening. CaClC, cathodic closing contraction. OaOC, cathodic opening contraction. OaClTe, cathodic closing tetanus. AnClC, anodic closing contraction. AnOC, anodic opening contraction. AnClTe, anodic closing tetanus. ELECTRODIAGNOSIS AND ELECTEOPEOGNOSIS. 195 Using symbols, tlie normal reaction is expressed by CaClC > AnClC > AnOC > CaOC. Anodal closure contraction may equal cathodal contraction, as AnCIC = CaClC. Wlien reaction of degeneration is present, the anodal opening contraction may lead the series, giving AnOC > AnClC > CaClC > CaOC, or it might be properly repre- sented as follows : AnOC > CaClC = AnClC > CaOC. Some of these varieties in reaction of degeneration occur so regularly as to be regarded as typical forms ; for instance, where AnClC > CaOlC, or AnClC = CaClC. Independence of Trophic and Paralytic Phenomena. — Ac- cording to de Watteville, trophic changes in muscle may be inde- pendent of paralytic phenomena, and may affect both muscle and nerve or muscle alone. Pig. 180 shows the relations between the motor and the assumed trophic centres, and between the ner- vous and muscular fibres. The trephic as well as the voluntary and reflex influences are sup- posed to converge in the multi- polar ganglion cell, G. If the lesion be at c, or in the cerebral centres above, the characteristic symptom is paralysis (loss of motility), but there is no atrophy nor loss of electroescitability. A lesion involving both c and in causes paralysis with atrophy of muscle, but not of nerve, and gives qualitative and quantita- tive changes in galvanomuscular irritability, the nerve responding to both galvanism and faradism, as in amyotrophic lateral sclero- sis. If the lesion is confined to the trophic centre (m), the muscle atrophies, but is not paralyzed, and presents qualitative altera- tions in reaction. Blectroner- vous excitability is present. The phenomena are those of partial ED, and occur in progressive muscular atrophy, bulbar paraly- sis, mild acute poliomyelitis, etc. Erb's diagram, showing the relations between the motor and assumed trophic centres and the nervous and muscular fibres : M, muscular fibre ; N, nerve fibre with its ending, e : G, mul- tipolar ganglion cell, from the anterior horn of gray matter or bulbar nuclei ; c, path of impulse from the brain, anterolateral columns ; r, path of reflex excitation from the sensory sphere ; m, trophic centre for the muscle ; n, trophic centre for the nen'e ; m-m', path of trophic influence to the muscle ; n-n', path of trophic influence to the nerve. (De Watteville.) "When G is destroyed, there is loss of motility, loss of reflex action, atrophy both of nerve and muscle. The electrical phenomena are those of the reaction of degen- 196 NBEVOUS DISEASES. eration fully developed. The same phenomena must obviously be present when N" is destroyed at one point completely {i.e., including m' and n'). G is destroyed in anterior poliomyelitis (iufantile paraly- sis) ; ]Sr, in severe peripheral paralyses." Table shoivlng the Connection between Certain Pathological States and their Electro- diagnostic Phenomena. (Modified from de Watteville.) Seat of Lesion and Disease. PROMINENT Symptoms. Electeical Reaction. Cortex and pyramidal tracts (c). Cerebral hemorrhage, embolism, thrombosis, tumors, abscess, and lateral sclerosis. Pyramidal tracts ; ganglion cells of ventral horns of the cord (c and m) . Amyotrophic lateral sclerosis. Trophic centres for muscle to cells of ventral horns of cord, or to bulbar motor nuclei {m extending to G). Progressive muscular atrophy of central origin ; bulbar paraly- sis ; mild acute poliomyelitis. Multipolar ganglion cells (G). Anterior poliomyelitis. Nerve and muscle (N, n' and ra'). Rheumatic, traumatic, or toxic dis- ease of nerve and muscle. Muscle (M). Muscular wasting in phthisis, dis- eases of joints, idiopathic myo- sitis ; primary myopathies. Paralysis v?ithout muscular degenera- tion ; contractures. Paralysis and mus- cular degeneration ; contractures. At first no paralysis ; later paralysis and muscular followed by nerve degenera- tion. Paralysis and atrophy of nerves and mus- cle, mth abolition of reflexes. Paralysis and muscu- lar degeneration. Paresis and simple atrophy. Normal. Nerve normal ; partial ED in muscle. Nerve normal ; partial ED in muscle. ED for nerve and muscle. Partial or com- plete ED for nerve and mus- cle. Gradual diminu- tion of electrical response. Peculiarities in the Electrical Reactions. — In many forms of neuritis, and especially in that due to lead poisoning, nonparalyzed nerves and muscles may show changes in electrical irritability indi- cating the presence of unsuspected degenerative processes. (Gum- pertz. ) Putnam found that even powerful and painful currents failed to cause contraction of the extensors of the finger when the anode of the faradic battery was applied to the musculospiral nerve, although the response to the faradic current and that to the direct excitation of the extensor muscles were apparently normal, but almost the same results were obtained with normal subjects. The reactions in multiple neuritis are worthy of special mention. They vary in dif- ferent paralyzed muscles, as would be expected, because of the local variations in the intensity of a multiple disease. Sometimes polar changes are not present, although the response to both currents may be diminished ; sometimes with total loss of faradocontractUity no galvanic polar changes can be determined ; and sometimes electrical changes are present in unparalyzed muscles. Polar irritability will also vary much at different stages of such a disease as poliomyelitis. ELECTEODIAGNOSIS AND ELECTROPROGNOSIS. 197 Fig. 181. Electrodiagnostic Technique.— Some points to be observed are (1) to make the patient as comfortable as possible ; (2) to see that the muscles are relaxed and at rest ; (3) thoroughly and equally to moisten the electrodes ; (4 ) to pass the current through equal lengths of the two parts compared ; if one side is compared with the other, by making one large electrode stationary in a central region, as the sternum or sacrum, and applying the other smaller electrode to the nerve or muscle ; (5) to begin the tests on the healthy part, determining first the least strength of current that will cause contractions, and then carefully to make the test in exactly the same way on the dis- eased part. Usually the nerve and muscle are first tested with the faradic current. The Myotonic Reaction. — To obtain the myotonic reaction — a peculiar form of electrical response observed in Thomsen's disease — a large electrode is placed upon the sternum or upon the back of the neck, and another of medium size in the palm. Allowing a medium current to flow, a tonic spastic condition of the muscles of the arm is developed. In a little while, particularly after changing the poles with the commu- tator, curious wave-like contractions take place, these moving downward when the anode is in the hand, upward when the cathode is in the same position. ( Jacoby. ) Brb has compared the single waves to those produced by a stone falling in water. The amount of current requisite for the production of the phenomena varies from six to twenty milliamperes. Erb asserts that this reaction is always characteristic, but that it may be found in normal and nearly normal muscles. Electrosensibility. — The electrosensibility of the skin, some- times important in the diagnosis of hysteria or malingering, is de- termined by faradization with a metallic brush (Pig. 182) or with other metallic electrodes. Two parts of the body can be com- pared, or the application can be made to the same area in two individuals. The strength of the current which excites the first trace of sensation, and also that which causes distinct impressions of pain, should be noted. Ley den's method of using compasses con- nected with a faradic apparatus may be employed. In any method provision can be made for reading off the distance separating the Leszynsky's diagnostic electrode: the handle is so constructed that the circuit can be opened and closed without removing it from the skin ; the comiections are com- pletely insulated, its shape adapts it to the operator's fingers and hand, and the curs'e on the shaft attached to the motor point facili- tates its adjustment and manipu- lation. 198 NERVOUS DISEASES. ends of the induction apparatus. One electrode is placed upon the portion to be examined, the other, or indifferent electrode, may be applied anywhere. Averages are obtained for different parts of the body, and these enable deviations from the normal to be detected. Fig. 182. Bernhardt has divided the surface of the body with reference to cutaneous electroseusibility into nine zones. These and the average minimum coil distance of sensation and of pain for these various regions are given in the following table (combined from two tables by Eobinson) : Zones. Ge.N-ER.1L Electeo- sensieility. Paevful Electeo- sensibility. 1. Tongue (tip of tongue, palate, tip of no^e) 2. Face (eyelids, gums, red lips, cheeks) 3. Forehead . .... 4. Shoulder 5. Trunk (sternum, nape and front of neck, occiput, spine, arm, forearm, buttock) . 6. Thigh (saci-um, thigh, dorsum of foot) 7. Hand (back of hand, leg, ball of fingers) . 8. Patella . . ... 9. Digital (palm, ti]) of toes, sole of foot) . . Ififi.O mm. 150.5 " 144,5 " 137.0 " 128.0 " 122.1 " 116.0 " 111.0 " 114.5 " 136.7 mm. 130.5 " 128.0 " 112.5 " 110.8 " 99.1 " 92.8 " 88.0 " 67.8 " Electroprognosis. — The value of electricity in prognosis — mainly in the prognosis of paralyses — has been largely foreshadowed in the remarks on electrodiagnosis. Having determined that a paralysis is central, the gravity of the prognosis is made evident ; and, on the other hand, if the diagnosis has been decided in favor of a peripheral lesion, although the electrical changes are more serious, the iirognosis is comparatively good. An understanding of the subject of partial degeneration reactions may help to settle the cornual nature of a iirogiessive atrophic disease, and, in so doing, decide for it a serious prognosis and a chronic course. As time advances in the treatment of certain peripheral paralyses, as Bell's palsy, the prognosis lieeoines more and more certain as the electrical reactions change for better or worse. Step l)y step in some of these cases the stages of degeneration can l)e marked by the sinister changes in electrical response until finally no leaction whatever can be ob- tained. Paradic contractility may be entirely lost for a time in cases with comparatiAcly favorable prognosis. ELECTROTHERAPEUTICS. 199 ELECTROTHERAPEUTICS. Special Methods of Electrical Application. — A current is direct when tlie anode is applied at or near the neuraxis and the cathode Fig. 183. Sympathetic. Sternomastoid. Spinal Aco. Nerve. Sternomastoid. Plirenic Nerve. Deltoid. Musculospiral Nerve. Triceps. 4. Ext. Carpi Uln. 5. Ext. Digit. Com. 6. Ext. Dig. Min. Teres Major. Teres Minor. Serratus Magnus. Ulnar Nerve.;/ Flexor I and IV. ; ^ Flexor II and III. ''/' Fl. Dig. Prof. (/ Fl. Carpi Ulnaris. '',■ Fl. Carpi Eadialis, Gastrocnemius. Soleus, Flexor Digit. Communis. Ramus N. Peron. Prof. pro Extens. Dig. Brev. Interossei. Latissimus Dorsi. Obliquus Abdom. (Intercostal Nerve.) ^■"■Eectus Abdom. '""■■Transversus Abdom. --,5-Tensor Vag. Fem. -Crural Nerve. -Gluteus. ,..--Biceps. '■'■>Vastus Externus. , Peroneal Nerve. ^Gastrocnemius. .-•'' ,/,-Peroneus Longus. Soleus. .--_■;!_- Extensor Digit. Com. Tibialis Anticus. Ext. Halluc. Longus. Soleus. Ext. Halluc. Long. Flexor Halluc. Long. Extensor Digitorum Communis Brevis. Motor points of trunk and limbs. (Lincoln.) towards the periphery, while the reverse positions of the electrodes give an indirect current. In a unipolar application the anode or the cathode is applied to a selected spot, and the other electrode is placed 200 NERVOUS DISEASES. Fig. 184. upon a part so distant that the eifects of the two poles cannot com- mingle. In a cutaneous application both the skin and at least one electrode should be dry. Applications can also be made to the skin by the dry or slightly moist- ened hand. For deeper seated applications to motor nerves and mus- cles the electrodes should be covered with some substance like absorbent cotton, sponge, or cham- ois skin, which should be thoroughly wetted with warm water or warm salt water. Firm pressure should be made over the motor point or muscle to be reached. For paralysis either di- rect or indirect muscular electrization may be used ; in the former the elec- trodes are applied as di- rectly as possible to the muscles ; in the latter the muscle is caused Points for muscles and motor nerves of the face : 1, m. cor- rugator supercilii ; 2, m. compressor nasi et pyramidalis nasi ; 3, m. orbicularis palpebrarum ; 4, m. levator labii superioris alfeque nasi ; 5, m. levator labii superioris (proprius) ; 6, m. \q contract through itS zygomaticus minor ; 7, m. dilator! narls anterior! et posterior! ; 8, m. zygomatlcus major ; 9, m. orbicularis oris ; 10, ramus com- municans pro m. depressor angull oris (triangularis menti) et levator labii inferioris (levator menti) ; 11, m. levator lab!! !n- ferioris (levator menti) ; 12, m. depressor labii inferioris (quad- ratus menti) ; 13, m, depressor anguli oris (triangularis menti) ; 14, ramus subcutaneiis colli n. facialis ; 15, ramios cervicalis pro m. platysma myoides ; 16, m. sternohyoideus ; 17, m. omo- hyoideus ; 18, m. sternothyroideus ; 19, m. sternohyoideus ; 20, m. frontalis ; 21, m. attrahens aurem et attollens aurem ; 22, m. retrahens aurem et nttollens aurem ; 23, m. occipitalis : 24, n. facialis ; 25, ramus auricularis posterioris pro n. facialis ; 26, m. stylohyoideus : 27, m. digastricus ; 2.s, rami buccales n. facialis ; 29, m. splenius capitis ; 30, ramus subcutaneus max- ilte inferioris ; 31, ramus extemus n. accessor!! W'illisii ; 32, m. sternocleidomastoideus ; 33, n. acccssorius ; 34, m. steruocleido- by placing 0116 electrodC, mastoideus ; 35, m, levator anguli scapul;v ; 36, n. thoracicus -.-i .i f^^it nr Vrnid posticuK (m. rhombnide!) ; 37, n, phrenicus ; 3,s, m. omohyoid- """"'^ ^^^ ^"°^' " ' eus ; 39, n. thoracicus lateralis (m, serratus magnus) ; 40, u. iu a baslu of Warm Salt axillaris ; 41, ramus plexi brachialis (n. musculocutaneus pars w,.-,fp,. -n-Viile the Othcr iS es). ' ' . applied to some portion of the limb. For the riic, a moistened rheophore is applied to the closed eye, and a second to any convenient spot ; for the ear, a nerve supply, by ap- plying the electrodes to motor nerve points. Motor points, nerves, and important muscles are shown in Figs. 183, 184. Joint applications can be made by apply- ing electrodes to oppo- site sides of the joint, or li. mcdiani) ; 42, 43, n, thiiracici anteriores (m. pectorales; ELECTROTHERAPEUTICS. 201 medium sized electrode is placed so as to cover tlie tragus, and the indifferent pole to the hand or the sternum ; for the nose, a moist rheophore is applied to the back of the neck, and a metal sound, insulated except at its extremity, to the nasal mucous membrane ; for the tongue, one electrode is applied to the neck, while the other is moved over the base and border of the tongue. Care and Method. — Electricity sometimes falls into unmerited disrepute because of the extreme carelessness and want of interest with which it is used. It is better that applications should be fre- quent rather than severe and long continued. As to the duration of a single application, it is difficult to give fixed rules. Lincoln suggests as an average time three to five minutes to the spinal cord, one to three minutes to the organs of sight aud hearing, two minutes to a single large muscle, five minutes to a group of muscles, and twenty minutes for general electrization. Incautious applications may produce vertigo or even syncope or faintness, results probably brought about through direct or reflex effect upon the pneumogastric nerve. Various annoying phenomena, as local or general rashes, blisters or burns of the skin or mucous membrane, and pain in the skin and muscles, may occur. If the muscles and coarse nerves of the trunk and limbs can be exhausted by electricity, much more certainly can the delicate retina be exhausted and its functions im- paired or destroyed by this agent ; and the nerves of hearing, smell, and taste can likewise be injured by overstimulation. Eitter, through experiments performed upon his auditory nerves for scientific pur- poses, destroyed his sense of hearing. Electricity in Neurological Therapeutics. — Electricity is of value in the treatment of neurasthenia, hysteria, and paralytic and other diseases of the peripheral nerves, also for the relief of pain, particularly when of neural origin, for sleeplessness and headache, for a few affections of the spinal cord, brain, and nerves of sense, and for occupation neuroses. General Faradization. — General faradization, which is most used in the treatment of neurasthenia and hysteria, is usually applied in either a reclining or a sitting position. (1) In the reclining position, beginning with the limbs, preferably the lower extremities, the elec- trodes are applied either directly over the muscles or to the motor points, care being taken to include as far as possible every muscle and group of muscles. The operator passes from the toes and feet to the legs and thighs, taking each set of muscles in turn. The upper limbs are next faradized, beginning with the fingers and hands and ascending to the shoulders, and the muscles of the back, chest, and abdomen are treated last, although it may sometimes be advisable to treat the muscles of the back, loins, and abdomen before the upper extremities. Violently contorting the muscles should be carefully avoided. Prom time to time the electrodes should be rewetted. 202 NERVOUS DISEASES. (2) In the sitting position, one metliod is to place in the patient's hand one of the well wetted electrodes ; the other is held by the operator, who at first, with his free hand, makes applications to the head, face, and neck, after which, the patient still keeping one electrode in his hand, the operator passes the other down the back and arm. The patient then shifts the electrode to the opposite hand, and the oper- ator passes down the arm of that side. Both electrodes can be taken into the hand of the operator and rapidly glided over the arms and trunk. The lower extremities are treated last. Another plan is to have one or both feet upon a large metallic electrode covered with a moistened cloth or chamois skin, while the operator passes the other carefully over all accessible portions of the body. Unnecessary ex- posure should be avoided. The operator should be satisfied with a moderate application. General faradization can be completed in from twenty to forty minutes. Treatment should not be too soon after meals, as it may interfere with digestion. The preferable time is midway between meals. The muscles should be relaxed during the application. "When possible, both electrodes should be held in one hand, as shown in Fig. 185, as this leaves the other hand free to regulate the strength of the cur- FiG. 185. Pgjjj QP fQj, other purposes. The electrodes are held pointing back- ward, the handle of one between the index and the middle finger, and that of the other between the ring and the little finger. The disks can be thus brought close to- gether or separated several inches. Galvanofarad i z a t i o n. — The Method oThoidmg electrodes in one hand, galvanic and faradic Currents can be used simultaneously by a process called galvanofaradization, which may be either general or local- ized. It requires a double electrode with one part for each cur- rent. The copper plate may be connected at one part with the pole of the faradic and at another with that of the galvanic appa- ratus, and the circuit thus completed for both currents. In local- ized galvanofaradization it is necessary to have in use two double electrodes. By a proper construction and adjustment of the elec- trodes it is possible to localize the two currents very near to each other. (Beard and Eock\\'ell. ) Cataphoresis.— Adamkiewicz first called attention to a method of treating pain in the superficial nerves b>' the application of chloro- form til the affected area by means of an anodal diffusion electrode. The Ayres-Adamkiewicz electrode is shown in Fig. 186. The pioximal end of the reservoir can be unscrewed and the whole in- terior exposed ; and to allow of freer transudation of sufficient fluid ELECTROTHERAPEUTICS. 203 Fig. 186. m ■V i. Fig. 187. 3 tlirough the carbon plate several small apertures have been made. In this modified electrode a carbon column is made solid with a dia- phragm abutting against a metallic plate. Peter- son considers the Adamkiewicz electrode faulty on account of the metal cylinder with its carbon but- ton. His electrode is shown in Pig. 187. When cataphoresis is employed the drug solution must be placed upon the anode, as the process is one of anodal diffusion, and the movement of the current carries substances in one direction only, from the anode to the cathode. Medicaments can be made to act by cataphoresis to reach morbid tissues, to produce ul:>- sorption, as an alterative, to bring about local anes- thesia, and to relieve pain in the superficial nerves. (Peterson.) Three methods of cataphoresis are (1) by the bath, (2) by solution of a drug on any ordi- nary sponge electrode, and (3) by the cataphoric elec- trode. Aconitia with cocaine, helleborin, — which should be used with caution, — ouabain, strophan- thin, chloroform, and a weak solution of carbolic acid are efficient anes- thetics. By anemic cata- phoresis the drug is re- stricted to that ijart for which it is intended by cutting off the blood stream, either by an Esmarch bandage or a rubber ring, or by com- pression with a disk-shaped electrode. The medicine is incorporated in a small plaster composed of pulverized gas car- bon and gelatin. (Morton.) Treatment of Pain by Rapidly In- terrupted Faradic Currents. — Dentists have long used the rapidly interrupted faradic current as an anesthetic. Some faradic instruments are made with sep- arate induction coils, one with slow or moderate interruptions for the treatment of motor nerves and muscles, and the other arranged for exceedingly rapid in- terruptions in order to produce sensory effects. Hutchinson found that when the vibrations were kept so as to sound the note the marked anesthetic effects of the current were produced and maintained. Tic douloureux has been entirely relieved and sleep induced by this method of treat- The Ayres- Adam- kiewicz electrode. Peterson's improved cataplroric electrode : A, disk made of metal tliat will not oxidize ; the stem passing through the hard rubber cover, C, is held in place by the nut D, which holds the tip for connecting with the battery ; B, soft rubber ring which is held in place by A, at the same time insulating the skin from jl, allowing the current to pass from A to the skin through medicated paper contained in the cavity formed by A and B. 204 NERVOUS DISEASES. ment, placing the negative pole under the nape of the neck and the positive — a flat sponge three inches square — upon the forehead. Kennelly and Peterson, at the Edison laboratory, investigated the effect upon themselves of a current alternating two hundred and eighty-eight times per second. They made the remarkable dis- covery that as the vibrations increased in frequency a benumbing effect was produced upon the sensory nerves, and with the highest number of vibrations a comj)lete loss of sensation resulted in the parts in which the current was applied, so that pricking with needles and knives and the applications of cold and of hot water were not felt at all. When the current was turned off sensation was restored. Voltaic Alternatives. — When an electrode on a nerve is changed from the anode to the cathode, and the reverse, a series of closure excitations are given, which fall for the cathode in the polar region and for the anode in the peripolar region respectively ; and in either case the excited region has just before been under anodic influence. Physiology teaches us that the instant the polarizing current ceases to flow the anodic region passes into a state of increased excitability, and this augmentation is more marked the longer the anodic influence has lasted. Voltaic alternatives therefore act more powerfully than simple closures of the circuit, and their action is intensified by previous current duration. (De Watteville.) The use of voltaic alternatives is the most energetic method of electrical stimulation, and rapid reversals are more effectual than slow. This mode of treatment has been strongly recommended in forms of optic nerve atrophy by Pox, Paught, and Eiggs. Voltaic alternations are fre- quently used by neurologists in the treatment of neuromuscular affections. Miscellaneous Uses of Electricity. — Chronic poliomyelitis may make considerable improvement under the use of galvanism applied to paralyzed nerves and muscles, and a galvanic current of medium strength is a valuable remedy for chronic neuritis. Tremor, when functional or toxic, is sometimes greatly benefited by galvan- ism, applying the anode to the affected part, and the cathode to the spine or to some other indifferent spot. Chorea has been treated by all forms of electricity, — by sparks from frictional machines, by general and peripheral faradization, and by gahanization of the head and spine. Hysterical or nervous deafness, and some forms of tinnitus, may be successfully ti'eated by faradism or galvanism. In treating tinnitus with hyperesthesia with galvanism, the anode is applied to the neighborhood of the ear, while tinnitus with anesthesia calls for the cathode to the ear or near it. A rheostat must be em- ployed, or other\\'ise the unpleasant phenomena produced by the applications may compel the procedure to be stopped. Faradization is useful for those forms of tinnitus which depend upon paralysis ELECTROTHERAPEUTICS. 205 of the intrinsic muscles of the ear. In weakness of sight, when no lesion can be discovered — a condition which may be due to malnutri- tion, and a consequent oversusceptibility to fatigue — galvanic treat- ment with a weak current to the closed eyes is sometimes efficient. Hiccough, nervous asthma, and nervous vomiting are more or less amenable to electrical treatment by applying a weak current — the anode to the pneumogastric nerve, and the other electrode on some indifferent spot. Care should be taken not to place or remove the electrode abruptly, otherwise vertiginous attacks and even syncope may be produced. Writer's cramp is treated by passing a mild current in a descending direction through the nerves and muscles affected, at the same time exercising the muscles with light gymnas- tics. The anode may be placed in the axilla, and the cathode on the ulnar nerve at the elbow ; or the anode over the median nerve in the upper arm, and the negative over the iiexor longus poUicis. (Poore.) The faradic current may, in some instances, be usefully conjoined with galvanism. Spermatorrhea, spermatophobia, and psychical or physical impotency may be benefited by the use of either the faradic or the galvanic current. Applications are made to the spinal column ; or one rheophore is placed upon the spine and the other applied to the perineum, or to the genitals, or to the urethra with an electrical bougie. Sleeplessness may be successfully treated by a weak gal- vanic current, placing flat electrodes on the temples for thirty sec- onds to one minute. Localized faradization is useful in hysterical aphonia, and in some cases of aphonia the result of organic lesion. Hemicrania during the attack is sometimes benefited by mild faradi- zation of the painful region of the head, the application being made with the dry or slightly moistened hand. For cerebral neurasthenia weak galvanic currents to the head and general faradization, with rest and full feeding, have proved useful. Erb has strongly advo- cated the use of the galvanic current in the treatment of insanity. Cerebral galvanization, and the central galvanization of Beard and Eockwell, are used in mild mania, melancholia, and the early stages of general paralysis. In cerebral galvanization the electrodes are usually applied longitudinally, one to the occiput and the other to the forehead. The current. should be weak, at first not appreciable, but slowly increased by the use of the rheostat or current controller ; the application should not be continued for more than three to five minutes. In central galvanization a weak current is used, and one electrode, usually the cathode, is applied to the epigastric region, while the other is placed first on the forehead, and then successively on the top of the head, along the sternocleidomastoid muscle in the neck, to the nape of the neck, and down the spine. The whole application should occupy from fifteen to twenty minutes. General faradization is a useful adjunct in the treatment of neurasthenic melancholia. 206 NERVOUS DISEASES. FRANKLINISM OR STATIC ELECTRICITY. Franklinism and Franklinic Machines. — Static, frictional, or frauklinic electricity, < )r franklinism, the first form of electricity used in medicine, was supitlantecL for a time after the discoveries of gal- vanism and faradism, was again brought into prominence in several eras, and was then relegated to obscurity; probably it has now received il.s proper position, although the tendency is still on the one hand to deny it any virtue, and on the other to claim tVir it too much thera- peutic importance. Neither "static" nor "frictional" is a term altogether applicable to the description of this agent as now used. Underlying the construction of static machines are four principles,— that bodies may be electrified by friction ; that tliey may be electri- fied by induction or proximity; that electrified bodies not only attract non-electrified bodies but communicate electricitj" to them by contact; and that bodies similarly electrified, either by each other or from the same source, show mutual repulsion. (McClure.) The first static or frictional machines were based upon the fact, known for centuries, that friction of substances like amber or glass by silk, and of resinous substances by flannel or catskin, would develop electricity of the so- called positive or negative character. A ball of sulphur was made to turn upon its axis and was grasped by the hands ; later globes and tubes of glass and glass plates were used ; still later, cylinders of glass Fig. 188. Toepler-Holtz electrical machine. instead of plates N\ere nia(l(> to re\'olve between various appliances. In the latter part of the last century the influence or induction static machines were first used, but attracted little attention. In the franklinic machines now used the electric current is started by PEANKLINISM OR STATIC ELECTRICITY. 207 friction, it is increased and continued are employed to store or condense the tant influence machine was made by chine, as first made, one revolving and ( The present improved apparatus is machine, and one form of it is shown : by induction, and Leyden jars electricity. The fiist impor- Holtz, of Berlin, in 1865, and was known as Holtz's electrophanus machine. In the Holtz ma- . one stationary plate were used, known as the Toepler-Holtz in Fig. 188. The instrument, Fig. 189. The Rarmey improved static machine, with charger attached. of comparatively small size, has some therapeutic powers, although Morton asserts that curative results are obtained only from powerful machines and powerful administrations. An excellent larger form of static electrical machine is shown in Fig. 189. The main machine used in treating the patient is charged by a smaller one of what is known as the Wimshurst's pattern. Some other improvements of recent addition are the doing away with the catskin on the stationary 208 NERVOUS DISEASES. plates, and dispensing with the rubbers, which prevents wear of the lacquer on the revolving plates. The large machine can be charged without opening the case, an important matter in the summer months. The charging is done by connecting the two chains of the pole pieces of the larger machine and separating the sliding rods about half an inch. On revolving the small machine for a minute, and then start- ing the larger one, the latter will be found fully charged. Static Electrodes and Accessory Appliances. — Various elec- trodes and other accessories are required for static applications. The chief of these are an insulated platform with a wooden stool or chair, brass chains and hooks for proper attachments, two or three pairs of Leyden jars of different sizes, with a brass rod to connect them, and a set of electrodes, the most important of which are brass balls and points, wood balls and points, rollers of metal and of wood, an umbrella electrode, and special electrodes for Morton's interrupted static current. Some pieces of catskin and a supply of calcium chloride will also be found useful, the latter to be placed within the case to absorb moisture. Methods of Applying Static Electricity. — The chief methods of applying static electricity are by insulation, by sparks, by the static breeze, by the aigrette, and by the static interrupted current. In the method by insulation the patient is placed upon the insulated stool or platform and is connected with the machine by a chain. The other pole or conductor is then connected with the earth, or "grounded," as it is termed, which is often done by attaching it to a gas fixture or to the stopcock of a water basin. The conductors are drawn widely apart, and then the plates are revolved rapidly and the patient becomes charged, which may be shown by the rising of the hair, and even by the bluish or purplish light emitted from pointed portions of the body. The insulated stool or platform may be connected with either the positive or the negative pole, and the patient can thus be charged with positive or negative electricity of high potential. The methods of using the spark are direct and indirect. In the direct method the patient is put upon the insulated stool or platform, and this is connected with one of the conductors of the machine. The electrode or applicator is attached to a chain which is connected with the other conductor, and the rods joined to the two conductors are separated, so as to give a spark of greater or less length, and the applicator, held by the physician, is approached to the patient. The effect may be much increased by attaching small Leyden jars to the poles of the machine and then connecting their outer coating by a metallic rod or chain, bringing the poles or conductors into closer approximation. A severe shock can be given by this method, and it is necessary to be careful in its administration. In the indirect method of taking sparks, the patient being insulated and charged as described above, an electrode or applicator connected with a gas pipe PRANKLINISM OE STATIC ELECTRICITY. 209 or faucet is approached to him, when sparks pass between the patient and the electrode. If, instead of a bnlb or ball, a pointed electrode is used, a fan shaped spark or brush, the static breeze, will pass between the applicator and the patient. A so called electrostatic current is produced by passing the insulated ball electrode over the patient's clothing, which acts as an insulator. Ozone is developed during the action of an electrical machine, owing to the splitting by the elec- trical spark of molecules of oxygen into single atoms, some of which coalesce to form molecules of ozone. It can be administered to the patient by an insulated disk electrode furnished with points, which Fig. 190. Morton's electrode for applying the frankliiiic interrupted current. is held near the patient's open mouth, but not near enough to allow sparks to pass. The patient, breathing deeply at the time of the appUcation, inhales the ozone. What is termed the aigrette is pro- duced by bringing a rather blunt piece of wood or metal near the patient, which gives a form of discharge intermediate between the spark and the breeze. W. J. Morton was the first to describe a method of developing a rapidly interrupted and graduated current by means of a circuit breaking electrode (Fig. 190), two brass balls Fig. 191. Morton's method of applying the static induced current : a, rotating plate ; b, b, collecting combs ; c, c, prime conductors ; d, d, discharging rods ; e, e, Leyden jars ; f, f, conductmg cords ; g, g, sponge or other electrodes. constituting the circuit breaker. The spark circuit breaker practi- cally represents the vibrator in the primary circuit of an induction 14 210 NERVOUS DISEASES. coil, the specific inductive capacity of tlie air replacing the spring and its magnetic attractability. In applying the interrupted static current (Pig. 191) the discharging rods of the machine are brought into contact ; and if a Holtz machine is used, the connecting rods which unite the Ley den jars are removed, and to them are hooked conduct- ing cords attached to the electrodes. The machine is set in motion and the discharging rods are separated very slightly. The current can be graduated to any strength by the amount of the separation of the poles and the size of the jars. It is not necessary to insulate the patient. Nervous Diseases in which Static Electricity is Useful.— The nervous diseases in which static electricity is of genuine value can be summarized in a few words. They are (1) neurasthenia and hys- teria ; (2) chorea ; (3) obstinate neuralgia or neuritis ; and (4) some forms of local spasm, tremor, and paralysis. It has been strongly recommended by a few observers, as by Shaw and Morton, in the treatment of poliomyelitis. The good effects of static electricity are due chiefly to counterirritation, reflex inhibition, or psychic impres- sion. Its method of action has been compared by Morton to the action of blisters, sinapisms, the cautery, acupuncture, hj'podermatic injections of water, and to the effects of tuning forks, percuteurs, magnets, and metals. Early in the history of static electricity, exci- tators or applicators made of different substances were used in the treatment of various affections. It was held that catharsis was produced by thus carrying purgative substances into the system. Becquerel described the transport of ponderable substances by electric discharges. Proofs of the transport of substances by static electricity are that the odor differs with the excitation, that differ- ent therapeutic results are obtained with different excitations, and that loss of weight is sustained by metallic excitation if this is con- tinued for some time. Magnets in the Treatment of Nervous Affections. — Large magnets applied to the irritable spines of the hysterical, as shown by Benedikt, will sometimes cause the sensitiveness to disappear; and diverse effects, as the relief of hysterical contractures and of anesthesia, can be produced by the use of magnets. Peterson and Kennelly performed a number of physiological experiments with magnets of enormous power at the Edison laboratory, at Orange, New Jersey, and concluded that the human organism is in no way affected by the most powerful magnets known to modern science; that neither direct nor re\ersed magnetism exerts any perceptible influence upon the iron contained in the blood, upon the circu- lation, upon ciliary or protoplasmic movements, upon sensory or motor nerves, or upon the brain. The therapeutic effects achieved by the use of magnets would therefore seem to be mainly through mental impression. GENERAL THERAPEUTICS. 211 GENERAL THERAPEUTICS. General Hygiene. — Many diseases of tlie nervous system are directly or indirectly due to herediti/, and it is therefore of the highest importance for their prevention that care should be taken in contracting marriages. The marriage of relatives, although not necessarily productive of evil, should as a riile be axoided. If the entire stock is healthy, no evil is to be apprehended, but if a t(in- dency to any serious constitutional affection exists, it may be inten- sified in the offspring by intermarriage. Much can be done to i)re- vent the development of nervous affections by the caieful trauiiiifi and educatmi of children, which should be individualizeil as far as possible, especially for children with neurotic tendencies. Education should be as objective as possible. Sleeping should be carefully regulated, but the number of hours required cannot be stated absolutely. The following may serve as a general guide : four years of age, twelve hours ; seven years, eleven hours ; nine years, ten and a half hours ; fourteen years, ten hours ; seventeen years, nine and a half hours ; twenty-one years, nine hours ; twenty-eight years, eight hours. Alco- hol and tobacco, and even tea and coffee, are undoubtedly injurious to many neurotics. Travel, amusement, and natural exercise, skil- fully directed, may be made more efficient in the treatment of the nervous and the insane than drugs or special therapeutic procedures. Diet. — An abundance of good food is as necessary for brain workers as for muscle workers. Properly prepared nitrogenous food is necessary for brain and nerve work. ^Neurasthenics need easily assimilated food in small bulk but of high nutritive value. For them some of the artificial preparations, such as peptonoids, beef extracts, malt, and malted milk, are often of great service. Experi- ence should guide as to their use. Often too little water is drunk both by nervous patients and by others. The suggestions given by Seguin with reference to diet can usually be followed with advan- tage. Concerning the diet and hygiene of nervous patients, he says that lithemia and oxaluria frequently accompany neurasthenia, and the excessive use of sweet and starchy foods is a potent cause of this condition. In regard to diet for nervous patients generally, they should drink large quantities of water, and, as they usually avoid a diet of fatty foods, physicians should insist on their eating pork, fat roast beef, and butter, and on their using cream and cod liver oil. Sweet and starchy foods should be eaten very sparingly, as they require to be transformed into food by complicated chemical actions within the body, while oil, butter, cream, and fat are already pre- pared for emulsion. All green foods of the spinach group are of special value. Climate. — Under general etiology the effects of climate, and especially of high altitudes, have been considered. Notwithstand- 212 NERVOUS DISEASES. ing the injurious influence sometimes exerted by such altitudes, inland regions of moderate elevation may be of great service to anemic and debilitated nervous patients. Camp life is for them especially I^eneficial. Most forms of organic nervous disease do best at the seasliore or at low inland levels. Some sleepless and neurasthenic paticuits are immediately and permanently benefited by the seashore. Now and then, however, cases of insomnia are not only not b(;uefited but are made worse by a stay by the sea. Such neurasthenics, as advised ]>y Daly, should l")e sent not too far inland, to get away from the ocean's roar and still have the tonic effects of the sea air. Idiosyncrasies and differences in the underlying causes of the ins(jmnia douljtless have much to do with the varying reports as to the effects of the seashore in insomnia and other nervous dis- turl)ances. Patients wliose pains are aggravated by the east winds or before storms may at first l^ecome worse at the seashore, but when they have become stronger they will often make marked i]ni)rovement. (Boardman Eeed.) For the sleeplessness of brain exhaustion sea air, with tonics, good food, massage, electricity, light exercise, and pleasant surroundings, will be found beneficial. A most important element in determining whetlier a change of climate will be Ijeneficial to a x'fitient is the mental attitude of the invalid. "If by removing the patient from his surroundings to others, a hopeful exp(3Ctancy of good can Ije made to take the place of despairing a|)prehension, then a possibility of improve- ment is established which did not exist. But if the converse of this takes place, none of the natural advantages of climate can overcome the depressing influence of low .si^irits." (Ford.) Hydrotherapy. — In continental Europe hydrotherapy has long held a x'lace in the treatment of many nervous diseases, i^articularly in the " cures" or courses of treatment at various spas and health resorts, and in ]-ecent years it has been largely introduced into this country, but deserves to l)e more generally used. The treatment may be either local or general. For the thorough carrying out of hydrotherapeutic treatment a special room or rooms with water- proof walls and floors are necessary, although much can be done by improvised methods in a house with a good bath room. Appliances of various kinds are coming more and more into general use, as forms of apparatus for covering the lindjs, and the hot box in which the whole body of the patient, witJi the exception of the head, can be ])laced. Some of the general la^^•s of hydrotherapy are as fol- lows : cold and warm baths affect the central nervous system in a reflex manner, stimulating the sensory nerves of the skin and th(! vasomotor nerves; short cold l)aths, especially when combined with siirinkling, showering, or lubbing, are powerfully stimulating, exhilarating, and tonic ; prolonged warm baths and the hot pack are relaxing, fatiguing, and soporific ; warm baths, by soothing GENERAL THERAPEUTICS. 213 peripheral Irritability, exert ;i calming influence over the central nervous system ; cold applications to the skin stimulate the vaso- dilator nerves, dilate the peripheial vessels, and increase the blo(jd pressure ; warm applications also dilate superficial capillaries, but by diminishing the tone of the vessel walls reduce arterial tension. To lower the irritability of indiA'idual nerves, or of the entire nervous system, prolonged warm baths or the hot pack are indi- cated. (Peterson.) Various Forms of Baths. — In the cold plunge the patient sud- denly plunges or is immersed in cold water, staying only for a mo- ment, and when he comes out is rubbed vigorously. Brine baths, either hot or cold, contain about twenty-five pounds of salt to thirty gallons of water. The half hath is taken by the patient reclining in a tub only partially covered by the water, while at the same time vigorous friction is performed, or water is poured or dashed o^er him. In the sitz hath the patient sits in a tub of water with the feet outside on a raised surface ; the water should reach the umbilicus. Mud baths are prepared by mixing well seasoned earth containing mineral matters with water containing the same mineral matters. In treatment by the dry paeli the patient is wrapped tightly in one or two blankets, which are surrounded by an outer cloth. In the hot wet pach one or two blankets are spread upon a bed, and on these is placed a large sheet which has been dipped in very hot water ; this is wrapped close around the naked patient. Turkish and Russian baths are useful in some forms of nervous disease, but the condition of the heart, vessels, and lungs, and the general powers of resist- ance of the patient, should be considered. The most frequently used local douches are hot and cold, or the alternating hot and cold or Scotch douches. Jets of water can be thrown upon the spine from the nozzle of a tube connected with the water supply of the house, or with an apparatus made for this purpose, into which water is forced by compressed air. Similar results may be obtained by hot or cold affusion or by the use of a strong spraying apparatus. Thermic Mineral Baths. — One of the best methods of treat- ing multiple neuritis locally is by daily a]>plications of- very hot water, afterwards wrapping the portion treated in rubber dam, or m some similar material, to keep up warmth and gentle perspira- tion. Vogt has published the results of the treatment of forty cases of neuritis by thermal baths, nearly the entire number being cured or greatly improved. The baths were used in their natural temperature (32° C. or 90° F.) for from ten to fifteen minutes every other day. Thermal baths, siich as are found at the German spas, and at the mineral springs in Virginia, North Carolina, Georgia, Arkansas, California, New Mexico, Colorado, Montana, and other parts of this country, are beneficial in the treatment of neuritis, especially when subacute or clironic. Peale has catalogued more 214 NERVOUS DISEASES. than six hundred mineral spring resorts within the limits of the United States, and nearly one hundred of these, mostly in the Western States and Territories, have facilities for thermic mineral baths. As thermal springs are found of all temperatures from warm to hot, any of tlie forms of ordinary warm and hot baths may be duplicated in them ; but besides tlie effects following ordi- nary baths there are here others, resulting from the absorption of the mineral ingredients of the natural mineral waters. The external administration of natural thermal and mineral waters is frequently more advantageous than their internal use. Temperatures of Different Forms of Baths. — In the follow- ing table are given the temperatures for the different forms of baths and the average duration of the baths, although these may be varied according to the intention of the treatment and the condition or idiosyncrasies of the patient : Bath. Tempeeatuee, DEGEEE.S Fahrenheit. DvEATioN OF Bath. Cold bath 60- 75 Five to ten minutes. Cold brine bath. . 70 Five to ten minutes. Cold jet and fan douche . . 50- 70 One minute. Cold plunge 60- 70 Instantaneous. Cold rain bath 50- 70 Five to ten seconds. Cold wet pack . 40- 60 r)ne hour or more. Half bath 65- 82 Ten to thirty minutes. Sitz bath, cold . 50- 70 Five to twenty minutes. Sitz bath, tepid . . 70- 90 Five to twenty minutes. Sitz bath, warm 90- 98 Five to twenty minutes. Sitz bath, hot 100-125 Twenty to thirty minutes. Tepid bath ... ... 8.1- 9.5 Warm bath 90-104 Ten to thirty minutes. AVarm bath prolonged 70- 90 One half to two hours. Mud bath . . . 90-100 Hot bath . . . 104-110 Hot wet pack .... 130-140 Turkish bath 160-200 Fifteen to twenty minutes ; for shorter time, followed by cold affusion. Russian bath . Steam. Diseases in which Special Forms of Baths are Useful.— The following are some of the methods suggested for various nervous dis- orders : spinal douches or affusions for chorea ; cold sitz baths for impotence, spermatorrhea, or incontinence ; douches hot, cold, or alternating for spiual hyperesthesia ; for migraine or anemic head- aches hot comiirosses to the head ; for congestive headaches hot foot baths ; for melancholia douches gradually made cooler, also some- times the shower or plunge bath ; for the agitated form of melan- cholia general warm baths, with affusions to the head, or warm shower baths ; for mania prolonged warm baths, with or without cold to the head, the hot wet pack, the cold wet pack ; for neurasthenia GENERAL THERAPEUTICS. 215 cold shower or immersion baths, douches, and affusions, at first cau- tiously used ; mud baths for rheumatic and gouty neiu'itis ; the hot wet pack for insomnia and excitement ; Turkish and Russian baths for alcoholism, chronic neuritis and myelitis, and insomnia, tinrf sea bathing is admirable for toning up debilitated nerves and muscles, and cold brine or sea icater baths are also of value, and may be used when the patients cannot staud the bufteting of the waves. Hot brine baths are both sedative and stimulant in action. Among incurable diseases which may be ameliorated by hydrotherapy are locomotor ataxia and other forms of sclerosis, and chronic myelitis, with sec- ondary degenerations. When hydrotherapy is used, strict attention should be paid to the organic conditions. In locomotor ataxia, and in general paralysis of the insane, for instance, it is important to proceed with caution. Vasomotor and trophic affections, like erythromelalgia, angioneurotic edema, and abnormal sweating, are sometimes amenable to hydrotherapeutic treatment. Massage. — By the best authorities the essential massage pro- cedures are included under four heads, — namely, strohing, friction, kneading, and percussion. Stroking is a light, continuous pressure, made by the under surface of the fingers or by the palm of the hand, the movement being usually from the periphery of a limb or Fig. 192. Friction of the fingers in massage treatment. part towards the centre. Friction or rubbing is a forward move- ment of the hand with forcible pressure ; and it is executed in va- rious ways, according to the particular purpose to be accomplished. Kneading is a process of deep grasping and working of the tissues with the thumb, fingers, and thenar eminences. One or both hands 216 NERVOUS DISEASES. can be used. Percussion is striking or tapping with the hand or fingers, or with a hammer or other instrument. It can be per- formed with the ends of the half flexed fingers, with the flat of the fin- gers extended and sepa- rated, with the ulnar bor- der of the hand, or even with the closed fist. In the lighter forms of per- cussion, which are most employed, the movement is from the wrist. These different methods are il- lustrated in Figs. 192, 193, 194. No one should attempt treatment by massage without train- ing and preparation, and even with these a certain knack and capacity for the work are necessary in order that a mas- seur or masseuse may be successful. Twisting and mauling move- FiG. 194. Position of tiie hands in friction of broad surfaces. Position uf ihc liands in compression or deep massage. ments should be avoided. For many peripheral affections, such as palsies of the face or limbs, neuralgia or neuritis, local massage may be all that is re(iuired ; but neurasthenia, hysteria, nervous GENERAL THERAPEUTICS. 217 dyspepsia, and other neuroses call for general massage. Massage of the head and neck is often an admirable adjuvant treatment of headache and insomnia. Movement Treatment. — Movements are active, pansive, single, and duplicated. Active movements are those which are under the control of the one making or taking part in them. Passive move- ments come from without ; they are performed on the patient and independently of his will. He is subjected to pushings and puUings, to flexions and extensions, to swingings and rotations. A single movement is one in which only a single individual is engaged. In duplicated active movements the elements of resistance play an im- portant part. The operator, with carefully considered exertion, per- forms a movement which the patient resists, or the reverse. By changing the manner of operating from time to time any group of muscles can be brought into play. Movement apparatus run by steam is sometimes used, and under careful supervision may be of great benefit. To some extent semiactive and semipassive or dupli- cated active movements may be carried out by such machinery, which may be made to cover the whole range of passive exercises. Systematized Active Exercises. — The methods of systematized active exercises chiefly used by me are (1) the respiratory exercises of Blaikie, with or without dumb bells ; (2) exercises with pulley and weight apparatus. The Pichery system of elastic straps, styled "op- position gymnastics," can also be used. Elastic cords with handles attached are firmly fastened in convenient places, and by making traction in different directions almost any muscular action can be elicited ; but the force used cannot be as thoroughly controlled as by the pulley and weight apparatus. In the prolonged treat- ment of patients, some advantages accrue from the use, conjointly or alternately, of exercises with and without apparatus. Exercise treatment should be as far as possible personally directed, and the director of these exercises should be discreet and thoroughly well fitted for his work. The treatment should begin with the simplest forms of exercises, and these should be constantly increased and elaborated as the patient gains in strength and skill. Usually re- spiratory exercises should be combined with muscular movements, as on these two powers depends the ability to perform all bodily ex- ercises. Inherent nervous force has also something to do with the capacity to perform bodily exercise. The special efforts of breathing include taking deep, full breaths through the nose and mouth, forced expiration as well as inspiration, counting with a loud voice while holding the breath, etc. The development of the lungs and ab- dominal walls, and the greater aeration of the blood which is con- veyed to weak spinal or encephalic centres, make them of decided value in cases in which active movements are applicable. In my own practice I have used systematized active exercises in the treat- 218 NERVOUS DISEASES. Fig. 195. ment of idiocy, insanity, chorea, hysteria, neurasthenia, nervous palpitation, lithemia, diabetes, curvatures, ataxia, chronic neuritis, muscular atrophy, and occupation neuroses. For gout and lithe- mia, to jn'omote excretion and nutrition ; for anemia and spaneniia, to assist assimilation and further oxidation ; for headache, sleepless- ness, and nervous irritability, to soothe aud calm the nervous sys- tem ; to aid elimination in cases of lead, arsenic, mercury, and other metallic poisonings ; and for diabetes, to favor the action of the skin and increase combustion, these exercises have a value which cannot be too highly extolled. In hysteria the advantages of any treatment which involves specific direction and the adroit calling out of the volition of a patient must be evident. Even in paralysis from or- ganic disease of the brain, as in many cases the amount of palsy is disproportionate to the cerebral lesion by which it has been initiated, efforts consistent with safety should be made to unite again the para- lyzed limb with the volitional centres. Special gymnastic methods employed in the treatment of chorea will be given when that dis- ease is considered. The treatment by rest, seclusion, massage, and electricity can be successfully combined with that by systematized exercises. After the patients have progressed to a certain ex- tent and their nutrition has been placed on a firm basis, respiratory exercises without apparatus, or with light dumb bells, should be carefully begun. In Fig. 195 is shown a cabinet gymnasium, made for the author by A. G. Spalding & Bros., of Philadelphia. It contains almost everything necessary in the treat- ment of office or home patients by sys- tematized gymnastics. In the treatment of ataxic affections the use of balancing or acrobatic gymnastics is of some value ; and Mortimer Granville advises a method which consists in directing the patient to stand with his eyes closed in his Cabinet gymnasium. lydttt, after pouriug a Small can of water down his spine, or applying a mustard poultice over the full length of the spine for ten minutes or a quarter of an hour. Even bicvcling has been recommended for nervous patients by Graeme Hammond and others. Cases of neurasthenia, melancholia, and other nervous troubles will derive much benefit from our present hobl)y, for the wheelman must develop— whether he chooses or not^his will, his independence, his self-reliance, aud the accurate control of his nuiscles. (Egbert.) GENERAL THERAPEUTICS. 219 Fig. 196, Vibratory Therapeutics.— Mortimer Granville, Boudet, Charcot, and others have strongly advocated the treatment of pain by mechanical vibra- tions. Granville has de- vised several forms of per- cutenrs for exciting the nerves by vibration. One of these is a clockwork in- strument (Fig. 196). The others are worked by elec- tricity, and are more con- venient and have a wider range of usefulness (Figs. 197, 198). Various acces- Mortimer Granville's clockwork percuteur, showing the method of using it : D, winding pivot ; C, ivory button ; while this is pressed by the finger the hammer continues in aetion ; when the pressure is taken off it stops ; by pressing the button A the length of stroke can be increased, and the speed slightly reduced, while the force of the blow is augmented ; B, the pointed ivory hammer with which the percussion is made ; a flat headed hammer, or a brush, can be substituted for the ivory point. Mortimer Granville's flat disk electrical percuteur. sory appliances, as disks, brushes and points similar in construction to electrodes, are used for percussing and vibratina' Fig. 197. A-te t. ^ 4.- difterent regions and tissues. The method of treatment with the flat disk is shown in Fig. 197, and with the wire brush in Fig. 198. Light or firm press- ure can be used according to the depth of the affection and the tenderness of the surface. Headaches are often treated by percussion with the disk, and superficial pain, various pares- thesias and dysesthesias, by application of the wire brush to the skin. Charcot, having ob- served that patients suffer- Fig. 198. ing from paralysis agitans were relieved by railway or other long journeys, had a vibrating armchair con- structed to give a movement similar to that of a running train. A vibrating helmet has been invented by Gilles de la Tourette, which can be run by a small motor. These forms of vibratory treatment sometimes relieve symp- toms, and in peripheral nerve affections are occasionally curative. Whether they are as Mortimer Granville's wire brush electrical percuteur. 220 NERVOUS DISEASES. efficient as alternating electrical currents of great rapidity may be questioned. The Weir Mitchell Rest Treatment. — Best in the treatment of nervous disease, first reduced to a system by Weir Mitchell, has become an acknowledged therapeutic measure in all parts of the world. It includes rest in bed, seclusion, massage and Swedish movements, electricity, and systematized feeding. For full details of this treatment the writings of Mitchell, Playfair, Sinkler, and others can be consulted, and with reference to massage and elec- tricity the instructions given elsewhere in this chapter are suf- ficient. The massage treatment and the electrical treatment are usually general. Patients should be carefully chosen, for any one who applies the rest treatment at haphazard will score more fail- ures than successes. The rest treatment is most valualile in neur- asthenia and hysteria, but it may be used with advantage in other affections, as chorea, exophthalmic goitre, neuritis, and myelitis, in some cases of melancholia and mania, and even in locomotor ataxia for the relief of pain and to improve the general nutrition. The opium, chloral, alcohol, or other drug habit can also sometimes be advantageously treated by this method. The moral influence of the physician is of great importance in the rest treatment. The patient must be made to understand thoroughly what the treatment is to be before it is begun, and it is better for the doctor not to undertake it until he has the full consent of the patient and that of responsible relatives or friends. A physician who is fitted to succeed in carrying out a treatment of this kind may find occasion to change his programme, but it is a serious mistake to modify too readily a plan which has been adopted. Full and Partial Rest Treatment. — The treatment may be either /»?? or pariiaJ. In the former the patient is kept alisolutely at rest, and is waited on hand and foot for periods varying from one month to two. Writing, reading, crochetting, etc., are absolutely forbidden, but the patient is read to or talked to by the nurse as seems best. After a variable period the patient is allowed to sit up for a short time once a day, and soon this period is lengthened and the nnml^er of times a day increased. Systematized active exer- cises, muscular and respiratory, may now be used, and can be gradu- ally increased ; later the patient is permitted to walk or drive. In the partial rest treatment tlie patient is kept at rest for stated periods during tlie day. Seclusion is usually of paramount im- portance. In Philadelphia, houses for private patients are gener- ally used. Nurses, healthy and tactful, and well adapted to be Cdinpanioiis as well as to serve their patients in ordinary nursing capacities, aic necessary. The best nurses for these cases are young, actiN-e, quick witted, intelligent women, capable of firmly but gently contrdlling tlie patient. (Mitchell.) GENERAL THERAPEUTICS. 221 Diet in the Rest Treatment.— An essential feature of the rest treatment is a combination witli it of excessive feeding, made possible by passive exercises obtained through the steady use of massage and electricity. In most cases the diet should at first be chielly skimmed milk, carefully kept fresh, Mhich, at the start, is best given every two or three hours in quantities of about four ounces, taken slowly with a spoon or sipped. Horlick's malted milk or some of the infant foods may be advantageously alteinated with the milk ; and after a week or ten days some of the best extracts of beef, or home made beef tea, may be used. Soon broiled meats, oysters, chicken, and vegetables sparingly, are added in increasiug amount. Properly administered massage and Swedish movements and the use of electricity will do much to counteract the tendency to constipa- tion which is not unusual, but it is occasionally necessary to use drugs, among the best of which is the pill of strychnine, aloin, aad belladonna, either with or without cascara or podophyllin. Draughts of hot water taken before breakfast will often prove of service. Other simple remedies are liquorice powder, tamar indien, or pills of ox gall and watery extract of aloes. Every second or third day it may be necessary to unload the lower bowel with a large hot water enema. Bach patient should be carefully studied as to the effects of milk diet. Morton has devised a tumbler which is convenient for giving milk by accurate dosage. It has engraved upon it the hours when the milk is to be taken, and also the quan- tity to which it is to be increased from day by day. SCHEDULE FOR FULL REST TREATMENT. — (J. K. Mitchcll.) Cocoa at 7 a.m. Cool sponge bath with rough rub, and toilet for the day. Breakfast at 8 a.m., with milk. Eest an hour after. Bight ounces peptonized milk at 10 a.m. Massage at 11 a.m. Eight ounces milk or soup at 12 m. Beading aloud by nurse half an hour. Dinner at 1.30 p.m. Eest an hour. Eight ounces peptonized milk at 3.30. Electricity at 4 p.m. Supper at 6.30, with milk. Rest an hour. Reading aloud by nurse half an hour, 8 p.m. Light rubbing by nurse with drip sheet at 9 p.m. Three ounces malt extract with meals ; tonic after meals. Eight ounces peptonized milk with biscuit at bedtime, and a glass of milk during the night, if desired. 222 NERVOUS DISEASES. Laxative (cascara), 10-30 drops p. r. n. Later, Swedish movemeuts are added after the massage. SCHEDULE FOE PAETIAL REST TREATMENT. — (S. Weir Mitchell.) A.M.— Oil waking, cup of cocoa or beef extract. Take bath. (Temperature given.) Lie down on lounge while using drying towels ; or, better, be sponged and dried by attendant. In this process the surface to be rubbed red, or, if drying one's self, flesh brush to be used. Bed or lounge again. Breakfast. Before each meal take three ounces of malt extract ; aperient at need in malt. Tonic after each meal. Detail as to breakfast diet. If eyes are good, may then read, seated in bed. At 10 to 11 A.M. one hour's massage. Eest one hour ; may be read to, or read if eyes are good, or knit. At this time, 11 a.m., four ounces of beef soup or eight ounces of milk. At noon may rise, dress slowly, resting once or twice a few minutes, and remain up until 3 p.m. (See children, attend to household business ; see one visitor, if desirable. ) 1 to 1.30 p.m. — Malt, etc., and lunch. Detail as to diet. At first, as a rule, let this meal represent dinner. Tonic, and after it rest on lounge, occupied as above, reading or being read to. If possible, drive out, or use tramway, so as to get air. Walk as littJe as possible. On return from drive repeat milk and soup. About 5 P.M., electricity, if used at all. Eest until 7. Supper at 7. Detail as to meal. Malt as before, with or without aperient, as occasion demands. Tonic. To spend evening with family as usual. Best not to use eyes at night for near view. Bed at 10 p.m. No letters to be written for two months, when most of these details have to be revised. Suspension Treatment.— Suspension, a treatment which has long been employed in spinal caries, a few years ago came into use in the treatment of locomotor ataxia, and since then has been largely einploAed in this and other degenerative and neuraxial in- flammatory diseases. While little can be said in favor of its cura- GENERAL THERAPEUTICS. 223 The Cliarcot-Motclioukowski suspension apparatus. Fig. 200. tive virtues in tliese affec- tions, it certainly lias been beneficial in relieving serious symptoms, and apparently it retards the progress of the disease. Motchoukowski, of Odessa, was the first to dis- cover the therapeutic value of suspension, and published his plan in 1883. Charcot tested the method in 1S88 with unexpected and striking- results in the treatment of locomotor ataxia. Gilles de la Tourette, Eulenberg, Men- del, Blocq, de "\Vatte\ille, Weir Mitchell, D. D. Stewart, and many others, have ap- plied the treatment to ataxics with satisfactory results. The forms of apparatus are all modifications of Sayre's suspension ap- paratus for the application of plaster jackets. In that shown in Pig. 199 the straps are made to go under the armpits and aroimd the head and neck. Weir Mitchell, in order to take pressure from the armpits, modified the apparatus usu- ally employed, as shown in Pig. 201, in which the lift is made from the elbows and the head is drawn up as may be necessary. A separate pulley and cord are used to govern the amount of pull on the head. The vertical straps are widened under the elbows, and a wide band is carried around the front and ujjper arm. Method of Stretching the Spine. — The Bonuzzi method of stretching the spine, named after its deviser, requires no apparatus, and gives results com- parable to those of suspension. In con- sequence of the result of some experi- ments made on the cadaver, this method is asserted to stretch the spinal cord more than three times ;is much as sus- pension, and its use is strongly recommended by Benedikt, Bernhardt. Application of tlie chin necli hand of the Charcot-Motchouliowslii suspen- sion apparatus. 224 NERVOUS DISEASES. Fig. 201. and others. It is certainly efficient in locomotor ataxia in improving the station and gait and in alleviating the pain. It is necessary to be some- what cautious in its use, as local spinal and muscular traumatism may occur. The i^atient being laid on a couch, with the head and shoulders raised by a pillow, the operator grasps the ankles and carries the feet and limbs upward and flexes the trunk until the knees reach the forehead and even the shoulders, the diverging ankles being then i^ulled downward towards the floor. Stretching the legs in the treat- ment of sciatica is carried out by a similar method. A method of sus- pension recommended by Bogroff, of Odessa, is to place the patient on an inclined plane at an angle of 60 to 100 degrees for ten to fifteen minutes, only straps for the arms being used. Stillman has suggested an apparatus by which the cord and the spinal column can be extended while the patient is in a horizontal position or hanging from the neck with the back resting upon a curved board. Surgical Treatment of Nervous Affections. — The surgical treatment of nervous affections will be considered under special dis- eases. It includes nerve stretching, section, resection, suturing, and ligation ; trephining of the spine and skull for tumors, abscesses, hemorrhages, etc. ; paracentesis of the ventricles and of both the cranial and the spinal dura. Psychic Therapeutics. — For nervous patients, the psychic or mental treatment, or " moral treatment," as it is sometimes termed, is often of first importance. In affections like neurasthenia, hys- teria, and the traumatic neuroses the personal influence of the doctor may be the potent agent in effecting a cure ; in organic incurable diseases of long duration it supports the patient in his sutferings and encourages him to a useful life in spite of them; in some ty])es of insanity, like mania and melancholia, it checks, guides, and encourages the patient. The neurologist must be au- thoritatiA-e and yet not domineering, firm and yet not harsh. He must be unflincliing to withstand patients and their friends when he has a certain course to follow. Suggestion without hypnotic pro- cedure may lead the way to cure, of which innumerable instances are given in works like Tuke's "Influence of the Mind upon the Body." MitcheU's suspension apparatus. GENERAL THERAPEUTICS. 225 Hypnotism. — In recent years hypnotism has been turned to many therapeutic uses, but with only moderate success. The con- sensus of conservative opinion is against its value in the treatment of insanity ; it is of less value than ordinary suggestion. Tempo- rary success has been obtained with it in the treatment of inebriety. Its most useful field is probably in the treatment of hysterical affec- tions, and even here it may be useless or even worse ; but this subject will receive fuller consideration elsewhere. Local Remedies. — Camphorated chloral is a thick, syrupy liquid which results from rubbing together equal parts of camphor and chloral. Morphine, atropine, or chloroform may be added to it. For the relief of local pain it is painted over the surface with a brush or cotton, and may be kept in position a short time covered with oiled silk, but usually it cannot long be borne, owing to the burn- ing pain produced. Camphorated menthol, composed of equal parts of menthol and gum camphor, combined with lanolin in the pro- portion of one part to four, may be used in the same manner and for the same ends as camphorated chloral, but it is not so eificient as the latter. The menthol pencils have had considerable popularity, but are of little value except where the pain is superficial and not severe. Antifebrin, for external use, can be combined with lanolin or vaseline in the proportion of twenty grains to the ounce. Among valuable anodyne ointments are those of veratrine, aconitine, atro- pine or belladonna, and opium. Liniments are not entirely out of date, but only the stronger preparations, such as the compound chloroform liniment, need to be considered. Mercurial Inunction. — When mercurial inunction is used for nervous syphilis, as for other purposes, the physical condition of the patient must be attended to most carefully. The best preparation is the official ointment of mercury of fifty per cent, strength, which can be made with lanolin. Oleate of mercury may also be em- ployed. One fourth to one half drachm daily is a safe amount to use in ordinary cases, and this may be increased to a drachm where a rapid effect is desired and where the patient stands the treatment well. An exact amount can be administered by having the prescrip- tion divided into fifteen or thirty grain doses, each wrapped in oiled or paraffin paper. General or local baths should be used before its administration, and whenever possible it is well to have a trained masseur or masseuse make the application. Cold Applications. — Cold is of great value in the treatment of neuralgia, neuritis, and facial and other forms of local spasm, and can be administered by ice bags, by packing the limb in ice, or by various sprays. Ehigolene jets or the ether spray may be used. The eyes should be protected when the application is made to the face, and care must be taken not to use the spray too long or too many days in succession, or a slough may be produced. Mixtures of salt and ice 15 226 NERVOUS DISEASES. furnish a simple and convenient method of applying intense cold. Bags filled witli ice, or ice water circulating through bags, may be employed, and different saline solutions may be mixed with the ice in order to secure definite temperatures. In 1884, Debove recom- mended chloride of methyl as a freezing agent for sciatica, facial neuralgia, and other painful affections, and Jacoby introduced this method of treatment to the American profession in 1887, recom- mending as the two best refrigerants chloride of methyl and fluid carbonic acid. Dobisch recommends for the purpose of procuring local anesthesia a spray composed of ten parts chloroform, fifteen parts sulphuric ether, and one part menthol, to be used with a spraying apparatus. After one minute's application of this spray complete anesthesia of the skin and neighboring tissues is obtained, which lasts from two to six minutes and suffices for the performance of minor operations, and may be also used cautiously for local pain- ful affections. In one of the forms of spinal ice bag the ice is applied in a bag that reaches from the lower part of the neck to the sacrum. The bag should have two or more compartments, and the ice should be in small pieces. It should be worn for one or two hours daily, or, in acute disease, until the disturbance is subdued. Hot Applications. — The hot spinal bags should not be applied at a higher temj)erature than 120° F. Hot water bags, which can now be had of different patterns, are useful and easy of applica- tion for the treatment or temporary relief of many nervous affec- tions accompanied by pain. One of the most soothing and effective methods of treatment of either localized, diffused, or multiple neu- ritis is by means of hot douches or hot sponging of the affected parts two or three times daily, in the intervals wrapping the limbs or neu- ritic areas in some material, such as rubber dam, which will keep the parts warm and induce a gentle perspiration. In continuing the use of either hot water or ice, strict attention should be given to the effects, and neither should be continued when uncomfortable or painful results ensue. The Revulsor. — Hamilton has described an instrument for the alternate application of dry heat and dry cold, which consists of Fig. 202. Hamilton's hot and cold revulsor. two chambers of brass, three inches in diameter by one and a half inches in depth. These have screw plugs inserted, so that they may be removed and the chambers filled, one with salt and cold water and the other with hot water. These chambers are fixed on GENERAL THERAPEUTICS. 227 Fig. 203. a rod and separated by an insulating or nonconducting substance. The rod terminates in a handle. The flat surface, covered by- thin flannel, is placed against the bare back, on either side of the spinous processes of the vertebrse, and the instrument is moved up and down quite rapidly. As the heated surface moves instanta- neously to where the cold one was before, the effect is quite marked. Lavage. — Lavage or washing out of the stomach, which has become so popular for many gastric disturbances in recent years, is sometimes useful in the dyspepsias which accompany neurasthenia and for the relief of sitophobia, or refusal to take food, among the insane. E6gis recommended it for the latter purpose in 1880, and also for the treatment of melancholia itself. The exact composition of the gastric juice should be determined in order to decide as to the liquid to be used. Cupping Apparatus. — Various forms of cupping apparatus — from the small cup for the temple to the Junod's boot (Fig. 203), made to encase an entire limb — are occasion- ally employed. The application of revulsives to the lower extremities rather than to the spine is called for in some acute and chronic diseases of the spinal cord. Thyreoid Treatment. — Brown-Sequard, in 1856, recommended the use of various glands of the human body for therapeutic purposes ; and again, after Schiff, in 1880, demonstrated that ablation of the thyreoid gland resulted in artificial myxedema, Brown- Sequard suggested the injection of the ex- tract of thyreoid for the cure of this disease. Fenwick, Murray, and "Wallace Beatty were among the first to adopt this recommenda- tion. Horsley called attention to Schiff' s ob- servation on the transportation of the thy- reoid gland into the peritoneal cavity, which showed that thyreoidectomy lost its dangers and an essential amount of its efiects, and sug- gested the thyreoid gland of the sheep in cretinism and cachexia strumipriva. Vassale demonstrated the important physiological effects of intravenous injections of thyreoid juice in dogs from which the gland had been removed, holding that the thyreoid gland prevented autointoxication. Preparations of thyreoid are usually made from the thyreoid glands of sheep, and are of several kinds, as (1) the thyreoid, prepared by cooking; (2) thyreoid extracts, usually prepared by maceration with glycerin or alcohol ; and (3) powders prepared by evaporation and other measures. The prep- arations are given either by the mouth or by hypodermatic injeo- Junod's boot. 228 NERVOUS DISEASES. tions. The dose usually administered is equivalent to one lobe or lialf a thyreoid. To obviate nauseous taste, the powders may be given in capsules or in keratine coated pills. About fifteen grains of the powder, as usually prepared, or thirty drops of the glycerin extract, represent about half an average thyreoid. It is believed that glycerin extracts will retain their virtues for eight or ten weeks, but the best results cannot be expected from a liquid prepa- ration of a much greater age than this. Thymus Treatment. — Extracts derived from the thymus gland have been used in progressive muscular atrophy, but no results of value have yet been reported. (Macalester and Dana.) Dercum has suggested that as the experiments of Brieger, Kitasato, and Wasser- mann show that the tetanus bacillus, although it grew in thymus infusion, did not develop spores, and that animals inoculated with such cultures were made highly immune to the cultures of tetanus grown in other media, the thymus juice should be tested with a view to a possible therapeutic effect ; as its administration beneath the skin in cases of tetanus could certainly do no harm, and might do good, and it might also be administered by the mouth, like the thyreoid gland in myxedema. Cerebrin and other Tissue Extracts. — Hammond has recom- mended the use of an organic extract made from the brain of an ox, and called cerebrin, which is administered hypodermatically in doses of five minims, diluted at the time with a similar quantity of distilled water. Various contributions on the subject have been published since the original paper of Hammond, some with ap- proval, with reports of successful cases, many others critical and condemnatory. The subject may be considered unsettled, with the weight of authority against it. Among the diseases and symptoms for which it has been tried are ueurasthenia, hysteria, neuralgia, melancholia, dementia paralytica, locomotor ataxia, and epilepsy. Extracts of other tissues than the brain have been largely used, as medullin, prepared from the spinal cord, pancreatin, from the pan- creas, gastrin, from the stomach, and cardin, from the heart. Some of the results obtained are scarcely worthy of discussion. In all injections of animal substances the greatest care should be taken to have the procedure aseptic and antiseptic. Testicular Therapy.— In 1889, Brown-S^quard put forth a re- markable claim as to the virtues of testicular fluid which attracted worldwide attention and almost equally wide ridicule and con- demnation. These injections have been used in widely different diseases, largely those which involve exhaustion or degeneration of the nervous system, as neurasthenia, impotence, locomotor ataxia, brain exhaustion, melancholia, and other forms of insanity, and numerous atrophic and dystrophic diseases. The preparations are administered either subcutaueously or intravenously. They include GENERAL THERAPEUTICS. 229 (1) the fresli testicular fluid, and (2) extracts obtained from the gland. The following are Brown-S6quard's directions for the prepa- ration of the fluid used by him. To obtain the testicular fluid, the testicle is crushed in distilled water immediately after it has been taken from a dog or a guinea-pig. The crushing is always done after the addition of the water, which is in a quantity never exceed- ing three or four times the volume of the testicle. The liquid is then filtered through filter paper or a Pasteur filter. For each hypodermatic injection use nearly sixteen minims of the filtered liquid. The conclusions reached by Venturi and Prondo with refer- ence to the injection of testicular remedies in the therapy of mental disease probably approach the truth. They conclude that such in- jections have given negative or at best only transitory results ; some patients were rendered suddenly more excitable, and the spinal fimctions were reinforced briefly. Immunity. — Immunity is that condition of the body which enables it to resist infectious or other morbid processes. The ex- periments of the last few years indicate its great value in the pre- vention of such affections as tetanus and hydrophobia ; and doubt- less in time other nervous and mental diseases of infectious origin may be favorably influenced or cured by immunization. Studies made by Behring have shown a uniform peculiarity of blood serum in one who has been rendered artificially immune, and this has been recorded formally in what is now termed Behring' s law, which is as follows : " If an individual is rendered artificially immune against a certain infectious disease, then his blood or its serum has acquired the property of transmitting immunity against the same infectious disease to a susceptible individual (no matter of what species) into whose organism it can be brought in sufficient quantities." On this law is based the action of blood serum, or of the precipitates derived from it, in the treatment as well as in the prevention of tetanus and other infectious nervous diseases. Serum Therapy. — As experiments have demonstrated that pathogenic microorganisms in the body will elaborate toxins which cause certain symptoms and diseases, and as the body cells or fluid constituents of such animals, suitably stimulated, are capable of elaborating antidotal antitoxins, it follows that the serum con- taining such toxins and antitoxins is a therapeutically active substance, which may improve or cure the disease, or produce immunity from its future visitations. (Threlkeld-Edwards.) A practical objection to the use of serum as a therapeutic measure is the large amount which is required for injection. The healing value of the serum is one thousand to two thousand times less than its immunizing value. Sixty-six grammes of immunized serum from the blood of the horse, containing 0.5 per cent, of carbolic acid, were injected into four places beneath the skin of the back in an 230 NERVOUS DISEASES. adult man suffering from tetanus ; on the day following fifty grammes were injected, and still later forty-five grammes more. Tizzoni and Cattani obtained an alcoholic precipitate from the serum — a tetanus antitoxin — which they believed to have the same value as the serum itself Tizzoni estimated that of his serum seventy cubic centi- metres would be a dose for a case of moderate severity in man in the beginning. At a later stage two hundred and ten cubic centi- metres would be required. This would equal five to six centi- grammes of the alcoholic precipitate in the first instance and ten to twelve grammes in the latter. Dercum collected the records of thirty-four cases of tetanus of various origins treated either by the powder of Tizzoni or by the immunized serum. Of these twenty were successful. The first case of tetanus successfully treated with tetanus antitoxin was reported by Dr. Eudolf Schwarz, assistant at the surgical clinic at Padua. Tetanus antitoxin was sent by Professor Tizzoni, who obtained it from the blood serum of a dog which had been rendered strongly immune against tetanus. The antitoxin was used hypodermatically in doses of fifteen grains dissolved in water. Nuclein Therapy. — Yaughan believes that the immmiizing substance is the nuclein of the cell, that part which gives to the germ its distinctive properties. An animal may be rendered im- mune by treating it with the blood serum of another immune animal ; but even in this case the immunity is primarily due to the antitoxin generated in the cells of the immune animal. A horse rendered immune to tetanus has the serum of its blood injected into a mouse, and this animal becomes for the time being immune to tetanus poison. It is supposed that immunity depends on the altered activ- ity of the cells of the spleen, the bone marrow, the thyreoid and thymus glands, and possibly of other glandular organs, removal of these organs leading to the formation in the system of toxic substances. Vaughan's experiments with yeast nuclein showed that solutions of it rapidly inhibited the multiplication of the staphylococcus pyogenes aureus. Testicular nuclein from the testi- cles of a bull, a guinea-pig, and a rabbit acted in a similar manner. Five to twenty drops of a glycerin solution used hj-podermatically in a case of nervous exhaustion had a marked stimulant effect. Vaughan also obtained nucleins from the thyreoid, and from the brain and spleen. He believes that the germicidal properties of blood serum are due to soluble nucleins, and that the germicides which hold most theraiieutic hope must be of cellular origin. The word nuclein is used in a broad sense to indicate that part of the cell which under normal conditions is endowed with the capabilities of growth and reproduction. In nuclein therapy, as Vaughan sug- gests, the active substance can probably be used in larger doses than in blood serum therapy. The effect in immunity and cure being proportional to quantity, this must always be considered. GENERAL THERAPEUTICS. 231 Doses of some of the More Potent and Newer Drugs used in Neurological Practice.* Acetanilid (antifebrin) grs. 3-10 Aconitine gr. jhs-ih Agathin grs. 8-10 Amyl nitrite m. 1-5 Amylene hydrate m. 30-60 Antipyrin ... grs. 5-20 Apomorphine bydrochlorate gr. J-J- Bromamide . ... grs. 10-15 Butyl chloral hydrate (croton chloral) . . . grs. 5-10 Caffeine citrate grs. 2-5 Chloralamid grs. 10-30 Chloralose grs. 3-10 Chloral hydrate grs. 3-20 Cocaine hydrochlorate grs. J-2 Codeine sulphate grs. ^2 Coniine hydrobromate gr. ^VtV Curarine sulphate gr. y^^-jV Duboisine sulphate gr. yl^rTV Eserine sulphate gr. ^ j-^V Exalgin grs. J-5 Fluid extract of gelsemium m. 3-10 Hyoscine hydrobromate .... . . . gr. x^Ty^sV Hypnal grs. 10-20 Methacetin grs. 5-15 Methylal m. 10-30 Nitroglycerin (spiritus glonoini) m. J-3 f Paraldehyde m. 30-60 Phenacetin grs. 2-10 Phenocoll hydrochloride grs. 5-15 Salicylamid grs. 3-5 Salipyrin ... ... grs. 15 Salol grs. 5-15 Salophen grs. 15 Sulphonal grs. 10-30 Tetronal grs. 10-30 Theine grs. i-2 Thymacetin grs. 5-15 Trional grs. 10-30 * To Dr. E. C. Seguin, of New York, the profession is greatly indebted for a series of valuable studies in the medicinal therapeutics of nervous diseases. The contributions of this distinguished neurologist, of which I have made frequent use, include papers first published in the New York Medical Record, New York Medical Jcmmal, Archives of Medicine, Journal of Nervous and Mental Diseases, and other medical journals, most of them having been subsequently brought together in his " Opera Minora." One of the most valuable is a paper on "The Efficient Dosage of Certain Remedies used in the Treatment of Nervous Diseases," read before the Medical Society of the State of New York in 1882 ; another is entitled " Lectures on Some Points in the Treatment and Management of Neuroses," which appeared in the New York Medical Record during 1890, and was reprinted. t Of one per cent, solution. gm. 0.200 - 0.666 gm. 0.00016 — 0.0006 gm. 0.533 — 0.666 c.c. 0.066 — 0.333 c.c. 2.000 — 4.000 gm. 0.333 — 1.333 gm. 0.008 — 0.016 gm. 0.666 — 1.000 gm. 0.333 — 0.666 gm. 0.133 — 0.333 gm. 0.666 — 2.000 gm. 0.200 — 0.666 gm. 0.200 — 1.333 gm. 0.016 — 0.133 gm. 0.033 — 0.133 gm. 0.003 — 0.006 gm. 0.0006 — 0.0016 gm. 0.0005 — 0.001 gm. 0.001 — 0.003 gm. 0.033 — 0.333 c.c. 0.200 — 0.666 gm. 0.0005 — 0.001 gm. 0.666 — 1.333 gm. 0.333 — 1.000 c.c. 0.666 — 2.000 c.c. 0.033 — 0.200 c.c. 2.000 — 4.000 gm. 0.133 — 0.666 gm. 0.333 — 1.000 gm. 0.200 — 0.333 gm. 1.000 gm. 0.333 — 1.000 gm. 1.000 gm. 0.666 — 2.000 gm. 0.666 — 2.000 gm. 0.033 — 0.133 gm. 0.333 — 1.000 gm. 0.666 — 2.000 232 NERVOUS DISEASES. Efficient Dosage. — While drugs should not be abused, on the other hand they should be used in an efficient manner. Less harm is done by the large doses than by the reckless, long continued, or irregular administration of remedies. Uncured nervous diseases, such as choreas, cerebral and spinal syphilis, and certain neu- ralgias, are frequently cases in which the attending physician has prescribed the proper remedy but has exhibited it in doses wholly insufficient. The practitioner should be familiar with the maximal doses of physiologically active remedies ; he should be observant of all the circumstances which render a patient susceptible, always making allowance for idiosyncrasies ; and he should remember that curative effects are often obtained in the interval between physio- logical and toxic effects. (Seguin. ) The table of doses given on page 231 indicates average doses, such as would be accepted by most authorities ; but in the paragraphs which follow, some con- sideration will be given to the manner of using particular drugs. The Abuse of Drugs, and their Untoward Effects. — Too little attention is usually paid to the effects on digestion of power- ful hypnotics, narcotics, and sedatives. Good effects may be coun- teracted, in part at least, by gastric and intestinal disturbances. Drugs differ much in this respect ; chloralamid, for instance, has been shown to delay and paraldehyde to accelerate digestion of fibrin when given in large quantity. Putrefaction is prevented or delayed by paraldehyde, but is not influenced by chloralamid. Strong solutions of sulphonal delay digestion and weak solutions have but little effect on it, while neither retard putrefaction. (Gor- don.) Hypnotics, narcotics, and sedatives are much abused, par- ticularly in the treatment of neurasthenia, hysteria, mania, and melancholia. Chapin has called attention to the evidences of the abuse of drugs presented by patients on their admission to hos- pitals for the insane, in dilated sluggish pupils, diminished mental reflexes, feeble heart beat, flabby pasty tongue, and tumid stomach. The routine hospital methods of administering such drugs are also well known, but are happily going out of use. The accumulation of drugs in the system must be carefully considered. Potassium bromide, for example, is eliminated very slowly, and bromism is not infrequently a serious complication in the treatment of epi- lepsy. Preparations of opium are not usually well borne by chil- dren ; but bromides can be given in larger proportionate doses than to adults. Idiosyncrasies should not be disregarded. As drugs used in nervous diseases include the most powerful remedies of the pharmacopeia, not only their physiological but also their special untoward effects should be thoroughly understood. Kiernan and Baum ha\'e presented in tabular form excellent summaries of these untoward eff(H'ts, from which the table (page 233) of some of the important and newer renunlies has been condensed. GENERAL THERAPEUTICS. 233 Untoward Effects of some of the More Potent Drur/s. Dkugs. General, Lungs, Heart. Brain and Coed. Eye, Ear, and Throat. Skin, Liver, Kidneys, Bladder. Acetanilid or antlfebrin. Amyl nitrite. Antipyrin. Caffeine. Cannabis In- dica. Chloral hy- drate, Ohio- ralamid, and chlo- ralose. Cocaine. Coninm. Duhoisine. Exalgin. Gelseminm. Glonoin. Hydrastin. Hyoseyamus. Methylal. Methacetin. Paraldehyde. Phenacetin and pheno- coll. Physostigma. Sulphonal, tetronal, and trional. Cardiac failure, edema of lungs, cyanosis, fever, dyspnea, pallor, hyperidrosis, nausea, diar- rhea. Cyanosis, col- lapse, pallor, hy- peridrosis, nau- sea. Nausea, collapse, syncope, hyperi- drosis, fever, car- diac failure, dyspnea, diar- rhea. Cheyne-Stokes breathing. Aphrodisia, vom- iting, diarrhea, amenorrhea. Dyspnea, bron- chitis, pneumo- nia, heart fail- ure, purpura, fever, hyperidro- sis, diarrhea. Anaphrodisia, collapse, diar- rhea, constipa- tion, nausea, fever, amenor- rhea, tenesmus. Vomiting, nausea. Collapse, vomit- ing, diarrhea, fever. Cyanosis, fever, hyperidrosis, collapse, dysp- nea. Dyspnea, coryza. Coryza. Collapse, syucope, fever, hyperidro- sis, heart failure. Dyspnea, cardiac irritability, fever, nausea. Anesthesia, hyper- esthesia, vertigo, headaclie, deliri- um, formication, stupor, ataxic symptoms. Vertigo, stupor, hallucinations, spasmodic cough, hyperesthesia, an- esthesia. Anesthesia, hyper- esthesia, convul- sive phenomena, ataxic symptoms. Delirium, halluci- nation. Vertigo, delirium, ataxic symptoms. Vertigo, ataxic synaptoms, stupor, delirium, convul- sive attacks, anes- thesia, analgesia, hyperesthesia. Vertigo, delirium, ataxic symptoms, hyperesthesia, transitory frenzy. Vertigo, ataxic symptoms, hyper- esthesia. Vertigo, delirium, local hyperesthe- Coma, delirium, ataxic symptoms, anesthesia, ver- tigo. Vertigo. Vertigo, ataxic symptoms, anal- col- Hyperidrosis, lapse. Hyperidrosis. Dyspnea, gastral- gia, diarrhea, cyanosis, nausea. Fever, collapse, hyperidrosis. Nausea, vomit- ing, gastralgia. Collapse, dysp- nea, hyperidro- sis, cardiac irri- tability, nausea, diarrhea. Amblyopia^ throat irrita- tion, edema of glottis, tinnitus, dilate 1 pupils, conjunctivitis. Yellow vision, amblyopia, throat irrita- tion. Conjunctivitis, amblyopia, throat edema, tinnitus. Diplopia. Amblyopia, tinnitus. Conjunctivitis, edema of epi- glottis, amblyo- pia, yellow vis- ion, photopho- bia, cnoroiaitis, tinnitus. Amblyopia, dip- lopia, throat irritation, con- junctivitis. Vertigo, ataxic symptoms. Vertigo, delirium, ataxic symptoms, numbness. Vertigo, stupor, ataxic symptoms. Vertigo. Vertigo, stupor, delirium, pares- thesia, ataxic symptoms. Vertigo, hyperes- thesia. Vertigo, ataxic symptoms. Vertigo, stupor, paresthesia, ataxic gait, formi- cation. Amblyopia. Conjunctivitis, pupil Immo- bility, throat irritation. Amblyopia. Amblyopia. Amblyopia. Amblyopia, con- junctivitis. Pupil immobil- ity, amblyopia, throat irrita- bility. Diplopia. Amblyopia. Amblyopia. Dim vision, dip- lopia, tinnitus. Tinnitus, dim vision. Amblyopia, tin- nitus. Erythema, papules, pus- tules, vesicles, icterus, al- buminuria, cystitis. Vesicles, erythema, cysti- tis, cystalgia. Erythema, vesicles, pap- ules, pustules, green urine, cystitis, albuminu- ria, glycosuria, icterus. Erythema, dysuria. Erythema, dysuria. Erythema, acne, pustules, papules, purpura, bald- ness, urticaria, pruritus, icterus, albuminuria, gly- cosuria, strangury. Erythema, papules, urti- caria, vesicles, icterus, glycosuria. Erythema, dysuria. Erythema, icterus. Erythema, icterus. Erythema, strangury, ic- Erythema, strangury, gly- cosuria. Erythema, purpura, stran- gury, green urine. Erythema, ptistules.lcterus, bladder irritability. Erythema, urticaria, blad- der irritabilitv- Erythema. bladder irrita- bility. Erythema, papules, nail ulceration, purpura, gly- cosuria, icterus. Erythema, papules, dys- uria, icterus. Urticaria, erythema, dys- uria. Erythema, papules, pru- ritus, urticaria, bladder irritability. 234 NERVOUS DISEASES. Hypnotics. — Amylene hydrate, one of tlie new hypnotics, is some- wliat similar in its action to chloral and paraldehyde. It quiets cerebral excitement, and also the excitability of the spinal cord and oblongata, and has some effect on the sensory nerves. It can be given in doses of half a drachm to a drachm, or even more, under special circumstances, and in delirium tremens and in the insomnia of some forms of insanity it is of great value. Chloralamid is a hyp- notic of proved value, safe in proper doses, and rarely depressing. In ordinary cases it stimulates the respiratory centres, the blood pressure remaining uninfluenced. It is especially useful in insomnia accompanying the high arterial tension of Bright' s disease. "When given for hypnotic effect its physiological action is noticed in from thirty to ninety minutes, and the sleep induced lasts from five to nine hours, is natural and refreshing, and is not followed by any unpleasant sequelse. Duboisine sulphate is both hypnotic and sedative, belonging to the same order of drugs as hyoscine hydrobromate and atropine, and is useful in some forms of mental disease with excitement, as in mania, agitated melancholia, agitated dementia, and choreic insanity. It can also be used in short convulsive hysterical attacks. The asso- ciation of a sedative with a somnifacient effect sometimes makes it particularly useful. It has been given hypodermatically in doses of one one-hundredth to one sixtieth of a grain, but the former is prob- ably the safer dose for this method of administration. Sypnal, a hypnotic whose action is much like that of chloral and antipyrin, is known in two combinations, one monochloral of antipyrin, which has forty-seven parts of chloral to fifty-three of antipyrin ; the other iichloral of antipyrin, which has sixty-six parts of chloral and thirty- four of antipyrin. Injected into the veins of a dog, the two combina- tions had the same toxic " coefficient," — one gramme for every kilo- gramme of the weight of the animal. (Gley. ) It has hardly any taste, and no odor, which makes it superior to chloral, particularly for chil- dren. It produces hypnotic effects in smaller doses than those of chloral. The properties of its component parts (chloral and antipy- rin) are manifest in its action ; thus it is both hypnotic and analgesic. It is serviceable in insomnia due to pain. (Friinkel.) Hyoscine hyAro- hromate has secured a prominent place in the armamentarium of the neurologist and alienist. It is especially useful in insomnia with delirious excitement. Mcthylal is a hypnotic of some virtue, but on the whole inferior to chloral, hypnal, or somnal. Paraldehyde is a nearly pure hypnotic, and one that is undoubtedly effective, and less dangerous to the heart than chloral. Its nauseous taste and the gastric disturbances produced by it are objections to its use, but these can be partly overcome by giving close attention to the form of prescription. It may be administered in drachm doses. Somnal, like sulphonal and trional, is a hypnotic that has prob- ably come to stay. It will induce sleep when loss of sleep is not GENERAL THERAPEUTICS. 235 dependent upon pain. In tlie sleeplessness of mental strain or anxiety, of hysteria or mild mania, and that which occurs after acute diseases, it is especially indicated ; but it is of little value in the insomnia of organic disease of the brain. Although suJjjJionul occasionally produces untoward eflects, it is an invaluable hypnotic, but the method of using it must be carefully considered. As is well known, its effects often come on late, and therefore it is best to administer it some hours before the time when it is needed to produce sleep, as in several doses of from iive to ten grains, begin- ning in the middle of the afternoon and repeating every two or three hours. The plan suggested by Mairet, of administering large doses for a day or two and then smaller doses, is sometimes a good one ; thirty to forty grains or even more may be given for one or two evenings, and then doses of fifteen grains or less every even- ing can be continued. Another drawback, besides its slowness in promoting sleep, is the tendency of its hypnotic action to continue the next day. Occasionally a patient shows a striking idiosyncrasy against its use. Trional is a safe and valuable hypnotic when given in appropriate doses. It can be administered in water, wine, or milk, and acts promptly, differing in this respect from sulphonal. Tetronal is a drug allied to trional and probably of nearly equal value. Among remedies which have attained some reputation as hypnotics, but have not been proved to be of sufficient value to rank with drugs like chloral, sulphonal, trional, chloralamid, and even hypnal and somnal, may be mentioned chloralose, urethan, and ural or uralium. Analgesics. — Analgesics act differently on different parts of the nervous system. General anesthetics and local anesthetics alleviate pain, the latter by preventing the reception of painful stimuli, and the former by acting upon nerve centres so as to abolish the per- ception of pain. Pain can also be prevented by hindering the transmission of sensory impressions in the spinal cord. Cocaine acts energetically upon nerve trunks when locally applied or when injected subcutaneously, and affects both the conductivity and the reflex irritability in the spinal cord. Atropine, veratrine, and other local analgesics have a distinct local anesthetic action. Acetanilid and antipyrin act powerfully upon the spinal cord. (Brunton.) Du- quesnel's aconitia or aconitine, if used properly, is often efficient in the treatment of neuralgic affections, and especially of trigeminal neu- ralgia. Patients should first be tested with small doses, as one four- hundredth to one two-hundredth of a grain, and then the dose can be pushed up to one one-hundredth two or three times daily. I have had both successes and failures with this drug. Seguin has strongly recommended its use in trigeminal neuralgia. "With this remedy he recommends red iodide of mercury to be given, the dose gradually increased from one twentieth to one fifth or one sixth of 236 NERVOUS DISEASES. a grain, combined with potassium iodide. Aconitine is a remedy of considerable value in exophthalmic goitre, exerting a powerful influence on nervous fast pulse. Success has been achieved in the use of agathin in the treatment of sciatic and supraorbital and some other forms of neuralgia, but it often fails. Codeine sulplmte is of value in the treatment of the opium or morphine habit. After iirst reducing morphine to the minimum, codeine can be substituted, at first giving doses of about one grain and gradually reducing. This is continued from ten to fourteen days. Acetanilid, bromo-cafifeine, and quinine are used as auxiliaries. Codeine has peculiar power in lessening the irritability of the intestinal nerves, and possibly also of those of the respiratory organs. It is therefore useful in nearly all forms of abdominal pain, like colic, gastric, renal, and ovarian neuralgia. ExaJgin has some virtues as sleep producer, pain re- liever, and suppressomotor. In chorea it has been used with suc- cess. It is said to act excellently as an analgesic in children. Methylene blue has been used in the treatment of facial neuralgia, an- giospastic migraine, nervous headache, muscular rheumatism, and herpes zoster. It is of use only in purely nervous pain. Thymace- tin is a derivative of thymol, analogous to phenacetin : it is a white crystalline powder, slightly soluble in water. In hemicrania and in habitual headache and neuralgic pains the action is similar to that of phenacetin, rapid and certain in some cases, slight or absent in others. In headache due to organic brain lesion it is uncertain. Other drugs which have obtained some reputation for the relief of pain are hromamidc, phenocoll, &n(\. pyrodin. Conium. — Conium and its preparations, when reliable, have an important place in neurological therapeutics. Attention should always be paid to the source from which the drug is obtained, for, like other vegetable neurotics, it may deteriorate by keeping, and sometimes the preparations, as originally made, are inert. Physio- logical experiments have proved that coniine acts directly upon the efferent or motor nerves, paralyzing these nerves, although it has some but much less decided effects upon the sensory nerves. It is probably also a powerful sjiinal depressant. My clinical experience teaches me that it has sonu' quieting effect upon the cerebral hemi- spheres. The fluid extract of conium, the preparation chiefly used by me, is of value in hysterical excitement, in common acute mania, and in chorea. In the treatment of mania it can be combined with the bromides and used alternately with hyoscine hydrobromate. In chorea I usually give the fluid extract in equal dose with Fowler's solution of arsenic, begi]ining with two or three minims of each, and increasing day l)y day until quieting or constitutional effects are produced. It makes a useful addition to a bromide mixture in the treatment of epilejisy. I have had a limited experience in the use of hydrobromate of coniine, and believe it to be a valuable drug. GENERAL THERAPEUTICS. 237 The dose usually given by me is from -^^ to -^ grain, but I have given as much as xV grain, and it can probably be used in still larger doses. Seguin recommends as much as a drachm of the fluid extract of conium as a dose. In the treatment of insomnia, general irrita- bility, localized spasms, and chorea such doses cause almost imme- diate toxic effects, and are safe only when patients can be carefully watched. It is best to begin with four or five minims and rapidly to increase until fifteen minims or more are taken and the desired effect is produced. Gelsemium. — Among powerful remedies of the motor depres- sant group is gelsemium. It is a drug which should be used with caution, and yet one that needs to be administered in efficient dose in order to obtain a good result. Some indi^dduals show special idio- syncrasies against gelsemium. Sinkler has reported a case in which five drops of the fluid extract of gelsemium produced alarming toxic symptoms in a patient who had been taking the remedy three times daily for about two weeks ; and in another case a dose of seven drops caused visual disturbances and unsteadiness of gait. Bassette has reported a case of chronic spasm of the muscles supplied by the spinal accessory nerve, in which the patient was first placed upon the fluid extract of gelsemium in doses of five drops four times daily, and this dose was increased daily by one drop until twenty- four drops four times daily were taken, up to which time no constitutional effects were visible. She was then placed upon Parke, Davis & Company's normal liquid gelsemium, beginning with five drops three times daily. The dose of this was increased until she took twenty drops, when she began to see double and to feel dizzy. The drug was omitted for one day, and she was then again put upon twenty drops, and this was increased to twenty-five with no effect. (Two drops of the fluid extract are equal to one minim.) For three weeks this patient took for the greater part of the time twenty-six drops, or thirteen minims, every two hours, night and day ; for another part of this time, alternately, either thirteen minims or seven and a half minims, every two hours, or about this amount. For the remaining forty- seven days she took about thirteen minims eight times daily. Antispasmodics. — Although sometimes derided, we have in the old fashioned antispasmodics remedies which are of real service in the treatment of functional nervous disorders. Some of these anti- spasmodics are asafetida, valerian, surabul, cimicifuga, and musk ; the last is too expensive for ordinary use, but where expense is no object it may be used with decided effect in hiccough, hysterical attacks, and conditions of extreme nervous exhaustion. Sumbul has a value fairly comparable to that of asafetida and valerian, although some specimens of the drug are valueless. It may be used in the form of a tincture, fluid extract, or solid extract. When 238 NERVOUS DISEASES. administered in the fluid form it is best given alone, diluted with water at the time of its administration ; or the fluid extract may be combined with simple elixir. The piU long known as GoodelFs pill, or the compound sumbul pill, is a convenient method of ad- ministering this drug ; or it may be given in combination with salts of valerian, or preparations of asafetida or hyoscyamus, without arsenic or iron. Cardiants. — Not infrequently, patients suffering from nervous disease, functional or organic, have a weak or diseased heart and slow and sluggish circulation. The remedies most useful in such conditions are preparations of caffeine, cactus, digitalis, and strophan- thus. It is not necessary for me to dwell upon the virtues of digitalis and strophanthus. Cactus ffrandifonts is less used and its virtues are less well known, but it is an admirable stimulant to the vasomotor centres. It is valuable in some forms of nervous cardiac palpitation. I usually give the fluid extract in doses increasing from five to ten minims. Caffeine has also a stimulating effect on the heart muscle and nerve centres, increasing blood pressure. It is invaluable in some forms of nervous headache, in various depressive states of the nervous system, in the cardiac neuroses, and in heart disease associated with kidney affections. Alterative Tonics. — When in neurological practice an alterative tonic effect is desired, a good preparation is a combination of the syrup of hydriodic acid and compound syrup of the hypophosphites, in the proportion of equal parts, or of one part of the former to two parts of the latter. Small doses of sodium iodide can be added. Such a combination will be found of value in cases of neurasthenia and melancholia with hepatic and intestinal derangements, ia old syphilitics, and in neuritis which has become chronic. Turpentine has been too much discarded in neural affections, such as chronic sciatica and lumbar or lumbosacral neuritis or myositis, commonly called lumbago, in which it may be the most efBcient remedy that can be administered. It should be given in doses of fifteen minims or half a drachm, or even more, in a properly prepared emulsion, and a careful watch should be kept for such untoward effects as strangury. Arsenic and mercury are sometimes valuable in similar cases, and may be given advantageously in the old fashioned Dono- van's solution, or in one of the two, three, or four chloride mixtures. Metallic Tonics.— The metallic tonics have an old and a well deserved re])utation in the treatment of chronic nervous diseases, both functional and organic ; and gold, silver, zinc, copper, arsenic, iron, and other metals furnish salts of great value. Sodium and gold chloride, although perhaps it has attained an unmerited reputa- tion in some directions, is a valuable tonic, and I not infrequently use it in the treatment of hysteria and other affections, usually after the manner long since recommended by Niemeyer, giving pills of GENERAL THERAPEUTICS. 239 one tenth or one twelfth of a grain three times daily, and increasing the number of pills until three are taken three times daily. Both the nitrate and the oxide of silver are remedies of great value. Silver nitrate has long borne a good reputation in the treatment of scle- rosis, and formerly it was much employed for epilepsy. It acts bene- ficially in the degenerative nervous diseases apparently by retarding the progressive pathological process and giving tone and strength to that part of the neuraxis which is still intact. The great objection to its use is the fact that it may cause argyria, or discoloration of the skin. It is difficult, if not impossible, to know just how far to go in the administration of such a drug before producing discoloration. Probably the advice given by Wood, to suspend its administration for one week at the end of every third week, and not to extend its use over a longer time than three months without a protracted intermission, is as near a practical rule as can be obtained. Silver oxide may be used instead of the nitrate, in doses of about one grain. The salts of copper, formerly used to a considerable extent in the treatment of hysteria, have gone largely out of use ; but these prepa- rations are of undoubted value as nerve tonics. They may be used with advantage in cases of hysteria or melancholia associated with neurasthenia. These ijreijarations stimulate the circulation as well as act as nerve tonics, and are worthy of trial in hysteria, chorea, and allied aifections. Barium chloride formerly bore a favorable reputation in the treatment of scleroses and of epilepsy. I have had some experience in its use, but believe that it is not of suf- ficient value to recommend it in preference to any of the better known drugs employed for these affections. A number of well known therapeutists have published physiological studies of this drug which show that it is of value in cases of failure of the heart muscle. It should be prepared of the strength of five grains to the ounce of water. Phosphorus. — Doubtless some preparations of phosphorus, and phosphorus itself, are useful remedies in the treatment of nervous diseases. As already shown, complex derivatives of phosphoric acid are present in considerable amount in nervous tissues, and especially in the brain. Seguin summarizes the facts with reference to phos- phorus as a neurotherapeutic agent as follows : "Phosphorus should be given pure, in the shape of a solution in alcohol and glycerin (Thompson's solution or tinct. phosphori, Sj-^jr grain), or dissolved in oil (oleum phosphoratum), or as pil. phosphori. The i)ills in the market give altogether too small doses of phosphorus, which should be administered in doses varying from ^V of a grain to ^V) three times a day,— the oil and pills after food, the tincture (diluted, if neces- sary, with glycerin) on an empty stomach and without water. Food, however, conveys an appreciable amount of phosphorus into the system in a naturally assimilable state." The oil of phosphorus of 240 NBEVOUS DISEASES. the Prussian pharmacopeia is one of the most efficient preparations of phosphorus, and was much used at the out- door neurological ser- vice of the hospital of the University of Pennsylvania when I was connected with that department. Bromides. — Such preparations as the bromides of arsenic, zinc, iron, magnesium, and calcium have proved of little value in my hands. Better results are to be obtained from the use of the well known bromides with Fowler's solution, or the iron, arsenic, zinc, etc., separately. In the long continued use of bromides, whether for epilepsy, migraine, or whatever the disease, it is of vital importance to study the patient as well as the disease. Susceptibility to the bromides is increased by the existence of organic, cardiac, and cere- bral disease. Moderate doses in such cases will sometimes produce profound bromism. The hygiene and diet of patients taking bro- mides are of the greatest importance. Patients under their use, and nervous patients in general, are much benefited by the use of cod liver oil and of fatty foods. Preparations of malt are also of great value, and maltine with peptones, as recommended by Graeme M. Hammond, may be found of service in epileptic and other patients suffering from exhaustive diseases or from the effect of depressing drugs. With bromides, as with other potent remedies, the dose can sometimes be regulated by a consideration of the body weight of the patient. Thus, Cesare Agostini found that in the great majority of cases, with the average dose of ten to fourteen grammes, intermitting every third day, a quantity corresponding to twenty to twenty-five centigrammes per hectogramme of weight of the individual, harmless in physiological experiments, produced a cessation or a notable diminution of convulsive attacks. Among organic bromine compounds, ethylene bromide has something to be said in its favor. Donath believes that it is less harmful than the bromine salts commonly used, because it does not contain the alkalies to which the deleterious effects of the latter are prob- ably due. As it is insoluble in water, but mixes readily with alcohol and the fixed oils, it is best administered in five per cent, mixture with some bland oily emulsion or in spirit of peppermint, well dihited. The dose is from one to three decigrams, two or three times a day. For children of eight or ten years the dose of five per cent, emulsion is from ten to twenty drops, two or three times a day. In the use of the liromides, as of the iodides, the occurrence of acne cannot be depended upon to guide the dosage. This eruption may be dependent upon some idiosyncrasy or pecu- liarity of the patient and an unhealthy state of the skin, with over development of the sebaceous glands, and deficient excretion in other channels than the skin. Large dilution of the bromides in alkaline water, and full doses of arsenic at intervals, will do much to control the acne. (Seguin.) FORMULAS. 241 FORMULAS. * Instead of discussing further in a general way the special uses and metliods of administration of drugs most frequently used in neurological practice, I shall give a series of formulas for the internal, external, and hypodermatic administration of many of these drugs, in some instances with brief comments on their uses and methods of preparation. Not a few of these prescriptions may be found useful in several, perhaps many, nervous affections. Amtlene Hydrate. 0.0. R Amylene hydratis, . . fgiij ; H 25 ; Extraoti glycyrrhizse fluidi, . . . f^ss; 15 00; AquiB destillatse, q. s. ad . fj^j- ^^^ ""• M. Sig. — Tablespoonful, in a wineglassful of water, at bedtime, or as directed. Amylene hydrate can also be administered hypodermatically in chloroform water; but an objection to this method of administration is the comparatively large dose required. Sodium Bromide. Gm. et c.c. U Sodii bromidi, 5Jss; 45 00; Aquae destillatse, • • fgvj. 180 00. M, Sig.- -Teaspoonful three or four times daily. Strontium Bromide. Gm. et c.c. R Strontii bromidi, 5vji 24 00; Aquae cinnamomi • ■ fgvj. 180 00. M. Sig. — Dessertspoonful or tablespoonful, in a wineglassful of water, three times daily. Strontium bromide acts well in some cases of epilepsy in doses of fifteen grains to a drachm, and seems to be better borne by the stomach than some of the other bromides. * In the formulas both the customary and the metric weights and measures have been given. In turning one into the other, Remington's method of con- version has been adopted, to avoid inconvenient fractions. The table of equiva- lents given by him is as follows : gr. j = about 0.06 gm. (64.7989 mg.). gr. xv= " 1 gm. (97.189 eg.). 3j = " 4 gm. ( 3.8879 gm.). gj = " 30 gm. (31.10348 gm.). In liquid measure one minim is considered the equivalent of 0.06 cubic centimetre, one ounce of 30 cubic centimetres, and one drachm of 3.75 cubic centimetres. In the prescriptions which follow are many new words, the names of newly introduced drugs. It has been considered best not to give a genitive to some of these words. 16 242 NEKVOTJS DISEASES. Chloral with Beomide. R Chlorali hydratis, . . f Jss ; Sodii bromidi, ^j ; AquEe destillatae, . f^^j- M. Sig. — Teaspoonful three or four times daily. Gm. et c.c. 15 30 180 Bromides with Conium and Fowler's Solution. Qm. et c.c, 12 00 8 00 Jt Potassii bromidi, 3'ij i 12 Sodii bromidi, 3ij ; 8 Lithii bromidi, Sj l 4 Extract! conii fluidi, Liquoris potassii arsenitis, aa f^ss j 1 Elixiris aromatici, . . f^ij ; 60 Aquse destillatae, q. b. ad . f^vj. 180 M. Sig. — Tablespoonful, in a wineglassful of water, three times daily, after meals. 00 00; 00. Hydrobromic Acid. R Acidi hydrobromici, Syrupi limonis, C.c. Aquas destillatae, aS f^ij. 60 1 00. M. Sig. — One or two teaspoonfuls, in a small tumblerful of water, three times daily, half an hour after meals. Chloral, Morphine, and Atropine. ]J Atropinae sulphatis, . . . . . . gr. ^ ; Morphinae sulphatis, . .... gr. iv ; Chlorali hydratis, . . . ^iij J Aquae destillatae, fgj. M. Sig. — Twenty drops in water, as directed. Gm. et c.c. 012; 24; 12 00; 30 00. Chloralamid. ]j^ Chloralamid, .... Jiij J Tincturse cardamomi compositae, . ... f^j ; Elixiris aromatici, q. s. ad f^iij* M. Sig. — Dessertspoonful to tablespoonful, before bedtime, or as directed. Gm. et CO. 12 00; 30 00; 90 00. Gm. et c.c. Chloralose. 5; Chloralose, 53 ; Alcoholis, . f^ij ; Syrupi aurantii, fgj ; Aquae, q. ». ad f§iij- M. Sig. — Dessertspoonful or tablespoonful, in a wineglassful of water, before bedtime, or as directed. 4 00; 7 50; 30 00; 90 00. Chloralose is most frequently given in capsules. FORMULAS. 243 Hyoscine Hydrobbomate. Jt HyoBoinse hydrobromatis, Aquje destillatae, M. Sig. — Five to ten drops as directed. Gm. et c.c. gr.i; 015; fg«^- 15 00. Hypnal. Gm. 3t C.C R Hypnal, ... . ^iss; 6 00; Syrupi aurantii, . . . . fgj ; 30 00; AquEB destillatiB, q. s. ad , fgiij. 90 00. M. Sig.— Tablespoonful at bedtime, or as directed. Hypnone. Co. R Hypnone, . . . fgss; 1 88; Alcoholis, ... fgij ; 1 50; Syrupi aurantii, .... . fo'J > 60 00; Aquae destillatae, q. s. ad . . . . . fgvj. 180 1 00. M. Sig. — Tablespoonful, in a wineglassful of water, as directed. As hypnone slows respiration and reduces blood pressure, it should be administered with care. It has a pungent taste, and therefore it is best to give it well diluted, as in the above pre- scription. Methylal. c.c. R Methylal, Syrupi rubi idgei, . . . . Aqu£e destillatEe, q. s. ad . M. Sig. — Dessertspoonful or tablespoonful, in a wineglassful of water, as directed. . . fSvj; 22 50, m; 30 00, fS"J- 90 00. Paraldehyde. Jt Paraldehyde, f5j ; Tincturae vanillse, . . "L^^ij ; Alcoholis, . . f^Y; Aquae destillatae, .... fjiij ; Syrupi, q. ». ad f^'y- M. Sig. — One to two tablespoonfuls at bedtime. C.c. 3 75; 72; 18 75; 11 25; 90 00. SOMNAL. C.C. R Somnal, fS^J; 22 60; Spiritus frumenti, f^^^ > 15 00; Aquae destillatae, q. s. ad . . . fgiij- 90 "0. M. Sig.— Dessertspoonful, in a tablespoonful of water, at bedtime, or as directed. SULPHONAL. R Sulphonal, . . . . . . . 3ij- Ft. chart, no. viii. gig. — One powder to be taken in hot water or hot milk, as directed, Gm. 8 1 00. 244 NERVOUS DISEASES. Sulphonal is insoluble in water at ordinary temperature, but moderate doses will partially dissolve in hot water. When the use of a small amount of alcohol is desirable or is not objectionable, sulphonal may be given with whiskey and water, using one or two drachms of whiskey. Milk to some extent disguises its unpleasant chalky taste. It may also be suspended in mucilage of acacia and given in tablespoonful or wineglassful doses. Gm. et c.c 12 00; 30 00; 90 00. Teteonal. ]J Tetronal, . . . . 3iij ; Spiritus frumeuti, . . , . ... f^j ; Elixiris aromatici, q. s. ad fo"J' M. Sig. — Dessertspoonful or tablespoonful, in a wineglassful of water, before bedtime, or as directed. Tetronal can be given in powders, in capsules, or with water or milk. Trional. Gm. et c.c. R Trional, Spiritus vini gallici, . . Elixiris aromatici, q. s. ad M. Sig. — Dessertspoonful or tablespoonful, in a wineglassful of water, before bedtime, or as directed. Trional, like sulphonal and tetronal, can be given in the form of powders. Uealium. •Diij; 12 00; ®; 30 00; fgiij- 90 00. Gm. et c.c. R Uralii, Jjss; 6 00; Alcoholis, f3jss ; 5 63; Syrupi rubi idiei, . . .... f 5j ; 30 00; AquEe destillatse, q. s. ad . . . f^iij- 90 00. M. Sig.— Tablespoonful at bedtime, or as directed. Physostigma. Gm. U Bxtracti physostigmatis, . gr. t ; 30; Extract! gentians, . . . . 353. 2 00. M. et div. in pil. no. xxx. Sig. — One pill three or four times daily. Agathin. Gm. et c.c. R Agathin . . . jy . S 00; Spiritus vini gallici, . . . , . f ^ss ; 15 00; Elixiris aromatici, q. a. ad . . . f=iij. 90 00. M. Sig. — Dessertspoonful in a wineglassful of water, every three or four hours, Bromamide, U Bromamide, Ft. capsul. no. xij. 3ij. Gm. 8 100. Sig. — One every three hours. FORMULAS. 245 Bromamide lias some anodyne as well as antipyretic properties. Codeine Sulphate. Gm, et c.c. JJ Codeinse sulphatis, . . . . gr. xij ; I 72 ; Elixiris aromatici, . . . fgj ; 30 00 ; AqusD destillataa, q. s. ad . . . f5iij' 90 | 00. M. Sig. — Teaspoonful erery four hours. In the treatment of the morphine habit, either pure codeine, or the sulphate, phosphate, or muriate, is used. The pure codeine is not suitable for hyjjodermatic administration. The phosphate is the most soluble. (Mattison. ) The dose given in the above prescription is one-half grain ; but a much larger initial dose can be given in the morphine treatment. EXALGIN. Gm. et c.c R Exalgin, . . . 3ss; 2 00; Spiritus vini gallici, f^j ; 30 00; Aquae destillatae, q. s. ad . . . f^iij. M. Sig. — Tablespoonful twice daily. 90 00. Exalgin, like other coal tar preparations, is given with brandy, whiskey, or rum, to make a more perfect solution. If this use of alcohol is objectionable, exalgin may be prescribed with aromatic elixir, which contains alcohol in a less objectionable form. Methylene Blue. Gm, et c.c. R Methylene blue, . . . 3ss; 2 00; Elixiris aromatici, Aquae destillatae, . . . . . aa f^jss. 45 00, M. Sig. — Tablespoonful, in a wineglassful of water, erery four hours. Methylene blue, being soluble in about fifty parts of water, can be given in a prescription like the above ; usually, however, it is dis- pensed in capsules. Phenocoll Hydrochlokide. Gm. et c.c. R Phenocoll hydroohloridi, . . Jij ; 8 100; Aquas destillatie, , fgiij. 90 | 00. M. Sig. — Dessertspoonful, in a wineglassful of water, every four hours, or as directed. Thymacetin. Gm. et c.c. R Thymacetin, . . 3j ; 4 00; Elixiris aromatici, f^j ; 30 00 ; Aquas destillatae, q. s. ad .... . . f^iij- 90 00. M. Sig. — Dessertspoonful or tablespoonful every three hours, or as directed. Thymacetin, which acts like phenacetin, may be given in doses of about the same strength as the latter. 246 NEEVOUS DISEASES. Hydrastis. Co. R Extract! hydrastis fluidi, fgj ; 30 I 00; Aqu8e destillatse, q. s. ad . ... fgiij. 90 | 00. M. Sig. — Teaspoonful, in a wineglassful of water, every four hours, or as directed. Eydrastinine, or some of its salts, is sometimes used hypoder- matically. The sulphate is soluble in water, and can be prepared so that five minims shall equal one grain. Hydrastis and its derivatives are chiefly tonic alteratives and antiperiodics, but, having some action on the vasomotor centres and the heart, may sometimes be used in apoplexies and hyperemic states of the ner- vous system. When applied to the skin, or used hypodermati- cally, the alkaloid, hydrastine, is a local anesthetic : it may there- fore be resorted to in local and superficial neural affections, like neuralgia or neuritis. Cannabis Indica, Nux Vomica, Eegotin. 5^ Extracti cannabis indicse, gr. vj ; Extracti nuois vomicEe, gr. vijss; Ergotini, . . . 3ss. 2 M. et div. in pil. no. xxx. Sig. — One three times daily after meals. Gm. 36; 45; 00. Cannabis indica rivals opium and cocaine in the fascinating in- fluence it exerts over many neurotics, and therefore a cannabis habit must be carefully guarded against. It is an excellent adjuvant of bromides when both a sedative and an analgesic effect are desired. The best preparations are the solid and fluid extracts. Croton Chloral. (Botyl Chloral.) Gm. et c.c R Croton-chlorali hydratis, . . gr. xl ; 2 40; Syrupi, fgj; 30 00; Aquae destillatse, q. s. ad . . . ... f5iij. M. Sig. — Two teaspoonfuls every four hours. 90 00. Salophen and Phenacetin. Gm. U Salophen, Phenacetin, . . ... aa 5j. * I "0. M. et div. in chart, no. xij. Sig. — One powder every four hours. This would serve admirably in the treatment of acute multiple neuritis, with or without joint and cardiac complications. Sodium salicylate, cinchonidine salicylate, salol, salophen, salicylamid, and salipyrin are all remedies of determined value. Sodium salicylate, salol, and salophen are of most value in the acute and subacute stages of neuritis. Salophen seems to be securing for itself a FORMULAS. 247 permanent place, because of its less poisonous nature than salol, at the same time that it contains more salicylic acid. Cinchonidine salicylate, either used alone or combined with phenacettn and small doses of strychnine, is a very efficient preparation for the chronic forms of mild or moderate localized neuritis, for which both the neurologist and the general practitioner are so often consulted. Salipyein. R Salipyrin, , . ... Glycerini, . , . . Syrupi rubl idaoi, Aquae destillatse, q. s. ad . . . M. Sig. — Dessertspoonful every two, three, or four hours, Gm. et c.c. 3iij; 12 00; f^ss; 15 00; fS; 30 00; fgiij- 90 00. Salipyrin can be given also in capsules. Sodium Salicylate, Bromide, and Iodide. JJ Sodii salicylatis, Sodii bromidl, Sodii iodidi, aa 3ij ; Aquae destillatse, q. b. ad f^YJ. M. Sig. — Dessertspoonful, in a wineglassful of water, three times daily. Gm. et c.c. 8 100; 180 I 00. Oil of Gaultheria. C.c. R Olei gaultheriae, . f^ij ; 7 50 ; Mucilaginis aoaoiae, Syrupi, Aquae destillatae, . . aa f§ij. 60 00. M. Sig.— Dessertspoonful to a tablespoonful, in a wineglassful of water, three times daily, after meals. The oil of wintergreen seems in some cases to act more efficiently than any of the salicylic preparations, particularly in acute, severe cases of neuritis. Strychnine, Phenacetin, R Stryohninae sulphatis, gT. ss ; Phenacetin, gr. xx ; Cinohonidinae salicylatis, , . ... gr. xl. M. et div. in pil. no. xx. Sig. — One pill four times daily. AND Cinchonidine Salicylate. Gm. 03; 20; 2 40. Strychnine, Salol, and Cinchonidine Salicylate. R Strychninse sulphatis, . . . gr. ss ; 03; Salol, Cinchonidinse salicylatis, . . . . aa gr. xx. 1 20. M. et div. in pil. no. xx. Sig. — One pill three or four times daily. 248 NERVOUS DISEASES. Zinc Bromide, Valerianate, and Oxide. R Zinci bromidi, Zinci valerianatis, Zinoi oxidi, . . aa 383. Confectionis rosae, q. 3. M. et div. in pil. no. xl. Sig. — One pill three times daily. (Eggis.) SUMETJL AND VALERIAN. B Tincturse sumbul, Tinoturaa Valerianae, . . aa f^j. Sig. — Teaspoonful every two hours in sweetened water. Valerianates op Quinine, Zinc, and Iron. Jt Quininse valerianatis, Zinoi valerianatis, Ferri valerianatis, . . . . . . aa Jss. M. et div. in pil. no. xxs. Sig. — One to two pills three times daily. Gm. 2 1 00. C.C. 30 I 00. Gm. 2100. Three Valerianates with Aloes. 5t Extracti aloes aquosi, .... gr. xvj Zinci valerianatis, Quininge valerianatis, Ferri valerianatis, aa 3ss. M. et div. in pil. no. xxx. Sig. — One pill three times daily after meals. (Whitla.) CoMPOOND Sumbul Pill. R Acidi arsenosi, . . . Ferri sulphatis exsiccati, Extracti sumbul, .... Asafoetidse, M. et div. in pil. no. xl. Sig. — One pill three times daily after meals. (Goodell.) Sumbul. B^ Extracti sumbul fluidi, ... . f^vj ; Elixiris aromatici, q. s. ad . . . . . . f^iij. M. Sig. — One or two teaspoonfuls every four hours, as directed. Cactus Grandiflorfs and Nux Vomica. Gm. 00; 00. Gm. • • gr.j; 06; aa gr. xl ; 2 40; gr. Ixxx. i 80. C.c. 22150; 90 I 00. C.c. Ji^ Extracti cacti grandiflori fluidi, Tincturse nucis vomicae, . .... aa foij ; ^l^^^J Aquas destillatae, q. s. ad . . . . f^iij. 9 I 00. M. Sig. — Teaspoonful or dessertspoonful, in a wineglassful of water, every four hours. Sparteine. 5^ Sparteinie sulphatis, . .... gr. v. Pulveris glycyrrhizas, q. ». M. et div. in pil. no. xl. Sig. — One pill every three or four hours. Gm. 0|30. FORMULAS. 249 This dose can be increased, when it is desired to produce a de- cided effect, by giving two or even three pills at one time. Sparteine is a useful drug as an adjuvant to digitalis, or sometimes used alone in neurotic cases with cardiac disease. Dr. W. E. Hughes, who has reported favorably on the use of this drug in cardiac and renal cases, believes that the dose should not be less than one quarter of a grain, three times daily, and that it may be administered hypodermatically in doses as large as one grain. Hypophosphites with Hydriodic Acid. C.c. U Syrupi hypophosphitum, Syrupi aoidi hydriodici, . . . . aa f§iij ; 90 I 00. M. Sig. — Dessertspoonful, in a wineglassful of water, three times daily after meals. Tdepentine. Co. 50; R Olei terebinthinse, . . f^vj ; 22 Pulveris acacige, Pulveris sacchari, . ... . aa ^v ; 20 Aquse mentliEe viridis, q. s. ad . . f^^j. ^80 M. Sig. — Dessertspoonful or tablespoonful, in a wineglassful of water, three times daily. 00; 00. Compound Arsenical Pill. Gm. 06; 00; 80. ^ Acidi arsenosi, .... gr- j ; Cinchoninse sulphatis, . 3j ; 4 Ferri et potassii tartratis, ... . . . gr. Ixxx. 4 M. et div. in pil. no. xl. Sig. — One three times daily after meals. Gold and Sodium Chloride. 6m. R Auri et sodii chloridi, . . . gr. v; 30; Tragacanthse, . 5j. ^ 00. Sacchari, q. s. M. et div. in pil. no. xl. Sig. — One three times daily, to be increased until three are taken three times daily. This method of using sodium and gold chloride, recommended by Niemeyer, has long been used by me in the treatment of hysteria. Oil of Phosphorus Mixture. 0.0. R Olei phosphorati, . Tt\, xlviij ; 2 88; Olei gaultherias, . . ... ■ ^ xxiv ; 1 44 ; Mucilaginis acacise, q. s. ad fSi'J' 9" 0"- M. Sig. — One or two teaspoonfuls, in a wineglassful of water, three times daily after meals. Silver Nitrate. Gm. R Argenti nitratis, . . . . . . gr. v ; Extracti glycyrrhiza3, Pulveris glycyrrhizse, . . aa q. s. M. et div. in pil. no. xxx. Sig. — One three times daily. 30. 250 ) NERVOUS DISEASES. PiPERAZIN. Gm. et c.c. ]J Piperazin, . . ... . 3iij ; Syrupi aurantii, . f^ss ; Aquae destillatse, q. a. ad . . . ... . f§iij. M. gig. — Dessertspoonful to be added to two quarts of water and drunk 11 15 90 25; 00; 00. during one day Piperazin ranks among the most active of uric acid solvents, and is one of the most valuaWe remedies, carefully used, in the treatment of gouty and lithemic patients with nervous symptoms. It is best administered alone. Aconite, Colohicum, and Belladonna. C.c. Gm. et C.C r. XX ; 1 20; S; 4 00; f§j; 30 00; fgiij- 90 00. JJ TincturSB aooniti radicis, Tincturae colchici seminis, Tincturae belladonnae, . . ... aa tl^ Ixxx. 4 1 80. M. Sig. — Six drops every six hours until relieved. The above will be found efficient for the relief of sciatic or other forms of neuritis dependent upon a gouty condition of the system. LlTHinjI BiBOEATE AND SODIUM BiCAEBONiTE. ]J Lithii biboratis, Sodii bicarbonatis, Syrupi aurantii, . . Aquae destillatae, q. s. ad . M. Sig. — One or two tablespoonfuls to be taken at a time. This is useful in acute attacks of lithiasis with nervous manifes- tations. The dose given can be doubled and repeated once or oftener. GUAIAC, ClMICIFUGA, AND EETTHROXYLON. C.C. 5^ Tineturae guaiaci ammoniatge, Extracti cimicifugae fluidi, Extracti erythroxyli fluidi, . . aa fgj. 30|00. M. Sig. — Teaspoonful, in a wineglassful of water, three times daily. When constipation coexists, an equal proportion of iiuid extract of cascara is added. This prescription will be found valuable in neuralgia and various forms of neuritis. (Eshner. ) Cimlcifuga, a favorite remedy for chorea with Dr. George B. Wood, is not infrequently used by me in the treatment of this affection, and of neurasthenia, hysteria, and general nervousness. The most efficient preparation is the fluid extract, which can be given in doses of fi-oiu fifteen minims to one drachm. Coca, par- ticularly in the A-arious forms of the wines of coca, has had a great vogue, largely through exploitation by ambitious pharmaceutical firms. A good wine of coca has some value in temporarily stimu- lating and toning an exhausted nervous system, but it is a prepara- FORMULAS. 251 tion likely to be abused. Next to cocaine or its salts, the fluid extract of erythroxylon coca in doses of from half a drachm to one drachm is the most efficient preparation, and can occasionally be used with advantage as a nerve tonic. C.c. Ncx Vomica, Cloves, Chloroform, and Cardamom. 5t Tincturae nucis vomicEe, . Olei caryophylli, ... Spiritus ohloroformi, .... . . Tincturge cardamomi compositge, q. o. ad . . M. Sig. — One or two teaspoonfuls, in a wiueglassful of water, after meals. This is a useful formula in nervous dyspepsia, or in the flatulent dyspepsia which is often present in some types of neurasthenia. Compound Kola Pill. fSij; 1 50; f5ss; 1 88; fSij ; 7 50; fgiij- 90 1 00. after meals. (Griffith.) R Ferri arsenatis, ... gr- Ji ; 08; Bxtracti nucis vomicae. gf- i'j ; 18; Extracti rhei, . . gr. XV ; 1 00; Extracti kolae. Extracti cinchonse, . . . . aa 3ss; 2 00; Pulveris kolae, ... .... 3j- 4 00. M. et div. in pil. no. xl. Sig. — One pill four times daily. (Regis.) Kola is a cardiant and cerebral stimulant, and is now sold in the forms of fluid extract, tincture, and specially prepared wines and cordials. It seems to have some of the virtues of drugs like caffeine and coca ; but it has not yet obtained a settled position. CiNCHONiNE Sulphate with Iron. Gm. gr-j; 06; 3ss; 2 00; 3j- 4 00. R Strychninae sulphatis, . . Ferri reducti, ... . . Cinchoninge sulphatis, M. et div. in pil. no. xxx. Sig. — One three times daily. Ointment of Aconitine and Veratrine. ^ Aconitinae, ... Veratrinae, Glycerini, Cerati, M. et ft. ung. Sig. — Apply once or twice daily. Care should be taken to see that there is no abrasion of the skin at the place of application. Ointment of Veratrine and Morphine Hydeochlorate. Gm pt c.c. gr. iv ; 24; gr. XV ; 1 00; f3ij; 7 50; 3vj. 24 00. Gm. R Veratrinse, Morphinae hydrochloratis, .... Unguenti aquae rosae, M. et ft. ung. Sig. — A piece the size of a pea to be rubbed over the painful nerve. (Bamberger.) aa gr. iv ; gss. 0|24; 15 00. 252 NERVOUS DISEASES. If an accurate dose is desired, the ointment can be divided into equal parts, and each part can be wrapped in paraffin paper, after the manner already described in discussing mercurial inunction. Iodoform Ointment. Gm. g lodoformi, . . . . . . gss; 15 00; Petrolati mollis, ... . . gijss. 75 00. M. et ft. ung. Sig.- —Use as directed, once or twice daily. Collodion with Canthaeides. Jt CoUodii cum cantharide, ^3^^- Sig. — Apply with camel's-hair brush, as directed. Co. 15100. This and the next prescription may be used as an absorbent counterirritant in localized neuritis. Iodoform Collodion. Gm. et c.c ]^ lodoformi, . ... ... . gr. xx; 1 20; Collodii flexilis, ... . . . fgj. 30 00. M. et ft. solutio. Sig. — Brush upon the part as directed. Compound Chloroform Liniment. C.C. g; Chloroformi, ^Sltheris, Spiritus camphorae, Tincturae opii, ... . . aa fgj ; 30 00; Tincturae capsioi, . . . . f§ss. 15 00. M. Sig. — For external use as directed. Compound Origanum Liniment. C.c. R Tincturse aconiti radicis. 01 ei origani, Spiritus camphorce, Spiritus chloroformi, Aquee ammonise, Alcoholis, aa fgss; aa fgj. 15 30 00; flO. M. et ft. lin. Sig.- —For external use. This is a powerful counterirritating liniment which can be ap- plied by rubbing with the hand or with iiannel, and is useful in the treatment of lumbago and other neural and muscular affections. R Oleitiglii, Olei olivjr, Ft. linimentum. Liniment of Croton Oil. aa fgj. Sig. — For external use as directed. C.c. 30 100. Corrosive Sublimate Wash for Lavage of the Stomach. Gm. et c.c. R Hydrargyri chloridi corrosivi, gr. j ; 106; Aquae destillatse, . Oj. 480 1 00. M. FORMULAS. 253 In cases of hyperacidity, the stomach is first washed out with the above antiseptic solution, after which simple alkaline lavage without antiseptics is used. (E6gis.) Creolin and Sodium Bicarbonate for Lavage. Gm. ]J Creolin, . . . gr. vijss ; Sodii bicarbonatis, . gr. xlv ; 2 Aquse destillatse, . . . . Qj. 480 M. et ft. tmulsio. 4&; 70; 00. Lactic Acid for Lavage. Gm. et c.c. R Aeidi laotici, gijss; 10 I 00; Aquae destillatse, Qj. 480 | 00. M. In cases of achlorohydria and of dyspepsia from fermentation, antiseptic lavage with the above prescriptions is used, to be followed by washing with acid wash. (E6gis.) Hydrochloric Acid Wash for Lavage of the Stomach. C.c. U Aoidi hydrochlorici, fjss; 1|88; Aquse destillatse, . . Oj. 480 1 00. M. Resorcin for Lavage. Gm. et c.c. R Resorcini, ^ss; 2 100; Aquae Oj. 480 I 00. M. Salol for Lavage. » Gm. et c.c. R Salol, Jss; 2100; Aqua), .... Oj. 480 1 00. M. Hypodermatic Medication. — Among remedies most frequently used hypodermatically are salts of morphine and atropine, hyoscine hydrobromate, theine, cocaine, ether, chloroform, salts of strych- nine, and preparations of mercury. Other remedies less frequently used but efficient, administered in this way, are duboisine sulphate, chloral, antipyrin, coniine hydrobromate, apomorphine, and prepa- rations of arsenic, curarine, sparteine, and eserine. After some gen- eral remarks on the use of a few of these remedies, a series of hypo- dermatic formulas, derived from various sources, or from personal experience, will be given. Many of these drugs are sold in the form of soluble, compressed hypodermatic tablets, the list of these including preparations of the following : apomorphine, atropine, ergotin, cocaine, duboisine, eserine, hyoscyamine, mercuric chlo- ride, morphine, morphine and atropine, nitroglycerin, pilocarpine, and strychnine. Subcutaneous injections of ether are valuable in the treatment of sciatica and other nerve affections ; one cubic centimetre (fifteen minims) can be injected best where the nerve 254 NERVOUS DISEASES. trunks are few, and well covered with skin and fat. Care should be taken, as local paralysis has followed its use. Bartholow strongly advocates the deep injection of chloroform in the treatment of neuralgias. My own experience has been confined to a few cases of sciatica, which were greatly benefited by its use. The pain caused by the injection, and the tendency to the formation of swellings and abscesses, are objections to its employment, and as high an authority as Anstie declared it to be unfit for hypoder- matic use. Bartholow, following Salkowski, gives aqua chloroformi as the vehicle in some of his hypodermatic formulas. This aqua chloroformi is simply distilled water, containing the small amount of chloroform which it will take uj), this, according to Salkowski, pre- venting the formation of microorganisms because of its germicidal powers. Chloral hydrate is seldom called for hypodermatically, but in severe forms of convulsion, and in mania with deUrious excitement and extreme insomnia, it may occasionally be resorted to with advantage, either alone or in combination with morphine, or with both morphine and atropine. The usual dose for hypoder- matic medication is not more than ten grains. The pain and local irritation to which it usually gives rise are contraindications to its use, and it should be resorted to only when it cannot be efficiently employed either by the mouth or by the rectum. DnBoisiNE Sulphate. Gm. et c.c. R Duboisinse sulphatis, . gr. j ; | 06 ; Aquae chloroformi, . . f Jss. 15 1 00. M. Sig. — Five minims contain nearly one fiftieth of a grain. (Bartholow.) EsEEiNE Sulphate. Gm. et c.c. 5t Eserinae sulphatis, . gf-j; 106; Aquae destillatae, . ... f^^^- ^^ ' *"'• M. Sig. — Two minims equal one one-hundred and twentieth of a grain. Dose, from two to four minims. HYOSCV AMINE. Qm. et c. R Hyosoyaminae sulphatis, . . . . . . gr. ss ; 1 03 ; Aquae destillatw, ... . ... fgss. 15 1 00. M. Sig. — Five minims equal one ninety-sixth of a grain. Cocaine. Gm. et c.c. R Cocainae hydrochloratis, . . gr. iv; 124; Aquae destillatx, . . f Jss. 15 1 00. M. Sig. — Five minims equal one twelfth of a grain. Cocaine hijdrochlorate is easily soluble in water, and can be ad- ministered hypodermatically in doses of from one twelfth to one fourth of a grain, in simple aqueous solution ; or dissolved in liquid FORMULAS. 255 petroleum or other similar oils. (Bartholow. ) The extraordinary differences in susceptibility to this drug should be borne in mind. The minimum dose will affect one person toxically, while another will stand the maximum dose or the continuous use of the drug without unpleasant effects. The tendency to the formation of the cocaine habit should not be overlooked. CONIINE HyDROBROMATE. ]J Coniinse hydrobromatis, Aquae destillatae, M. Sig. — Five minims contain about one ninetieth of a grain. (Bartholow.) Authorities seem to differ considerably as to the minimal and maximal doses of this drug. The dose for administration by the mouth is given by some to be as much as from one sixth to one half a grain ; by others, from one thirtieth to one fifteenth of a grain. With what is known of the drug, five to ten minims of the above solution should be safe for hypodermatic administration. Gm. et c.c. gr- J ; 06; fSJ- 30 00. CURAEINE. Gm. et c.c • • gr-j; 06; • • «• 30 00. Gm. et c.c. aaSj; 4 00; gr. Tiij ; 48; m- 30 00. 5^ Curarinae sulpbatis, Aquae destillatae, M. Sig. — Five minims equal one ninety-sixth of a grain. Curara can be used instead of curarine sulphate, preparing a solution that will contain one one-hundredth of a grain of the drug to the minim. The dose of curara is from one twenty-fourth to one sixth of a grain. Theine. (Caffeine.) R Theinae, Sodii benzoatis, Sodii chloridi, Aquae destillatae, .... M. Sig. — Six minims equal one half grain of theine. Theine has been recommended by Mays for the relief of painful affections, and I have found it of value, in doses of from one to two grains, in superficial neuralgia or neuritis. Fowler's Solution. C.c. R Liquoris potassii arsenitis, . . f^j. 30100. Sig. — Dose, from five to twenty drops. (Bartholow.) Sodium Arsenate. C.c. R Liquoris sodii arsenatis, ... . . f,^j- 30|00. Sig. — Dose, from ten to thirty drops. (Bartholow.) The tincture of lavender used in the preparation of the liquor potassii arsenitis should be omitted, because of its irritating proper- 256 NERVOUS DISEASES. ties when used hypodermaticaUy. (Bartholow.) Large and vliat would seem under ordinary circumstances dangerous doses are recommended by some authors, but the results which have been obtained by such almost heroic treatment have certainly been good ; especially in severe and obstinate cases of chorea has the hypoder- matic use of the solutions of sodium arsenate and potassium arsenite proved of great value. Mercuric Chlobide. Gm, et c.c. R Hydrargyri ohloridi corrosivi, . . . gr. j ; I 06; Aqua) destillatiE, fgj. 30 1 00. M. et filt. Sig. — Dose, ten minims. Merciiry, used hypodermatically, is of great value in the treat- ment of nervous syphilis. The bichloride is simply dissolved in water, as recommended by Bartholow, Wolff, and others. Soluble compressed hypodermatic tablets are sold containing one sixtieth of a grain of mercuric chloride and one fourth of a grain of sodium chloride. The insoluble compounds of mercury, and particularly calomel, are sometimes to be j)referred in syphilis of the nervous system, as in the treatment of syphilis of other tissues and organs. The most rapid results are obtained from the soluble compounds, but the tendency to relapse is greater than after the use of the insoluble preparations. The mercury can be given with advantage in some forms of gray oil. An objection to the use of mercury hypodermatically is the paiu which is produced ; but, in spite of this drawback, many x^atients who realize the speedy and decided benefit obtained from the use of the remedy hypodermatically wiU ask for its administration in this way in preference to the slower, if less painful, method by the mouth or by inunction. Between the scapulae and various positions in the back are convenient places for its administration. The directions here given are chiefly taken from papers by Dr. L. Wolff, of Philadelphia. Calomel. Gm. R Hydrargyri ohloridi mitis, Petrolati liquidi, . aa gr. Ixrij ; 4 I 02; Lanolini, 3j. 4 1 00. M. Sig. — One cubic centimetre to be injected not oftener than two or three times the first weelt. Each cubic centimetre contains three hundred and seventy-one milligrammes of mercury. Calomel stands at the head of the insoluble mercurial prepara- tions. Amyl Nitrite, Nitroglvcebin, and Other Nitrites. C.c. R Amyli nitritis, ... ... . . f^ij. 8 1 00. Sig. — Dose, from two to five minims. FORMULAS. 257 Bartholow says that for subcutaneous injection the amyl nitrite itself should be used as indicated by the above. Commonly this drug is used by inhalations, in doses of from one to five minims, dropped upon the handkerchief or upon absorbent cotton. Instead of the pure drug, which is exceedingly volatile, an alcoholic solu- tion can be prepared for inhalation. It can also be administered by the mouth. Wood recommends to give it in this way on a lump of sugar. Mtroglycerin is most conveniently administered, both hypodermatically and by the mouth, in the form of com- pressed tablets, usually of the strength of one two-hundredth to one one-hundredth of a grain. Spiiit of glonoin, which is sometimes pre- ferred, is a one per cent, alcoholic solution of nitroglycerin. Potas- smm nitrite and sodium nitrite, which may be used for nearly the same purpose as amyl nitrite and nitrogij'cerin, can be given by the mouth in aqueous solution, well diluted, in doses of from two to three grains of the pure drugs. Eegotinin. 5^ Ergotinin, . Acidi lactici, ... Aquae destiUatse, M. Sig. — Five minims equal one thirty-second of a grain. Ergotinin can be administered by the mouth, using a formula hke the above so as to give about one thirtieth of a grain in a teaspoonful. As ergot in some form is often required in neuro- logical practice, it is imj^ortant to be able readily to command its most efficient preparations. Ergotinin is one of the most effective of these. Ergotin is a less definite and less efficient preparation. Kloman extols the physiological and therapeutic action of ergotole as compared with that of ergot, saying that the effect of the drug is more certain and more acceptable to the patient, and the hypo- dermatic use is less irritating and less painful. Ergotole, while nearly three times as strong as the jjharmacopeial fluid extract, and representing all the active ingredients of ergot, has none of its nauseating smell, taste, or irritating properties. Gm et c.c. gr- iij ; 18; gr- f J ; 36; fgj- 30 00. Strychnine Sulphate. Gm. et CO. R Strychninae sulphatis, Aeidi borioi, aa gr. ij ; 0)12; Aquae ohloroformi, f §j • 30 | 00. M. Sig. — Five minims equal one forty-eighth of a grain. Strychnine Nitrate. R Strychninae nitratis, ... Acidi borici, ... Aquae chloroformi, M. Sig. — Five minims equal one forty-eighth of a grain, 17 Gm et c.c. gr- ij ; 12; gr. iij ; 18; fgj- 30 00. 258 NERVOUS DISEASES. Strychnine liypodermatically is useful in peripheral paralyses of toxic, infectious, and other origin, but not infrequently irritation of the subcutaneous tissues and even abscesses result from its use. Usually the best method of preparing the drug for hypodermatic use is simply to dissolve it in water, preferably hot water, but boric acid can be used to render it less irritating. Chloroform water can be substituted for distilled water. Strychnine is a valuable remedy in the treatment of alcoholism and of drug habits in general, having decided virtues in toning the nervous system, in removing, at least for a time, morbid cravings, and in supporting the heart and the respiratory functions during the treatment. Both the sulphate and the nitrate of strychnine can be used in doses of one forty-eighth to one twenty-fourth of a grain, or in some cases even one twelfth of a grain, according to indications. In the treatment of the morphine habit nitrate of strychnine can be administered with morphine, increasing the former and decreasing the latter rapidly, and so regulating the increase and decrease as to reach the maximal dose of strychnine, when the morphine is entirely omitted ; or codeine may be used in decreasing doses instead of the morphine salt. Apomorphine. Gm. et c.c. JJ; Apomorphince hydrochloratiy, . gr. ij ; 12; Aquse destillata?, . . f^j. M. Sig. — Fifteen minims contain one sixteentii of a grain nearly. 30 00. (Bartholow.) Apomorphine, in doses of one tenth of a grain, has been used with success in cutting short hysterical attacks, also instead of mor- phine in breaking up the morphine habit. Elaeomyenchysis. — Corning has recommended the intramuscu- lar injection and congelation of oils in the treatment of chronic local spasm. He holds that by injecting melted oil into a spastic muscle in suf&cient quantity to interfere materially with the blood-flow and metabolism, then solidifying by means of cold, there would result interference with nutrition and curtailment of the action of the muscle, the hardened oil acting as a species of intramuscular splint. He has reported a case of chronic spasm of the splenius muscle in which this method was successfully tried. These injections should be made while the muscle is flexed, to allow of more even distri- bution, and to secure splinting in this position. If necessary, ether may be administered to accomiilish this where we are confronted with S('\'er<^ tonic spasm. The s'-cimd point of importance is the distribution of the oil, which should be made readily through the affected muscle ; moderate massage greatly facilitates this part of the operation. iV needle of large size provided with an ample lumen is necessary for the injection, and the syringe should hold at least half an ounce and should be heated to 110° P. before filling. CHAPTEE III. DISEASES OF THE MEMBRANES, SINtTgES, AND VEINS OF THE BEAIN, AND ENCEPHALIC MALFORMATIONS AND ABEEKATIONS. Associations and Complications. — In considering special dis- eases of the nervous system, difficulties at once arise, and will increase and vary in character as the work proceeds. Diseases of the mem- branes and sinuses of the brain, for example, must be independently treated, and yet their discussion cannot always be separated from that of affections of the scalp, the skull, the organ of hearing, and the brain itself. It will be necessary to refer again, at least inci- dentally, to diseases of the brain envelopes and of the sinuses or great venous bloodways which are found in them. Inflammation of the dura is frequently associated with disease of the ear, or it may be the result or the concomitant of grave blood affections. Sinus throm- bosis also may spring from aural disease, and, like inflammation of the dura, may be associated with inflammation of the pia, and the latter with abscess of either the cerebrum or the cerebellum. One of the varieties of dural inflammation occurs and recurs during the course of general paralysis of the insane. Inflammation of the soft membranes in several of its forms may be conjoined with inflamma- tory disease of the superficial layers of the brain cortex, giving rise to meningoencephalitis. Some chronic encephalic affections, as idiocy, imbecility, and the cerebral palsies of children, can be referred to meningeal hemorrhage or to inflammations of the hard or soft mem- branes of the brain during infancy. Functions of the Dura. — The dura is, next to the skull, the most important protector of the brain. It is supplied with blood from three meningeal arteries, an anterior (predural), a middle (medidural), and a posterior (postdural). The middle meningeal, by far the largest and most important pathologically, is a branch of the internal maxillary. Meningeal hemorrhage is most frequently due to lesion of this vessel. Veins accompany the arteries of the dura, although others, smaller in size, are independent and open into the sinuses. The dural blood supply is full and free. The investigations of Peli as to the relative depth, on each side of the skull, of the sulcus which lodges the middle meningeal arteries are of interest. In the sane, on the left side it was larger in sixty- five per cent, and on the right in twenty-three per cent. ; in the insane, the percentages were fifty- nine and a fifth on the left and twenty-six on the right. The dura undoubtedly possesses an im- 259 260 NERVOUS DISEASES. portant nerve supply, although, strange to say, this has been ques- tioned. Froment, Arnold, Cruveilhier, Bonaniy, and Duret have given the best descriptions of these nerves. Duret has demon- strated that their irritation may produce hyperesthesia, pain, and reflex motor and vasomotor disturbances. These nerves spring from the fifth pair, and are distributed nearer to the internal than to the external surface of the membrane, which explains why some lesions of the dura are more likely than others to lead to spasm. The dif- ference depends, in part at least, on the site and intensity of the lesion with reference to the internal and external aspects of the membrane. Subdural hemorrhage is more likely to give rise to reflex spasms than are extravasations between the membranes and the skull, unless the blood tears through the membrane. A spicule of bone, in like manner, driven into the dura, is more likely to cause reflex dural spasms than a depressed fragment, while a tumor arising in the membrane is more likely to bring about the same result than an exostosis, or a neoplasm growing from the agglutinated mem- branes into the brain substance. Functions of the Pia. — The pia is a delicate membrane, com- posed mainly of bloodvessels and connective tissue ; practically it is a vascular mesh or network. It everywhere closely invests the brain, dipping into its fissures. It differs in function from the dura, not serving to protect the brain ; in fact, not a few of the most serious lesions of the eneephalou originate in or around its vessels, which may be ruptured or occluded, or may constitute the lines along which tuberculous, syphilitic, or other forms of disease are located. Its function is mainly nutritive, the vessels which compose it supplying a large portion of the brain with blood. The vessels lie on the sur- face of the membrane, being covered only by the thin arachnoid, now generally considered as the parietal layer of the pia. They are also encased in perivascular sheaths, constituted of denser i)ortions of the membrane. The i^erivascular spaces thus formed are lymph canals, which penetrate with the vessels into the brain substance and communicate with the subarachnoid spaces or cisterns. In con- sidering lesions of the pia, therefore, the vessels and lymphatics play an important part. The nerve supply of the pia, as of the dura, has been the subject of much investigation and difference of opinion. It is well known that affections of the pia-arachnoid are frequently attended with head i^ain, and yet it is doubtful whether this mem- brane, like the dura, has sensory nerves. In recent years it has been often shown at cerebral operations that this membrane is practically insensitive. The pain of pial disease is probably, therefore, com- monly dependent upon coincident involvement of the nerves of the dura, or of the sensory nerves and ganglia at the base. Nerves, however, have lieeu traced in this membrane by Purkinje, Koelliker, and others, and are in all probability vasomotor in function. They DISEASES OF THE MEMBRANES AND SINUSES OF THE BRAIN. 261 have been shown to originate from the gangliated system, and from the third, fifth, sixth, se\'enth, ninth, tenth, and eleventh ijairs. They accompany the arteries in the membranes and in the brain substance. Following the most recent anatomical aiithorities, in a previous section I ha\'e spoken of the arachnoid as if it were a sepa- rate membrane, but, as suggested by J. Batty Tuke, it would tend to obviate error if the term arachnoid were entirely dispensed with and the visceral and parietal layers of the pia were spoken of as we speak of similar layers of the pleura. The term aruehnopia or pia-arach- noid can be used as a compromise. It must be understood that no membrane exists between the arachnopia and the dura. Pacchionian Granulations. — Pacchionian granulations need to be borne in mind in the discussion of the diseases of the meninges. Inexperienced physicians and students, on first making autopsies, may get mistaken ideas as to the meaning of the appearances pre- sented by them. When superabundant, closely clustered, and of large size, they probably do in many cases indicate chronic patho- logical disturbances. These Pacchionian granulations may appear in at least four places, — on the outside of the dura, on its inner surface, on the arachnopia, and within the superior longitudinal sinus and the parasinoidal spaces or lacs sanguins. They often indent the calvarium, and in rare instances they penetrate it. They are always found in greatest abundance along the median edges of the hemicerebrums. It is generally conceded that these granu- lations are enlargements of the normal villi or tuft-like eleva- tions of the parietal layer of the pia or so-called arachnoid. In the newly born the villi are present, but they do not take the shape of Pacchionian granulations until a few years after birth. When the subarachnoidal space is injected, the fluid will pass into these Pacchionian bodies, and from them into the sinuses and para- sinoidal spaces. While they distend the subdural spaces related to them, they do not penetrate into the general subdural caA'ity. The fluid filters through the villosities into the sinuses and para- sinoidal spaces. These facts throw light on the increase in number and size of these formations in meningeal disease and in all affec- tions which may cause increase of subarachnoidal pressure. In brain tumors, in tubercular meningitis, in chronic alcoholism, and in general paralysis of the insane, these bodies jnay be of hu-ge size and sui^erabundant. Their presence and character should therefore always be noted. Repeated attacks of meningeal hyper- emia probably assist in their development. It is supposed by Browning that when the parasinoidal spaces are present these granulations are not so likely to cause depressions in the skull, because they have free spaces in which to grow. Some clinical symptoms have been attributed to Pacchionian granulations, but only a few can with any positiveness be regarded as due to them. 262 NERVOUS DISEASES. Browning mentions cases where such granulations were near the Gas- serian ganglion and the motor nerves of the eye, causing ocular neu- ralgia and paretic symptoms. Meyer refers various neuralgias to them. Headaches have been attributed to them in some instances, but with doubtful propriety. Possibly they may cause sinus throm- bosis. They sometimes produce little flat elevations of bone along the median line of the crown of the head. Browning refers to a varix of the sinus longitudinalis which he believed developed from the parasinoidal spaces, and quotes a case of Meschede's in which a patient had suffered from epilepsy for thirty years, and after death a varix the size of a beau, which had reduced the bone to paper thickness, was found. Classification of Diseases of the Brain Membranes. — Dis- eases of the brain membranes include (1) affections of the dura ; (2) affections of the pia or arachnopia. Dural diseases include hyper- emia, several forms of inflammation called pdchnmeningitis, hemor- rhage, tumor, and abscess. Diseases of the pia include hyperemia and anemia and various forms of inflammation called leptomenhtffitis. Varieties of Pachymeningitis. — Pachymeningitis is divided into external pachyhieniiu/ltis and internal pachij meningitis. Internal pachymeningitis is subdivided into hemorrhagic, purulent, and serous. In rare cases the entire membrane may be involved in a general pachymeningiti.'i, usually dependent upon a severe traumatism, or a virulent infection, as syphilis. From an etiological standpoint, dural inflammation, like pia], may be variously subdivided. Gussenbaur has reported a case of what he regards as primary circumscribed tubercular pachymeningitis. Although the case followed injury, Gussenbaur rejected the diagnosis of traumatic meningitis, as no symptoms appeared for four weeks, and as, after operation, micro- scopical examination showed, in granulations removed from the dura, miliary tubercles containing giant cells. Among so-called etiological varieties are the traumatic, solar, syphilitic, rheumatic, gouty, alcoholic, and erysi])elatous, and forms of aural and nasal origin. In an old case of secondary dementia following melan- cholia, which had developed facial erysipelas ten days before death, extensi\'c purulent pacliynieiiingitis was found by me associated with leptomeningitis and sinus thrombosis. Leptomeningitis is much more likely to occur with infectious diseases, but these also at times give rise to x>aeliymeningitis. DURAL HYPEREMIA. Dural liyperemia or congestion seldom exists alone, but is some- what frequently associated with either congestion or inflammation of both the inner and outei' membranes and of the brain substance. In the latter case its symptoniatology cannot be differentiated from that of the other parts attacked. It may be actiA'e or passive, acute EXTERNAL PACHYMENINGITIS. 263 or recurrent. The passive forms dependent upon obstruction to the circulation, as by thrombi and growths, are discussed in other con- nections. A form of active pachymeniugeal hyperemia, with abrupt onset and rapid course, occurs in children, usually ending fatally. From the very nature of the affection, the course of any form of dural congestion is likely to be brief. The symptoms are those of the early stages of an acute pachymeningitis, — headache, A'ertigo, nausea, delirium, insomnia, local or general spasms, sense of fulness in the head, and tinnitus. Signs of retinal irritation and pupillary changes are sometimes present. These changes are probably due to irradiation of irritation by dural branches of the trigeminus to the basal ocular nuclei and ner^■e tracts. Dural hyperemia, when an independent affection, is usually due to some locally acting cause, as traumatism or sunstroke. It is difficult and usually impossible to make a positive diagnosis of pachymeniugeal hyperemia, but when the symptoms given above occur abruptly or in a recurrent fashion, and other affections of the brain and its membranes can be excluded with reasonable certainty, the diagnosis may be assumed. The prognosis is relatively favorable, except in the children's affec- tion to which reference has been made. The treatment is the same as that of acute pachymeningitis. EXTERNAL PACHYMENINGITIS. External pachymeningitis is inflammation of the outer layers of the dura. It is rarely, if ever, a primary disease. The most com- mon symptoms are headache, fever with delirium, vertigo, nausea or vomiting, and sometimes local or general spasms. Paralysis or paresis, due either to reflex irritation or to pressure by the puru- lent effusion, has been noted in rare instances. External evidences of injury or of purulent effusion in the ear or in other parts may be present. When suppuration takes place, septic symptoms and those of compression may develop, the patient suffering with fever and delirium, and, if not relieved, perhaps dying in coma. Uncon- sciousness may develop early in se^'cre cases. It is probable that very few of the symptoms of external pachymeningitis are due to the affection of the outer lamina of the dura ; they are rather the evidences of the direct or indirect involvement of other parts, as the soft membranes, the brain, and some of the cranial nerves. A peculiar form of external chronic meningitis is sometimes present in old age, particularly in those who ha^-e led a dissi])ated life or who have been the victims of an infectious disease, as syphilis or tuberculosis. The symptoms in such cases are usually not definite, but dull headache is one of the most common, and is usually asso- ciated with some mental obtuseness and deterioration due largely to senile brain degeneration. As external pachymeningitis is generally a secondary or associated affection, its course and duration must de- 264 NERVOUS DISEASES. pend largely upon its causes, the most important of whicli are trau- matisms, cranial caries, purulent disease of the ear, erysipelas of the face or scalp, and possibly infectious diseases. Sunstroke and heatstroke are occasional causes, especially in hot climates. The diagnosis is made by a consideration of the causative affections and associated conditions. The prognosis is, on the whole, unfavorable, although in the traumatic and other purulent varieties the patient may sometimes be greatly relieAcd or even cured by surgical pro- cedure. The treatment is usually that of the affection giving rise to the pachymeningitis. Trephining for the removal of the pm-u- lent effusion may be effectual. When external pachymeningitis is due to syphilis or any infectious disease, its treatment should be in accordance with these indications. For the pachymeningitis of old age nothing can be done but to support the failing strength of the patient and carefully regulate the functions of the various organs. DUBAL HEMATOMA (HEMORRHAGIC INTERNAL PACHY- MENINGITIS). Definition. — Hemorrhagic internal pachymeningitis or hematoma of the dura is the only form of inflammation of the internal surface of the dura which has been well described ; and even yet the symp- tomatology of this affection has not been defined with great clearness, although many pathological observations have been put on record. This disease reveals itself as a more or less recent, flat, meningeal blood tumor, or as a series of superimposed layers of connective tissue showing evidences of former extravasation. "\V. Be-s-au Lewis strongly inclines to the view that this affection is always, at least among the insane, of hemorrhagic origin, and therefore should not be discussed as a pachymeningitis ; but, as the question is still an open one, it will be best to consider it here among the meningeal inflammations, giving the views which have been held by distin- guished authorities. Clinical History. — Apoplectic seizures may occur in the progress of this disease, although their nature is not commonly recognized. Chronic hemorrhagic pachymeningitis, as an independent affection, gives such symptoms as dull headache, vertigo, usually of the mild type, tendency to somnolence, and paresis, more or less marked, of one or both sides of the body. While the affection is usually bi- lateral, it is generally, e^'en in such cnses. more extensive on the one side than on the other, and hence the paresis produced by compres- sion of the brain usnally predominates in the limbs of one side. The lind)S are more frc(|uciitly henuparetic than the face, which is prob- ably accounted for by the i)ositiou of the lesion. Occasionally con- vulsions, which may Im> unilateral or general, occur at intervals in the progjcss of the disorder. Pupillary contraction, usually on one side, may be present. Nystagmus and optic neuritis are mentioned DUEAL HEMATOMA. 265 as symptoms by some authorities, but I have never met with them in cases which have fallen under my own observation. Conjugate deviation of the eyes and spastic conditions of the limbs are (some- times observed. Fraenkel has I'eported a case which was evidently chronic, but which came under his observation at the time of an apo- plectic seizure. When the patient attempted to turn the eyes to the left a marked nystagmic tremor developed as soon as they reached the median position, which they did not cross. Both knee jerks were exaggerated, with left sided patellar and ankle clonus. The triceps jerks and all bone and muscle reflexes were lively in both arms. Cremaster and abdominal reflexes were abolished. Attempts at straightening the flexed arms caused tetanic spasm with opisthot- onos. Three days after admission (seven from the first complaint) the patient presented spasms of the entire body, with deep coma and grad- ual resolution of rigidity, and disappearance of the patellar and foot clonus, but with lively knee jerk. The pupils reacted until shortly before death, which occurred on the eighth day. The temperature was normal until shortly before death. Difficulty of swallowing existed in the same case. The autopsy showed an immense recent hematoma, with chronic changes in the membranes. The duration and course are important, as they often serve to fix the diagnosis. The disease is essentially chronic, often lasting through years. At intervals apoplectic and inflammatory exacerbations take place, so that the symptoms naturally ari-ange themselves into those of the chronic condition and those of the special attacks. The disease is said to be acute in children who are subjects of hemorrhagic rachitis. The following summary of symptoms is chiefly as given by Hugue- nin, to whom we owe the most elaborate discussion of this disease : (1) the characteristic course shows an acute diffused affection of the brain with severe symptoms, an acute attack, followed by fair recovery, and intervals of comparative health ; (2) evidences of a sudden and increasing compression are headache, drowsiness, loss of consciousness, fever, characteristic pulse, and sometimes violent initial symptoms of irritation ; (3) the symptoms during the inter- val are headache, diminution of intelligence, impairment of memory, drowsiness, partial paralysis, disturbances of speech, and sudden mental excitement without cause, mixed with symptoms of paralytic dementia. Etiology. — This disease occurs most frequently in the aged, in those prematurely senile, or in those broken down by infectious dis- eases or alcoholic excesses. It is of comparatively frequent occur- rence in wards for chronic nervous diseases and among chronic patients in the insane hospitals. Many cases have been discovered in autopsies in the Philadelphia Hospital, most of which were not recognized during life, but had other more readily diagnosticated diseases of the viscera and bloodvessels. Chronic alcoholism, syph- 266 NERVOUS DISEASES. ills, and tuberculosis are important in its etiology. It is not infrequent in general paralysis of the insane, and it is sometimes determined by the existence of diseases which affect the blood, as scurvy, small- pox, and typhus fever. It is chiefly a disease of the male sex. Cranial traumatism may be an exciting cause. Diagnosis. — When the disease is an independent affection of the aged, the diagnosis is much assisted by a consideration of etiology and history. The occurrence of special attacks of an apoplectiform nature and the increase of the symptoms at intervals are helpful. When confronted by the problem of diagnosis at the time of a hem- orrhagic attack, some of the affections which will need to be differ- entiated are intracranial and ventricular hemorrhage. The paralyses due to hemorrhage into the basal ganglia and capsule are usually flaccid, and such cases present peculiarities of temperature, pulse, and respiration which are significant. The longer duration of the symptoms would help to decide against ventricular hemorrhage. Owing to the rigidity present, some cases show a resemblance to tetanus, but the coma or other conditions of impaired consciousness and mentality would contraiudicate this diagnosis. A careful study of the symptoms of the chronic affections given above, especially those which show the progressive character of the disease and its tendency to apoplectic exacerbations, will be suflB.cient to make the diagnosis, if, as is not often the case, the physician has in mind this usually diagnostically neglected disorder. Pathology and Morbid Anatomy. — Two distinct views as to the origin of this disease have been held. As early as 1856, Vir- chow expressed the opinion that the iirimary condition is one of inflammation, which gives rise to a highly vascular neomembrane, from whose newly formed capillaries hemorrhages from time to time take place. The other view is that the hemorrhage is primary. It would seem certain that in some cases, at least, the hemorrhages take place indejtendently of any inflammatory disease. Houssard, in 1817, was the first to show that the lesion was situated Fig. 204. l)etween the inner surface of the dura and what was then known as the outer surface of the arachnoid, — in other words, that it was a true dural disease. In a large majority of cases the lesions of this disease occur on both sides of the brain, very commonly in the same position, over a space which largely corresponds to the parietal bone and the motor region of the brain, pswidomembrnne formed often extending bcvoud thesc limits. As a rule, on the dura nl'tur a Mnall ,-, ' .-,.,,.<• i „ „f hemorrhufu. (oberstc-iner,) the appearance presented IS that ot layeis oi tliin, soft tissue, which vary in color and con- sistency according to the age of the lesion. In recent cases, or in those in which recent hemorrhages have occurred, the blood may be DURAL HEMATOMA. 267 Fig. 205. more or less fresh ; older cases present firmer, denser, and lighter, but pigmented appearances. Sometimes several thin, flat sacs con- taining degenerated blood are found, one aboxe the other. In rare instances abscesses are gradually formed. The conA-olutions of the brain beneath the position of the lesion, particularly if it is old and extensive, are flattened and atrophied. According to Wigles- worth, hematoma may be of venous origin, due U> the imjiaired nutrition of the brain in atrophic and blood diseases. Obersteiner has described and illustrated the two processes by A^-hich the layers characteristic of this affection are formed. In Fig. 204 is shown the false membrane which is left after the absorption of the encapsulated blood resulting from a small hemorrhage from the dural veins into the subdural space, while Fig. 205 represents the organized new membrane which results from a condition of irritation of the inner surface of the dura, and which is probably, according to Olier- steiner, accompanied with emigration of leu- cocytes out of this membrane. Such neomem- branes may be deposited layer upon layer. Prognosis. — As the disease is essentially chronic and progressive, and occurs princi- pally in the aged and broken down in health, the prognosis is unfavorable. Probably, if recognized early, — at the time that the mem- brane begins to form or when the first hem- orrhage takes place, — something could be done by treatment, which should be for the relief of constitutional coiiditions, and per- haps in some instances the direct removal of the clot. When the false membrane has reached considerable dimensions, and after several acute apox)lectic recurrences, the prognosis is unqualifiedly bad. A large hematoma may cause death rapidly. Treatment. — If the disease is recognized during a hemorrhagic attack, treatment calculated to arrest the bleeding, as complete rest, moderate elevation of the head, and cold api^lications, is indicated. Blood maybe abstracted by leeches to the temples or mastoid region. Venesection is commonly not to be resorted to, because of the weak condition of the patients. Diuretics, cathartics, mercury, opium, and bromides may prove of seivice. For the chronic conditions, attention to the habits of the patient, particularly the interdiction of alcohol, and the careful management of the kidneys, heart, and lung complications, are necessary. Eemedies like the iodides and mercury may be tried as absorbents in the intervals between the attacks. Trephining for the removal of the clot has been employed in a few reported instances. Neomembrane of the dura re- sulting from pachymeningitis hemorrhagica. (Obersteiner.) 268 NERVOUS DISEASES. PURULENT INTERNAL PACHYMENINGITIS. Purulent internal pachymeningitis, or suppurative inflammation of the internal surface of the dura, is extremely rare as an inde- pendent affection, but its existence has been noted. Its symptoma- tology is probably that of a subacute stage of hemorrhagic internal pachymeningitis ; in other words, the phenomena are those of dural and pial irritation and brain compression, such as headache, vertigo, vomiting, septic fever, drowsiness, pressure paresis or paralysis, spasms, rigidity, and pupillary changes. Its causes are those of suppurative meningitis of other forms, as aural and nasal disease, purulent pleurisy, endometritis or peritonitis, ulcerative endocar- ditis, carbuncle, cranial injuries, and erysipelas. Commonly puru- lent pachymeningitis is associated with suppurative leptomeningitis, under which head its pathogenesis will be considered. In the case of facial erysipelas referred to on page 262 a carefiil autopsy was made by Drs. Osier, Jamieson, and the writer. As the intracranial lesion was mostly a widespread purulent internal pachymeningitis, and as records of such cases are rare, the notes made at the time of the autopsy will lie given in some iletail, and will ser^e as a descrip- tion of the gross iDathology of this disease. On removal of the skull cap, the external suiface of the dura was found to be normal. Pacchionian granulations were numerous and distinct. In the lon- gitudinal sinus was a recent clot. The inner surface of the dura of the right hemisphere was smooth ; on the left side over the bases of the frontal lobe aud the operculum it showed a grayish semij^urulent exudation. The membrane here was closely adherent in a patch nearly two inches in diameter. Over a greater part of the anterior half of the hemisphere the dura presented a thin, recent, fibrinous exudation, A\'ith many localized s];iots of extravasation. Correspond- ing to the iiatch of solid exudate was an area of thick purulent lymph, covering the pia-arachuoid. The basal dura showed in the anterior fossa recent thin exudation with numerous ecchymoses. In the left middle fossa the dura was covered with a tenacious, dis- tinctly creamy lymph. Stripping the dura from this fossa, an ex- tensive layer of purulent exudation was found beneath it. It was here much more almndant than in the other regions. The longi- tudinal sinus and the right lateral sinus were free from exudation or signs of inflammation. The left lateral sinus along the attachment of the tentorium was closed by a tlirombus. This was loose at the petrous portion where it turned downward and inward. The sinus was completely occluded and contained pus. The fifth nerve and the Gasserian ganglion were partly infiltrated with x>ns, but it did not extend into tlie oi-bit or along the course of the optic nerve. No suppuration was jii'esent in the sphenoidal cells. On the right side was also purulent exudation. The left tympanic mucous membrane DURAL HEMORRHAGE. 269 was swollen and hemorrhagic, but did not contain pus. The brain shoved extensive subarachnoid gelatinous edema of the cortical sulci. The membranes and vessels at the base were normal. Over the anterior margin of the left temporal lobe, extending into the Sylvian fissure and over the posterior portion of the third left frontal convolution, was a layer of thick, curdy, purulent lymph lying upon the arachnopia. At the apex of the temporal lobe in the third temporal convolution was a very small purulent focus. When the Sylvian fissure was fully opened, it was seen that the exudation extended for a short distance into it. Sections of the hemispheres showed no region of focal disease. The lungs were edematous and congested ; the left presented several septic infarcts, one at the an- terior margin containing creamy pus. The spleen was large and contained no infarct. The diagnosis of purulent internal pachy- meningitis must be based largely on a study of causation and the symptoms of pressure, irritation, and sepsis above given. The prognosis is unfavorable. Surgical treatment in rare instances affords some hope. Otherwise the treatment is that of suppurative leptomeningitis, which wall presently be considered. SEROUS INTERNAL PACHYMENINGITIS. Under the name of serous pachymeningitis, Henoch, Gowers, and others have described a rare condition met with in young children and occasionally in general paralytics. This affection is to be dis- tinguished from the serous meningitis in which the effusions are either cortical or ventricular, and which has been best described by Quincke ; but both diseases originate from the same general patho- logical causes. In serous pachymeningitis, as described by Gowers, a membranous layer lines the dura and is continuous at the base with another layer covering the arachnoid, from which it is sepa- rated by a fluid. Such cases have sometimes been described as external hydrocephalus. The microscope may reveal extravasations in the outer layer. Enlargement of the head is present in some cases and absent in others. When, as may be the case, the brain is compressed and atrophied, the patient may show decided evidences of mental deficiency, but commonly cerebral symptoms are few in number. Eedness of the scalp has been noted. Fever of irregular type may be present. Splenic enlargement has been found in children. DURAL HEMORRHAGE. Varieties. — -Under the name of meningeal hemorrhage several varieties of hemorrhage of the dura are described ; the chief of these are known as the supradural or epidural and the subdural. These affections are usually traumatic, and are of great surgical importance. 270 NERVOUS DISEASES. Supradural Hemorrhage. — When tlie extravasation is supra- dural ttie symptoms are chiefly general. Contralateral paralysis, however, may serve as a broad localizing indication when the bleed- ing is over the motor area, if external appearances are wanting. Unilateral affection of the pupil is often a sign of the utmost im- pi )rtance, particularly if one pupil is found widely dilated, the other Ijeing natural or contracted in size, and if the dilatation be on the side of the face corresponding to the injured side of the head. Jon- athan Hutchinson has studied and discussed the importance of this valuable symptoiu, and in honor of him Jacobson proposed to call it the ''Hutchinson pupil." Hutchinson regards the symptoms as due to direct or indirect compression of the third nerve. The pupils also furnish valuable indications as to the probability of recovery. The more dilated, insensitive, and immovable they are, the less favorable is the prognosis. Fig. 206. Sites of the most common Viirieties of meningeal hemorrhages ( from the middle meningeal or medidural artery): /.hematoma, frontotemporal ; II, hematoma, temporoparietal; JJJ, hema- toma, parietooccipital. (Elliot, alter Krijnlein.) Subdural Hemorrhage. — Subdural or intermeningeal hemor- rhage, if cxteiisivo, gives general symptoms much like those -ffhich are pi'e.'^eiit in supradural clot, — namely, loss of consciousness, changes in temperature, in jnilse, and in i-espiration, and vomiting. A sub- dural clot will usually brui.se and possibly will even tear the brain surface. Coitieal as well as dural spasm may be present. Para- DURAL HEMORRHAGE. 271 lytic symptoms will be definite and pronounced, as tlie lesion is in the motor region. Cheyne-Stokes breathing may or may not be present. Mode of Origin and Treatment of Dural Hemorrhages. — Usually both supradural and subdural hemorrhage are due to serious injury ; frequently fracture and hemorrhage are associated, Ijut it is of vital importance to remember that the hemorrhage may occur without fracture, or that the latter may be confined to the internal table of the skull. As a rule, dural hemorrhages, traumatic or of other origin, are from lesions of the middle meningeal (medidural) artery. According to Kronlein, they may be divided, as shown in Fig. 206, into three classes, (1) frontotemxjoral, (2) temporoparietal, and (3) parietooccipital, according to the branches of the middle meningeal artery ruj)tured. The meningeal hemorrhages which so often give rise to the cerebral palsies of children, like those in the adult, are also commonly from branches of the meningeal arteries, and are therefore supradural or subdural, the latter giving rise to the more serious results. (Fig. 207.) In the newborn, or in very Fig. 207. Meningeal hemorrhage in a newborn child. (McNutt.) young children, the usual symptoms of dural hemorrhage may be overlooked, and be noticed only when the child attempts to move its limbs or to talk. Most cases of meningeal hemorrhage due to indirect violence are subdural. The treatment of supradural and of subdural hemorrhage is mainly surgical, and in this field many brilliant results have been achieved, particularly in recent cases. The concurrent testimony of neurologists and surgeons is in favor of early trephining for the removal of the clot. 272 NERVOUS DISEASES. DURAL TUMORS. Very many intracranial tumors grow from tlie pia or from the agglutinated inner and outer membranes, but occasionally neoplasms are limited to the dura in their development and give rise to symp- toms wiiich can be referred almost exclusively to this membrane. Such a case has lieen put on record by me, and a summary of it will serve to present the usual featui'es of this affection. The patient, a man, thirty-two years old, when admitted to the hospital suffered from severe headache, sleeplessness, obstinate constipation, and loss of appetite and flesh. No paialytic symptoms Avere present, and the tendon phenomena were normal. The right pupil was slightly larger and responded to light more slowly than the left. The head pain, located by the patient over the right eye, was of varying intensity, and was always worse at night. In a short time the patient died with uremic symptoms. Eight years before his death he had been rendered unconscious by a blow on the head, and after this he suf- fered for a long time from headache, from which he eventually recovered, remaining free from the symptom until three months before his death. He used alcohol to excess. The autopsy showed an area of thickening of the skull about an inch and a half in diam- eter, beginning one inch above the line of the external meatus, being at this point strongly adherent to a tumor or thickening of the dura. The mass was flat, tough, almost circular, one eighth of an inch in thickness, and whitish yellow in appearance. The dura and pia were agglutinated and adherent to the brain beneath the growth, and both skull and brain were bruised and eroded. The growth was so situated as to cross the fissure of Sylvius over portions of the post- central, subx)arietal, and supertemporal convolutions, its anterior limit being the middle of the latter. The lesion was strictly menin- geal, but in enlarging had slightly invaded both the skull and the brain substance. Subsequent microscopical examination showed the growth to be syphilitic. Dural tumors are most frequently of trau- matic origin. A fibroma may originate in this membrane as the result of a recent or an old injury, or syphilitic infection may be focussed in this way, as in the case just given. Carciuomata, es- pecially the melanotic variety, sarcomata, the psammomata or small calcareous growths, and tuberculous growths may also arise from this membrane. The diagnosis of a tumor limited to the dura is not readily made, which is unfortunate, as such a neoplasm is very amenable to surgical treatment. It might be regarded as fairly determined in a case with a history of injury to the skull giving a symptomatology of severe localized pain, with tenderness on percus- sion in the same area, and with attacks also of vertigo and nausea or vomiting, spasms of diiral type, and unilateral disturbance of the pupil. The affection might be confounded with a localized pachy- LEPTOMENINGEAL HYPEREMIA AND ANEMIA. 273 meningitis, or leptomeningitis with various toxemias. The diag- nosis of dural tumor was made in a case which came under my observation, and which proved to be chronic nephritis, with vas- cular and other changes and uremic phenomena. The prognosis is usually bad. Some of the growths can be successfully removed by trephining, and the syphilomata are amenable to active treat- ment with mercury and iodides. DURAL ABSCESSES. As the result of cranial injury or of infection in any of the various ways already referred to in speaking of purulent pachy- meningitis, a more or less localized supradural or subdural abscess may be formed ; but this affection need not be referred to in this connection further than to say that its diagnosis and treatment are sufficiently considered in the discussion of suppurative meningitis and under intracranial localization and abscess of the brain. DURAL EPILEPSIES. Forms of epilepsy dependent upon dural irritation need to be differentiated from cortical and other forms of convulsive seizure, but this subject will be more fully discussed under ei^ilepsy, and attention is directed to it here merely in order to complete the sur- vey of affections in which the dura plays the chief role. Exiieri- ments upon the lower animals, and especially those made by Dupuy, Brown-Secjuard, Burdon Sanderson, Duret, and Francois Franck, and in 1874 by a committee of the New York Society of Neurology and Electrology, have shown that electrization of the dura pro- duces muscular twitching, usually on the side of the body to which the irritation is applied. During an operation I have seen severe general spasms produced by a faradic current accidentally applied to the dura. I have also recorded cases in which spicules of bone in the dura gave rise to serious chronic epileptiform attacks. A distinct separation cannot always be made between dural and cor- tical epilepsy ; but in the latter the convulsion uniformly begins in the side opposite to the half of the brain that is irritated. In dural epilepsy, and perhaps in other forms of spasm due to trigeminal irritation, the attack frequently begins on the same side as the focus of irritation, but unfortunately this distinction is not radical, as the convulsions may begin on either side. Definite signal or initial symptoms are usually wanting in dural cases, one-half of the body instantly plunging into spasms. LEPTOMENINGEAL HYPEREMIA AND ANEMIA. Cerebral anemia, or congestion of the brain, has always been a favorite diagnosis with some practitioners ; and yet the occurrence of the disease as an independent affection has been doubted. It has a real existence, but is not so frequent as was once supposed. 18 274 NERVOUS DISEASES. Hyperemia of the brain, for anatomical reasons, is largely hyperemia of its soft membranes — the arachnopia. The pial vessels ramify everywhere over the surface of the brain, covering the crests of the convolutions, dipping into the fissures and threading their intricate windings and l^ranchings, and, entering the cortex, passing as nearly straight vessels into the interior of the brain. Even the central or ganglionic system first takes its way through the membranes in cer- tain areas at the base of the brain. Membranes and brain substance take part together in congestion, as in anemia. All encephalic anemia or hyperemia is, therefore, als<:» meningeal — that is, meningo- encephalic — and chiefly cortical, as the arteries become smaller and practically do not anastomose in the interior of the brain. In the light of these facts, and as the varieties, clinical history, etiology, pathology, diagnosis, prognosis, and treatment of hyperemia and anemia of the membranes cannot be separated from those of the brain substance, they will be considered under diseases of the brain itself. EXTERNAL LEPTOMENINGITIS (so-called ARACHNITIS). Some of the older writers describe arachnitis as an independent disease ; others confuse under that name varieties of what are now known as leptomeningitis and pachymeningitis. Certainly a pure arachnitis cannot be recognized through a definite symptomatology. If, as has been suggested, the arachnoid is not regarded as a separate membrane, but simply as the parietal layer of the pia, then an in- flammatory affection of this membrane might perhaps be better spoken of as an exiernul leptomeniiu/itis. L. Meyer found epithelial products on the superior surface of this layer or membrane in chronic cerebral irritation. The enlargements and increase in the Pacchio- nian granulations in drinkers, in epileptics, and in the insane may perhaps be regarded as disease of this layer. In newly born infants hemorrhages of the pia or brain cause imbibition of blood by the so-called arachnoid ; and opacities and thickenings from repeated congestion are usually met with in old age. In a large number of autopsies made in Vienna upon suicides, considerable arachnoidal hypertrophy was noted. (Eoseutlial.) Small disseminated white patches rif thickened arachnoid may be scattered over the whole brain couA'exity, especially in idiots. (Ober stein er.) LEPTOMENINGITIS. Method of Discussion, and Varieties. — How best to discuss leptomeningitis is a question that confronts the medical teacher and writer. Aulliors differ much in their ways of handling the suljjcct. Some, like Hugucnin, take many pages for the separate consideration of various forms of the disease. A common method of recent textbooks is to subdivide it into purulent or suppura- tive leptomeningitis, tubercular leptomeningitis, and epidemic cere- LEPTOMENINGITIS. 275 brospinal meningitis. Some treat tlie entire subject under one head, not even excepting the epidemic cerebrospinal form. All forms of encephalic leptomeningitis will be included here in one general class, special paragraphs being devoted to the clinical his- tory of particular etiological varieties, when these are stamped with peculiarities allowing them to be differentiated. In the first place, acute and chronic leptomeningitis or inflammation of the arachno- pia must be recognized. Acute leptomeningitis includes a number of special varieties, as purulent or sup2)ur((tive, non-pundcnt, usually infantile, serous, tubercular, and epidemic ccrcbrospimd. The sympto- matology is more determined by localization than by the pathology or etiology of the disease, and for this reason it is advisable to have especial regard to the situation and diffusion of the lesions. Leptomeningitis, therefm-e, from this point of view, may be basi- lar, when the base of the brain is solely or chiefly affected ; vertic- alar (Barr), when the convexity is the region chiefly invaded ; or general, when all the surfaces of the brain are attacked with some approach to uniformity. Leptomeningitis either of the base or of the convexity may also show a tendency to occur with most severity in special localities, as in the cervico-oblongatal region, or in and around the Sylvian fossa. The term idiopathic is sometimes applied to forms of meningitis, but it should be discarded. Here, as elsewhere, the term is generally a cloak for ignorance. Many etiological varieties of leptomeningitis might be erected, but it is preferable to consider these, with the exception of the tubercular and syphilitic forms, under general etiology. General Symptoms Common to all Types of Acute Lepto- meningitis. — All forms of intracranial leptomeningitis may have certain symptoms, both general and local, — the former dependent upon the fact that the brain meninges are involved, and the latter upon the special meningocortical areas which are invaded. Accord- ing to the etiological and other varieties of the meningitis, however, the symptoms will differ somewhat, but always within a certain range. All forms of pial inflammation give rise to headache, and this, on the whole, is one of the most constant phenomena ; but even this well accredited symptom is not necessarily present in every case ; certainly it is not present in every stage of the disease. Its presence and severity are probably dependent upon the extent of the lesion, and sometimes upon its situation. The pia and brain substance, xmlike the dura, are poorly, if at all, supplied by sensory nerves. When both the dura and the pia are attacked with inflammation, or when the G-asserian ganglion and the fifth nerve at the base are involved, as they frequently are, pain in the head is likely to be of great severity. Great increase of intracranial tension probably also gives rise to pain. In a case seen by me with Dr. W. H. Eihl, of Philadelphia, the patient being a man twenty-eight years old, no 276 NERVOUS DISEASES. headaclie was present during his illness, whicli lasted several weeks ; the auto^jsy showed disease over a considerable area of the motor convexity and the niesal surface of the hemisphere. I have made autopsies in several other cases of convexity meningitis in which no history of headache was present. The truth about headache and localized head pains may be summed up in the statement that they are symptoms of frequent but not of constant occurrence. Pain and hyperesthesia of the head and face and of other parts of the body may be produced by irritation of cortical sensory areas. Peculiar mental changes are common, and are sometimes determined by the special regions involved, as the prefrontal lobe ; but they are more frequently due to general irritation and pressure. They may be irri- tability, peevishness, restlessness, delirium, or maniacal excitement, or, on the other hand, depression, moodiness, obtuseness, somnolence, apathy, stupor, or coma. These symptoms of disturbed mental action differ much in different stages of the disease. In the prodromal periods of protracted cases the irritative symptoms predominate ; in the middle and later stages, those of depression. Optic neuritis, either single or double, may also be present, but it may be absent in any type. Vertigo is a symptom in a fair percentage of cases. Nausea and vomiting, like vertigo, may be present or absent in leptomeningitis, although these are rather constant phenomena in acute inflammations of the dura. Changes in temperature, j)ulse, and respiration belong to all types of acute leptomeningitis ; but they differ much in character in different varieties, and even in different cases of the same variety. The temperature may be greatly or moderately elevated, or even sometimes depressed. In one of my cases of tubercular leptomeningitis in a child, the temperature during the entire period of the disease ranged between 97° P. aud 99.7° P., but I have known it to range throughout between 101.2° P. and 107° P. The pulse may be slow, irregular, and intermittent, or very frequent ; it seldom becomes wiry. Eespiration is often strikingly affected, Cheyne-Stokes breathing being common as the disease progresses to a fatal termination. Symptoms of Basilar Leptomeningitis. — Any of the patho- logical or etiological varieties of leptomeningitis may be limited to the base of the brain. Th(^ symptoms presented by a case of acute basilar leptomeningitis will depeiid upon its diffusion and intensity. When severe and widespread, all or nearly all of the cranial nerves may be involved, giving affections of smell, sight, hearing, and taste, A'arious forms of stralusmus from iiaralysis of the ocular muscles, or facial, trigeminal, spinal accessory, or lingual paralysis. Spastic affections of the muscles supplied by any of the motor cranial nerves and affections of any of tli(> sensory cranial nerves may also be l)rcsent. Occasionally a severe trifacial neuralgia is due to a local- ized meningitis at the base of the brain and in the vicinity of the LEPTOMENINGITIS. 277 Gasserian ganglion. The ocular and facial muscles are specially likely to suffer, because of the tendeuey to coucentratiou of the inflammation near the origin of the nerves which suj)ply these muscles. Affections of taste and smell may be due to the spreading of purulent inflammation to the cortical olfactory tracts and centres, as well as to involvement of these ner\es of special sense. Tem- perature changes may be present, due to invasion of heat centres in the pons and in the vicinity of the tuber, and polypnea or rapid breathing may be a symptom from involvement of the latter region. (Ott.) Forms of alternating hemiplegia or hemipaiesis may be caused by implication of the cranial nerves on one side and pressure on the motor tracts supplying the limbs of the othei' half of the body. Optic neuritis is a frequent symptom, and deafness with signs of auditory neuritis is infrequent. Eetraction of the head and tetanoid symptoms may be present in almost any case, but are more commonly found when the region of the oblongata is specially attacked. Gee and Barlow have described a form of basal menin- gitis which usually occurs in children under two years old, and which has special features g■i^'ing it diagnostic importance. It is probably, at times at least, tubercular. The most common symp- tom is cervical opisthotonos ; other symptoms, also common to different varieties of leptomeningitis, are fever, vomiting, rigidity, local or general spasm, and hydrocephalus, which is supposed to be due to the closure of the ventricular cavities by the gluing together of the cerebellum and the oblongata. Symptoms of Leptomeningitis of the Convexity. — Any of the varieties of leptomeningitis may attack the convex surface as well as the base of the brain. In convexity or verticalar meningitis cranial nerve symptoms will of course be absent, unless the process at the same time attacks a spot here and there at the base, as some- times happens. As inflammation occurs most frequently over the motor cortex, the predominating symptoms will be motor, such as paresis or paralysis of face or limbs, motor aphasia, usually partial, and spasms, often unilateral, or beginning unilaterally and becoming general, and showing themselves clearly to be of cortical type. Occasionally the primary cortical visual centres are involved, giving hemianopsia or sector defects, or various irritative visual phenom- ena, such as phosphenes, color vision, and hallucinations of sight. "Word blindness and letter blindness, usually partial, are observed in rare cases, as are also word hearing defects or irritative auditory phenomena. Mental symptoms are nearly always present, and will vary with the intensity of the lesion in special localities. When the prefrontal lobes are specially affected, hebetude, inattention, moroseness, and apathy may be present. Delirium is a more fre- quent and pronounced symptom than in the basilar form, while optic neuritis is decidedly rarer. 278 NERVOUS DISEASES. Acute Purulent Leptomeningitis. — The statement has been made that all leptomeningitis is purulent, but in serous menin- gitis pus is not i^reseut, at least not to the naked eye. It is prob- able that occasionally a true leptomeningitis does not pass beyond the early nonsuppurative stage, the disease aborting or the patient succumbing to the toxic influence, which at the same time that it initiated a meningeal inflammatory process overwhelmed the cen- ti-al nervous system. This may be the explanation of those cases which present during life striking symptoms of meningitis, but which show slight or no evidences of inflammation of the mem- branes after death. Some forms of acute delirious mania have been supposed, on rather uncertain grounds, to be due to a rapidly developed leptomeningitis, but it is more probable that these cases are dependent upon a general toxemia which affects the entire brain and perhaps in some instances the entire nervous system. The general symptoms which have been given as common to all types of leptomeningitis, with the paiagraphs describing the disease of the convexity and of the base, may be regarded as a clinical picture of an average case of purulent leptomeningitis. It only needs to be said that in the purulent as in other forms of leptomeningitis great variations in symptoms are observed. It may begin abruptly and run a rapid course to death. This is particularlj' true in cases asso- ciated with abscesses of the brain or with extensive suppurative disease of the cranial bones. As a rule, the affection is more or less prolonged, and in rare instances but a few symptoms are present. Latent cases may depend upon the fact that tlie greatest virulence of the disease is not expended upon regions that give rise to active symptoms, but on more latent cereliral zones, as the prefrontal or the right temporal lobes, or the cerebellar hemispheres. Serous Meningitis. — Under the name of serous meningitis (menhifjUis seros(^) Quincke has described an aft'ection which he be- lieves to occur frecjuently, which is to be distinguished from all the other forms of meningeal inflammation. The inflammation of the membrane results in serous effusions, both cortical and ventricular. (Some cases come on rapidlv, some slowly ; some are acute, others chronic. Fe\-ei' is usually slight, or may be absent or unnoticed. When present it is of iri'cgular type. Head pain and retraction of the n«',k are not infrequently absent. Mental changes may occur, but are not commonly so d(H'ideil in character as in other types of le])tomeningitis. Other symptoms often present are insomnia, joint pains, delirium, local palsies, vomiting, slow and irregular pulse; in rare cases there are une(iual pupils, epileptiform convulsions, and optic neuritis with secondary atrophy. The disease is one of child- hood and youth. Tlie diagnosis of the acute form is to be made chiefly from suppurative and tubercular meningitis, which can be done by close comparis( m with the symptomatology of these affections. LEPTOMENINGITIS. 279 Prom suppurative meningitis two of the most important diagnostic distinctions are the less marked fever and the more frequent pres- ence of choked disks. In the serous form the symptomatology is of milder type and more variable in character. It is almost impossi- ble in some cases to distinguish the disease from tubercular menin- gitis. In serous meningitis the temperature is practically normal. Huguenin treats at length of an acute nontubercular infantile lep- tomeningitis, an afiection which has been described as acute non- tubercular hydrocephalus. He believes the hydrocephalus to be of inflammatory or at least of hyperemic origin. Quincke's descrip- tion of serous meningitis applies in some particulars to this form of infantile leptomeningitis, which may therefore be regarded as one of the forms of serous meningitis. Effusions may occur in these cases in a variety of ways, as by fluxions to the brain and pia ; in connection with general dropsy, particularly in such diseases as scarlet fever ; in the so-called marasmic disorders ; with neoplasms, abscesses, and other focal lesions ; and in venous stases from disease of the lungs or of the heart, and with obstructive deformities. This affection may come on in children previously healthy, or it may follow infectious diseases, diarrhea, injury, or any depressing or deteriorating influences. In many of the cases examined post mor- tem no macroscopic purulent appearances have been found. The symptomatology differs but little, and in some cases not at all, from that of tubercular leptomeningitis. A prodromic or at least a long prodromic period is not as likely to occur as in the tubercular form. In rare instances the disease is fulminant, arising with great sudden- ness and violence, as with severe general convulsions. The first stage is not long ; slight fever may be present at the onset ; severe convulsions are somewhat common ; headache, restlessness, moaning, delirium, moroseness, vomiting, constipation, twitchings, hyijeres- thesia, photophobia, and sensitiveness to sounds are frequent. The symptoms differ somewhat according to the age of the child. Head- ache will be complained of l>y older children, who also early in the disease may not be able to stand or walk. Spasm of the glottis may be present. Sometimes the patient dies in a few days after gen- eral convulsions. If the child survi^-es such convulsive attacks, the symptoms above described will be generally aggravated, and others vill be added, as the hydrocephalic cry and abnormal reactions of the pupils. The pulse, respiration, and temperature may show great variations ; a pulse abnormally slow may rise in frequency with great rapidity, and the same is practically true of temperature and respiration. Vomiting may be severe and persistent. As a rule, the patient sinks gradually into coma, but occasionally recovery takes place. This may not be perfect, the commonest symptom ■which remains being hydrocephalus. The duration is variable, death coming on in some cases in a few hours or a day, but ordi- 280 NERVOUS DISEASES. narily the disease lasts from ten to thirty days. While the above is a sketch of the disease as it usually occurs, the symptoms, as in tubercular leptomeningitis, may differ widely from this picture. Acute Tubercular Leptomeningitis. — Tubercular meningitis as it occurs in children is one of the best known intracranial dis- eases. In some textbooks the descriptions would seem to indicate that it is invariably a disease of childhood ; but it may occur at any age, in either acute or chronic form. In one of my cases, a man sixty- five years old, who had an internal pachymeningitis of one hemi- sphere, miliary tubercles were scattered over the postfrontal and parietal lobes of the other hemispheres, and there were also several foci of superficial softening caused by tubercular obliterations of small vessels. Both lungs were infiltrated with miliary tubercles. Similar cases in the aged are seen with comparative frequency in the postmortem examinations made at the Philadelphia Hospital. Cases of tubercular leptomeningitis verified by autopsies have been observed by me at all ages from a few months to seventy years. Eelatively, however, the disease is less common after middle life. Experience would seem to confirm the view, long held, that the form of tubercular meningitis which occurs in early childhood is usually basilar, or rather that the lesions largely predominate at the base of the brain. It is customary to study acute and subacute tubercular meningitis as occurring in more or less definite stages ; but, while this has some practical advantages and is borne out to a fair degree by the facts, these stages frequently cannot be separated. One of these subdivisions, which can bring the greatest number of clinical facts to its support, is into (1) a prodromal or invasional period ; (2) a period of irritation ; (3) a i^eriod of depression ; and (4) a terminal period. Invasion symptoms are emaciation, gastro-intestinal disturb- ances, such as anorexia, nausea, vomiting, diarrhea or constipation, vertigo, fever, usually of moderate degree, sleeplessness or unusual drowsiness, irritability, restlessness, peevishness, languor, apathy, aphasia, general convulsions, and hysterical attacks, although the last are not common. In the early period or irritative stage of the fully developed disease the most common symptoms are head- ache, fever of irregular type, constipation, tache cerehrale, local spixsms or general convulsions, paresis or paralysis of cranial nerves, particularly of the ocular and facial nerves, sometimes paralysis of the extremities, and spastic phenomenal varying according as the motor couA-exity or the base is involved. Besides the taclie eke- bralc, or tachr mfningiliiiiie, which is a red line made by passing the finger over the skin, various cutaneous eruptions are often observed, as erytliema, herpes labialis, and urticaria-like eruptions. In one case seen 1)y me, a peculiar odor was given off like that from the cutaneous glands. Other symptoms are flushings, retraction of the head and neck, and opisthotonos ; sinking of the abdomen, occa- LEPTOMENINGITIS. 281 sionally followed by tympanites ; nodding, side to side, and rotary movements of the head ; nystagmus and pupillary changes, more commonly dilatation, but sometimes contraction, and often differ- ences on the two sides ; and occasionally great thirst. Deep seated or superficial tenderness may be noticed, and this, which is also sometimes present in cases of epidemic cerebrospinal meningitis, may be due to the concurrence of neuritis with the meningitis. In one case pressure along the femur seemed to cause much i)ain. Coldness in the extremities and difficulty in swallowing are occasion- ally observed. The symptoms just given are those of what might be termed the fully formed disease in its usual type, and include those of the period of irritation and, in part, those of the stage of depression. In the fourth or terminal period, many of the symptoms already described are added to or become intensified or aggravated ; paresis deepens into paralysis ; local or general spasms occur with greater frequency ; indifference becomes apathy , and apathy stuj^or ; respirations become irregular, and finally breathing is of the Oh'eyne- Stokes variety ; emaciation is extreme, evacuations are involuntary, and temperature changes, like those of the pulse, are very marked. Tubercular Cerebrospinal Meningitis. — Cerebrospinal menin- gitis is occasionally of tubercular origin and has some clinical interest. Cases have been put on record by Magnan, Hayem, Liouville, Shaw, Moxon, Debove, Galliaux, and Eskridge. The case recorded by Esk- ridge was seen and studied by the writer in consultation. The post mortem and the microscopical examination made by Dr. L. Brewer Hall showed tubercles ijresent chiefly in the membranes of the spinal cord, less abundantly in the meninges of the brain, and in slight degree in the lungs. The bodies and horns of the ventricles were enormously dilated. Although tubercular deposits were re- vealed by the microscope, they were not detected by macroscopic examination. Usually in cerebrospinal meningitis the deposit takes place first and is most abundant in the membranes of the brain, but in rare instances, as in the al)ove case, this order of events is reversed. Debove has also recorded a case in which the primary lesion was spinal, the patient being a man twenty-nine years old, who was suffering from pulmonary phthisis. The point has been made that cases of this kind should not be classed as tubercular cerebrospinal meningitis, but rather as instances of general tubercu- losis, with accidental or special tubercular deposits occurring in the encephalic and spinal membranes ; but such a criticism has little force, as in most cases of tubercular meningitis some involvement of other organs will be found. The etiology, pathology, prognosis, and treatment of tubercular cerebrospinal meningitis are practically the same as those of tubercular meningitis of any form. The symp- tomatology will vary according to the absolute and relative extent and severity of the lesions which exist within the spine and within 282 NERVOUS DISEASES. the cranium. lu the case reported by Eskridge, the patient, sixteen mouths old, was taken sick with fever, headache, tossing of the head from side to side, with a temperature of 103° F., pulse 150, respiration 84, and tetanic convulsions, with some im^DOsed clonic movements and rigidity of the limbs. The fever was decidedly paroxysmal in type. C'heyne-Stokes respiration was sometimes present. Eetraction of the head and choreiform movements of the head and neck were prominent symptoms. The child was at times passionate and almost maniacal. For short intervals it was more conscious and rational and suffered much less than during the ordinary course of the affection. Stomach irritability and diarrhea were present. Late in tlie disease the child suffered terribly with head pains, and had severe attacks of convulsions with opisthotonos, and irregular clonic spasms, rigidity, and contractures. The duration of the case was eight months. Some of the most important conclusions drawn by Eskridge are, that tuljercular deposit may first take place in the meninges of the cord, and then extend to those of the brain, although the reverse is the rule ; that tubercular cerebrospinal meningitis gives rise to special sj^mptoms, and by a careful analysis of a nmuber of cases it may be recognized ; and that it is also probable that many cases of so-called cerebrospinal meningitis that have a duration of several months and then prove Fig. 208. fatal are tubercular in character. Acute Hydrocephalus. — It will be seen from the preceding paragraphs that one of the com- monest results of acute meningitis of various types is effusion into the ventricles, with great disten- tion of these chambers, while effu- sion beneath the arachnopia also occurs, but with less frequency. This gives rise to hydrocephalus or dropsy of the brain, which is called internal when ventricular, and external when subpial. The term aente hydrocephalus has been somewhat confusingly employed in textbooks. Sometimes it is dis- cussed as the name of a special affection ; often it is used as a synonym for tubercular menin- gitis. Both of these usages may lead to error, as hj'drocephalus is always a i-esult of some pathological process, and as tubercular meningitis may be present without hydrocephalus. Sometimes even \ Hydrocephalus in a case cil' subacute tuber- cular mening-itis. LEPTOMENINGITIS. 283 in the acute cases hydrocephalus is iu part or altogether me- chanical, as when the forameu of Magendie is closed by adhesion between the cerebellum and the oblongata, in Gee and Barlow's oblongatal form of meningitis. It is supposed that in rare eases an inflammation of the ependyma or lining membrane of the ventri- cles, a so-called epcnihjmitis, gives rise to ventricular effusion. The appearance of the head and face in a case of hydriicei)halus asso- ciated with subacute tubercular meningitis is sho\\'n in Pig. 1*()S. Dr. Eobert Whytt, of Edinburgh, in 170S, in describing the most common form of acute hydrocephalus, first directed attention to the connection of this affection with acute inflammation of the meninges. Later it was shown that the membranes were usually the seat of tubercular deposits. Epidemic Cerebrospinal Meningitis. — Usually in works on neurology and general medicine cerebrospinal meningitis is dis- cussed separately ; but, while this plan has its advantages, no good reason exists for not considering the disease under the general head of meningitis or leptomeningitis, except its Si)ecial importance as an endemic or an epidemic. Its lesions are similar to those of sup- purative meningitis of other types, and its pathdgenesis shows the presence of the same microorganisms, although some of these, and especialty the pneumococcus, play a predominant part in epidemic cerebrospinal meningitis. This disease has been known in an en- demic or an epidemic form for centuries, although in former times, according to Stille, it was generally confounded with typhus. It wiis not recognized as a special disease until the beginning of the present Fig. 209. Convulsion in a case of cerebrospinal meningitis. (J. Lewis Smith.) century ; its literature has since become voluminous, and the bac- teriological investigations of recent years have given a new stim- ulus to its study. While usually endemic or epidemic, it occa- sionally occurs sporadically. As Stille says, no other disease wears 284 NEEVOXJS DISEASES. sucli various masks of symptoms. Marked prodromes are often absent, but ^\'ben preseut they are sucli as general malaise, head- ache, and pains in the limbs. These may last an hour or two, or in rarer instances from one to twction, although a chronic low grade leptomeningitis, as shown by IJevan Lewis and Batty Take, may doubtless be developed in this way. Occasionally cases which ap- licar to 1)0 clearly instances of a meningeal inflammation occur in overworked a-nd ()\'erworried school children, and in adults engaged ill liard and embarrassing pursuits, but doubtless in most of these cases the exi)]anation is to be sought in tlu^ reduction of the sys- tem, which allows an infection to do its work. The special causes LEPTOMENINGITIS. 287 of serous meningitis, as given by Quincke, are acute and chronic alcoholism, injuries, excessive mental effort, and acute infectious diseases, although he does not believe in its bacterial origin. Tu- bercular meningitis is, of course, due to the presence of the tubercle bacillus, but many general reducing causes may lead to the de\'el- opmeut of the tuberculosis, as heredity, poor food, bad hygienic surroundings, and especially overcrowding. Epidemic cerebro- spinal meningitis most frequently occurs in winter or spring, and, like other forms of meningeal inflammation, attacks those who are crowded together and are lining in general under bad hygienic sur- roundings. It occurs in country districts, and here probably as much because of bad sanitation as for other reasons. The causative influence of climate and that of miasmatic conditions have not been established. The disease is probably not contagious, or, if contagi- ous, is so to a slight degree only. Purulent meningitis may occur at any age, and the sexes show but little difference. Tuljercular meningitis is most frequent in children and young adults, who are also most frequently the v^ictims of cerebrospinal meningitis, which has occurred in children less than six months old ; it may, how- ever, attack persons of any age. Statistics with reference to sex are so uncertain that nothing positive can be said about this factoi'. Pathogenesis. — The cerebrospinal membranes form a remark- ably favorable breeding place for bacteria. (Putnam.) The micro- organisms which give rise to purulent leptomeningitis are of several Fig. 210. b I'i^/Slf d Wjc^S: ^ f.*(y,. jK Some of the microorganisms of leptomeningitis ; a, staphylococcus pyogenes aureus ; 6, streptococcus pyogenes ; c.pneumococcus or micrococcus Ian ceolatus; tl, bacillus tubercu- losis. kinds, and include the streptococcus pyogenes, the staphylococcirs pyogenes aureus, the intracellular diplococcus of Weichselbaum, and the pneumococcus or micrococcus lanceolatus. Tubercular lep- tomeningitis originates from the tubercle bacillus, which may find its way to the membranes of the brain from diseased glands, joints, and bones, lungs, intestines, or any other tissues or organs. All recent investigators are agreed that the pneumococciis is the microorganism most frequently present in epidemic cerebrospinal meningitis. It has been estimated that from eighty to a hundred per cent, of healthy people carry about in their mouths this microbe, a fact which makes it unnecessary to search for the cause of the disease in air. soil, or water. These micrococci are most frequently carried from the mouth 288 NERVOUS DISEASES. into the intestinal tract and tlience into the blood current. (Plexner and Barker.) A moment's consideration will show that in many of the al)ove cases septicemia is the real cause of the meningitis, as when it develops in connection with various purulent diseases, disorganizing clots or thrombi, caseating glands, endocarditis, or phlebitis. The symptoms in leptomeningitis are partly due to the exudation, partly to the irritation of the sensitive membranes by the micrococci, and partly to the absorption of their toxic products. (Putnam. ) Pathological Anatomy Common to all Types of Leptomen- ingitis. — The macroscopic appearances vary, in any form of lepto- meningitis, with the stage of disease at which death occurs. As this fatal termination is usually after exudation and supf)uration have taken place, the changes are, as a rule, of striking character. An inflammatory process may have been initiated in the arachnopia by the infection, death resulting very early from an overwhelming toxemia, and therefore few gross appearances are present, and these are usually those of intense hyperemia of the swollen tissues, vary- ing from a widespread vivid redness to scattered patches of greater or less intensity of coloration. It may be correct to regard such cases as instances of inflammation without exudation, although the fatal result must not be attributed to the meningitis, but to the toxemia. Even in cases where cultures show the presence of the microorganisms which usually give rise to the meningitis, no gross appearances may be observed. In a case seen by me, the patient dying with symptoms of acute delirious mania, the membranes showed no macroscopic changes, but cultures made from the cere- brospinal fluid revealed the pueumococcus, and the staphylococcus aureus and albus. Certain appearances are common to all varieties except the pure serous form of the disease. These are areas of redness scattered over the surface, opacities most marked over the basal subarachnoid spaces, along great vessels, and over the fissures, and exudates of lymph and collections of pus here and there or diffused over very large surfaces. Occasionally, in old cases, casea- tion or some other form of tissue degeneration takes place. The exudate may be in points or in spots ; more commonly it is in iso- lated or in imperfectly united areas of irregular shape. The velum interpositum and the choroid plexus may show decided changes, even of a puriilent character. Pus, wherever found, varies from a white or whitish yellow to a greenish color. The ventricles are frequently but not invarial)ly dilated, the dilatation which causes an acute hydrocephahTs being more constant in the tubercular than in otlicr varieties, excojit the serous meningitis of noutubercular origin. With less frequency the fluid in the spaces beneath the arachnopia is also increased. The fluid in either locality is not in- frequently turbid from the presence of lymph. Occasionally an in- LEPTOMENINGITIS. 289 flammatory or a granular appearance of the ependyma is observed. The appearances, even in advanced cases, vary, of course, with the localization and diffusion of the lesion. Vertica- lar or convexity leptomeningitis shows the most Fig. 211. striking changes over the motor cortex and around the Sylvian fossa, but fibrinous exudate or pus may be seen anywhere on the lateral or mesal aspect of the hemicerebrum, or on the basal tem- porooccipital cortex. Meningitis occurring here probably should be classed with convexity menin- gitis rather than with the basilar form, which attacks chiefly the central regions of the base. ^'^ '^'^"™ " """"^ °^ T1.1,, ..,.,, .. -, tubercular meningitis. In basilar leptomeningitis the opacities, deposits, (otereteiner.) exudates, and pus involve the A-arious cranial nerves and vessels, and are often especially marked in the inter- peduncular space at the beginning of the Sylvian fissure and over the pons and the oblongata. Lesions in Special Varieties of Leptomeningitis. — In the serous varieties of leptomeningitis the fluid may be turbid, and is probably often of parasitic origin ; Quincke believes that the ven- tricular effusion, which is usually clear, is only exceptionally due to infection. He compares it to the effusion that occurs in angioneu- rotic edema and the intermittent type of joint affections. As Gowers has put it, it is important to remember that meningeal tubercle and tubercular meningitis are not quite identical, as in general tuber- culosis tubercles may be found in the membranes without signs of inflammation, and yet these may cause considerable cerebral disturb- ance. In tubercular leptomeningitis, while the macroscopic appear- ances are, as a rule, well marked, the microscope may sometimes be required to decide as to the nature of the lesion. This was true in part of one of the cases reported by Dr. Ott and the writer, and also of Eskridge's case of tubercular cerebrospinal meningitis. At the autopsy in the latter case, tubercles could not be detected by the naked eye by either the reporter or myself, and no exudate was any- where present ; but an expert microscopist, who knew nothing of the case, found tubercles in several of the organs examined, including the brain membranes. In another case, recorded by Galliaux, which was determined microscopically to be tubercular cerebrospinal men- ingitis, the membranes presented nearly their normal appearance. In tubercular leptomeningitis the most marked appearances are usually present at the base, especially in children. Miliary tuber- cles may be widely diffused or distributed in many foci. Often the exudate has a jelly-like appearance ; at other times it is purulent : great variations are shown, according to the stage of the process. Miliary tubercles are usually minute grayish white nodules, although they sometimes attain a considerable size and may occasionally be so 19 290 NERVOUS DISEASES. clustered together as to form a tubercular mass or tumor ; and vessels may be obliterated by their pressure, spots of softening being pro- duced in this way. The optic nerve sheaths are often distended. The convolutions may be flattened by intraventricular pressure, or more rarely by subpial fluid or by exudation. The vessel walls are sometimes crowded with leucocytes. Thrombosis even of large arte- ries occasionally takes place, as in a case recorded by Angel Money, in which a large branch of the right middle cerebral artery was occluded and caused a hemiplegia. This should be remembered when looking for an explanation of some of the cases of complete or nearly complete hemiplegia occurring suddenly in the course of the disease. Even sinus thrombosis may be present, and tubercular deposits may be found on the internal surface of the dura. In nearly all cases tubercular disease is found in other organs, very commonly in the lungs, the spleen, the mesenteric glands, and the intestines. Microscopic examination shows the membranes thick- ened by an increase of fibrous tissue, infiltration of rounded cells forming pyriform masses around the vessels as they dij) down into the cortex ; and on the larger vessels of the pia, ovoid masses which do not encroach on the calibre of the tubes. These deposits and the thickened membrane take the stain more readily than do the healthier parts. Goodall has recorded some original observations on the changes that take place in tubercular leptomeningitis. He found in the cortex, just under the meninges, very small round cells which gave off many fine processes, forming a meshwork with neigh- boring cells. These cells or some of their processes reached the meninges and explained the adherence of the pia to the brain. The processes could not be traced deeper than the third cortical layer. The minute vessels Avere dilated. In many specimens the nerve cells of the second and third layers were stunted and atrophied, often only the nuclei being left. Lesions in Epidemic Cerebrospinal Meningitis. — In epidemic cerebrospinal meningitis many of the appearances already described are present. The fulminant malis'uant cases may not show exuda- tion, but only transudation of coloring matter of the blood, with extreme congestion of the membranes, although numerous micro- scopical changes may be found. In cases of the average type — those which end fatally in a week or ten days — pus is usually found in the soft membranes both of the brain and of the spinal cord, being most marked in positions already described for other forms. The ence- phalic dura on its inner surface is sometimes implicated, the spinal dura more commonly, but the pathological changes are generally so limited to the arachnopia that the disease may be considered as chiefly a form of lepttnneuingitis. The spinal changes may be more decided than those within the cianium ; the spinal dura often bulges from the pressure of accumulated fluid. It is not usually adherent LEPTOMENINGITIS. 291 to the pia ; an abundant exudate is found in the latter, and this may be very irregularly distributed both vertically and on the various aspects of the cord. The vessels of the pia and of the substance of the cord are deeply injected. The substance of both brain and curd is sometimes softened. Spleen, kidneys, liver, lungs, and other organs may show signs of inflammation or changes such as are found in other severe general diseases. The following summary, from notes made at the time of the autopsy, of the macroscopic appearances in a typical adult case, recorded by Dr. Cahall and the writer, xjre- sents a picture of the lesions usually found post mortem. The peri- cranirrm was very vascular, and the ^'eins of the dura were gorged with dark venous blood on the outside, while the inner side of the membrane showed marked arterial injection. It was adherent to the convexity of the right hemisphere at the upper border of the quadrate lobule. In front of this lobule, on both sides, were Pac- chionian adhesions of the dura to the brain. The frontal lobes, especially on their convexity near the longitudinal fissure, were edematous, with a few slight opacities of the pia. At the base was liquid and semilicxuid pus about the optic chiasm, interijedun- cular space, pons, and oblongata. All the cranial nerves except the olfactories were bathed in pus, and were more or less softened. The crura, pons, oblongata, and fornix were also superficially soft- ened. The parietal pia (or arachnoid) between the oblongata and the cerebellum was covered by a thick layer of pus. The puncta cruenta were well marked, numerous and dark. The basal ganglia were normal, except for some venous puncta. The fissure of Syl- vius presented nothing abnormal on either side, and all the cere- bral vessels appeared normal. The spinal cord was flat and spread out on its membranes, and its dural vessels were injected externally and internally. On section of the dura, pus exuded freely. The membranous coverings of the spinal nerves within the canals were almost ecchymotic, most noticeably in those given off opposite the lumbar enlargement, and especially on the left side. The whole cord was surrounded by yellow creamy pus, its lower half being covered dorsallj' with a yellow gelatiniform pus layer, while in front the same covering was found only over the lower two inches. The spinal vessels were gorged with blood. A few adhesions between the pia and the dura were noticed behind, and many throughout the whole length of the cord in front. The lower ends of both sciatics and of their two divisions (the internal and external popliteal) were removed ; they were marked externally by several distended blood- vessels. The second, third, and fourth digital nerves of both feet presented nothing abnormal, but slight pressure at their ends with forceps caused blood to appear. Microscopical Appearances in Cerebrospinal Meningitis. — The bloodvessels of the membranes and of the substance of the brain 292 NERVOUS DISEASES. and cord are much dilated. The tissues are swollen, the cells which cause the increase being small with round deeply staining nuclei and a small amount of protoplasm ; others, fewer in number, are of epithelioid type. In the spinal tissues a few cells having the appear- ance of leucocytes with polyform nuclei are found. Single red blood corpuscles free in the tissues, and globular masses which probably represent partly disintegrated red corpuscles, or particles of hemo- globin, are abundant. Cellular infiltration is marked at the roots of the spinal nerves, and especially in the angles between the roots and the cord. The predominating cells resemble lymphocytes or mono- nuclear cells of granulating tissue. In different positions the cells attain a larger size. Hemorrhages are present both in the spinal and in the cerebral pia. Marked changes in the ganglion cells and axis cylinders are common. The ventral roots show fewer alterations than the dorsal, and not a few of the nerve fibres are swollen. The thickness of the exudate is less on the crests of the convolutions than in the fissures, but it is not uniform anywhere. The vessels of the encephalic pia are much dilated, and the leucocytes with polymor- phous nuclei are more abundant in the brain than in the cord. Besides the leucocytes, lymphoid cells and larger cells, some with vesicular nuclei, are found. Fibrin plays a small part in the exudate. (Flexner and Barker.) Diagnosis. — The diagnosis of acute leptomeningitis is considered under at least three aspects : (1) the differential diagnosis of its various types ; (2) the diagnosis from other diseases of the nervous system ; aud (3) the diagnosis from diseases other than those of the nervous system. Acute purulent leptomeningitis is to be separated from the serous, tubercular, and epidemic forms chiefly by facts relating to the last three. In serous meningitis Quincke advises lumbar puncture and examination of the fluid obtained, to assist in the diagnosis, regarding as suggestive of hydi'ocephalus from blood stasis a specific gravity of 1009, with an amount of albumen of more than two parts per thousand. Other points in the diagnosis of serous meningitis are given under the clinical description of this disease. Tubercular leptomeningitis is to be distinguished from the simple purulent variety by tlie history of heredity, by the more fre- quent prodromes, by the greater tendency of the tubercular disease to attack children, by the more common location of its lesions at the base, by its greater oscillations in temperature, and occasionally by the presence of tubercles in the choroid coat of the eye, as discovered by the ophthalmoscope. Epidemic cerebrospinal men- ingitis can be separated from other types by the presence of an endemic or an epidemic, by its usually abrupt onset with few pro- dromes, by the presence^ of marked spinal symptoms, by the unusual severity of the encephalic manifestations, by the peculiar skin erup- tions, and by the absence of a history of the predisposing and exciting LEPTOMENINGITIS. 293 causes of otlier forms of leptomeningitis. The diagnosis is most difia- cult in sporadic cases. The epidemic disease, as a rule, runs a more rapid course than the other types. A point of some diagnostic im- portance is the presence of herpes labialis, which is said to occur in about half the epidemic cases, but is rarely present in the tubercular disease. From culture experiments made from nineteen cases of herpes labialis, Klemperer believes that the eruption represents a peculiar localization of the infecting agent. The diseases of the nervous system from which leptomeningitis must usually be distin- guished are brain tumor, abscess, uremia, hydrocephaloid disease, and hysteria ; and among diseases not of the nervous system, typhoid fever, typhus fever, pneumonia, any of the eruptive fevers, and the gastrointestinal diseases of children. The diagnosis of any form of leptomeningitis from other disease should hinge not alone upon the presence of such phenomena as headache, vertigo, and vomiting, delirium and fever, but on such more convincing manifestations as optic neuritis and localized spasms or palsies, either cortical or of the cranial nerves. Optic neuritis may be present in brain tumor, as in leptomeningitis, but it is more common in the former, in which it is usually of a higher grade of intensity. It may be absent in both affections. The pain of brain tumor is more agonizing, and is often more localized by the patient. Tumor cases come on with slower steps, usually having a more or less prolonged prodromal stage. Localizing symptoms are of a more definite and pronounced character. Eapidly growing tumors may be very difficult to diag- nosticate from leptomeningitis. Temperature oscillations are much more common in the latter. Abscess of the brain and purulent leptomeningitis may be associated in the same case. When abscess exists as a separate affection, the diagnosis will be based in part upon the fact of its most frequent occurrence in special localities, as the temporal lobe and the cerebellum, where it gives rise to symp- toms indicating disturbance of the functions of those portions of the brain. Symptoms indicating implication of the cranial nerves are more likely to be due to leptomeningitis. It must be remembered that encephalic abscess may be latent for a long time. Occasion- ally uremic attacks simulate fulminant or at least a rapidly devel- oped leptomeningitis. Some of the points of differentiation are for the latter the history, the evidences of disease of the kidneys, heart, and bloodvessels, the less marked fever, the more abrupt convulsive manifestations, the greater tendency to stupor and apo- plectiform conditions, and sometimes the presence of albuminuric retinitis. In children suffering from cerebral anemia, as the result of exhausting disease, or from general malnutrition, — a condition first designated by Marshall Hall as hydrocephaloid disease, some of the symptoms suggest tubercular leptomeningitis ; but localizing phenomena are usually absent in the former, and the conditions are 294 NERVOUS DISEASES. more those of apathy or stupor from profound exhaustion, — fever, headache, retraction of the head, cranial and limb palsies and spasms, etc., being absent or infrequent. The complication of hys- teria with leptomeningitis, as with other forms of organic disease, is sometimes observed. Hysteria may simulate tubercular menin- gitis, although not very closely if a careful study of the patient is made. I have seen a train of hysteroepileptic phenomena, such as pseudoheadache, general spasms with opisthotonos, anesthesias, paresthesias, and paresis, set down as due to meningitis ; but such cases are readily cleared up by a careful study of pulse, respira- tion, and temperature, by a history of the case, and by the absence of the persisting phenomena, local and general, of leptomeningitis. The acute febrile affections are most likely to be taken for lepto- meningitis in their early stages, chiefly because of the presence in such cases of headache, delirium, and sometimes of spasms. Pro- dromes are more likely to be present in meningitis, particularly of the tubercular variety, and of these loss of flesh is especially im- portant. Such symptoms as prolonged irritability and photopho- bia are more common in meningitis. The temperature, pulse, and respiration are not characteristic, as in some of the infectious fevers, particularly typhoid. In Ijrief, the special features of the general febrile diseases are absent, while those of the difierent forms of meningitis are j)resent, the mistakes arising from a misinterpreta- tion of a few symptoms. From intestinal diseases the diagnosis is to be made chiefly by the presence of symptoms of local intra- cranial disease, such as cranial palsies, optic neuritis, and local spastic affections of brief duration. Prognosis. — The prognosis in all forms of leptomeningitis is comparatively bad, and in tubercular meningitis it is absolutely un- favorable, although Hasse believed in the curability of miliary tuber- cular meningitis of the pia, and others have reported cases that were cured if they were not instances of mistaken diagnosis. Acute pur- ulent leptomeningitis maj^ sometimes be cured by surgical procedure, and occasionally recoveries are reported from the use of internal and external treatment. Eecovery sometimes takes place in serous men- ingitis either under treatment or liy processes which are indepen- dent of treatment. The cure may be effected through cessation of the exudation, or by compensation causing widening of the channels of exit. The dilatation of the ventricles may disappear as children grow older. The prognosis of cerebrospinal meningitis is grave, although in epidemics not a few abortive cases are observed, and a fair percentage of cases may recover, particularly towards the de- cline of the epidemic. The fulminant cases often die within a few hours or days. In all cases the prognosis is serious if stupor and coma come on early. The mortality is greatest in childhood. The tendency to relapse should not be overlooked. One attack does not LBPTOMENINGtlTIS. 295 give immunity from others, aud even when recovery takes place serious sequelas are often left. Treatment. — The treatment of leptomeningitis will of course be influenced by its special etiology ; thus, when preceded by syphilis, rheumatism, gout, etc., remedies directed to these constitutional states, if they can be used early, are indicated. All forms of acute leptomeningitis present certain common symptoms aud indications for treatment. It is first necessary to enjoin complete mental and bodily rest. The patient should be kept in the quietest part of the house ; bright lights and all noises and other sources of dis- turbance should be excluded as far as possible, and sudden alter- ations in surroundings should be carefully avoided. Pood should be administered regularly, but with the least possible disturbance of the patient. Even the mattress should be carefully chosen to make the rest as perfect as possible. Among external applications for the relief of headache and spinal pain are ice bags on the one hand, or very hot applications on the other ; one will some- times afford relief when the other will not. Opium, which in some form is the standby for the relief of pain in meningitis, can be administered by the mouth or hypodermatically. Among the best preparations for administration by the mouth are laudanum, the deodorized tincture, and the salts of morphine or codeine. For hypodermatic use morphine preparations are best. The amount necessary to ease the suffering cannot be gauged by ordinary rules ; doses twice or thrice those usually given may be required. Opium is useful as a cerebral stimulant as well as a narcotic in the active forms of leptomeningitis, and especially in cerebrospinal meningi- tis, in which it sustains the strength of the patient while relieving the pain. It may be given in moderate doses, frequently repeated, with an occasional exhibition of large doses, which, however, may be continuously required. In harmony with others, I have observed the great tolerance of ox^iates both in tubercular and in cerebro- spinal meningitis. When convulsions are severe aud refui- fre- quently, large doses of bromides, chloral, or chloralamid should be given, or, if these are already in use, the doses should be increased. Opiates serve sometimes to relieve other symptoms, such as insom- nia, restlessness, and delirium, but frequently f>ther drugs are re- quired, and may be given alone or in combination with the opiates. Among these are chloral, cannabis indica, paraldehyde, sulphonal, and trional, which can be given in full doses, using some of tlie formulas in the section on General Therapeutics. The combination of sulphate of morphine, chloral, and the bromides may prove most efacient ; paraldehyde is useful during cerebral excitement ; and tri- onal in large dose is an excellent hypnotic, particularly when used in the evening as an addition to the narcotic and sedative treatment which has been pursued during the day. Hyoscine hydrobromate 296 NERVOUS DISEASES. occasionally proves serviceable, but is not so efficient as it is in mania. For tlie nausea and vomiting, cracked ice, small quantities of carbonated water, cerium oxalate alone, or with small doses of powdered (i])iuni, and bismuth subnitrate or subcarbouate in com- bination with codeine, and sometimes with salol, may be given. Counterirritants or hot applications over the epigastrium are also serviceable. As the gastrointestinal disturbances are usually of cerebral origin, the remedies which are pushed for the purposes of subduing brain excitability may be of more service than those which are directed especially to the digestive tract. The abstraction of blood, preferably by leeches to the temples or back of the ears, should be resorted to early in sthenic cases of simple or cerebro- spinal meningitis. It is contraindicated in the tubercular form, and in all forms in the later stages or when the patient is weak or anemic. In rare instances venesection may be resorted to, as in violent meningitis following sunstroke or traumatism, and occa- sionally in cerebrospinal cases. For the reduction of temperature the most efficient remedies are sponging, and drugs such as anti- pyrin, phenacetin, acetanilid, and quinine, the last being used alone or combined with hydrobromic acid. Aconite or veratrum viride may prove useful in sthenic cases. Among remedies which have received almost universal commendation in different forms of men- ingitis are the mercurial and iodine preparations. They are of especial value in the acute purulent form and in cerebrospinal men- ingitis, and have caused great apparent improvement even in the tuberculai- form. The best methods of administering mercury are by inunction and by reY)eated small doses of calomel, the biniodide or the bichloride. The drug should be pushed until slight consti- tutional effects are visible. Potassium or sodium iodide or hydri- odic acid can be given in doses proportionate to the age of the patient and the severity of the disease. Other valuable measures are the use of iodoform, in doses of two to three grains, iiutil ten or twelve grains are taken in the course of the day ; Lugol's solu- tion, two to three minims, given in simple syrup or in a bland emulsion ; inunction of the shaven scalp with mercurial ointment, ointment of oleate of mercury, or a twenty per cent, iodoform ointment. A good combination in almost any form of leptomenin- gitis is that of the itxlides and bromides with narcotics, such as cannabis indica, hyoscine, or morphine. Mercury and opium are l'ref|ueiitly gi^^en together advantageously. Surgical treatment, while not applicable to epidemic (•eiebros]>inal meningitis, may be demanded in simple punihMit leptomeningitis, and offers some hope even in the tuberculous form of the disease. If an abscess can be localized, or if the purulent leptomeningitis is believed to be confined to an accessible area, trephining can be resorted to for the removal of the pus, or for antiseptic irrigation. Lauphear, CHRONIC LEPTOMENINGITIS. 297 Keen, and Senn have advocated the surgical treatment of tubercular leptomeningitis, recommending opening the skull and washing out the meningeal spaces with iodoform and glycerin emulsion or with other germicidal preparations. Of course the surgical treatment of aural, nasal, or any other form of diseiise which has led to the meningitis must be carefully considered. Sometimes a leptomen- ingitis will be present on the side of the brain opposite to that on which the aural or mastoid disease is located, as in a case seen by me in consultation, in which purulent disease of the left ear was present, and among other severe symptoms were paralysis of the limbs and unilateral convulsions on the same side as the aural disease. Trephining of the mastoid did not afford relief. The pa- tient died, and a purulent leptomeningitis was found extending from a point an inch and a half back of the tip of the left hemisphere to the parieto-occipital fissure, and from the longitudinal fissure nearly to the Sylvian. This case might have been successfully treated by trephining over the area of leptomeningitis, which was large but was strictly limited to a region which could readily have been reached and irrigated. Ord and Water house successfully treated tuberculous meningitis by trephining and irrigating the subarach- noid space. The first case of leptomeningitis thus treated was by Barker. The treatment of serous meningitis consists, for the acute forms, in antiphlogistic measures, the application of cold and of leeches, complete mental and bodily rest, and the use of intestinal derivatives. Mercury by inunction or hypodermatically, pilocarpin, quinine, and antipyrin during febrile exacerbations, flying vesicants, iodine, and cautious inunctions with tartar emetic ointment, are included in Quincke's recommendations. In cases of imminent danger he recommends lumbar puncture, removing from five to eight cc. of fluid through a hollow needle introduced at a distance of one cm. from the middle line beneath the second, third, or fourth lumbar vertebra. For the prevention of tuberculous meningitis all measures which tend to improve constitutional conditions, such as good food, fresh air, and good ventilation, are important. It is possible that great good might be done in aborting acute lepto- meningitis, or in reducing its gravity, by treating it early from a bacteriological point of view. In the presence of an epidemic and in the early stages of infectious forms of meningitis, the adminis- tration of mercury, potassium bicarbonate, sodium salicylate, and similar drugs might in this way do something. CHRONIC LEPTOMENING-ITIS. General Considerations. — Hemorrhagic internal pachymenin- gitis is usually a chronic affection, as is also external leptomenin- gitis, or arachnitis so called, the latter often being the result of re- curring attacks of acute inflammation or congestion. Besides these 298 NERVOUS DISEASES. diseases, other forms of membranous inflammation to whicli the term chronic properly belongs are met with somewhat frequently, particularly in the victims of alcoholism, traumatism, and inso- lation. If infection is the almost invariable cause of meningitis, either acute or chronic, the above and other etiological influences may so diminish cerebral and systemic resistance as to allow the omnipresent germs of infection to originate and maintain chronic inflammation of either encephalic or spinal membranes. The form of chronic meningitis to which attention is here briefly directed is that which affects the entire pia, but it is rarely confined to that membrane, the brain substance often and the dura less frequently taking part. Chronic leptomeningitis may be either primary or secondary, but it is commonly the latter. For practical reasons, nervous syphilis, alcoholism, and cerebral traumatism will be considered in special sections, and because of this the subject of chronic meningitis can be dismissed here more briefly. It is discussed in this connection in pursuance of the plan of making localization and diseases of special structures the chief method of classification. Chronic leptomeningitis of a low grade is a common pathological lesion in a large number of those who die insane ; al- though even in them it is not to be regarded always, or even often, as the special pathological cause of the mental disorder, but rather as a condition which has developed step by step with the progress of the mental disease — a part of the general structural breakdown of the patient. The changes in the membranes in these cases are brought about not infrequently by the recurring congestions which accompany the waves of excitement through which the patients pass. According to Bevan Lewis, the pia is abnormally thickened in fully forty-eight per cent, of those dying insane, partly from fibrinous exudates which have organized, partly from plastic lymph, and often from an edematous swollen condition of the conjoined soft membranes. These statistics include many general paralytics, but also many cases of acute mania or acute melancholia. (Batty Tuke.) Clinical History. — Because of the variations in the intensity of the inflammation and the irregularities as to location and diffusion of the lesions in different cases, it is almost impossible to present the symptomatology of chronic meningitis in a thoroughly satisfactory manner. The local symptoms will be those presented by different types of acute leptomeningitis ; the general symptoms are usually much less severe ; and both local and general manifestations are modified l\v the mental and jdiysical conditions which are slowly induced. Like the acute form, it may be of the convexity or of the base, or it may be focal in any position. Syphilitic leptomeningitis, when focal, (ifteii shows an inclination towards certain localities, as tlu' foramen magnum, the junction of the pons and the oblongata, or of the pons and the crura, and the prefrontal, the Eolandic, or CHRONIC LEPTOMENINGITIS. 299 tlie Sylvian convexity. The symptoms in any type may vary accord- ing as one or other of these positions is attacked. When the pre- frontal region is the seat of the disease, they will be largely psychical, such as apathy, inattention, and mental slowness ; when the inflam- mation is in the motor region, various forms of paresis and spasm maybe present or come and go ; or the manifestations may lje \'isual, auditory, aphasic, gustatory, or olfactory, when other cortical areas are invaded. If basilar, the cranial nerves will suffer most, and alternate hemiplegias of various types, and usually imperfectly de- veloped, may be present, as oculomotor, motor trigeminal, facial, or abducens paralysis of one side, with bemiparesis of the limbs of the other. The form of basilar meningitis described by Gee and Barlow as occurring near the foramen magnum, to which reference has already been made, may be a chronic affection, and is sometimes spoken of as chronic infantile men- ingitis. Certain symp- toms woirld seem to be common in almost all types of chronic lepto- meningitis. These are dull headache, mental changes, muscular weakness, even without true paresis, vertigo, more rarely nausea or vomiting, and tinnitus. Optic neuritis of a low grade is a common but not a constant sign. Occasionally a case of chronic leptomeningitis may present symptoms of striking or unusual character, as in a case reported by me of athe- toid spasm, myotonia, and diffuse bilateral dis- turbances of sensation, which was found to be due to chronic convex- SIy(jtonia and athetoid spasm in a ease of convexity menin- gitis, with cortical and snljcortical softeniaig. ity meningitis of both hemispheres with cortical and subcortical soft- ening, the lesion being most marked in the posteroparietal region. This patient nine years before his death had a sunstroke followed by a fit ; subsequently he had similar seizures, at first with great 300 NERVOUS DISEASES. frequency and later at longer Intervals. He gradually developed a spastic state and athetoid movements, with paresis first in one limb and then in another, and eventually in the face, chiefly on the left side. Violent choreoid and athetoid movements were produced by willed efforts, and by manipulation, and sometimes were apparently spontaneous. When he opened his mouth the muscles of the face, neck, tongue, and extremities took part in a series of athetoid and chronic contractions, much more marked on the left side of the body, although distinctly present on the right. (Pig. 212.) Knee jerk and muscle jerk were increased ; ankle clonus and front tap were present. Percussion of the muscles gave phenomena similar to Erb's myotonic reactions. At intervals he had attacks of Jack- sonian epilepsy, and shortly before his death had general convul- sions. Strange to say, he did not suffer from chronic headache. In this case, in addition to a true leptomeningitis, shown by deep injection of the pia, and thickening and infiltration of the mem- brane with plastic lymph, which was more or less adherent to the brain substance, cortical and subcortical softening were present. The symptoms were therefore both meningeal and subcortical, but the case was primarily one of a severe form of verticalar menin- gitis. As chronic leptomeningitis is frequently secondary to other affections, such as brain tumor, atrophy, and fracture, the symptoms will be complicated with those of the primary affection. Grave hysterical manifestations may be present and for a time may over- shadow the organic affection. Under a temporary exciting cause, or from a sudden increase in the virulence of the infecting agents, the sufferers from chronic meningitis may have acute attacks at- tended with headaches, convulsions, increase of optic neuritis, fever with delirium, or temporary stuporous states. The symptoms of these paroxysms are much like those which occur in the course of brain tumors. Etiology. — Chronic leptomeningitis, like acute leptomeningitis, is usually due to infection ; but various causes already referred to, such as traumatism, alcoholism, and insolation, play an important part in the development of the disease. Insolation is a more fre- quent fact(n- in the production of pachymeningitis. Chronic lepto- meningitis, like acute leptomeningitis, has been ascribed to gout, rheumatism, diabetes, influenza, typhoid fever, scarlet fever, etc. It is usually a disease of adults. It occasionally follows in the wake of acute l('i)t(>meniugitis. Pathological Anatomy. — The pathological appearances, which vary according as the aflfecticm is tubercular, serous, or purulent, differ from those of the acute form already described chiefly in being less marked in character. In syphilitic cases flbrocaseous and gum- matous thickenings are common over the surfaces of the convolutions, and infiltration of the cortex is not infrequently present. Dura and CHRONIC LEPTOMENINGITIS. 301 pia are often agglutinated, and the latter membrane may be continu- ously or irregularly adherent to the cortex. In advanceil cases many of the vessels which constitute the pial network are obliterated, c(n'- tical and subcortical softening resulting. Cranial nerves and vessels may be bound down by old or recent exudate. Eetent intiltrations of the pia may be present in some cases. Peculiar looking cells are often found aggregated into spherical clusters, which become homo- geneous and finally calcified. They are often surrounded l)y very small cells and recently formed fibrous tissue. (Ziegler.) Effu- sions of serum, pus, or lymph may be present, but the latter is most constant in chronic cases. Pacchionian granulations are frei|uently increased and enlarged. The lesions may be found in any location, and may be variously diffused. In many cases of chronic alcoholism, and in some cases of insanity to ^^'hich reference has been made, the lesions are not of the marked character which is indicated by the above description, but consist chiefly of opacities of the parietal layer of the pia, with some thickening and deposits in the vis- ceral portion of this membrane. Vessels as well as membranes are sometimes changed by chronic inflammatory processes, some forms of chronic leptomeningitis being part of a general process which attacks vessels and viscera or any of the bodily organs or tissues. In the syphilitic nodose periarteritis which has been best described by Ziegler and Bruce, marked changes may be found in the mem- branes as well as in the vessels. In chronic leptomeningitis of long duration, atrophy of the brain is commonly present. Convolutions, lobes, or even the entire brain niay present a shrunken appearance, and the absent cerebral substance is substituted by cerebrospinal fluid. Diagnosis. — The diagnosis of chronic leptomeningitis may be difficult. It must be based chiefly on a study of causation ; on the history of a slow development ; on the age and sex of the patient ; on the persistence of certain symptoms, such as mental change, dull headache, or discomfort in the head ; on the presence of cortical or cranial nerve symptoms, and of low grade optic neuritis. In the early stages of general paralysis of the insane, the patient may be supposed to be suffering from a form of chronic curable leptomenin- gitis, but the progressive development of the physical and mental symptoms of this form of insanity will usually soon clear up the diagnosis. The diagnosis will need to be made mainly from such affections as brain tumor, chronic Bright' s disease, and hysteria or neurasthenia. From tumor of the brain it is chiefly to be distin- guished by the greater intensity and the more focal character of the symptoms in tumor cases. Optic neuritis is usually of higher grade in brain tumor. The symptoms of the two affections may be com- mingled. Occasionally localized syphilitic meningitis cannot be distinguished from syphilitic brain tumor. The headache, mental 302 NERVOUS DISEASES. changes, eye changes, and convulsions which may occur in the course of chronic nephritis have led to its being confused with chronic leiitomeningitis ; but the two affections can usually be differ- entiated by close attention to the signs and symptoms referable to the disease of the kidneys, as by investigation for albumen and casts, by examination of tlie eyes for allniminuric retinitis, and by the effects of medication. Occasionally chronic leptomeningitis is set down as hys- teria or neurasthenia, but a close study of the patient will enable the IM'actitionei- to delermine the presence of organic disease. In some cases of neurasthenia, particularly if the patient is suffering from abnormal refraction, the eye grounds present an appearance some- what like that of a true optic neuritis of low grade. In children and young adults the differential diagnosis of tubercular leptomen- ingitis from a form of hereditary leptomeningitis, due to inherited syphilis, may be of great importance. Probably in most cases an absolute diagnosis cannot be made except by the therapeutic test, but the usual signs of inheiited syphilis, such as nasal flattening and notched teeth, will be helpful. In a doubtful case it is best to treat the patient with large doses of mercury or of the iodides, especially the latter. It is not improbable that many of the cases of tubercular meningitis reported as cured have been of this char- acter ; but that they do not all belong to this category is shown by the case reported by Freyhan, who made a diagnostic puncture in the lumbar region and obtained a fluid in which were found pus cor puscles and tubercle bacilli. This patient is reported to have re- covered under treatment. Prognosis. — Little need be said about prognosis, which is usually more or less unfavorable. Active treatment in syphilitic cases and iu those due to insolation or traumatism will sometimes effect a cm-e or a proximate cure, and will at least make life much more bearable. Treatment. — Mercury and the iodides, especially when syphilis is susi)ecte(l, but in any case for their absorbent powers, may be used either cautiously or boldly according to indications or the general strength of the patient. Although seldom curatiA'e, they often do good by preventing exacerbations and decreasing the intensity of tlu^ symptoms which cause suffering. Ergot and the bromides may be used with good results at intervals. Persistent counterirritation, particularly with the Paquelin cautery at the back of the neck, will be found to give great relief. Hot or warm baths, a sojourn at hot mineral s])rings, a change of climate in cases which are much affected liy sea-son and weather, are all worthy of trial. Much of the treat- ment will necessarily be symptomatic, as, for instance, for the relief of pain and insomnia, and may involve a careful use of opium, chloral, trional, and other hypnotics, S(Hlatives, and narcotics. As the general health of i)atients is always much impaired, nutrients and tonics will often prove of value. THROMBOSIS OF THE INTRACRANIAL SINUSES. 303 Fig. 213. THROMBOSIS OF THE INTRACRANIAL SINUSES. The Dural Sinuses.— As the intvacrauial sinuses are consti- tuted by folds of the dura, it is convenient to consider the diseases of these large bloodways in connection with affections of tlie brain membranes. The most important sinuses both medically and sur- gically are about fifteen, although the number is variously giv'en by different anatomists. Allen makes it sixteen. The variations are caused by some considering as separate sinuses parts which others include under one. Basal and vertical views of the most important sinuses are shown in Pigs. 213 and 214. The feeders of these sinuses are the veins of the brain, skull, orbit, ear, and other parts ex- ternal to the skull. The sinuses differ from veins in not accompanying ar- teries, in not having valves, and in not having muscular coats. They are lined, like the veins, with a delicate membrane which may become the seat of iniiammatory disease. It wiU not be necessary fully to describe these sinuses ; the illustrations and le- gends * will be sufacient to call to mind the most im- portant anatomical points. The term sigmoid sinus is applied to the S-shaped portion of the lateral sinus which lies in the sigmoid groove of the temporal and occipital bones, and is in direct relations with the mastoid and jugular re- gions. This curved por- tion of the sinus is not well shown in Pigs. 213 and 214, but is seen in Pig. 215, which is a diagram slightly modified from part of an excellent scheme by Browning has extended the simplified terms of Wilder, usually mono- nyms, to the veins, sinuses, and meningeal vessels. For meningeal he has substituted dural, as the sinuses and so-called meningeal vessels lie wholly in the dura. The simplified terms are given first in the legends and text, the commonly used names in parenthesis. Basal cranial sinuses, sliowing also the right orbit : 1, torcular (toreular Herophili or confluence of the sinuses) ; 'J, ophthalmodural (ophthalmic) vein ; 3, cavernous sinus ; 4, circular sinus ; 5, preoccipital (anterior occipital) sinus ; i;, V, superpetroas and subpetrous (superior and inferior petrosal) sinuses ; 8, postoccipital (posterior occipital) sinus ; 9, commencement of internal jugular vein ; a, eyeball ; b, optic nerve ; c, occipital foramen ; d, e, f, anterior, middle, and posterior fossse. (Leidy.) 304 NERVOUS DISEASES. Fig. 214. Macewen of tlie intracranial and extracranial venous anastomoses. It is of the greatest importance to understand the position and rela- tions of this sinus, lying as it does so close to the middle ear, the mas- toid antrum and cells, all of which are so frequently the seats of infective in- flammation. A thromhus occasionally extends from the superior petrosal into 4 this sinus, while the re- verse process is of frequent occurrence. One lateral sinus, generally the right, is often larger than the other. The Interrelations of the Veins and Sinuses. — It is important to under- stand the relations of the veins of the brain, of the skull, and of the parts out- side of the skull, to the sinuses. According to Duret, all the veins of the cerebral gyres in their confluences are disposed after two plans, perpendicular to one another, one vertical and mesal, which is con- nected with the longitudinal sinus and veins of Galen, the other posterior and horizontal, situated at the base of the brain and con- nected with the cavernous and petrous sinuses. The veins of the convexity and mesal surface in general empty into the longitudinal sinus ; those of the inferior surface of the cerebrum — of the frontal, temporal, and occipital lobes — into the lateral, petrosal, and cavern- ous sinuses. Communication is free between the superior and inferior cerebral veins. The veins of the ganglia and interior of the brain unite to form the veins of Galen and pass out of the great transverse fissure to enter the tentorial or straight sinus, commonly, however, uniting to form one vein before entering the sinus. Super- cerc'bellar (superior cerebellar) veins terminate in the tentorial or straight sinus ; the subcerebellar (inferior cerebellar) veins in the lateral sinuses ; the paracerebellar (lateral anterior cerebellar) veins in the superpetrous (superior petrosal) sinus. Duret found that the cerebral veins had more important anastomoses than the arteries, but that individual variations were numerous. Often it is thought that two branches anastomose when they are simply side by side at the bottom of a fissure. The veins of the hemisphere send off arbor- izations in the convolutions. The ophthalmodural or ophthalmic Vertical view of the dural sinuses : 1, longitudinal (superior longitudinal) sinus ; 2, termination of super- cerebral (superior cerebral) veins ; Z, falcial (inferior longitudinal) sinus ; 5, tentorial (straight) sinus ; 6, 7, superpetrous and subpetrous (superior and inferior pe- trosal) sinuses of the right side ; 8, right lateral sinus ; 9, commencement of the left lateral sinus ; 10, internal jugnlar vein ; a, falx ; b, tentorium ; c, cerebellar fossa ; d, partition of the nose ; c, frontal sinus. (Leidy.) THROMBOSIS OF THE INTRACRANIAL SINUSES. 305 veins empty into the cavernous sinuses, as do also the veins of the external ear by way of the petrous portion of the temporal bone. The veins of the mastoid regions empty into the lateral sinuses. The cephalic extremity of the longitudinal sinus communicates by the foramen cecum with the nasal fossse. The veins of the diploe communicate with many of the sinuses. An important fact to bear in mind in connection with cerebral thrombosis is that the veins empty into the sinuses in a direction opposite to that of the blood current in the latter, also that the most important sinuses are crossed Fig. 215. Scheme showing some of the most important relations of the intracranial sinuses and veins : A, A, A, longitudinal (superior longitudinal) sinus ; £, faleial (inferior longitudinal) sinus ; C, C, cavernous sinus ; D, D, lateral sinus (straight portion) ; E, E, sigmoid sinus (cun'ed portion of lat- eral sinus) ; F, superpetrous (superior petrosal) sinus ; G, basilar sinus ; H, subpetrous (inferior petrosal) sinus ; I, I, tentorial (straight) sinus ; J, J, circular sinus ; K, marginal sinus ; L, occipital sinus ; M, sphenoidal (sphenoparietal) sinus ; N, internal jugular vein ; 0, foramen magnum ; ■P, jugular bulb ; 1, occipital vein ; 2, mastoid vein ; 3, 3, veins of Galen ; 4, temporosphenoidal veins ; 5, anastomotic vein ; 6, medidural (middle meningeal) veins ; 7, medicerebral (middle cere- bral) vein ; 8, veins from the labyrinth ; 9, vertebral vein ; 10, posterior external jugular vein ; 11, ophthalmodural (superior ophthalmic) vein. The frontal, parietal, and occipital superior cere- bral veins are shown communicating with the longitudinal sinus. (After Macewen.) by white fibrous bands or trabeculse. Roy and Sherrington found that closure of both external jugulars caused expansion of the brain. It is therefore important to remember that pressure in the veins influences the volume of the brain. All the blood in the intracranial sinuses eventually finds its way into the jugular veins. Definitions and Varieties. — Sinus thrombosis, or clotting of the blood in the cerebral sinuses, is always a serious and often a fatal disease, and in its different forms is of both medical and sur- gical interest. It may be primary or secondary. The primary form 20 306 NERVOUS DISEASES. is often spoken of as marantio or marasmic, and the secondary as infective or injla minatory. Clinical History of Primary or Marantic Thrombosis. — A patient attacked with this disease generally becomes somnolent and later stuporous and comatose, and may have as other symptoms con- vulsions, paralysis, retraction of the head, edema of the scalp, and bleeding from the nose. In the majority of cases fever is not present or is scarcely discernible ; occasionally the temperature is raised one or two degrees. The disease may be present with scarcely any symptoms except stupor deepening into coma, when it is extremely difficult to diagnosticate it from anemia of the brain. In adults paralysis is comparatively common. The duration is from three or four days to several weeks. Occasionally young children recover, sometimes having as sequels impairment of mental powers and a tendency to convulsions. Both spasm and paralysis are probably often due to the meningeal hemorrhages which occur as a result of the thrombosis. Besides the usual coagulability of the blood, the heart may be weakened, and the total amount of blood circulating in the body may be reduced. Primary thrombosis is of most fre- quent occurrence in the longitudinal sinus, but in rare instances it has been observed in the lateral and cavernous sinuses. Clinical History of Secondary Sinus Thrombosis. — Secon- dary sinus thrombosis has symptoms which are necessarily com- mingled with those of the diseases from which it originates or with which it is associated, as affections of the external and internal ear, cranial caries, cerebral or cerebellar abscess, carbuncle, facial ery- sipelas, or other local affections of the head or face associated with suppuration. Headache, muttering delirium, stupor, and coma are general symptoms in many of the types of infective thrombosis, and are sometimes due as much to an accompanying meningitis as to the thrombosis. Occasionally the patient is maniacal, and symptoms of general septicemia, such as chills and irregular fever, may be pres- ent. Three types of secondary or infective thrombosis are described by Macewen, — the puJmvnury, the abdominal, and the meningeal. In the pulmonary type the symptoms, which, in the first place, are due to the plugging of the small acsspIs and the formation of infarcts in the lungs, are irritative cough, si'attered .stitches of pain or diffused pain, and in a short time prune juice exx>ectoration, which soon becomes of a brownish gray hue, owing to the admixture of pus, and which is found to be swarming with microorganisms. A purulent generalized pneumonia may result. Great fetor of the breath and diarrhea with I'etoi- of the discharges from the bowels are usually present. Acute pain in the region of the liver may be complained of, and is due either to the extension of inflammation from the lungs or to primary congestion or inflammation of the liver, but hepatic al iscess is rare. The brain usually remains clear until the end of the THROMBOSIS OF THE INTRACRANIAL SINUSES. 307 disease. The abdominal or typhoid type shows characteristic symp- toms at the end of the first or at the beginning of the second week. They are such as dry furred tongue, anorexia,, vomiting, abdominal pains, diarrhea, — the stools being very fetid in character, — mutter- ing delirium, languor, stupor, and a measly rash. In brief, the symptoms are so much like those of tyiihoid or enteric fever that a mistaken diagnosis has not infrequently been made. The headache is of violent character, vomiting is frequent, the temperature is high, but rigors are uncommon. In the meningeal type excitement and irritability, a mixture or alternation of spasm and paresis, great hyperesthesia, and disturbances of the cranial nerves are prominent. Sometimes spinal leptomeningitis may accompany the intracranial affection, when spinal symptoms will be present. The patient becomes comatose towards the end, and throughout the disease psychical and other cerebral symptoms are more common than in either the pulmonary or the abdominal type. The symptoms of the different types may be commingled in any case, and will of course vary with the particular sinus affected, as will be next considered. Longitudinal Sinus Thrombosis. — Certain local symptoms will depend on the special sinus affected ; some of the sinuses even present differences in the general symptoms. Owing to its situation and great size, for example, the longitudinal gives positive disturb- ances of the character already indicated in considering marantic thrombosis. Prom a study of the symptoms observed in three cases with autopsies, Du Pasquier believes that somnolence, coma, a state of rigidity, a fixed and prolonged attitude in extension or flexion, champing of the jaws, blepharospasm, and tremor of the fingers indicate the existence of a clot in the longitudinal sinus. Among local manifestations attributable to the occlusion of this sinus are epistaxis, edema in the region of the nose and temple, and in young children prominence of the fontanelles. Cavernous Sinus Thrombosis. — Lying mesad of the cavernous sinus is the cavernous plexus of the gangliated system of nerves, and the abducens nerve ; while on or in its lateral walls run the oculomotor, the pathetic, and the first or ophthalmic branch of the fifth nerve, and therefore interference with these nerves may give very definite localizing phenomena. One or both eyes may be immovable ; one may be more prominent than the other ; ptosis may appear on one side and later on both. Optic neuritis may be shown by one or both eyes. Supraorbital or infraorbital pain may be marked, especially at the onset; and later, anesthesia of the con- junctiva and cutaneous distribution of the first division of the fifth nerve may occur. Other most important symptoms are dependent upon the communications of the sinus with the ophthalmic vein, which supplies parts both within and without the orbit. Exoph- thalmus is sometimes so marked as to suggest an orbital growth. 308 NERVOUS DISEASES. The eyelids and parts about the orbit may be greatly swollen. Thrombosis of the nasal, angular, or temporal veins, with or without suppuration, may be present. The frequency with which symptoms at first unilateral become bilateral is an important point in the study of cavernous thrombosis. Thrombosis of the petrosal sinus may be associated with or may extend into the cavernous sinus or from the latter into the former, so that in petrosal thrombosis some of the symptoms of cavernous thrombosis may be present. Lateral Sinus Thrombosis. — Thrombosis of the lateral sinus is usually of its sigmoid portion, and hence is often spoken of as sig- moid sinus thrombosis. It is commonly associated with diseases of the mastoid or of the middle ear, and will in the first place have symp- toms indicative of these aifections. The region of the mastoid may be swollen and edematous, and not infrequently the headache or head pains will be more localized to the posterior portion of the head. In some cases where the thrombosis extends downward into the internal and common jugular veins, the latter filled with throm- bic masses may be palpated ; in others sensitiveness to pressure in the retromaxillary fossa and on the inner border of the sternocleido- mastoid muscle, and edema of the soft parts of the neck, may exist. Sometimes hoarseness and dysphagia are observed. A benign thrombus filling the transverse occipital sinus cannot be diagnosti- cated, as a rule. If it extends through the emissary veins of this sinus and their anastomoses, it may form induration in the connec- tive tissue at the back of the neck resembling a phlegmasia alba dolens. (Eissler.) It is important to remember that edema and pain in the mastoid may be absent in lateral sinus thrombosis, and that these symptoms may be more prominent in suppuration and inflam- mation of the mastoid cells. The edema in thrombosis is often slight. In chronic otitis media the cessation of otorrhea coincident with accession of persistent otalgia extending into cephalalgia, high temperature with marked fluctuations, vomiting, and rigors, ought to be regarded as pointing in the direction of thrombosis of the sigmoid sinus. (Maceweu.) Etiology. — Primary thrombosis is often called marantic or marasmic, because of its frequent occurrence as the result of exhaus- tion or malnutrition, and is commonly associated with infantile diarrhea, wasting diseases such as cancer, phthisis, and pernicious anemia, or more rarely with the acute infectious diseases. It is usually a disease of either early infancy or extreme old age, but may occur at any period of life. Infective or secondary thrombosis may arise by extension of inflammation from the neighboring parts to the Willis of the sinus, which become inflamed, the blood coagulating and adhering to the inner coat of the vessel. Thrombosis arising in this way is frequently called phlebitic. A second method of origin is by the formation of a venous thrombus which soon extends into THROMBOSIS OF THE IJSTTKACEANIAL SINUSES. 309 the sinus. Pressure on a vein or sinus is an alleged cause of throm- bosis, but it certainly rarely originates in this way. Diseases of the ear have a most important practical bearing upon secondary sinus thrombosis as well as upon meningitis. All statistics tend to show the preponderating role played in these diseases by affections of the middle ear including the tympanic ca\'ity and its offshoots. Out of 43,730 aural cases analyzed by Biirkner, sixty-six and nine- tenths per cent, were of middle ear disease. Thrombosis and intracranial meningitis rarely follow acute primary suppurative disease of the ear. They are most common in the course of chronic aural affec- tions, for the obvious reason that, lining membrane and bone being more or less destroyed, the lymphatics and other channels for the removal of infectious material are no longer sufficient for this pur- pose, and contamination by way of the bloodvessels which coarse through the bones and by way of the labyrinth and nerve sheaths readily takes place. The lymphatics as well as the veins and the arteries play their part in propagating inflammation from the tym- panum to the brain and meninges. (Barker. ) Pathology. — In primary as in secondary thrombosis it is prob- able that the initial state is a radical alteration of the endothelium. (Ball.) The affected sinus, commonly the longitudinal, is found iilled with a mass of blood in various stages of change. In recent cases of marantic thrombosis the clot is usually soft and dark, but as time progresses it becomes yellowish and frialile. Sometimes it is large, filling the sinus or even extending beyond it into other sinuses and veins, but it varies much in this respect. Appearances of inflammation are absent in marantic cases. Edema, hyperemia, and cortical capillary hemorrhages occur as the result of the obstruction. When reco^-ery takes place the brain may become atrophied and hardened over irregular areas. As the result of infecti\'e throm- bosis, great changes take place in the walls of the sinus, which may disintegrate to such an extent as to cause a break in its conti- nuity, although hemorrhage is uncommon as the result of this, because of the coincident coagulation of the blood. The clot within the sinus soon disintegrates and becomes purulent. It swarms with microorganisms, which may infect the system in at least three ways ; (1) by way of the tributary veins, (2) by portions of the disinte- grated clot being carried into the general circulation, and (3) by spreading of the infective matter through the walls of the sinus into the neighboring parts. Variability in the character and virulence of thrombosis and other intracranial affections may be dependent in part on differences in the nature and activity of the microorganism present. Barker and Eohrer hold to the saprophytic nature of the bacilli usually found in aural discharges. Diagnosis. — In children marantic thrombosis most resembles the hydrocephaloid disease of Marshall Hall, or profound anemia of the 310 NEEVOUS DISEASES. brain, the two being often associated. The persistence of serious symptoms such as coma, spasm, and paralysis points to thrombo- sis. The most important diagnostic symptoms are those which dis- tinctly indicate interfeience with the circulation, as marked fulness of the nasal, frontal, or temporal Acins. In adults the disease is confounded with arterial thrombosis, from which it is to be differ- entiated by the less frequent oecurience in the latter of stupor, coma, and spasm, and by the more definite character of the paraly- sis in the former, which can usually be lefeired to some well known arterial distribution. Sinus thrombosis also may occur in adults without the arteriocapillary sclerosis which is so common in the arterial disease. The occurrence of convidsions towards the end rather than at the beginning of an acute infantile aifection is an important diagnostic point in iaxor of primary thrombosis. The diagnosis of secondary thrombosis will be made from the history of the case, from the general symiitoms which are present, and from the symptoms which indicate the invoh'ement of special sinuses. With regard to the history of the case, the presence of disease of the middle ear or of the mastoid, of facial erysipelas, of disease of the orbit or of the mouth, or of any purulent affection of the head, would turn the attention of the physician to the probable presence either of thrombosis or of meningitis, or of both. The general symptoms of sinus thrombosis when secondary are in the main those of meningitis, such as headache, delirium, sometimes stuijor and coma, and irregular fever. If purideut localized meningitis is pres- ent, the symptoms may indicate the parts affected, as unilateral paralysis, or paralysis of the cranial nerves, or affections of various cortical areas, as of the auditory or visual centres. In the diagnosis of special varieties of sinus thrombosis close attention must be also paid to the localizing symptoms. Thrombosis of the cavernous sinus might possibly be confused with several other affections, as local orbital disease, focal meningitis, neuritis of the third, fourth, or sixth nerves, tumor, aneurism, or e^'en nuclear ophthalmoplegia. Careful examination will usually be sufficient to exclude a gross orbital lesion. Focal meningitis of the region of the cavernous sinus may be very difficult to differentiate, and is often associated with occlusion of the sinus. In meningitis the symptoms which indicate involvemcMit of the ner\'es will be likely to precede those which show the presence of obstruction, such as swelling with edema. Optic neuritis is more likely to be present with meningitis than with pure thrombosis, but may be a symi^tom in either. Nea- ritis, even when syjihilitic in origin, rarely attacks more than one cranial nerve at the same time. The limitation of the phenomena to those parts within and around the cavernous sinus is, on the whole, against the diagnosis of tumor, although of course a growth may have any localization within the cranial cavity, making the diagnosis THROMBOSIS OF THE INTRACRANIAL SINUSES. 311 in some instances extremely difficult. Optic neuritis is of more frequent occurrence in tumor. Tlie absence of bruit and tinnitus will assist in excluding aneurism. Nuclear ophtlialmoplegia will be excluded by the fact that it runs a chronic progressive course, usually becoming bilateral, and by the absence of symptoms of irritation and obstruction. In considering the diagnosis of throm- bosis of the lateral sinus, the most important points are the history of purulent discharge from the ear ; the sudden onset of the illness with rigor, vomiting, and j)ain in the affected ear, oscillatory tem- perature, local edema and tenderness over the mastoid and the inter- nal jugular ; tenderness on deep pressure at the posterior portion of the mastoid, and below the external occipital protuberance ; stiffness of the muscles of the back and side of the neck. (Ballance.) Puncture with a hypodermatic needle will determine whether the venous channel is occluded. Symptoms attendant upon emboli being carried to other parts of the body will be of ^'alue for the diagnosis of thrombosis of the lateral or of any of the larger sinuses. Differential Diagnosis of Primary and Secondary Throm- bosis. — The following table from Macewen shows at a glance the main features which separate primary or marasmic from secondary or infective thrombosis : Marasmic (Primary). Infective (Secondary). 1. Chiefly affects the azygos* sinuses. 1. Chiefly affects the dual sinuses. 2. The clots tend to organization or 2. The clots tend to purulent disinte- are absorbed. gration. 3. Hemorrhages into cerebral cortex 3. Hemorrhages into brain seldom in about half the cases. occur. 4. Tendency to produce brain soften- 4. No tendency to brain softening. ing. 6. Seldom purulent infection as a se- 5. Purulent infection common ; septic quence. or infective emboli. 6. No accompanying leptomeningitis, 6. Often coincident purulent leptomen- cerebral or cerebellar abscess. ingitis, cerebral or cerebellar ab- Prognosis. — The prognosis of both primary and secondary thrombosis is bad, but recoveries from either may occur. The recovery from marantic thrombosis is usually not complete, the patient being left with some form of athetoid, choreoid, spastic, or paralytic disease. It gives rise to some of the forms of infantile spastic paralytic disorders. Eecovery from secondary thrombosis is usually due to successful surgical interference. Treatment. — If either primary or secondary thrombosis is dis- covered or suspected during the formative stage, something may be done for its relief. Stimulants, concentrated liquid nourishment, and constant application of heat to the head are useful measures. * The term azygos is applied to parts that are single, — that is, not in pairs. 312 NERVOUS DISEASES. Among tlie most efficient remedies to improve and stimulate cir- culation and aid general nutrition are drugs such as strychnine, strophanthus, digitalis, arsenic, and iron. Gowers suggests that attention should be paid to posture so as to aid the flow of blood in the sinus affected ; thus, flexion of the neck should be avoided when the thrombosis is of the longitudinal sinus. It is no longer true, as was asserted by Huguenin nearly twenty years ago, that we can do nothing to overcome the vascular occlusion itself, supposing it to have been established. Thrombosis of the lateral (sigmoid) sinus has been treated successfully by operation by Barker, Ballance, Salzer, Glutton, Macewen, and others, although in many cases operation has failed. Usually the jugular vein is tied, and the corresponding lateral sinus exposed and washed out through the jugular above the ligature. When the thrombotic clot has extended into the petrosal and other sinuses, or has caused purulent meningitis and abscess, the chances of success are poor ; although it is possible to operate successfully in the same case for both thrombosis and abscess or purulent meningitis. The prophylaxis of infective sinus thrombosis, as of purulent leptomeningitis and of intracranial abscess, is of first importance, and may demand the attention of both the general practitioner and the surgeon. Whenever possible, the formation of primary infective foci should be prevented ; but if these should be present, prompt and radical measures should be taken for their removal. To carry out these indications involves the most careful antiseptic treatment of all wounds and infective diseases of the face and scalp, and of the brain and its membranes, when these are exposed by injury, disease, or operation. Chronic purulent disease of the ear should be regarded as a constant menace to the brain and its sinuses and envelopes. DISEASES OF THE INTRACRANIAL VEINS. Little is known about diseases of the intracranial veins. Venous hemorrhage, although comparatively infrequent, occurs suflSiciently often to be worthy of some attention. Wiglesworth, as already stated, belie^'es that some cases of dural hematoma originate from venous hemori'hages. The intracranial hemorrhages which occur in young children during the paroxysms of whooping cough are, in some instances at least, from ruptured veins. In death from asphyxia, particularly if suddenly produced, hemorrhage may take place from veins and capillaries. I have twice had the opportunity of examining the brains of men who have been hanged, in both cases within a ^ery short time after execution, and numerous capillary and small venous extravasations were present in the floor of the fourth ventricle and elsewhere in the brain. Veins and sinuses are sometimes injured during surgical operations, causing hemorrhages. Occlusion of veins is much more common than hemorrhage. Throm- MALFORMATIONS OF THE BRAIN AND ITS ENVELOPES. 313 bosis of botli veins and sinuses may be coincident, as noted in the preceding section. Doubtless in many cases of sinus thrombosis the coagulse extend into the veins. Clots form somewhat readily in the cerebral veins, because the outpour of blood from the arteries into them is for most of them in opposition to gravity. Localized throm- bosis of a cerebral vein may gi^s^e rise to such cortical symptoms as monospasm or unilateral convulsions followed by monoplegia or hemiplegia. Thrombosed veins have been found in the motor cortex in a few cases of this kind. Emboli from a distance may lodge in the cerebral veins ; and j)hlebitis of the cerebral as of other veins is an occasional accompaniment of various infectious diseases. Arterio- venous aneurisms are sometimes met with, and may result in per- foration of the skull. So little is known about the clinical history of these affections of the encephalic veins that nothing need be said about their diagnosis and treatment. 1CA.LFORMATIONS OP THE BRAIN AND ITS ENVELOPES. Certain abnormalities of structure of the brain are best con- sidered in connection with diseases of the encephalic membranes, as these are often involved in the malformations produced. "Neuraxial malformations in general would perhaps be best considered together, so that, strictly speaking, the spinal abnormalities of structure homologous with those of the encephalon might be treated of here ; Fig. 216. Fig, 217. Anencephalus. (Hirst and Piersul ) E\( nc pitoiilu-i iHir«.t find I'ier«."l ) hut, as this method would probably disturb other points in the arrangement of the work, these affections will be discussed later. They include such diseases as rachiscMsis or sjpina bifida, which em- braces spinal meningocele, spina bifida occulta, and myelocele. Arrests and aberrations of brain development include such abnormalities as anencepMhis (Pig. 216), or absence of the brain ; exencephalm ( Fig. 217), or escape of the brain from the skull ; pseudencephalus, where 314 NERVOUS DISEASES. the brain aud its envelopes and vessels are represented by only a few rudiments ; cydocephalm, or cyclopia, where because of the fusion of the anterior cerebral vesicles of the two hemispheres the two orbits and eyes become merged into one, so that there is a single rudimen- tary eye ; and porencephalus, or limited arrests of development shown by the absence of convolutions or lobes causing irregular subpial cavities. PorencephaUis is frequent in the cerebral palsies of chil- dren, and will be considered more fully when these affections are discussed. Other abnormalities are enccpludocele (Fig. 218), or the protrusion or hernia of brain substance through an opening in the skull which is usually in the median line ; hydrencepha- locele, a form of encephalo- cele containing fluid, aud usually CO mmunicating with the ventricles ; aud meningocele (Fig. 222), pro- trusion from the cavitj' of the skull of a portion of the cerebral membranes, a pure meningocele being present when the tumor containing the fluid does not communicate with the interior of the brain. When brain sub- stance and membranes are together extruded from the cranial cavity, the tumor and cyst thus formed constitute a meningoencephalocele, a jjure encephalocele being present when the protrudiug brain sub- stance ruptures and forces its way through the membranes as well as through the cranium. Acrania, or absence of the skull, does not necessarily include anencephaly. Such monstrosities as acrania, an- encephalus, exeucephalus, pseudencephalus, and cyclopia have, of course, no therapeutic interest. Limited arrests and aberrations may occur, such as absence of the fornix, of the callosum, and of special association tracts, trilobar and cpiadrilobar brain, aud what is known as inoceqiifid, or deficiency of the occipital lobe. Most of these mal- formations are of scientific rather than of practical interest. In chrdnic hydr()ce]i]ialns aud in meningocele something can be done by treatment towards prolonging life, and these affections will be consid- ered in some detail. It may be imi:)oi-tant also to diagnosticate them from som(» of the curable or incurable organic diseases of the ner- vous system ; as, for instance, in a case of infantile cerebral palsy to deterjuine whether it is due to chronic hydrocephalus, to poren- ceiihalus, or to some other lesion, as hemorrhage, sclerosis, or tumor. Microccphdlm, or narrowing of the brain in all directions, will be Encephalocele. (Hirst ami Piersol CHRDNIC HYDROCEPHALUS. 315 more conveniently considered under idiocy and imbecility. In con- sidering tliese malformations it is of first importance to remember the facts and theories which have been presented in the section on the development of the nervous systein, and particularly those jjor- tions which relate to the cerebi'al A-esicles. Embryonal arrests and aberrations of vesicular development account for most of them. CHRONIC HYDROCEPHALUS. Definition. — Chronic hydrocephalus is an aflection in which an effusion slowly takes place into the ventricles (iiitcnial hi/droee^jhalnn), or subarachnoid spaces (external hydrocephahiti). Various forms of acute hydrocephalus have been considered in connection with tuber- cular and serous meningitis. Occasionally cases of this kind arising acutely pursue a subacute or chronic course, but one which, as a rule, is comparatively sliort. In rare cases, as has been indicated under serous meningitis, this affection is x)ractically cured, a small amount of hydrocephalic distention usually remaining. Clinical History. — Chronic internal hydr enlarge ; in others attention may not be directed to this enlargement for Aveeks, months, or even one or more years. In these the effusion is of ^'ery slow progress, and the disease is not infrequently attributed by the parents to a blow or fall or to some acute illness. When the enlargement of the head begins early, and sutures and fontanelles remain open and gradually widen, after a time the skull 1 lears a striking disproportion to the face, sometimes giving the head and face a triangular appear- ance, the latter narrowing to a point at the chin (Fig. 221). Usually the skull becomes rounded or ellipsoidal, but occasional irregulari- ties of the two sides of the head, or local irregularities, are observed, due to the manner in which local ossification has taken place. Sometimes the eyes are pressed down^vard Ijecause of changes in the orbital bones. The veins of the skin enlarge and beciune distorted, and the growth of hair is usually scanty. The child does not develop mentally, or, if at all, very slowly and irregularly ; at an early age it seems to be lacking in powers of attention ; it continues to be uncleanly, cannot be amused or corrected like other childi-en, and after a time general attention is directed to its defective intelligence. It is sometimes unable to hold up its head, and is usually restless, peevish, and hard to amuse and control. :N'ot infrequently it has attacks of spasm, or even a form of epileptic status, one seizure 316 NERVOUS DISEASES. succeeding another at short intervals. Strabismus is not uncommon. Tlie power of standing and walking may not be acquired ; or if the child learns to walk it is often at a late period and in an imperfect manner. In some instances, however, the body and limbs are sym- metrical, and the patient is able to walk and move its upper extrem- FiG. 219. Fig. 220. Chrnnir- liydrocfphnlns wilh iih-iiI;i1 liufi- ciency and epileptiform attaeks ; atroittiic paralysis with contract uns. ln.ir(i(cp!inluv \Mth Imbecility, parah tic and spastie conditions of tlie limlis are absent. ities with ordinary freedom and skill. These are cases in which the pathological conditidn docs not attain a high grade, but even these often show slowness, clumsiness, or uncertainty, and are nearly always very deficient mentally. Sight and hearing are usually pre- served and may be C(unparatively acute. Apparent dulness of sight CHRONIC HYDROCEPHALUS. 317 and of hearing may be due rather to mental weakness and apathy. Occasionally the head attains an enormous size, cases having Ijeen reported in which the head measured more than forty inches in cir- cumference ; and the dimensions may vary from this down to little or nothing above the normal. N()\v and then a hydrocephalic child seems to show unusual precocity, as in the case of one of the chil- dren at the Pennsylvania Training School for Feeble-Minded Chil- dren, who indulged in recitations, imitations of others, and grotesque profanity, which he was prone to exhibit on all occasions. Such appearances of intelligence are usually very superficial. The abo\'e description applies to cases which survive to at least a few years. Some die in convulsions soon after birth. Most cases die before puberty, although some live to middle life or very rarely to old age. I once made an autopsy on a case that had attained the age of nearly fifty years. In this case the head was not of unusual size, but the ventricles were enormously dilated. The man had preserved the full use of his limbs and possessed a fair degree of intelligence, and probably ranked as a high grade imbecile. The case shown in Fig. 219 is now about thirty years old, and j)resents marked atrophy with paresis and contractures of the right half of the body. He has con- vulsive paroxysms at irregular intervals. He is mentally deficient, and yet possesses considerable shrewdness and intelligence and is largely able to care for himself. The patient shown in Fig. 220 is of low grade mentally, but has not the atrophic and jjaralytic con- ditions presented by the preceding case, his face, trunk, and limbs being comparatively symmetrical. Etiology. — Chronic hydrocephalus of considerable duration — of several years at least — may be associated with some forms of brain tumor in childhood, as with gliomata of the cerebellum. The growths in these cases, or at least in some of them, probably produce the hydrocephalus mechanically by pressure on the veins of Galen or by closure of the foramens of Magendie and Mierzejewski. The most common type of chronic hydrocephalus is congenital, and is due to defect of structure, alterations in the quality of the blood, or possibly in some cases to prenatal inflammation of the ventricular ependyma. Pathology. — The bones of the cranial vault are usually much thinned and expanded, and are often widely separated at the sutures and fontanelles, as shown in Fig. 221. Wormian bones may be found in the interspaces between the usual bones constituting the skull, or in extreme cases the entire vault may present the appearance of islets of bone connected by tough membrane. Complete cranial ossifica- tion has, however, in some instances taken place, and rarely the skull may even be thickened. The lateral ventricles and their horns are, as a rule, enormously dilated, and sometimes the aqueduct, the fourth ventricle, and even the spinal canal may take part in the dila- 318 NERVOUS DISEASES. Fig. 221. Skull of a hyclrocephalK- infant. (Agnew.) tution. In congenital noninflammatory cases tlie fluid difi'ers little, if at all, from tbe normal cerebrospinal liquid. In acquired cases it is sometimes turbid or flocculent, and may even contain a \ery small quantity of pus or blood. In these cases, also, the memljranes at the base, the choroid plexus, and the epeudyma of the ventricles may be granular or otherwise changed. The fissures and gyres are largely obliter- ated ; the pia is usually thin, and the surface of the cerebrum .smooth. Structural changes are found in both the gray and the white substance, and yet they often preserve their functions to a remarkable degree, considering the amount of compres- sion which is exhibited. Diagnosis. — The diagnosis may be difficult until the peculiar changes in the conformation of the head ha^'e begun to take place. It will then be based upon a study of these changes and of the symptomatology of the disease already given. Occasionally the heads of rachitic infants bear a considerable resemblance to those of hydrocephalics ; but the differentiation is here made by a study of the other physical conditions commonly present in rachitics, such as changes in complexion and general apiiearance, softness and deformities of the ribs or of the bones of the extremities, and en- largement of the liver. The rachitic head is sc[uarer in shape than the hydrocephalic, the fontanelles are not so protrusive. Hyper- trophy of the brain with coincident enlargement of the skull is a rare affection, which perhaps might be confused with hydroceph- alus ; but in the former the fontanelles and sutures are unlike those in a case of hydrocephalus, and the general conformation of the head and face is different. Certain rare osseous dystrophies cause thickening of the cranial walls, and consequent enlargement of the head ; these may be difficult to distinguish from hydrocephalic enlargements. A peculiar percussion note due to thinness of the skull and brain walls i.s given in hydrocephalus, and this may assist in distinguishing the affection from enlargement of the head due to thickness of the bones. It i.s difficult and almost impossible during life to distinguish betweeu inteimal and external hydrocephalus. A very carefully made puncture might show that effusion was sub- aiachnoidal, but it must l)e remembered that only a few millimetres separate the subarachnoidal space from the enlarged ventricular cavities. Prognosis. — The prognosis of chronic hydrocephalus is very MENINGOCELE. 319 unfa^'o^able. A few cases make spontaneous partial recoveries ; and a few make slight temporary improvement under careful surgical treatment. Treatment. — The medical treatment of chronic hydrocephalus is scarcely worthy of discussion. Cathartics and diuretics can only temporarily affect the intracranial c(_)nteuts ; and absorl>euts, such as mercury and the iodides, while theoretically indicated, can du little or no good, as they do not reach the continuing cause of the disease. Tonics a.nd nutrients may improve the general conditi(.)n of the patient. The methods employed by surgeons have been directed to the relief of hydrocephalus by evacuation of fluid, either alone or in association with com]:)ression. The most common method of evacuation has been directly through the cranial walls or through the fontanelles or sutures. The puncture can be made at almost any position, particularly in cases of great enlargement ; but Keen and others have advised special points for puncture. Lumbar puncture has been suggested by Quincke and others. Evacuation of fluid without comi^ression avails nothing, as the fluid rapidly reforms. Even with comiDression in connection with repeated punctures little can, as a rule, be gained. Compression can be made by strips of diachylon plaster or any strong adhesive plaster, or by elastic bands. Fig. MENINGOCELE. General Considerations. — Meningocele may be either ence- phalic or spinal, but both forms have practically the same pathology. In encephalic meningocele a tumor is formed outside of the skull, by the escape of the arachnopia covered by the dura. The translu- cent vesicle thus formed, Avhich may be of varying size, communicates by a narrow neck with the sub- arachnoid cavity, and is filled, there- fore, with cerebrospinal fluid. It is usually in the median line and in the occipital or nasofrontal region. Clinical History. — In true me- ningocele the tumor is usually ob- served immediately after birth. It is commonly more or less rounded in shape, and the defect in the skull can often be felt. Crying and laugh- ing or any violent expiratory effort increases the tension of the tumor. The fontanelles are usually large and the sutures open. Various paralytic defects and deformities of the face and limbs may be present. The tumor, which is sometimes Meningocele. (Oraham.) 320 NERVOUS DISEASES. sensitive at first, gradually increases in size. Compression may cause cou\'ulsious and bulging of the anterior fontanelle and frontal bones ; occasionally the tumor is divided into two or more lobes. As a rule, the cases li\'e only a few days, weeks, or months. Etiology and Pathology. — Congenital meningocele is due commonly to embryonal arrest of development. Intrauterine hy- drocephalus is probably present in most cases. The pathological apjiearances, so far as known, are those already given in the general description of the affection. Diagnosis. — Meningocele has been mistaken for brain hernia, vascular growths, sebaceous t'ysts, and e\-en for abscesses. Accord- ing to ^\"einlechner, the diagnosis can be readily made if the tumor is jiartly reducible ; if it pulsates synchronously with the heart ; if it increases in size upon crying ; if an opening in the bone can be felt, and if cerebral disturbance follows pressure. AATien tliese signs are absent, the withdrawal of a small quantity of the fluid by means of a hypodermatic syringe will by determining that this is cerebrospinal fluid demonstrate its intracranial origin. An encepha- locele is usually opaciue and has a broader base, while a meningocele and a hydreucephalocele are generally translucent and pedunculated. Cranial fracture with laceration of the meninges and cerebrospinal effusion and possible communication with one of the lateral ventri- cles may gi\e rise to a spurious meningocele known also as acqi^ired cephalocele or traumatic cephalohydrocele. In such a case the traumatic origin is shown by a history of injury and the appearance of the tumor at a point other than one of the sutures. Dr. Francis Huber collected over twenty such cases. According to AVeinleclnier, quoted by Huber, the tumor may appear immediately after injury, or may be delayed several weeks or months. Pressure in such cases may cause no cerebral disturbance, and pulsation is usually absent. (Graham. ) Prognosis. — The prognosis is almost always very grave, death occurring in a short time. Sometimes the tumor bursts after attain- ing considerable dimensions. In rare instances, when the cleft and enlargemeut are small, closure takes place and reco\ery follows. In rare instances also surgical interference is successful. Treatment. — To protect the tumor from external pressure or injury, and with the hojie of limitiug or checking its growth, pads or covers can be used. The withdrawal of fluid with antiseptic pre- cautions and the application of pressure, or puncture foUowed by the injection of a solution of iodine ten grains, potassium iodide thirty grains, and glycerin one fluidouuce, has been followed by cure. Operatives treatment is much more likely to be successful when cdmnuinicatiou with the cavity of the cranium no longer exists. The radical o]ieratiou of removing the sac and closing the wound, with antiseptic precautious, has been successfully performed. CHAPTEE IV. ENCEPHALIC HISTOLOGY AND PHYSIOLOGY IN THEIR RELATIONS TO FOCAL DISEASES OF THE BEAIN. GENERAL CONSIDERATIONS. The best method of discussing focal diseases of the brain is one based in, a general way on its embryonic subdivisions, modified considerably by the requirements of practice, — by what experience has taught to be the most frequent sites and extensions of lesions. Hemorrhage, softening, tumor, or abscess may be limited to an embryonal subdivision, but on the other hand the same lesion may invade two or more parts. Cortical focal diseases are, as a rule, confined to the cortex and subcortex of the prosencephalon, but deep seated lesions commonly invade both prosencephalon and thalamen- cephalon, as where intracerebral hemorrhages and softenings partly destroy striata, capsules, and thalamus together. Other parts enter- ing into the formation of the forebrain — as the olfactory bulb, callo- sum, fornix, optic nerve, hypophysis, and conarium — are often the foci of disease or the seats of special processes of degeneration. The affections of the midbrain — which includes the iter, quadrigeminal body, and crura — are probably best considered apart or with those of the pons. Focal diseases of the cerebellum are probably also best considered separately, although the pons and cerebellum to- gether are derived from the fourth secondary vesicle, and hence jointly constitute an embryonic subdivision. Diseases of the pons and oblongata can be discussed in part separately and in part to- gether. Usually diseases of the cranial nerves are considered in a special chapter or chapters, and it is best perhaps to follow this method. The difficulties which beset any method are, however, great, as is illustrated by the fact that in the diagnosis of symptoms which may be dependent upon lesions of the cranial nerves — as hemianopsia or paralysis of ocular movements — it may be necessary to take into consideration affections of the mesencephalon, thalamen- cephalon, or prosencephalon. The focal diseases of the brain include hemorrhage, embolism, thrombosis, aneurism, tumor, and abscess ; and, in the next chapter, it will be found most practical to consider these focal diseases and some of their most important consequences, such as monoplegia, hemiplegia, hemianesthesia, monospasm, athe- tosis, aphasia, and hemianopsia ; and also some of the cerebral pal- sies of children, which may be due to arrests or destructive lesions of the forebrain, presenting characteristics dependent upon the time 21 321 322 NERVOUS DISEASES. and manner of their development. Postmortem examinations of tlie brain, especially with reference to the localizing and recording of lesions, are best considered in connection with the study of focal diseases, as is also localization in its relations to craniocerebral sur- gery. The general anatomy and general physiology of the brain, as of other parts of the nervous system, having already been con- sidered, it will only be necessary to discuss briefly the physiologj^ of special regions before considering their focal diseases. This dis- cussion will involve a summary of the minute anatomy of cortical and other structures, and a presentation of accepted facts regarding encephalic localization. MINUTE ANATOMY OP THE CEREBRAL CORTEX. General Features of the Cortex. — The depth of the cortex, or rind of the cerebrum, is usually reckoned as from two to three millimetres, but in health it may vary from one and two-tenths to four millimetres. The greatest depth is at the summits of the con- volutions ; regionally its maximum depth is in the mesal portion of the so-called motor region. It diminishes in depth backward from this region to the occipital pole, but all gross determinations of the thickness of the cortex in average normal brains are liable to error. The depth of the cortex of the right hemicerebrum is stated to be slightly less than that of the left, and the same is said to be true of the female as compared with the male brain. Various arrests and diseases may cause great variations of cortical thick- ness. The superficial extent of the cortex has also been shown by ingeniously contrived and executed methods of measurement to vary considerably in health, and sometimes enormously in disease. The specific weight of the cerebral cinerea, whether cortical or ganglionic, is somewhat less than that of the white substance. A vertical section of the cortex, particularly in certain locations, can be seen even with the naked eye to have a laminated arrange- ment. Histological Studies. — Since the wonderful discoveries of Golgi, whose methods have been adopted and improved upon by numerous investigators, intricacies of cell structure not dreamed of a few years since have been revealed, resulting in tlie general recognition of the ''neuron" or nerve cell as the unit of nervous and psychical function, and of the fact, now universally conceded, that these nerve cells transmit impulses by contact of their processes and bodies. We are therefore now able to apply more clearly to the solution of physiological and pathological problems the truths determined by liistology. Knowing the origin, course, and methods of association and communication between these nerve cells, we gain a clearer conception of the phenomena which are still properly re- ferred to special areas of the cortex or to subcortical ganglia and MINUTE ANATOMY OF THE CORTEX. 323 tracts, and also of the effects of disease and dissolution upon cere- bral structures. According to the views which prevailed down to the time of Golgi, the connections between neighboring nerve cells were supposed to be affected either by anastomosis of cells and processes or by fusion of other processes into a finely granular or 1790 Fig. 223. 1840 BaiJIc 'aryer 1852 Diagrams indicating the views of Vicq d'Azyr and Baillarger, and the earlier views of Koellilcer, as to cortical lamination. (After Dejerine. ) amorphous mass, called the granular substance. The stains and methods of microscopical investigations employed were unequal to the task of unsealing and unravelling the mysteries of this substance and the apparently anastomosing nerve fibres. Not only have views undergone a radical change with reference to the nature of formerly undemonstrated structures and the methods of cell communication, 324 NERVOUS DISEASES. Fig. 224. 3E=S??=^T^ Section of 1 uman cerebral rt x stained ■with s liuiu carm natc i I C D fliNt, second, third, and fourth hiyers ; p, pial tissue ; v, t>', bloodvessels. (Piersol.) but it has become necessary to modify other opinions, such as those re- lating to cortical lamination, and the methods of entrance and exit of nu- merous systems of nerve fibres into the various layers of the cortex. Discoveries of Golgi. — Golgi showed (1) that the protoplasmic expanses and branchings of the nerve cells preserved their indi- viduality to their free terminations; (2) that branching processes of adja- cent cells did not anastomose; (3) that processes did not blend and fuse into a granular basic sub- stance ; (4) that, in addition to the basic protoplasmic processes, the py- ramidal, the fusiform, and the poly- morphic cells gave off axis cylinder processes which in their turn had processes branching at right angles to their general course ; (5) that a plexus was formed by fine fibrils or collaterals ramifying into other fibrils of extreme delicacy ; (6) that some cortical nerve cells had long axis cylinder processes which pre- served their individuality for a great distance and became mediillated nerve fibres of the white substance, and that others had short axis cylin- der processes which lost their indi- viduality in the immediate neigh- borhood of the cells from which they sprang. He regarded the first as motor and the second as sensory cells.* Cortical Lamination.— Vicq d'Azyr regarded the cortex as con- stituted of only three layers. Bail- larger held to six, arranged from * In the preparation of this section I have made free use of the contributions of W. Lloyd Andriezen, and especially of his article on Some of the Newer Aspects of the Pathology of Insanity, in Brain, Part IV., 1894, pp. 548-692. MINUTE ANATOMY OF THE CORTEX. 325 Fig. 225. witlim outward in layers of alternating white and gray matter. Koelliker in 1852 consolidated these layers into three. The views of these authors are indicated diagrammatically in Pig. 223. With improved microscopical methods new subdivisions of different re- gions of the cortex were made by Meynert, Bevan Lewis, Mierze- jewski, Clarke, and others. The Eolandic cortex has been most studied as regards lamination and other structural peculiarities, and the descriptions and diagrams of recent years have been based chiefly upon investigations of this region. Its subdivision by Meynert into fi-^-e lay- ers is the one that has been generally given in textbooks, treatises, and mono- graphs, sometimes with slight modifica- tions in detail. Pour of these five layers are shown in the diagram, Pig. 224. The lamination of the cortex, however, differs in different regions of the brain, as es- pecially shown by Meynert and Bevan Lewis. Altogether, Meynert has de- scribed five regional types : (1) a com- mon cortical type ; (2 ) an occipital type ; (3) a Sylvian type ; (4) a type belong- ing to the cornu ammonis ; and (5) a type peculiar to the olfactory bulb. The investigations in regional variations of lamination by Meynert and Bevan Lewis, although of great interest and value, cannot here be given. The five layers as usually given, following Meynert, were made up of (1) an outer or superficial layer of basis substance and neuroglia, long thought to contain no nerve cells, but in which Exner later discovered an intricate nerve plexus ; (2) a clearly de- fined layer of closely packed small py- ramidal cells with their apices towards the brain surface, and axis cylinder pro- cesses passing inward ; (3) a layer chiefly of large pyramidal cells interspersed with small pyramids, often called the forma- tion of the cornu ammonis, because most strikingly developed in this region ; (4) tlie granular formation of Meynert, composedchiefly of small, rounded, angular nerve cells and also radiating meduUated nerve fibres : (5) the claustral formation of Meynert, a layer composed chiefly of fusiform or spindle-shaped cells interspersed with rather large but Perpendicular section of the gray substance of a cerebral convolution : 1, molecular layer; 2, layer of small pyramidal cells; 3, layer of large pyramidal cells ; 4, layer of poly- morphic cells; 5, white substance. (Ram6n y Cajal.) 326 NERVOTJS DISEASES. Fig. 226. sliort pyramidal cells. Bevan Lewis also described five layers as pe- culiar to the motor or Eolandic cortex, but did not separate them exactly after the manner of Meynert. Golgi recognized three layers as existing everywhere in the cortex, although these are not sharply defined in all locations, and also described three great types of cells, — the fusiform, the pyramidal, and the globular or polygonal. The pyramidal cells, according to him, were mainly in the superficial and middle layers, the globular cells occurring every- where, but most abundantly in the neighborhood of the fusiform or spindle- shaped cells, which were found almost entirely in the deepest of his three layers. Subdivision of the Cortex into Four Layers. — Following Eamon y Cajal, the now generally accepted di- vision of the cortex is into four layers : (1) a molecular layer ; (2) a layer con- taining small iDyramidal cells of vari- able shape, called by Andriezen the ambiguous ; (3) a layer of large py- ramidal cells with long apical pro- cesses ; and (4) a polymorphic layer. This method of subdivision into four layers is shown in Figs. 225 and 226. In some cortical regions striking de- partures from the usual arrangement into these four layers are found. In the cornu ammonis, for instance, the molecular layer and the large pyramidal cells are conspicuous, the ambiguous layer being practically absent. Types of Cells in the Four Corti- cal Layers. — Eight types of cells are now recognized as entering into the composition of the four cortical layers : ( 1 ) pyramidal cells with long ascending apical processes which reach the molecular layer ; (2 ) pyramidal cells with short ai>ical processes which do not reach the molecular layer ; (3) aiiil)iguous cells wliich have various subtypes, as the globose, fusi- form, and asymmetrical bicornute ; (4) granule cells with short and ijupeilVct protoplasmic piocesses ; (5) fusiform or triangular cells with asci'iuling axis cylinder processes, sometimes called Martinotti's cells ; (6) fusiform cells with descending axis cylinder processes ; Section of cereliral cortex (motor area) of a child, stained by Golgi's silver method : A, layer of neuroglia cells ; B, layer of small pyramidal ganglion cells ; C, layer of large py- ramidal cells ; D, layer of irregular smaller cells. (Piersol.) MINUTE ANATOMY OF THE CORTEX. 327 (7) oblique and inverted pyramidal cells with descending axis cylin- der processes ; (8) polygonal cells with short branching axis cylin- der processes, sometimes spoken of as Golgi's sensiti\'e cells. Other cells, fusiform and triangular, have been described by Eamou y Cajal as present in the molecular layer, and were regarded by him as embryonic. Andriezen has not succeeded in discovering these in man. The behavior of these cells in the presence of staining agents is, of course, a matter of vital importance in their study. Some, like the large pyramidal cells, are chromophUous, staining readily ; others are chromophobic, staining with diiiiculty. Among the latter are the triangular, the polygonal, and some fusiform cells. Various gradations in their reactions to stains are found throughout the list of cells. The Molecular Layer. — The outermost ijortion of the molec- ular layer, the most superficial film of the cerebral substance, is composed of a system of neuroglia fibre cells called by Andriezen the caudate cells. These cells and their processes form a fine felt- work of cortical glia fibres. A few other giia cells are found in the molecular layer. They unite the caudate cells with stellate fibre cells which are abundant in the alba and are sparsely present in the cinerea. !N"ext below are the neuroprotoiDlasmic structures, formerly classed under the general term molecular substance. The following structures have been determined as entering into the composition of this molecular substance : (1) descending neuroglia fibres from the caudate cells ; (2) transitional fibre cells and their processes ; (3) a forest of protoplasmic processes ascending and branching from the ambiguous layer ; (i) protoplasmic processes of tuftlike appearance ascending from the long pyramidal cells ; (5) cell bodies and protoplasmic processes of polygonal cells in- trinsic to the molecular layer (Golgi's sensitive cells) ; (6) special protoplasmic glia cells with their processes, found in this and in other layers of the cortex and first described by Andriezen ; (7) Exner's plexus— nerve fibres of various kinds, including axis cylin- der processes, some of which have been traced from the centrum ovale and which are probably either association, commissural, or projection fibres — intermixed with which is a larger number of naked processes, collaterals and terminals ; (8) fine, non-meduUated, terminal branches and collaterals derived from the thick fibres of the last system described, either as offshoots from below or from the peripheral branches in the molecular layer itself; (9) ascending axis cylinders from fusiform, triangular, and polj'gonal cells in the deeper cortex ; (10) branching short axis cylinders from deeply situ- ated local polygonal cells ; (11) ascending collaterals from the axis cylinders of the subjacent pyramidal cells ; (12) a few ascending col- laterals from Golgi's polygonal cells in or below the ambiguous layer ; (13) certain fusiform nerve cells, described by Eamon y Cajal, in the 328 NERVOUS DISEASES. Fig. 227. Gt. P. P. upper jjart of the molecular layer. This single layer of the cortex is thus seen to contain a wilderness of nerve fibres, but a wilderness which has proved penetra- ble to modern investigation. This molecular layer, espe- cially in certain regions, as that of the cornu ammonis, has been found to subdi- vide readily into three strata, which from without inward are termed (1) the stratum iiwleeidare, (2) the stratum lacunosum (corresponding to Exner's plexus), and (3) the stratum radiatum. A glance at Fig. 227, by Andriezen, which is intended to repre- sent the nerve fibre systems and plexuses of the entire cortex, shows the extraor- dinary complexity of these structures. The Ambiguous Layer. — To the second layer of the cortex Andriezen has applied the term ambiguous, because of the variability and indefi- nite shape of many of its cells. They are chiefly fusi- form, pyriform, triangular, or polygonal, with many small p^Tamidal cells interspersed, and hence the formation was called by Eamou y Cajal the layer of small pyramidal cells. One striking feature of the cells of this layer is their bi- furcating thick upper part, giving the appearance of two unequal horns. These cells, which are chromophobic, are enormously de- veloped on the posteroiuferior portion of the hippocampal gyre. They have distinct axis cylinder processes which usually come off obliquely and desceiul through the subjacent laminre. Some of these processes are in the deeiior parts of the cortex, while others have not been traced to their destination. On the confines of this layer, both above and below, the so-called Golgi's sensitive cells appear, and branch rapidly into a mesh work of terminal fibres. Cortex of human brain, showing the nerve fibre systems and plexuses (combined Wuigert'-s and Golgi's methods): c.z., clear zone (free of nerve fibre) ; MP., molecular plexus (Exner's), in the molecular layer ; A. str., ambiguous cell stratum; Subm. P., submolec- ular plexus ; Gt. P.P., great pyramidal plexus ; Pol. P., polymorphic plexus; \V,, white substance. (W. Lloyd Andriezen.) MINUTE ANATOMY OF THE CORTEX. 329 The Layer of Large Pyramidal Cells.— The layer of large pyramidal cells, often called the formation of the coruu ammonis, because of its enormous development in that region, is one of vast importance in the study of the cellular physiology of the nervous system. The pyramidal cells with short apical processes are found everywhere in the cortex below the molecular layer. Their termi- nations never pass into this layer, but end in the ambiguous layer. They are regarded by Audriezen as belonging to a diffeient system from the pyramidal cells with long apical processes. The layer of these large pyramidal cells is, however, more definite in position and connections ; the cell processes invariably reach upward and end in the molecular layer — mainly in Exner's plexus. These apical processes also reach to some extent into the molecular stratum, and send lateral branches into the radiate stratum or sublayer. The cell bodies increase in size as the layer is descended, — that is, as the polymorphic formation is approached. A basilar system of proto- plasmic processes extends downward, ending in the polymorphic layer. Andriezen has shown that both the apical and the basilar protoplasmic processes have definitely traceable connections. These are (1) the apical processes with naked collaterals and terminals of the medullated nerve fibres which ascend from the white substance and ramify in Exner's plexus ; the terminals and collaterals of the medullated fibres also come into contact with the processes of the ambiguous cells when these latter are present ; (2) the basilar pro- toplasmic processes with a system of fine medullated nerve fibres — whose terminals and collaterals are, however, nonmeduUated — which ascend from the alba. Thus are formed basilar and apical nervoprotoplasmic plexuses. While the vast majority of the fibres from the white substance end in the lacunar stratum of the molec- ular layer (Exner's plexus), a much smaller number terminates in its other strata. Thus are constituted the great extrlmic con- nections of these cells, which, however, have also intrinsic relations with the adjacent cells. One other important connection of the apical processes of the large pyramidal cells is with the axis cyl- inder processes of cells in the polymorphic layer, called Marti- notti's cells, which are usually fusiform or triangular. The in- trinsic cells come in contact with the pyramidal cells by terminal tufts of fibrils which clasp the bodies of these cells. These last described connections have been traced only in the regions of the cornu ammonis and fascia dentata. Certain nerve fit)res leave the body of the pyramidal cell at its base and pass downward through the polymorphic layer to enter the white substance, giving off a few delicate collaterals at right angles in the subpyramidal layer. These constitute the beginnings of the motor system of fibres. The Polymorphic Layer.— The main cell types in the poly- morphic layer are described by Andriezen as (1) pyramidal cells 330 NERVOUS DISEASES. with short apical processes ; (2) granule cells with short and im- perfect i)rotoplasmic processes ; (3) fusiform cells with ascending axis cylinder processes (Martinotti's cells) ; (4) fusiform cells with descending axis cylinder processes which pass into the white sub- stance ; (5) asymmetrical or oblique pyramidal cells intermediate in form between the fusiform and the true pyramidal cells ; (6) inverted pyramidal cells ; (7) polygonal cells with short branching axis cylin- der processes (so-called Golgi's sensitive cells). Andriezen regards the polymorphic system as a new development. The brain of the mammal possesses this layer, which is not found in the reptilian or amphibian brain, and which in the higher mammalian brains is in- tricately involved and complicated. Step by step this polymorphic layer develops in the higher order of mammalian brains. Differing from Meynert and Obersteiner, Andriezen regards the cells of this polymorphic system as having been originally pyramidal. It would seem that in the process of evolution, as more and more associations have been made, cells tending originally to be pyramidal have been twisted out of shape and position in this layer. The polymorphic cells have to a certain extent migratory powers. They are not the only association cells. The older systems of association fibres in the amiDhibian and particularly in the reptilian brain are found in the upper two layers of the cortex, and the callosum appears before the mammalian brain is reached. Cortical Termini of the Sensory Projection System. — The sensory excitations passing upward to the cortex by projection fibres are distributed mainly in the molecular and submolecular regions, the impulses affecting the processes of both the ambiguous and the long pyramidal cells. This has been shown to be true of the olfac- tory and optic projection fibres, and is probably true also of the auditory and fillet radiations. Andriezen found that the olfactory radiations end chiefly in three places : (1) in the callosal portion of the genu of the gyrus fornicatus ; (2) in the septum lucidum ; and (3) in the inferior ends of the hipjoocampal and uncinate gyres. The optic radiations were found to terminate chiefly in accordance with the views of Henschen, — namely, in the cortex of the calcarine fissure. With others, he believes that the fillet radiations have their endings in the posterojiarietal region, though a few of the fibics terminate cephalad of the central fissure. The entire cere- brum is regarded as an u])ward development of the sensory projec- tion systems. The fillet system includes fibres for the transmission of tactile, pathic, thermal, muscular, gustatory, and perhaps other forms of sensibility. The olfactory and optic projection systems terminate in special areas of the cortex, — those which are usually recognized as zones or ci^itres for smell and vision. Similarly the auditory radiations probably terminate in the superior temporal convolutions. In the molecular layer the terminal processes of the MINUTE ANATOMY OF THE CORTEX. 331 sensory projection systems come into contact Avith the apical pro- cesses of the cells of the ambiguous and pyramidal layers. For this reason, according to Andriezen, the pyramidal and ambiguous cells shovild be regarded as the first sensory cells of tlic cortex. Separate Sensory and Motor Localization.— The different theories as to the separate cortical localization of movements and of cutaneous and muscular sensation which have led to so much con- troversy have again become prominent in the light of the new re- searches just summarized. Those who contend against the doctrine that the Eolandic cortex is a purely motor region believe they have received additional support for their views. Let us recall here some of the varying hypotheses. Schiff holds that this region is the seat of tactile sensibility ; Munk, that it is a general sensory area ; Nothnagel and Hitzig, that it is related to the so-called muscular sense ; Bastian, that it is kinesthetic, the only true motor centres being bulbospinal ; others, in a more or less indefinite manner, that it is a sensorimotor region ; while the view of Ferrier, Charcot, and many others is that the area is a true motor zone, one containing centres of movements which involve conscious discrimination. Ac- cording to Horsley, in this region are represented tactile sensations in slight degree, the so-called muscular sense, and, preeminently, specialized movements. Some, like Waller, avoid the use of the terms motor and sensory centres, because this might imply spon- taneity, holding that every centre must be a point to which impulses come as well as one from which they go. Bechterew holds that the motor and sensory centres are quite independent, but that they lie very close to each other and sometimes one over the other. As shown by Forel and N'ansen, we have been too long handicapped by prevailing ideas of cell action and by theories of the parts played by the cell bodies as originating centres. Impulses are transmitted and transferred by processes as well as hy the cell bodies. The function of the latter is chiefly trophic. The new researches and theories do not compel an abandonment of former views as to special localizations, although different standpoints may need to be taken. As already stated, the use of the term centre in neurology is largely one of convenience. Disregarding theory entirely, the subdivision of the cerebrum into physiological lobes, as indicated in Figs. 47 and 48, on pages 36 and 37, for practical purposes remains a good one. While the whole cortex in some of its strata may be regarded as a great sensory expanse, its Eolandic portion and particularly the convolutions cephalad to the central fissure constitute a region which is related to specialized movements of various parts of the body. One calls it motor, another kinesthetic, another sensorimotor, and another executive. For the purposes of the physician and surgeon it is a motor sphere. Its irritation causes specialized movements ; its destruction impairs or abolishes these movements. It is as much 332 NERVOUS DISEASES. the area where the motor portion of the great sensorimotor act begins as where the sensory portion of it ends. The cerebral sen- sory area, cortical and subcortical, would from this point of view be that part of the cerebrum where the fillet radiations in their most compact form are nearest to the surface of the brain ; and therefore this region might continue to be described as in the pos- teroparietal, quadrate, and fornicate convolutions. Destruction of this region causes loss or impairment of sensation, while irritation of it gives rise to phenomena of sensory excitement.* CORTICAL LOCALIZATION. The Prefrontal Lobes.— In the diagrams Pigs. 228 and 229 the prefrontal region is termeil "higher psychical," a not altogether unobjectionable designation. It is the area entirely cephalad of that universally recognized as related to the representation of movement. All xjarts of the brain in some way take part in mentation, — the brain in its entirety is the great psychical organ, — but this particular portion of the cerebrum is related to the highest of the high pro- cesses which have become through evolution the especial attributes of man. Hitzig, Ferrier, Goltz, Munk, Horsley and Schafer, and Bianchi, among others, have experimentally studied the prefrontal lobes. These investigators have found more or less mental degrada- tion to be the result of ablation or partial ablation of these lobes, the animals losing the faculty of close attention and intelligent observa- tion ; and undoubtedly impairment and disturbances of a peculiar character occur both in the lower animals and in man from lesions of this portion of the brain. The higher and more complicated in- tellectual processes — those which involve such faculties as attention, judgment, and comparison — are always affected. Inhibition is im- paired. Bianchi extirpated one prefrontal lobe, and in some in- stances both lobes, in the dog and ape, and according to him these * Flechsig's Subdivision of the Cortex.— In this connection the most recent views of Flechsig sliould also be given. He makes two great divisions of the human convolutions. Tlie one includes those areas which receive or give origin to the sensory or motor filjres (optic radiations, jiyramidal tracts, fillet, etc.). The first area Flechsig refers to as "sensory centres." They include the areas of vision. The second divi.sion lias no direct communication with the corona radiata, and contains only association fibres, the callosum and commissural filjres especially. The areas of the second great class, "association centres," oc- cupy those portions of the brain that have not been allotted specific function by the localizationisls. In the brain of a child three months old almost the entire cor(]na radiata is meduUated, and the streams of meduUated fibres radiate to sensory areas. The association areas comprise four great tracts, the anterior portion of the frontal lobe, the island of Reil, the precuneus, and the posterior portion of the [larietal lobe. It is probable that at this early stage of develop- ment each sensory centre possesses its own sensory mechanism, distinct from every other. COKTICAL LOCALIZATION. 333 Fig. 228. VA O T O R Zones and centres of the lateral aspect of the human cerebrum. lobes are the organs in wMch the sensorial and motor products of the cortical zones are coordinated and synthesized. As stated on page 37, this region might be designated the lobe of re-representation or of Fig. 229. J R Zones and centres of the mesal aspect of the human cerebrum. 334 NERVOUS DISEASES. complex coordination. Bianehi believes that these lobes elaborate from one side the products of the cortical nerve cells of sense and motion in series, and from the other all the emotional states that ac- company single perception, from the fusion of which arises "psy- chical tone. ' ' Destruction of these lobes causes disintegration of the peisonality, and incapacity to form serially groups of images or rep- resentations, more or less psychical dissolution occurring according to the extent of the lesion. Hesitation, uncertainty, fear, lack of force, weakness of the highest faculties, and motor inquietude due to loss of control, may be present. Subdivisions of the Rolandic or Motor Cortex. — The divisions of the Eolandic or so-called motor cortex most in accord with known facts are shown in Pigs. 228, 229, and 230. The region for the lower ex- tremity is in the upper or most mesal portion, and is narrower than the other areas. The area for the upper extremity is in the middle portion of this re- gion, and that for the face in the lower. The imaginary horizontal sub- divisions are nearly in a line with the superfrontal and medifrontal fissures. Cephalad the region reaches a little forward of an imaginary extension of a line from the ascending branch of the Sylvian fis- sure to the edge of the hemisphere. Caudad it is Lateral surface of the tirain of a monkey : 1, centres of movements of the opposite leg and foot such as are con- cerned in locomotion ; 2, 3, 4, centres for the various com- plex movements of the legs and arms ; 5, centre for ex- tension forward of arm and hand ; 6, centre for movement of the hand and forearm in which the biceps is particu- larly engaged ; 7, R, centres for the elevators and depressors of the angle of the mouth respectively ; 9, 10, orolingual centres ; 11, centre of the platysma ; 12, centre for lateral movements of the head and eyes with elevation of the eyelids and dilatation of the pupil ; a, b, c, d, centres of movements of the fingers and wrists ; circles 13, 13', visual centres, including also occipital lobes ; circles 14, auditory centres. (Ferrier.) bounded l>y the retroceu- tral fissure, although probably sometimes extending somewhat back- ward towards the parietooccipital fissure. Some authorities include the superior parietal convolution in the lateral motor cortex ; but it is more probable that this region belongs to the cortical sensory sphere (fillet radiations), or that the sensory and motor zones here blend or digitate. On the mesal aspect of the hemisphere the motor cortex includes the marginal convolution from the caudal termina- tion of the callosoinarginal fissure forward to the knee of the gyrus fornicatus, having from before backward head, arm, trunk, and leg subdivisions as shown in Figs. 229 and 231. Subareas for the Lower Extremity.— While the cortical CORTICAL LOCALIZATION. 335 representation for different segments of the lower extremity has not been worked out as aecuiately as for the upper, it has been tletei- mined that movements of the hip and knee are localized lur\^'ard near the centres for the shoulder movements. The representation of movements of the hallux, or ijreat toe, has been determined to be about the junction of the middle and posterior thirds of the leg area, and that of toe movements most strikingly at its posterior part. Some investigators place the centi'es of representation for movements of the toes almost as far back as the parieto-occipital fissure. The ankle representation is probably situated between that of the knee and the areas for the gieat and small toes. On the mesal surface of the hemisphere in the general area for the lower extremity the centres of representation of movements of flexion at the knee and toes, of extension at the hip, and also of some other movements of the foot and the small toes, have been determined as shown in Fig. 231. Fig. 231. Mesal aspect of the human cerebrum, showing areas of representation for movements. Representation of Trunk and Spine Movements.— So far as has yet been determined by experiment and clinicopathological observation, spinal and trunkal movements are most strongly repre- sented on the mesal aspect of the hemisphere, cephalad of the area for the lower extremity. This representation seems to extend a 336 NERVOUS DISEASES. short distance over to the lateral surface, as indicated in Pig. 228. When the electrodes were applied to the lateral surface of the hemisphere near its edge, and most strikingly when applied to the mesal aspect, Horsley and Schafer obtained arching and rotation of the lower spine and pelvis. One or two cases have been recorded in which trunkal spasm or paralysis was apparently due to cortical lesions. Subareas for the Upper Extremity. — In Fig. 228 the arm or upper extremity area is seen in the mid-Eolandic region, occupying a larger space than either of the other great subdivisions of the motor zone. Numerous experiments and observations have shown that this area can be subdivided in an almost regular manner from below upward for the representation of movements of the chief segments of the upper limb in the same direction, that is, for the thumb and fingers, wrist, elbow, and shoulder. At the upper con- iines of the general area the representation of shoulder movements blends with that for movements of the lower extremity, and es- pecially for those of the hip and knee ; while at the lower boundary the representation of thumb and finger movements blends with that for upper face movements. Excitation experiments at these posi- tions call forth movements of both upper and lower extremities in the one case, and of the upper extremity and face in the other. It will not be necessary to recall the numerous experiments and rei^orted cases indicating the subdivisions of this zone. One impor- tant fact determined is that the representation of the upper ex- tremity is much greater cephalad than caudad of the central fissure. The positions of the foci of representation of nearly all the small segments of the upper limb ha^e been gradually differentiated. Subareas for Face Movements. — Somewhat closely crowded together around the foot of the central fissure are the centres of representation of the various important movements of the face, as determined by many experiments and many reported cases. The general results of the observations and investigations may be sum- marized in the statement that, as shown in the figure, the move- ments rei^resented in this area are, from above downward in order, for the orbiculoiialpebral movements, for movements of the angle of the mouth, and for movements of the lips and tongue. The platysmal movements are probably represented in the posterior and inferior portion of this general area. Subarea for Movements of the Lower Jaw. — Horsley has placed the centre for masticatory movements, that is, for the move- ments of the lower jaw, just behind the laryngeal and pharyngeal centres, near the lips and tongue representation. During an opera- tion he found that electrical stimulation of the precentral convolu- tion at about the junction of the upper and the middle face area caused lateral movements of the jaw and of the angle of the mouth. CORTICAL LOCALIZATION. 337 Laryngeal and Pharyngeal Representation. — N'ow and then is seen a case of liemiijlegia due to cerebral lesion in which ai»houia or some change of intonation is present. These cases in luy own experience have generally been left monoplegias, which would seem to bear out the view of Seguin that laryngeal rei^resentation is better differentiated on the right than on the left side of the cere- brum. A case of Seguin, and the experiments of Krause, Semon and Horsley, Ferrier, and Masini, indicate the probable location of this centre near the precentral fissure, cephalad of the areas for the pharynx, lower jaw, lips, and tongue. Bilateral extirpation or bilateral lesions seem to be necessary in some instances to produce decided phonatory impairment. Garel has reported a case of cor- tical vocal paralysis, with the details of an autopsy and a sketch of the locality of the lesion. The inferior portion of the precentral gyre on the right side was slightly adherent to the meninges. The membranes being stripped, the surface beneath presented a light yeUow discoloration. At the foot of the third frontal gyre were two points of red softening involving almost solely the cortical substance at the upper part, very slightly invading the white. The lesion of the precentral also penetrated slightly into the white substance. The most important of Horsley and Semon' s conclusions were (1) that in the monkey is a small area at the lower and anterior portion of the foot of the precentral gyrus, excitation of which produces complete adduction of the vocal cords (bilateral action) ; (2) that around this area is also represented abduction of the vocal cords, but only feebly and in association with other movements — as those of deglutition ; (3) that unilateral extirpation of the whole region produced no appreciable paralysis of the glottis closers or openers. From a general study of the subject of laryngeal cortical representation, Delavan arrives at conclusions as follows : (1) that unilateral irritation of a given cortical centre excites the correspond- ing bulbar centre and causes bilateral movement ; (2) that unilateral destruction of a given cortical centre is without result, as the in- fluence of the opposite cortical centre is sufftcient to excite the corresponding bulbar centre and thus to cause bilateral movement ; and (3) that bilateral destruction of a given cortical centre causes paralysis. A few experiments apparently show that pharyngeal movements are represented in regions of the cortex closely related to the laryngeal centres, probably a little more caudad. Laryn- geal, pharyngeal, and masticatory movements have an almost equal bilateral cortical representation, the cortical centres for each side being sufficient for the movements of both sides. Representation of the Movements of the Head and Eyes.— As shown in Fig. 228, various movements of the head and eyes are represented in a large area of the cortex,— the most cephalic of the great subdivisions of the motor zone. This area on the lateral aspect 22 338 NERVOUS DISEASES. of the hemicerebrum occupies the posterior portions of the super- frontal and niedifrontal convolutions, and the upper part of the posterior j)ortiou of the subfrontal convolutions. Perrier, Beevor and Horsley, and Mott have made valuable contributions to our knowledge of this cortical region. Ferrier found that irritation of the posterior extremities of the superfrontal and medifrontal convo- lutions caused deviation of the head and eyes to the opposite side. Destruction of these centres, according t(j some authorities, causes conjugate deviation to the side of the lesi<_)n. Beevor and Horsley studied the separate representation of the movements of the head and those of the eyes, and also of their associated movements. The movements of the head studied were simple lateral deviation with elevation of the muzzle (in dogs), and adduction with rotation of the head to the opposite shoulder. The movements of the eyes studied were simjjle opening of both eyes, turning of the eyes to the opposite side and upward, the same deviation with downward incli- nation, and partial or complete return of both eyes to the middle line; also movements of contractidu and dilatation of the pupils. They found that movements of the head had a larger cortical repre- sentation than those of the eyes alone. Mott succeeded in making three subdivisions of this area tor the movements of the head and eyes, — one for lateral deviation and downward inclination in the superfrontal convolution near the edge of the hemisphere and ex- tending over into the marginal lobule, a second for simple lateral de- viation, farther removed from the longitudinal fissure, and a third for lateral deviation or rotation to the opposite side with upward in- clination, still lower down towards the Sylvian fissure. The position of these subareas is indicated in the diagram ; but it must be borne in mind that experiments failed to demarcate them sharply in every instance. Most of the special movements of the eyes, like those of opening and shutting the eyelids, turning the eyes to one side, and dihitation of the pupils, have their representation near the hori- zontal limb of the precentral fissure. In a case of my own, during an operation, the caieful application of a weak fiiradic current to a spot in the posterior part of the medifrontal convohition caused distinct deviation of the head to the opposite side. Lesions of a destructive cliaracter aflccting this region do not often cause persistent paralytic devialiou of the head and eyes. Ferrier, Grassct, Landouzy, Wernicke, and Henschen, among others, have seen conjugate deviation produced in' irritations of the cortex of the infevioi- parietal lobule, and some of these oliserA-ers have noted the same effect from irritation of the su])ertemporal convolution; but movements of fliis kind are probably secondary to the visual and auditory sensations evoked. Persistent conjugate deviation is most likely to be de])endent upon lesions of the pons and oblongata, be- cause of destruction or irritation of oculomotor nuclei or root fibres. CORTICAL LOCALIZATION. 339 A special centre for the movements of elevation of the upper eyelid is probably situated in the posterior portion of the medifrontal con- volution, just above the face area, and close to the areas of repre- sentation for upward and lateral deviation of the head and eyes. In rare instances unilateral ptosis has been found associated with hemi- plegia, the cortical lesions being at the base of the second frontal gyre. In a few other cases the same symptom has been present with lesions in the vicinity of the angular gyre, but the explanation of this is probably similar to that which accounts for lateral rotation and other movements of the head and eyes from stimulation of this portion of the visual region : because of the destruction of this im- portant portion of the visual cortex, the eyes, and with them the lids, fail to respond in the usual manner to visual excitations. Mott found that the result obtained by bilateral stimulation of identical points in the areas for lateral deviation of the head and eyes was in- variably, if the eyes were not already looking straight forward, to bring them into this position and to produce visual fixation upon a distant object. Other experiments of bilateral stimulation of the areas of representation for upward and downward inclination gave results of a character which in a simihxr way corroborated those produced by unilateral stimulation. By stimulation of the occipital visual area he produced results similar to those obtained by frontal excitation ; but a very weak stimulation of the frontal area sufficed to overcome a strong occipital excitation. Other results of great interest were obtained by this experimenter. Unilateral and Bilateral Representation in the Cortex. — One of the most striking facts brought to light by the study of cortical localization is that the centres of representation for specialized movements are highly differentiated on both sides of the cerebrum. Another fact, of equal importance, is that the centres for such highly evolved functions or faculties as word seeing, word hearing, speech, and writing are especially developed in the left hemicerebrum, although they have some representation in both hemispheres, and one side of the brain can probably be gradually educated to sub- stitute the other. Those movements of the two sides of the body which are always or usually consentaneous have what is termed a cortical bilateral representation ; the centre in either hemisphere can act for movements of both sides. The bulbospinal centres related to these movements are almost equally innervated from each hemi- sphere, the commissures of these centres conveying impressions to and fro with great freedom. Destruction of the cerebral centre of one hemisphere does not cause paralysis of those muscles which are completely bilateral in their actions, as, for instance, the muscles concerned in respiration and phonation, and the trunkal muscles in general. Paralysis of those movements which are usually bilateral but which have some unilateral differentiation, while it may be recog- 340 NERVOUS DISEASES. nizable, is commonly less marked than that which occurs in parts of the body possessing highly specialized functions. The movements of the orbicularis palpel:)rarum or of the masticatory muscles may be impaired to only a slight degree by lesions which destroy their centrcis, while paralysis of the arm or leg from a lesion proportion- ately no more destructive may be much more complete and per- sistent. It is because of this bilateral representation that we have comparatively few records, with autopsies, of laryngeal, pharyngeal, and masticatory paralysis or spasm from cortical disease. In the ambidextrous, and in those who are altogether left handed but have acquired fair use of their right hands, cortical representation is probably bilateral. Border Centres and Overlapping Areas. — According to Fer- rier, the different centres of representation of specialized move- ments are separated from each other by hard and fast lines ; ac- cording to others, they merge into each other or overlap ; but all authorities seem to agree that the cortical representation of every movement, whether it be of a large or of a small segment of the body, is most concentrated at some one spot. Electrical irritation of an area extending considerably beyond such a point may, how- ever, call forth the movement in question. Horsley holds to the existence of true border centres, irritation of which may elicit movements of different segments of the body at the same time in almost equal degree. Movements of the face and of the upper ex- tremity, and particularly of the thumb, fingers, and wrist, may be evoked by stimulation of the cortex at a position corresponding to the boundary between the arm and face areas as given in Fig. 228. Such localities may be regarded for convenience as border centres. Because of the real or apparent merging of representation, difficul- ties sometimes arise in fixing the primary focus of a lesion. Two signal or initial symptoms may apparently be present, as when it is dif&cult or impossible to determine whether an attack of spasm begins in the face or in some portion of the upper extremities. The Representation of Cutaneous and Muscular Sensations. — In the diagrams Figs. 228 and 229 the posteroparietal convolu- tions, precuneus, and gyrus fornicatus are designated as sensory areas, by which is meant that they constitute a region of representa- tion for those foiniis of cutaneous and muscular sensibility which are cart of the motor cortex which can be examined experi- mentally theie is represented a definite movement or combination of movements, being the primary movement which is elicited by minimal stimulation only ; the secondary movements are due to the subsequent invasion by the discharge of nerve energy of those por- tions of the cortex which lie nearest to the parts stimulated and with which they are in close relation. (Horsley.) The primary movement gives the signal symptom of Seguin, and the secondary movements rej) resent the ' ' serial order' ' of phenomena. FUNCTIONS AND LESIONS OF THE BASAL GANGLIA, CAPSULES, AND CENTRUM OVALE. Functions and Lesions of the Striatum (Caudatum and Len- ticula). — The striate bodies in the embryo, as shown by Flechsig, Wernicke, Ediuger, and others, are related to the cortex. Even in the adult human brain, as shown in several illustrations in this work, they are seen to have direct although slight cortical connec- tions. According to Ferrier, in man and in the monkey little differ- ence exists between the results of complete destruction of the cortical motor centres and of that of the striatocapsular region ; but lesions of the striata, if the internal capsules are not directly or indirectly affected, do not cause permanent imjpairment of motion or sensation. He concludes that both parts of the striatum are centres of innerva- tion of the movements differentiated in the cortex, but that they are of lower grade of specialization. Ziehen found that their stimulation gave rise to contractions similar to those produced by stimulation of the anterior portion of the motor cortex. Marchi believes that these ganglia have mixed functions of motion and sensation. Danilewsky found that irritation of both the caudatum and the lenticula caused increase in blood pressure, but admitted that this might be due to the diffusion of the current to the peduncles. The experiments of Hali^ White indicate that the striate body as well as the thalamus, in rabbits at least, has the power of modifying the temperature of the body. Boiirneville relates a case of a large patch of red soften- ing in the centrum o^^ale and a recent patch in the right striatum in which the temperature liefore death was 104.8° F. White reports the case of a man paralyzed on the right side, who never spoke, nor took any notice of things around him, and who after a month had elapsed had a temperature of 102.4° F., with a fit at the same time. The autoiisy showed just above the precommissure a brownish patch about a quarter of an inch in diameter so soft that it left a hole when the brain was cut. Dr. Bagqjawlensky has re]iorted a case of elevated temperature where the only lesions were echinococcus cysis in the striatum. (Ott.) In cerebral hemorrhage and soften- ing from embolism the striatum is often involved with the internal CAPSULES, AND CENTRUM OVALE. 353 capsule, monoplegia, hemiplegia, and hemianesthesia being jiresent, but A\heu these affections are permanent they are probably always due to capsular lesions. Hemorrhage limited to either of the striate bodies has been known to cause temporary paralysis, but presumably through jjressure on the internal capsule. GoN^ers records a case in which a narrow vertical band iit softening extended through the length of the lenticula, no jjaralysis having been present, and even a recent hemorrhage limited to this ganglion has caused no symp- toms. Cases of athetoid and choreoid spasm have lieen obser\'ed in connection with lesions of the posterior portion of the lenticula, but either the internal capsule or the thalamus or both have usually been found implicated. Future investigations may give facts which can be turned into the channels of diagnosis, but the striatum at present may for clinical purposes be regarded as an uncertain region. Pseudobulbar Paralysis from Lesions of the Lenticula. — In some of the cases of so-called j)seudobulbar paralysis in which patients suffer from anarthria, or paresis of articulation, similar to that observed in paralysis of bulbar origin, among the most constant lesions found have been those in one or both lenticulas. In one of the earliest reports of such a case, by Kirchoff, a focus of soft- ening surrounded by sclerosed tissue was found in the lenticula, dis- ease of the pons and oblongata being absent. Eoss, Magnus, Noth- nagel, Drummond, Barlow, Eosenthal, Fer6, Jolly, Oulmont, Fuller, Browning, the writer, and others have also recorded cases. Boulay has collected thirty such cases, twenty-four of which were followed by autopsies ; in nearly all the cases the lesions, variously situated, were bilateral, and frequently they were symmetrical. Some were in the cortex, particularly affecting the lower extremities of the central and posterior extremities of the second and third frontal convolutions. As a rule, the glossolabiolaryngeal symptoms were not so marked in the cortical as in the subcortical and ganglionic cases. The lesions were in the cortex, lenticula, caudatum, thalamus, capsules, and centrum ovale, but the lenticula, and particularly its outer segment or putamen, was most frequently diseased in the typical cases. The most common lesions were foci of softening and of hemorrhage, the patients usually being aged and their vessels highly atheromatous. Functions of the Thalamus. — The physiology of the thalamus is still largely unsettled. Between the thalamus and the cortex, and between it and the parts below, run innumerable fibres. Ac- cording to one view, the thalamus receives from the sensory tract impressions which are transmitted to motor centres in the striatum, the two sets of ganglia forming the two sides of a great reflex arc. Eemoval of the thalamus, or destruction of that part of it in the neighborhood of the inspiratory centre in the wall of the third ven- tricle, was found to influence coordinated movements in the rabbit. (Christiani.) Meynert believed that the thalamus was connected in 23 354 NERVOUS DISEASES. function with the upper extremities ; but the facts of disease and experiment indicate that this ganglion is related to the face and leg as well as to the arm ; that it is essentially an organ for one half of the body, as is also shown by its position and its relations with other parts of the brain. According to one view, the thalamus receives sensory impressions before they are transmitted to the cortex ; and the experiments of Monakow led him to the conclusion that differ- ent portions of the thalamus are related to different cortical areas. Crichton-Browne regarded this ganglion as a great centre of general sensibility. Others have assigned to it motor functions. The weight of evidence, both from experiment and from disease, connects the thalamus with various forms of sensation. One view is that the thalami fulfil the same functions for tactile impressions that the Ijregeminum does for visual impressions ; that is, that these ganglia are the centres of the spatial senses, vision and touch, the centres in which the sensations are referred to positions in space. They are centres intermediate between special sensory centres and the higher centres of the cerebrum. (McKendrick.) The functional subdi- visions of the thalamus have not, however, as yet been accurately determined. According to the alluring theory of Luys, it can be subdivided from before backward into four ganglionic masses, — an olfactory, a visual, a general sensory, and an auditory centre, — these special cell nests being in relation, by means of definite fasciculi, above with the cortex, and below with the peripheral sense organs. This view of Luys's cannot be regarded as demonstrated, although portions of the thalamus or of its projecting masses have been shown to be related in some way to common sensibility, to sight, and to hearing. Numerous experiments, but especially those of Ott and Hale White, indicate that the thalamus or some portion of it is also a heat- regulating organ. Elevations of temperature resulted from puncture of the thalamus, but Ott has shown that in puncturing the anterior end of the thalamus the tuber cinereum may be wounded, and this structure has been demonstrated to be a centre both of thermotaxis and of polypnea or rapid breathing. Podauowsky and Popoff from a study of antipyretics, with division of the brain behind the striata, conclude that an especial vasomotor centre exists in the anterior part of the brain ; and Ott found that puncture of the anterior half of the thalanuis nearly always caused blood press- ure to fall, and that it never rose again to the original height, al- though the number of the pulsations remained about the same. Faradic irritation of the thalami, which, however, is not always to be absolutely trusted, because of spreading of the current, causes a rapid rise of blood pressure. Ott concludes that vasotonic centres are situated in the cephalic portion of the thalamus, and that these centres probably exercise some control over the monarchical vaso- motor centres in the oblongata. LESIONS OP THE GANGLIA, CAPSULES, AND CENTRUM OVALE. 355 Symptoms in Cases of Thalamic Disease. — In reported cases of disease of the thalamus the lesions have almost always invohed other parts. The symptoms have been sensory, motor, visual, audi- tory, olfactory, thermic, vasomotor, and psychic. All the forms of common sensibility (cutaneous and muscular sensations) have in some instances, as in one case of my own, been impaired or lost. Among motor symptoms, paralysis, ataxia, contractures, forced positions, particularly of the head and upper extremities, spasm, and athetoid and myotonic phenomena, have been observed. Among visual symptoms have been general amblyopia and hemianopsia, but particularly the latter, although I believe this is more commonly due to lesion of the pregeniculum, which can scarcely escape involve- ment in gross disease of the pulvinar of the thalamus. Impairment of hearing has been noted in very rare instances. Among vasomotor symptoms which have been reported are hemorrhage and vasomotor paresis or spasm. Elevation and depression of temperature, and stupor, mental slowness, and irritability, are also among the recorded phenomena. Most of the cases in which paresis or paralysis has occurred can be explained on the view that they were due to press- ure or to the extension of the lesion to the internal capsule. In one case, cited by Debierre from Hunter and A. Voison, the patient lost successively in three years smell, sight, hearing, and general sensi- bility, and remained insensible to all external sensory excitations ; the thalami were found destroyed by a neoplasm. Heat Centres and the Thermic Mechanism. — Physiologists have experimentally demonstrated the existence of heat centres in various parts of the neuraxis. A thermotaxic centre is one con- cerned in the regulation of the temperature of the body. A thermo- genic centre is one concerned in the production of heat, its irritation causing the evolvement of heat, and its destruction the diminution of heat. Thermolysis is the dissipation of heat, and thermolytic centres are concerned with this process. The following table by Ott presents in a compact form the views of this physiologist, which are based both upon his own experiments and upon a study of the literature of the subject. Corto-. —Thermoinhibitory centres: (1) cruciate; (2) Sylvian. FoEEBRAiN . . { i?as«.— Thermogenic centres : (1) caudate nucleus (cau- datum) ; (2) gray matter of septum lucidum (White) ; (3) gray matter in front of and beneath caudatum. f Thermogenic centre in the tuber cinereum. Inteebeain . { Polypneic and vasotonic centres in the tuber cinereum, [ connected with thermolysis. Apterbeain . . . I Thermolytic centres.— Respiratory and vasomotor. c ,, f Thermolytic centres.— Sudorific centres.— Thermogenic BPiNAL Coed . . < / l centres. 356 NERVOUS DISEASES. According to Hale White, a close parallelism exists between the temperature regulating mechanism of the body and the three evolutionary levels of Hughlings Jackson, which is illustrated dia- grammatically in Fig. 234. At the lowest level is the thermolytic portion of the mechanism, consisting of the cutaneous vessels with their vastiniotor ner\'es, the sweat glands with their nerves, and the respiratory apparatus also controlled by various nerves. The ther- molytic centres are in the oblongata and spinal cord. The second or middle level of the thermic mechanism is the thermal or heat producing, and its thermogenetic function is presided over by the Fig. 234. MUSCLES The three thermic mechanisms of the nervous system. (W. Hale White.) striatum, either in its caudate or in its lenticular division, possibly also, as shown by Ott's table and in the preceding discussion of the thalamus, by centres in the seiitum lucidum, in front of and beneath the caudatum, in the tuber, and in the thalamus. The third and highest level of the thermic mechanism is in the cortex. Heat Centres and Clinical Phenomena. — The researches on heat centres and the thermic mechanism ha\'e proved of value in the hands of Wood, Ott, Hale ^^"hit(^ and others, in explaining the phenomena of lever and the mode of action of antipyretic drugs; but in cases of focal disease of the brain and spinal cord, tempera- LESIONS OF THE GANGLIA, CAPSULES, AND CENTRUM OVALE. 357 tnre plieuomena abundantly present have not recei\ed the attention which the discoveries in thermic localization should suggest. In- teresting and sometimes extraordinary temperature disturbances are observed as the results of such lesions. The temperature may be elevated in one half of the body, or in a limited portion of it, as the result of a hemorrhage or other focal cerebral lesion. According to Bastian, after hemorrhage into one thalamus the temperatuie of the paralyzed side may for several weeks or months be one or two degrees higher than on the sound side ; and the same changes in temperature, but slighter in degree and more temporary, may result from lesions of the striatum. Ott has collected a meagre series of cases bearing on this question of heat centres, to some of which references have been made in preceding paragraphs. He cites two cases which he believes support the view that the cruciate and Sylvian heat centres in the lower animals are represented in the cortex of man. Horslej' has reported a case of hyperpyrexia due to punctiform hemorrhages in the pia of the medifrontal convo- lutions and to a large hemorrhage in the precentral gyrus. The case was one in -which he trephined, and the rise of temperature started at the moment of operation and was not preceded by a fall. McAlister has recorded the case of a paraplegic with a remarkably unstable temperature, one day running to 109.2° F. and in three quarters of an hour dropping to 97.8° F., another day reaching 110.4° F. and in half an hour dropping to 98° F. Ott believes that in this case there was a very excitable state of the spinal thermo- genic centres, due to impaired restraint from the cortical thermo- inhibitory centres and irritation from lesion of the spinal cord. Singular Instances of great elevation of temperature in hysterical patients have been recorded, but here the possibility that the tem- peratures were factitious must be borne in mind. Numerous cases of so-called hysterical fever have been put on record. In order to render more complete the survey of clinical phenomena in their relations to the thermic mechanism, brief reference will here be made to the effects of lesions of the pons on temperature, although its functions and diseases have not yet been discussed. Bastian long ago stated that in apoplexy of the pons, if the life of the patient be prolonged, the temperature on both sides of the body steadily rises, until at the time of death it may have attained 108° or even 110° F. In one of my own cases of pontile softening the rectnl temperature was for a time slightly elevated, and shortly before death it rose to 108° F. A few cases of pontile lesion, usually unilateral, are on record in which decided changes of temperature have occurred,— commonly elevation, with differences in the two sides of the Ixxly ; although in other reported cases the temperature has been below normal. The weight of clinicopathological as well as of physio- logical evidence is in favor of some change of temperature as the 358 :nervous diseases. effect of lesions of the pons, thalamus, striatum, tuber cinereum, and of some portions of the frontoparietal cortex. Lesions of the Geniculate Bodies (Pregeniculum and Post- geniculum). — The teudencj- of investigators in recent jears has been to connect the pregeniculum with the visual tracts and the postgeniculum with the auditory tiacts. Ynn Gudden believed that by his atrophy methods he had demonstrated that the visual centres at the base of the brain were in the pregeminum, pregeniculum, and pulvinar of the thalamus, and also that the postgeniculum and post- gemiuum had no relations to vision. Forel and many others have practically accorded with Von Gudden in these views. Darksche- witsch doubts the connection of the pulvinar with the optic tract, believing that most of the fibres which go to this body pass through it to the pregeminum. He also casts some doubt upon the relations of the pregeniculum to the optic tract, believing that although fibres of this tract can undoubtedly he traced to it, these may, like those of the pulvinar, pass onward to the pregeminum. One of my cases of thalamic disease, referred to in several places in this work, lends support to this view of Darkschewitsch, two thirds of the thalamus, including most of the pulvinar, having been destroyed without any resulting disorder of vision. Zacher has reported that he has found the postgeniculum attacked by secondary degeneration following de- struction of the first and second temporal convolutions. Lekarsky has shown tliat after softening of the cuneus descending degenera- tion of the optic radiations, of the pulvinar, of the pregeniculum, and of the capsule of the postgeniculum occurs. Subdivisions and Lesions of the Internal Capsule. — A knowledge of the position, shape, relations, and functional sub- divisions of the internal capsule is of great importance to the clinician, as in a large majority of the cases of hemorrhage and softening from apoplectic attacks more or less destruction of this region takes place. In this narrow strait between the ganglia are concentrated most of the motor and sensory projection fibres, as well as other important fasciculi, and therefore lesions destroying comparatively limited areas may give rise to widespread paralysis and anesthesia. Probably a close study of the symptomatology of cases i)f monoplegia and hemiplegia, with carefully made autopsies, will enable ns eventually to locate with considerable accuracy before death lesions in the internal cai)sule and centrum ovale as we now localize cortical lesions. Illustrations of varying types of hemi- plegia which largely indicate the degree of destruction in the in- ternal t'a])sule will l)e given in the section on monoplegias and hemi- plegias. The general subdivisions of the internal capsule, according to Ohersteiner, are shown in Fig. '235, and, fnun before backward, are a bundle to the thalamus; next the frontopontile tract; about the knee of the capsule, the so-called genual tract, which includes the Fig. 235. LESIONS OF THE GANGLIA, CAPSULES, AND CENTRUM OVALE. 359 fasciculi for the motor cranial nerves ; a little posterior to the knee the beginning of the pyramidal tract proper ; and still posterior to this, the sensory tract, or mrir/oiir fsciKsitif. The anterior segment, probably nearly a third of the anterior half or pregenual half of the internal cai>sule, occupied by a tract of fibres connected with the thalamus, is sometimes called Meynert's anterior peduncle of the thalamus. The genual subdivision for the motor cranial nerves, according to Debierre, contains from before backward the fasciculi of the inferior facial, the masticatory, and the hypoglossal nerves. The face fibres lie innermost, the arm fibres are in a median position, and the leg fibres are outermost. The differentiation of the internal capsule into its various subdivisions has been gradu- ally carried further and further by various methods, as by pathological observations, by embryological investigations as to the time and manner of appearance of separate fas- ciculi, by the study of secondary degenera- tions, and by careful experiments upon lower animals, — experiments by destruction and electrical irritation. The results from all these methods are in general accord. Im- portant experimental studies of the internal capsule have been made by Pranck, Beevor and Horsley, and others. The latter suggest that the main axes of the fibres of the internal capsule correspond, so far as anteroposterior arrangement goes, with the cortical foci of representation taken along the lines drawn at right angles to the direction of the upper two thirds of the fissure of Eolando. Placed in order from before backward are eye movements, head and face movements, upper limb movements, and lower limb movements. The arrangement in the capsule, according to them, is but an imita- tion of that in the cortex, which in its turn is but a peripheric pro- jection of the order of the metameres of the whole body. In Pig. 236 is shown a scheme of this arrangement of the motor fasciculi in the internal capsule. It is supposed by most observers that the optic radiations which come from the pregeminum, pregeniculum, and pos- sibly from the pulvinar, pass through the most caudal portion of the sensory subdivisions of the internal capsule. Obersteiner, Debierre, and others also speak, but with less certainty, of the olfactory radia- tions passing in this portion of the capsule. Functions of the External Capsule, Extreme Capsule, Claus- trum, and Amygdala.— The functions of these parts are still prac- Uuiizoutul section through the hitenial capsule : Ac, cau- datum ; ;\7/, 1', 2', 3', the three segments of the lenticula ; Tlw, thalamus ; 2, tract of motor cranial nerves ; 3, fron- tal pontile tract ; 4, sensory tract ; 5, anterior peduncle of the thalamus ; 6, pyramidal tract. (Obersteiner.) 360 NERVOUS DISEASES. Fig. 236. Eyes opened. Eyes turned. Mouth opened. Head turned. Tongue. Mouth retracted. Shoulder. Elbow. Wrist. Fingers. Thumb. Trunk. Hip. .vnkle. Knee. Hallux. Toes. tically unknown. The external capsule and extreme capsule doubt- less contain fibres which connect the cortex with other parts, but their character and exact connections have not yet been determined. It is highly probable that the extreme capsule which lies close to the insula contains some of the tracts which run between the sensory and motor centres concerned with speech. It has been held that in the ex- ternal capsule pass speech tracts from Broca's convolu- tion to the bulb. The situa- tion of the amygdala in the temporal cortex near the un- cinate convolution indicates its probable relation to the function of smell ; it has, in fact, been designated by Luys the olfactory ganglion. Lesions of the Centrum Ovale. — Various terms, as centrum ovale and corona radiata, have been applied to the white substance of the hemispheres. The exact lo- cation of particular fasciculi of the projection, commissu- ral, and association systems which are crowded into this region are gradually becoming more and more clearly defined, and to a certain extent these have been already considered, when discussing the sensory path, the pyramidal tract, and the various commissural and association systems, in previous sections in Chapter I. Lesions of special subdivisions of either the motor or the sensory projection systems will give symptoms similar to those produced by lesions of the areas or subareas of the cortex to which they come or from which they go. With reference to lesions of the projection fibres, one general diagnostic point of considerable importance is that tlie nearer the lesion is to the cortex the more likely it is to give rise to isolated or single symptoms, as to i^aralysis of a limb or portion of a limb, of the face or portion of the face, when the lesion cuts motor fasciculi ; or to anesthesia limited to a S(^gment of the limbs, trunk, or face, when the lesion severs sensory fibres ; while, on the other hand, when the lesion is deeply situated near the internal capsule the eomiilex of symptoms is more likely to constitute a hemii>legia or a hemianesthesia. Lesions of the Motor Projection System in the Centrum Scheme of the arrangement of the motor fibres in the internal capsule. (Beevor and Horsley.) LESIONS OF THE GANGLTA, CAPSULES, AND CENTRUM OVALE. 361 Ovale.— As shown when discussing the internal capsule, the bundles of the motor projection system are arranged in a regular order which has reference to the areas of representation in the motor cortex. It follows that those portions of the motor paths which lie between the cortex and the capsule must be arranged in a similar systematic manner. Subcortical motor symptoms will be produced by lesions situated in the white substance directly subjacent to the motor region, — in the irregularly wedge-shaped mass of fibres which pass from the posterofrontal and central convolutions in converging lines to the internal capsule. Irritative and destructive lesions in tliis region give a symptomatology which has some points of difference from that of the motor cortex. In favor of a strictly cortical or epicortical lesion of the motor zone are localized clonic spasm, epileptic attacks beginning with local spasm followed by paralysis, early appearance of local cranial pain and tenderness, and increased cranial temperature. In favor of a subcortical location of a tumor are local paresis or hemiparesis followed by spasm, predominance of tonic spasm, normal cranial temperature, and absence, slight degree, or very late appearance of local headache and of tenderness to per- cussion. (Seguin). Lesions of the Sensory Projection Systems in the Centrum Ovale. — With regard to fillet radiations in the centrum ovale, it is possible for the purpose of gross study to locate at least three great sets of fibres : (1) the bundle which conveys the impulses concerned with so-called common sensibility, the fibres of this bundle, as already stated, probably approaching or reaching the cortex in the limbic lobe and posteroparietal region ; (2) a bundle or set of fibres which proceeding from the lateral fillet turns downward so as to take its course to the superior temporal convolutions, conveying to them auditory excitations ; (3) gustatory fibres which pass to the lower and more inferior portions of the temporal lobe, probably chiefly to the fourth temporal convolution. Lesions of the centrum ovale may therefore give rise to symptoms referable to either of these sets of fibres : to anesthesias of various sorts when the lesions are situated beneath the limbic and posteroparietal cortex ; to word deafness or other interference with hearing when in the superior temporal sub- cortex ; and to disorders of taste when in the inferior temporal sub- cortex. Prom the primary basal centres for vision have been traced bundles of fibres termed collectively the optic radiations of Gratiolet, which pass to the cuneus and its immediate vicinity, constituting the fibres of the visual projection system. Lesions of these fibres, like lesions of the cortical centres for vision, will produce hemi- anopsia or central visual defects or both. According to Henschen, analysis of all cases shows that the occipital visual path is in the ventral portion of the optic radiations, where it forms a bundle less than a centimetre thick. The path in a part of its course lies about 362 NERVOUS DISEASES. the level of tlie second temporal gyre and second temporal fissure. The macular fibres have a median situation, while the fibres of the dorsal retinal quadrant lie dorsally and those of the \entral retinal quadrant ventrally. A very limited lesion might therefore strike either of these sets of fibres, thus causing quadrant or sector hemianopsia, or disturbances of central vision. When with lateral homonymous hemianopsia the patient also has hemianesthesia, the lesion is probably in the tracts between the cuneus and the basal optic centres, being large enough also to involve the sensory tracts. Such a lesion would be best reached beneath the position where on the lateral aspect of the hemisphere the parietal, occipital, and temporal lobes come together. Hemianopsia is more likely to be complete when subcortical than when cortical. Lesions of the sub- cortex of the genual portion of the callosal gyre, gyrus fornicatus, and the uncinate and hippocampal convolutions, which contain most of the olfactory projection fibres, give rise to disorders of smell. Lesions of Intracerebral Associating Tracts. — It is possible that we may in the future be able to give a symptomatology for lesions disrupting tracts connecting two convolutions, or one convo- lution with several convolutions of either the same or the opposite hemicerebrum. Lesions of Meynert's arcuate fibres, or fbrw propriw, must cause special symptoms. Attention might be called here to a few of the known tracts or fasciculi for which a symptomatology should be sought. Vialet has shown that from the inferior calcarine (or lingual) region a distinct fasciculus, passing transversely out- ward beneath the occipital cornu of the ventricle, is distributed to the second and third occipital convolutions of the external surface. Beevor has determined in a marmoset another fasciculus from the calcarine region which passes forward into the centrum ovale and may connect this part of the cortex with other parts of the visual area, as with the supramarginal and angular gyres. Experiments of Schiifer and Barrett have shown that a connection exists between the excitable areas of the external occipital convolutions and a certain area for conjugate head and eye movements in the upper and middle frontal convolutions. Special forms of visual disturb- ance and some of the forms of transcortical aphasia are probably caused by lesions of these bundles. One great tract of arching association fibres first carefully studied by Meynert is the cingulum, which, with other well known association tracts, is shown in Fig. 73, page (12. Doubtless lesions of each of these sets of fibres give special symptoms. A lack of consideration of the commissural and association fibres is the source of much confusion in analyzing cases. Most lesions generally regarded as cortical involve to a greater or less extent the subcortex ; and, as every convolution is connected with some other, and often with many others, association fibres must always be destroyed in tliese cases. LESIONS OF THE GANGLIA, CAPSULES, AND CENTRUM OVALE. 363 Microscopical Localization in the Cortex and Subcortex. — The discussion of fuuctions and lesions of the cortex and subcortex has been chiefly with reference to gross changes and coarse function- ing. The facts and views presented should prove of great value in localizing lesions of recognizable size and capable of causing symp- toms of a more or less intense and special character ; but many of the diseases and disturbances of the brain, whether classed under the general head of "mental" or "nervous," are wanting in special- ized manifestations which can be easily referred to focal lesions. They give a symptomatology which is definite but diffuse, and which is not readily assigned to its anatomical and physiological bases. These mental and nervous affections include the cerebral neurasthenias, chronic affections, such as those due to alcohol and other toxic agents, and progressive degenerative diseases of various types. The cortex and subcortex must be searched by the diagnos- tician, and later perhaps by the histopathologist, for a rational ex- planation of the morbid phenomena ; and this is a portion of the field of cerebral localization now being successfully entered with the aid of the new methods of research which have given us the won- derful revelations as to structure described in the section on the minute anatomy of the cortex. The changes in structure in these chronic, functional, and degenerative diseases remain for a long time, and in some cases always, of a microscopical character ; and the microscope is always needed to interpret fully their true extent and significance. Horsley and Gotch, in studying the mode of action of a simple nerve centre in the spinal cord, showed that a distinctly measurable block to the transmission of a nervous impulse occurred between the time of the reception of an afferent impulse by a spinal centre and its discharge from the cells on the efferent side (see page 121), this block representing the time taken to traverse what is called the field of conjunction ; that is, the region intermediate between the afferent or sensory and the efferent or motor spinal centres. Arranged in the cortex in stages or levels, as shown by Andriezen, is a series of nervoprotoplasmic plexuses which probably constitute cortical fields of conjunction. Exner's plexus represents one of these fields, and is probably the place of conjunction of the cerebral sensory and motor systems. In this as in other fields of conjunction the nerve fibres and the apical processes with which they come in contact l)ecome naked or noninsulated. Other fields of conjunction are represented by special structures in the poly- morphic layer. In these plexuses, which Andriezen describes as extending sheet-like throughout the cortex, projection, association, and commissural fibres come in contact with the protoplasmic pro- cesses of cortical nerve cells. With the new methods of research it is now possible to see the gradual change and decay which impair or destroy cells as anatomical and physiological units, and also 364 NERVOUS DISEASES. disrupt their various connections and associations. Apical and basal processes and the collaterals and terminals which come in contact with them can be seen to pass through various stages of degeneration ; cell bodies shrink and disappear in whole or in part ; fields of conjunction are destroyed ; and symptoms general and special arise. These minute changes of structure are the ana- tomico-pathological bases of such symptoms as amnesia, diminished power of attention and volition, diminished initiative and energy, diminished muscular power, blunting of the higher moral and ethical sense, insomnia, and serious disturbance in the balance between the cortical representation of the external world and the empirical Ego. (Andriezeu.) The earliest changes in many if not in most of the chronic cases above mentioned are in the cortical fields of conjunction, the regions in which anatomical units or groups of them are brought together. These fields of conjunction become less and less permeable to all forms of excitation, and one of the first results is delay in reaction time. The association system, which gives way first in these cases, is probably represented most in the polymorphic layer of the cortex ; it is the last and least organ- ized, although subserving the highest functions, especially volition, and in chronic processes of disintegration it is the first to go. Lesions of the Callosum. — Developmental arrests and lesions of the callosum occur with moderate frequency. Nearly a score of cases of tumor and rare instances of hemorrhage, softening, and other gross lesions of the callosum have been put on record. In idiocy the callosum has been found absent in whole or in part. Hochhaus collected records of twenty-four cases in which the callosum was absent. The symptoms of the recorded cases of lesion and arrest of the callosum have not been constant or distinctive, and the lesions have not been usually strictly limited to the callosum. Mott and Schiifer experimented with weak induction currents on the callo- sums of monkeys, and produced localized bilateral movements in all parts of the body. From before backward, in order, in different seg- ments of the callosum, electrical stinuilation caused movements of the head and eyes, the face, the shoulder, the trunk muscles, and the legs and tail. Cutting away one hemicerebrum, they found that by stimulating a thin middle strip of the callosum localized move- ments were pioduci'd on the side of the section, that is, on the side of the body opposite to that hemicerebrum with which the callosum was still connected, the order of movements being the same as above mentioned. jMeynert, Obcrsteiner, and many others taught that the fibres of the callosum connect only identical areas of opposite hemi- spheres, but this is now disprt)ved. The fibres of the callosum are extremely fine ; and the new methods of staining have shown that jnany of them are only collaterals from axis cylinder processes of pro- jection and arcuate fibre systems. Marchi's method in particular LESIONS or THE GANGLIA, CAPSULES, AND CENTRUM OVALE. 365 has revealed widespread connections of tlie callosal fibres far dif- ferent from those supposed to exist by Meynert. One or more con- volutions in one half of the brain may be united through the callo- sum with one or many portions of the opposite hemicerebrum, according as these regions are connected in function. The old descriptions of the courses of many of the callosal bundles may, however, in a general sense be still regarded as coirect : they diverge upward and downward and foiward and backward into all or nearly all portions of the cerebrum, in the anterior part forming the anterior forceps, and in the posterior part the posterior forceps. According to Obersteiner, the callosum is the commissure par excellence of the cortex, cortex and callosum being usually wanting in equal degree ; but Hamilton has advocated a different view, namely, that it is really a decussation of fibres arising from nerve cells in each hemisphere. These fibres after decussating run not into the cells of the opposite hemispheres, but directly down- ward into the internal capsule and parts below. Hamilton thinks it doubtful whether callosal fibres function in a direction down- ward, it being more probable that impulses pass along them from lower centres to higher. Sherrington and Muratoff both found that sometimes after lesion of the motor areas of the cortex — which Sherrington calls the "cord area" — they could trace secondary degeneration across the callosum into the opposite hemisphere. Having in regard the differing and newer views as to the course and functions of callosal fibres, it can only be said that lesions limited to the callosum would be likely to produce differing symp- toms, not always of a positive character. Destructive lesions might give some bilateral paresis or incoordination affecting certain seg- ments of the body according to the segment of the callosum in- vaded, in accordance with the determinations of Mott and Schafer. Irritative lesions, as tumors, should give bilateral spastic phenomena or convulsions, and such convulsions have been noted in several reported cases. Hallucinations have also been noted. In a series of cases studied by Francis, the symptoms which seemed referable to the callosum were bilateral convulsions, stammering, uncertainty of gait, slowness of speech, change in temperament, strabismus, dilatation of the pupils, and rotation of the head. Bristowe, who is referred to by Bramwell as having written the most complete account of callosal tumors, gives the following as the progress of a case: "first, the occurrence of headache and other somewhat ^'ague symptoms of progressive cerebral disease ; second, the gradual onset of more or less well marked hemiplegia ; third, the appearance in a greater or less degree of similar symptoms on the opposite side of the body ; fourth, the coming on of dementia, with drowsiness, loss of speech, difficulty in swallowing, and want of control over the rectum and bladder." 366 NERVOUS DISEASES. Lesions of the Cerebral Commissures and of the Fornix. — The precommissure has been generally regarded as a structure con- necting the opposite olfactory lobes and cephalic portions of the temporal lobes ; but that it unites only homologous portions of the two hemispheres may now be regarded as doubtful. It is more probable that, like the callosum, its connections are of a more irregular and heterogeneous character. According to Hamilton, it may be doubted, with reference to the so-called interhemispheric commissures, whether these are "commissures" in the old sense of the word. The combined actions of the two halves of the body where they exist, as in the case of some of the cranial nerves, are attained by decussation of tracts of fibres, and not by union of corresponding nerve cells on opposite sides of the nervous axis. The facts recently demonstrated regarding the diverse connections of the fibres of the callosum have a bearing upon this view, and similar facts will probably be demonstrated sooner or later with reference to the other so-called cerebral commissures. Whatever may be the method of transmission of fibres through the precommis- sure, it is probable that some of them at least pass to the cortical organs of smell, so that lesions of this structure may cause olfactory disorders. The postcommissure is almost certainly in large part a decussation, some of its fibres going to the nuclei of the third nerve, and others passing to the quadrigeminal body. Presumably, there- fore, lesions of this structure give rise to affections of equilibrium and of ocular movements, but clinical data regarding this matter are wanting. In part the postcommissure appears to be a decussation of the fillet, and its lesions therefore may also give rise to some sensory phenomena. Nothing that is known about the medicommis- sure can be applied in diagnosis. As already said when considering olfactory localization, Hill's view that the fornix is a part of the olfactory tract has much in its favor, and lesions of this structure should therefore give rise to olfactory symptoms. Lesions of the Ventricles.— The ventricles, their annexes, and their channels of intercommunication may be more or less occu- pied by lesions. Primary ventricular hemorrhage, which sometimes occurs but is rare, will be briefly discussed under encephalic hemor- rhages. In other forms of cerebral hemorrhage, and especially in the common type from rupture of the lenticulostriate artery, the blood may break its way through the intervening tissues and inundate a part or the whole of the ventricular system, passing into the diaccele or third ventricle and by way of the iter into the fourth ventricle, causing much destruction in its course. Such a hemorrhage consti- tutes one of the most serious forms of cerebral apoplexy. Tumors may invade the ventricles. The symptoms in such cases will be largely those of the parts with which the growths are connected, or upon which they exert pressure, or which they irritate. The extent LESIONS OF THE GANGLIA, CAPSULES, AND CENTRUM OVALE. 367 to which these cavities may be occupied by neoplasms before death results is extraordinary. I have seen tumors, usually gliomata, nearly filling the metepiccele, the patients having lived for weeks or months. lu one case in which a growth extended from the sub- geminal region to one lateral lobe of the cerebellum, involving the dorsal and lateral aspects of the pons and oblongatas, the prepeduncle and the medipeduncle, the tumor was large enough nearly to fill the fourth ventricle. The patient lived for several months under my own observation, and had been attacked by intracranial disease a long time previous to my seeing him. Tumors and hemorrhages into the paracoeles and diaccele may cause symptoms referable to the intraventricular striate body, the commissures, the fornix, the thalami, gemina, or callosum, according to their exact situation, ex- tent, and character. Lesions may produce hydrocephalus by blocking the iter or the foramens of Magendie and Mierzejewski. Abscesses of the ventricles are occasionally observed. Hamilton holds that it is possible that the walls of the entire ventricular system are endowed with the power of indicating position. Experiments of Christiani and Bechterew seem to indicate that the gray matter of the third ventricle plays the part of a balancing organ. When the gray matter of this ventricle was injured, they found that the same difficulty from loss of the balancing faculty was experienced as when the semicircular canals are the seats of lesions. Hamilton, in the case of a patient who had the symptoms of Meniere's disease, at the autopsy found two tumors loosely attached to the choroid plexus, their free ends floating in the distended lateral ventricles. He thought it possible that the tumors dangling in the ventricular fluid may have stimulated the epithelial lining of the cavities and excited the vertiginous symptoms, as distinct evidences of dis- ease of the ear were not present. Lesions of the Hypophysis, or Pituitary Gland. — ISTumerous observations and investigations would seem to show that the posterior portion of the pituitary gland — that which chiefly con- tains the nerve tissues — is vestigial and probably without im- portant function. On the other hand, the tendency of recent researches is to give the anterior portion some real functional im- portance. Vassale and Sacchi as the result of their experimental investigations in regard to the effects of destruction of the pituitary body conclude that although the symptom-complex following com- plete destruction of the pituitary gland offers analogies to that which follows extirpation of the thyreoid gland, they are unable to admit that the functional relations between these two bodies are such that one may, as Eogowitsch asserts, be a substitute for the other in the needs of the animal economy, and that as regards its functions the hypophysis belongs to the class of glands the de- struction of which gives rise to the formation and accumulation 368 NERVOUS DISEASES. Fig. 237. »» % '(»>« Section of human pituitary body : C, portion of posterior or nervous lobe ; P, portion of an- terior or glandular' lobe : a, tu- bular acini'; s, connective tissue septa ; D, bloodvessels. (Piersol.) within the organism of special toxic substances. Considerable clin- icopathological evidence flould seem to place the pituitary body in relation with the disease known as acromegaly, and probably with other forms of dystrophy, such as the adiposis dolorosa described by Dercum. In nine out of eleven cases of acromegaly with autopsies, collected by Dana in 1893, the pituitary gland was en- larged. That it is sometimes diseased with- out the occuirence of acromegaly or other dystrophy, as in cases reported by Black- burn, does not preclude the idea that lesion of this organ may cause such affections ; it may be that only certain perversions of the hypophysis give rise to such dystrophies. It has been thought that other glands may assume the functions of the pituitary body, but Oliver and Schafer found that intra- venous injections of pituitary extract mark- edly raised blood pressure, while thyreoid extract lowered it, and spleen extract at first lowered and then raised it. Slight enlargement of the gland has been known to take place in myxedema and in cretinism, and after extirpation of the thyreoid in animals. Gross lesions of the hypophysis are important inde- liendently of its functions, as they may give localizing phenomena because of its relations to neighboring parts, as the chiasm, the circle of Willis, olfactory bulbs and tracts, tuber, albicantia, and some of the basal sinuses and nerve tracts. Middleton Michel many years ago recorded a case in which the autopsy showed at the site of the hypophysis a tumor which had extensively invaded the adjacent soft parts. The patient complained of discomfort in the head and of cloudiness of vision, and was soon the victim of inter- mittent headaches. The imperfection of sight progressed rapidly until he was almost blind. The eyeballs preserved their parallelism, became sensitive to touch, and edema of the subconjunctival tissues was soon marked. He developed fever, insomnia, and delirium. Lesions of the Conarium or Pineal Gland. — Nothing need be said about the lesions of the conarium or pineal gland based upon its functions, as it is a vestigial structure and contains very little nerve tissue. It is, however, like the hypophysis, sometimes the seat of tumors, or it niay be invaded by tumors or other lesions of neighboring parts. Coats has described an adenoid sarcoma con- taining small pieces of cartilage, and others have recorded the oc- currence of other solid or cystic growths. Psammomata and small cystic growths are somewhat frequent. The smaller lesions, so far as known, give uo recognizable symptoms. Large neoplasms originating in the conarium may give thalamic and quadrigeminal LESIONS OF THE GANGLIA, CAPSULES, AND CENTRUM OVALE. 369 symptoms, such as anesthesia, incoordination, interferences with sight and hearing, as well as symptoms which indicate hydrocephalus from blocking of the iter. Max Plesch has advanced the idea that the conarium in mammals is connected with the temperature apparatus, but this is not probable, although its lesions might cause temperature phenomena by invading the thalami or other thermic centres. The fibres of the pineal gland to the ganglion habenulse, which are known to join the optic tract near the pregeniculum, Darkschewitsch regards as pupillary in function. ' "^''^^p^'a' Lesions of the Tuber. — Polypnea is section of human pineai rapid or frequent respiration. Eichet ap- ^^'Z^^Z^J:^. plied the term to a form of respiration which tions partially iiningthe acuii ; he observed in dogs exposed to a tempera- fpie^fj'^"^''' '"'™''' *'''™- ture of 86° F. The number of respirations suddenly increased from 350 to 400 per minute. The production of polypnea he believed to be a function, of the oblongata. Its role is to regulate the temperature of the body, which is illustrated in the fact that an animal pants to cool itself. Eichet called this function thermopolypnea, and believed it to be ordinarily a reflex function, but central when insufficient. Through it temperature is regulated by an exhalation from the skin or from the lungs. Ott found that when he cut the chiasm, punctured the tuber, or touched it just behind the chiasm, he always arrested polypnea and thermo- taxis. Lesions of the tuber and its vicinity should therefore cause polypneic and temperature phenomena ; but clinical data bearing upon this point are as yet wanting. Lesions of Special Foci of the Basal Cinerea. — The optic tract receives a root from the region just behind the infundibulum. Hensen and Volckers have located the centre for movements of accommodation in the central gray matter of the floor of the third ventricle near the median line and just over the position of the albicantia ; movements of accommodation were elicited by electrical stimulation at this point according to them, and of the iris by stimu- lation of a point a little farther caudad. Loss of accommodation they held was due to destruction of the centre for accommodation in this region, and loss of pupillary response to light, to lesion of the second more caudal nucleus. Spitzka and Westphal reported cavses which in the absence of accommodative phenomena seem to conflrm the conclu- sions as to the cephalic position of the centre for accommodation. In one case total and in the other considerable external ojahthalmoplegia was present, accommodation being preserved in both. The nidi for accommodation were healthy. Berry and Bramwell have re- ported a case similar to those of Spitzka and Westphal, but without 24 370 NERVOUS DISEASES. autopsy. Borthen has reported a case of unilateral immobility of the pupil in which the pupil failed to respond to light, but accom- modation was normal. The left pupil was dilated. On allowing light to fall into the left eye there was no responsive contraction; contraction by convergence and accommodation was present, but very slow. When tlie normal eye was covered the left pupil con- tracted down to a diameter of three millimetres. Eeaction of the right eye was present, but reduced in the left. Borthen concluded that the affection might be due to a lesion of the nucleus for the con- strictor of the pupil or of the fibres connecting the opposite pupillary nuclei or to spinal irritation. By exclusion he inferred that the symptoms were due to nuclear disease. I ha\-e had under observa- tion a similar case of iinilateral immobility of the puj)il in a patient suffering apparently from disseminated gliosis or disseminated syph- ilitic disease of the cerebrospinal axis. These centres will be again considered when discussing affections of ocular movements due to nuclear and root til ire disease. Functions and Lesions of the Quadrigeminal Body The exact functions of both subdivisions of the quadrigeminal body — the pregeminum and the postgeminum — have not been established to the satisfaction of physiologists and clinicians ; but a practi- cal unanimity of opinion has been reached as to the pregeminum being in some way associated with visual processes. Some author- ities are inclined to regard the f[uadrigeminal body in man as an effete organ, but with Ferrier I believe that it has important func- tions in the human being, although these may lie relatively much less important than in many lower animals. Ferrier holds that the quadrigeminal body is an essential portion of the mechanism which coordinates retinal and general sensory impressions with the mes- enceplialic motor apparatus of eciuilibration and other adaptive reactions. In proportion as the higher cerebral organ for vision increases in the process of development, the quadrigeminal body seems to decrease, although it certaiidy continues to retain active functions connected with vision and station in man. Disorganiza- tion of the ganglia in rabbits caused blindness, dilatation, and immo- bility of the pupils, and marked disturbance of equilibrium and locomotion. The pregeminum is certainly connected with the oc- cipital cortex by sju'cial bands of fibres, — the optic radiations. The o|)tic lobes of fishes, which correspond with the pregeminum, are directly connected Avith the 0])tic nerves and are the chief central organs of xision in these animals ; but, on the other hand, it must be remembered that the quadrigeminuni is highly developed in lower animals in which the eyes and vision are in a \ ery rudimentary state : so that it is probable that only certain portions or layers of the pregeminum have visual functions. Entire removal of the optic lobes of fishes by Ferrier rendered station and locomotion LESIONS OF THE GANGLIA, CAPSULES, AND CENTRUM OVALE. 371 impossible. Mechanical and electrical stimulation of the quadri- geminum caused moie or less coordinated movements which sometimes took the form of spastic phenomena. Electrical stimulation of the pregeminum on one side in monlieys produced almost always dilata- tion of the opposite pupil, this being soon followed by dilatation of the pupil on the same side, also by elevation of the eyelialls upward and to the opposite side, witli numerous other motor manifestations. Bechterew with others believes that the postgeminum has distinct auditory functions and is also a motor or coordinating centre. He has traced the lateral or inferior fillet, which lies to the outside of the general fillet, from the apex of the superior oli^e to the nucleus of the postgeminum, and this lateral fillet is without doubt the most important basal tract for hearing. Irritation of the piostgeminum of the dog by Perrier caused a short bark or cry and every variety of vocalization ; and Goltz and Steiner believe that the postgeminal tubercles are centres for emotional manifestations, Itecanse in frogs the croaking cries in response to sensory irritation cease after their extirpation. In a case reported by Berry and Bramwell, in which the lesion was probably subgeminal, screaming fits occurred with- out apparent cause, and sometimes lasted half an hour, and these screaming fits were compared by them to the cries which electrical irritation of the postgeminum produces in lower animals. Lesions of the quadrigeminum iisually implicate both the pregeminum and the postgeminum, and therefore may give disorders of vision and hearing associated with those of equilibration. If restricted to the pregeminum, affections of vision and of ocular movements are most prominent. Trismus with opisthotonos, disordered or reeling gait, nystagmus, and special affections of the oculomotor, pathetic, and abducens nerves have been described in recorded eases. Subthalamic and Subgeminal Lesions. — A macroscopic lesion of the subthalamic region gives a complicated symptomatology, but one which will eventually be recognized in its details and properly referred. Edinger truly says of this region that its lesions involve such a tangle of different sorts of fibres that their symptoms are of the most manifold description, and a positive diagnosis can hardly be made. Eoci of disease in the vicinity of the crus implicate motor fibres to the opposite side of the body. Sensory and vaso- motor affections and oculomotor disturbances may also be present. With simultaneous paralysis of one oculomotor nerve and of the opposite side of the body a lesion under the quadrigeminum is prob- able. "Such ijatients ha\e either wholly oi' in i^art lost control of the limbs on one side of the body, the upper lid droops, the pupil is dilated, and the whole eye turned outward by the rectus externus. The same symptoms might come from a tumor at the base of the brain. It is therefore important for diagnostic purposes to know whether the ocular paralysis appeared simultaneously with 372 NERVOUS DISEASES. the paralysis of the extremities,— a condition of things which could only very rarely occur in the case of a tumor at the basis cerebri. If anesthesia appears it is only present on the side opposite the disease. The sensory fibres run to a great extent in the lemniscus." (Edinger. ) The red nucleus might be affected, and its connections which have been in large part traced are such as to indicate that it has some relations to equilibration. Some of the most important of these connections are with tlie thalamus, the lenticula, and the prepeduncles. Bechterew found the substantia nigra markedly de- generated and shrunken as a result of destruction of parts of the basal ganglia, and he Ijelieves that this structure is connected with the striata. Witkowski has also described descending degeneration Fig. 2.39. Section across the pregeminuni and the adjacent part of the thalamus : s, Syhian aqueduct; gr, gray matter of aqueduct ; c.q.s., quadrigeminal body, consistinjj of, I, stratum lemnisci, o, stratum opticiim, c, stratum cinereum ; Th, pulvinar of the thalamus: c.g.i., c.g.e., internal and external genicull ; hr.a., br.i., superior and inferior braohia : /, upper fillet; p. I., dorsal longitudinal bundle; r, raphe; ///, third nerve; n.JII, its nucleus; /.p.p., postcribrum (posterior perforated space) ; s.n., substantia nigra, above this te.sjmentum with its circular nucleus ; cr, crus ; //, optic tract ; M, medulla of hemisphere ; n.c, caudatum ; 1^., stria tenninalis. (Quain-Meynert.) implicating the substantia nigra. The complicated structures of the subthalamic and subgeminal regions are in part shown in Fig. 239, and comparison should be made with Figs. 76 and 77 on page 66. Lesions of the Crus. — The chief result of a destructive gross lesion of the crus is the production of alternate hemiplegia of the oculomotor type. From involvement of the descending pyramidal tract result paralysis of the leg, arm, and lower face of the opposite side, and, through implication of the third nerve at or near its super- ficial origin, paralysis of the part supplied by this nerve on the same side as the lesion, giving ptosis, dilated pupil, and paralysis of all the ocular muscles except the external rectus and superior oblique. Occasionally lesions in this position cross the median line FUNCTIONS AND LESIONS OF THE CEREBELLUM. 373 and give a complex of symptoms due to irregular bilateral iuvolve- ment of the pyramidal tracts and the third nerves. Some cases of oculomotor paralysis combined with monoplegia or hemiplegia present special features which make focal diagnosis difficult. The oculomotor paralysis may be on the same side as that of the ex- tremities and face ; and in such cases, if the history is of successive attacks, — and occasionally even when it is not, — the two sets of symptoms may be due to different lesions. This is perhaps the best explanation of the majority of such cases, which are usually syphi- litic. A lesion of irregular shape, chiefly on one side, but crossing the median line in the region of the root fibres of the third, might involve both the crus and the root fibres of one or both third nerves in the subthalamic or subgeminal region, other intermediate paits, such as the red nucleus, subthalamus, deep transverse fibres, and substantia nigra, not giving known symptoms. The fillet might escape, owing to its more lateral position. FUNCTIONS AND LESIONS OF THE CEREBELLUM. Anatomical Relations of the Cerebellum. — The gross anatomy and anatomical relations of the cerebellum have already been suf- ficiently described (see pages 67 and 73). The conclusions arrived at by Marchi, Bruce, and others, given there with reference to the cerebellar conducting tracts, are largely but not fully in accord with those of other investigators ; but the discrepancies are not suffi- cient to affect clinical deductions. The connections of the cerebel- lum are practically as given in the descriptions on pages 107 to 109, and as shown in the diagrams of Bruce and Van Gehuchten, but it must be borne in mind that the relations and interrelations of the cerebellum are not yet thoroughly known. The results obtained by all experimentalists and histologists agree in the main, and show that the cerebellum has traceable connections with the pre- frontal lobe, the occipital and temporal lobes, the red nucleus, and probably also with the thalamus ; with the quadrigeminal body, the pontile nuclei, the inferior olives, certain nuclei and fibre tracts of the oblongata, and with special regions of the spinal cord. Nearly all observers have confirmed one another as to the connection of one lateral lobe of the cerebellum with the opposite olive, this tract constituting a great efferent system, the cerebello- olivary system. Meynert first described atrophy of the inferior olive in associa- tion with atrophy of the opposite cerebellar hemisphere. Von Gudden and Vejas found that the cerebello-olivary tract under- went atrophy after removal of a cerebellar hemisphere in new-born animals ; and Bechterew and Bruce, Darkschewitsch and Freud have described myelination as occurring only in the last month of intra-uterine life, by which time the other constituent tracts of the rest) form body are fully medullated. These observations therefore 374 NEKVOUS DISEASES. confirm one another and prove beyond a doubt the intimate ana- tomical and functional relationship between the lateral lobe of the cerebellum and the opposite inferior olivary body. Perrier and Turner's experiments, in connection with facts recorded by other observers, support the view that the internal subdivision of the restiform body is an eflerent cerebellar tract which goes to Deiters's nucleus, this nucleus being an internode between the cere- bellar and the spinal system. In twi cases in which the lateral lobes of the cerebellum were removed by Ferrier and Turner de- generation was found in the spinal cord, especially in the antero- lateral regions. Minute Anatomy of the Cerebellar Cortex. — The cerebellum, whose functions have always been more obscure than those of the cerebrum, has also, like the latter, been subjected to the newer his- tological methods of investigation. The cerebellar cortex is usually described as composed of (1) an inner reddish gray or granular layer, (2) an outer gray or molecular layer, and between these (3) a row of large flask-shaped cells known as the cells of Purkinje. Fig. 240 shows this arrangement in the human cerebellum, while Fig. 241 is a skeleton drawing by Berkley of a cerebellar leaflet from the brain of a dog, the appearances ba^-ing been built up from sec- tions variously stained. The granular layer or zone is narrow at the base of the leaflet, gradually spreading out until its breadth is several times as great as at the base. Berkley describes no less than six different varieties of cellular bodies in the granular zone. Some of these forms are recognized by Piersol and others as most impor- tant, these being (1) small round multipolar cells with little proto- plasm and large nuclei ; (2) larger multipolar cells, few in number, and resembling somewhat the cells of Purkinje. The axis cylinder processes of the small cells pass to the outer layer. The axis cylinder processes of the large cells and the protoplasmic processes of both form arborizations within the granular layer. The cells of Purkinje are among the largest ganglion cells of the body, recalling the great pyramidal cells of the cerebrum, but presenting striking differences. Each cell possesses a large nucleus and also a nucleolus and an axis cylinder process which passes down into the white substance to become a medullated nerve fibre. Their protoplasmic processes are of great extent and interest, their direction in general being towards the cerebellar surface, as shown in Figs. 240 and 241. The numerous ramifications of these processes are not in all directions, but, as Obeisteiner says, are like those of an espalier fruit tree, in two directions only, so that in a section across a convolution the processes show a fanlike radiation, while in a section cut lengthwise they show simply as an edge. The Purkinje cells form a great con- necting link between the molecular and the granular layer. They are enveloped in a feltlike capsule or basketwork of fibres derived FUNCTIONS AND LESIONS OF THE CEREBELLUM. 375 from surrounding cells, gives a lymph space of great extent to the outer layer. Beyond the Purkinje cells, to- wards the surface, is a considerable num- ber of small rounded a,nd angular multi- polar cells, the largest of which are undoubt edly nerve cells. In the molecular layer, in a fine reticulated supporting neuroglia, besides the cells with their encapsulating basketlike tufts above described, are the ela- borate arborizations ot the protoplasmic pro- cesses of the Purkinje cells, and also small multipolar cells whose branched processes ex- t e n d peripherally, while other axis cyl- inder processes extend centrally but are prob- ably confined to this layer. In the outer zone of the molecular layer a few horizon- tal medullated fibres are seen. The nuclei of the neuroglia are seen distributed in this layer throughout its central and mid re- gions, becoming less obvious towards the pia, and in some places being entirely absent. On the outermost bor- der of the cerebellar leaflet subjacent to the The encapsulation of the Purkinje cells Fig. 240. Section of human cerebellum : H' white matter : G, granule layer ; 0, molecular layer •, P, cells of Purkinje ; x, axis cylin- der processes passing into granule layer; n, small nerve cell; V, pial bloodvessel ; p, pia. (Piersol.) pia is a condensation of substance known as 376 NERVOUS DISEASES. Fig. 241. the limitans externa, wMch is made up of a feltwork of fine glia fibrils derived from oval and pyramidal nuclei. Outside this limiting membrane is a subpial lymph space of considerable magni- tude, crossed by connective tis- sue fibrils which come from the innermost layer of the pia and go into the cerebellar substance. Here and there in the central white matter multipolar cells are found ; otherwise the white substance is like that of the cerebrum. From the white substance one set of fibres can be traced to the Purkinje cells ; another set passes to Dennis- senko's eosin cells in the gran- ular layer ; some of this set probably come in contact with other fibres before touching the eosin cells, some exceedingly fine but medullated fibres pass- ing on to the molecular layer. Still another set of fibres, much smaller in number and non- medullated, passes to the in- ferior and middle thirds of the molecular layer. Berkley makes an effort to separate the cerebellar fibre systems into efferent and afferent according to their connections and histo- logical peculiarities. Physiological Theories and Facts regarding the Cerebellum. — The size and structure of the cerebellum in all vertebrate animals indicate that its functions are impor- tant. Animals which swiftly and rapidly coordinate their moA'ements have cerebellums of large size and complex de- velopment. Bdinger has shown that osseous fishes, which are enormously developed as com- Skeleton drawing of half a cerebellar leaflet, built up from sections stained by various recent methods : A, core of medullated fibres ; A\ glia nuclei among them ; B, layer of granule or hema- toxylin cells ; C, granule layer with eosin cells, straight nerve fibres running to the Purkinje cells, and the anastomosing fibre plexus ; D, I>, eosin cells ; E, fibre plexus ; F, F, straight fibres run- ning through the granule layer ; (?, tangential fibres at the outer edge of the granule layer ; H, H, Purkinje bodies with outspreading branches ; H^, H^, turning of the terminal filaments beneath the pia ; J, pia ; A', nuclei in the subpial space ; L, L, small nerve cells in the inferior third of the molecular layer; M, filircs radiating ont of the granule layer ; N. nerve cells in the graiiule layer ; 0, row of pear-shaped and round nuclei at the outer edge of the granule layer ; 0', Purkinje cell space, capsule not drawn ; P, P, glia elements of the molecular layer ; Q, Q, fibnllce i>assing oflf from the pear-shapcil cells attached to the limi- tans externa : P, supposed glia nucleus in the granule layer ; S, limitans externa ; T, granule nuclei. (Berkley.) excellent swimmers, have cerebellum; FUNCTIONS AND LESIONS OF THE CEREBELLUM. 377 pared with those of the cartilaginous fishes, which live tranquilly in the deep. The lateral lobes of the cerebellum, so largely de- veloped in man and the higher animals, are practically wanting in amphibia and reptiles. A view commonly held, which seems to have originated with Nothnagel, that the vermis or middle lobe is the only part of the cerebellum with determinable functions, can no longer be regarded as correct. Histological studies and the experiments of Luciani and of Ferrier and Turner show that the lateral lobes, as well as the vermis, have important functions, and that their lesions should give recognizable symptoms. Gowers holds that while the middle lobe probably presides over the coordination of movement, it may act on the opposite cerebrum and other parts through the cortex of the lateral lobes. According to Berkley, the nerve elements of the cerebellum observed as a unit bespeak a sen- sory and not a motor organ, the great cells of Purkinje having a closer likeness to those of Clarke's column than to any other bodies in the nervous system ; but arguments as to function based upon the size and character of the cells must be received with caution. The cerebellum early attracted attention on the part of physiologists, as Plourens, Magendie, and Weir Mitchell, and has been the subject of continuous investigation. Some of its recent investigators are Luciani, Marchi, Borgherini and Gallerani, E. Eussell, and Ferrier and Turner. The facts elicited by all are practically the same, but different inferences have sometimes been drawn, as by Luciani and by Ferrier, although this in some instances would seem to have been due to different methods of interpreting phenomena, as when one observer describes an animal as rolling away from and the other as rolling towards the side of the lesion made in the cerebellar peduncle. Borgherini and Gallerani found that lesions profoundly affecting the cerebellum produced symptoms resembling those of locomotor ataxia, and that a superficial lesion of the organ, which in experiments falls of necessity on its dorsal and caudal aspect, gave as a constant and permanent result a tremor of the head and neck. They also found that injury to the cerebellum caused trophic disturbances, but was not accompanied by any modification of muscular force nor hy any alteration of special or general sensibility. One of the differences between Luciani and Ferrier is as to the immediate effects of cere- bellar lesion. Luciani regards these as irritative, while Ferrier de- scribes them as dynamic or inhibitory. These immediate effects have been described in much the same way from the days of Flourens and Magendie to the present time. In dogs, as detailed by Luciani, they are disquietude, frequent howls, pleurothotonos, tonic exten- sions of the anterior extremities, and a tendency to roll from one side to the other. After total extirpation of the cerebellum, the symptoms are bilateral, and pleurothotonos is replaced by opis- thotonos, and in monkeys the tonic extensions of the extremities are 378 NEEVOUS DISEASES. replaced by tonic flexion. Experimenters are in general accord in stating that lesions of the cerebellum do not produce sexual or psychical manifestations, nor discoverable impairment of special sensibility nor of any of the forms of cutaneous or muscular sensi- bility. An important fact is that one half of the cerebellum exerts its influence on the same side of the body as itself, its action on the spinal cord being direct and not crossed. According to Luciani, the permanent effects of cerebellar ablation — the eff'ects which per- sist after the irritative phenomena have subsided — can be arranged in three classes, which he describes as (1) asthenic, (2) atonic, and (3) astatic, regarding the three as simply external phenomena of one internal morbid process. The animals showed extraordinary disturbance of station and locomotion, and long persistence of un- steadiness of the trunk and limbs upon effort. According to Ferrier, the animals operated upon retained muscular strength, Luciani be- lieving, however, from his own experiments that this was much impaired. Luciani also differs from Ferrier with reference to tonic contractures, believing them to be present. Lesions of the Middle and of the Lateral Lobes. — Complete removal or large lesion of the vermis produces practically the same symptoms as ablation of the entire cerebellum or of its lateral lobes, but, unlike lesion of one lateral lobe, it does not affect one side of the body more than the other, and its eff'ects are more pronounced in the head and trunk than in the limbs. Extirpation of this lobe is followed by secondary degeneration of both postpeduncles, which has been traced to the nucleus of Deiters. Bruce and Bechterew have traced connections between this tract, called by Edinger the direct sensory cerebellar tract, and the roof nucleus of the opposite side. In a case of gliosarcoma recorded by de Michele, chiefly in- volving the postvermis or inferior vermis, the symptoms properly referable to the cerebellum seemed to be progressive weakness of the extremities, general impairment of nutrition, unconscious yell- ing or screaming, and lateral curvature of the vertebral column. The patient also showed other general pressure and invasion symptoms of brain tumor. While it is true that disease of one lateral lobe of the cerebellum has been recorded as having no symptoms, such records are probably indicative of lack of close observation, although a slowly growing cerebellar tumor may for a long time cause scarcely detectable phenomena. After destruc- tion of the lateral lobe, animals exhibit great unilateral disturbance of station or locomotion, and unsteadiness of trunk and limbs on muscular effort, on the side on which the operation has been performed. According to Luciani, both muscular strength and tone are impaired ; but Ferrier does not give these meanings to the phenomena, regarding them rather as phenomena of incoor- dination. He records that knee-jerk was either not impaired or was FUNCTIONS AND LESIONS OF THE CEREBELLUM. 379 increased on the side of the lesion. The astasia or weakness, which- ever it is, is usually more marked iu the upper extremities. In a case of iibrosarconia of the left cerebellar hemispheie recorded by Sobotka, the symptoms referable to the cereljellum were inability to walk for any length of time, enormously exaggerated knee .I'erk, and marked foot clonus, with right facial paresis, all the luauifestatious being slightly more marked on the right than on the left side. In a case of echinococcus of the left lateral lobe reported by Sonneu- burg, the symptoms were sleepiness, loss of coordination, diminished vision, and difficult speech, the patient also suffering from violent headache, vertigo, and disturbance of respiration. Lesions of the Cerebellar Peduncles. — The symptoms follow- ing division of the peduncles are very similar to those occurring after removal of the lateral lobe, the chief differences being a tendency on the part of the animals to roll around their longitudinal axes, — according to Magendie, Perrier, and others, towards the side of the lesion, according to Luciani, towards the opposite side. Ban- nister has reported a case of hemorrhage into the A'entral surface of the prepeduncle, which caused sudden disturbance of equilibrium, vomiting, with possibly contralateral paresis, also lateral decubitus on the side of the lesion and drawing of the head to the right side, and rigidity of the left arm. After section of the prepeduncle and velum a tract of degeneration can be traced backward into the ver- mis. According to Ferrier and Turner, the chief fact brought out in their study of degeneration in the sphere of the prepeduncle is that the brachium conjunctivum is efferent in function and under- goes complete degeneration after extirpation of the lateral lobes. Cases of irritative lesion of the medipeduncle have been reported in which the body has shown a tendency to gyrate involuntarily around its longitudinal axis, that is, to produce this form of forced movements ; but this symptom may be absent in destructive lesions. In the case of an irritative lesion the patient may have an irresistible impulse to lie on one side. Some cases of idiocy with whirling ten- dencies probably have irritative or atrophic lesions of this peduncle. The medipeduncle is more frequently the seat of separate disease than either of the others. , The postpeduncle has an external and an internal division, the external being connected with the spinal cord through the direct cerebellar tract, also with the clavate and cuneate nuclei and with the opposite inferior olive ; the internal division is connected with the so-called auditory nuclei. Ferrier and Turner found that degenerations following extirpation of the lateral lobes were limited to the external division, and that those following extir- pation of the middle lobe were limited to the internal division. A certain attitude after section of the postpeduncle was constant and characteristic, viz., curvation of the vertebral axis, with the con- cavity towards the side of the lesion, adduction and flexion of the 380 NERVOUS DISEASES. limbs on the side of the lesion, and abduction and extension of those on the opposite side. The direction of deviation of the chin was usually to the side opposite to the lesion. In several cases, after division of the postpeduncle, anesthesia of the cornea on the side of the lesion was observed, due to implication of the immediately subjacent secondary descending (usually called ascending) trigeminal root. The Flocculus. — Some investigations and observations have shed a little light upon the functions of the flocculus. Edinger, for example, has traced fibres from the flocculus into the nucleus of the abducens or external oculomotor nerve of the opposite side, but Bruce has not been able to trace this connection. As bearing upon this relation, the fact that in a very few instances nystagmus has been reported as associated with disease of the flocculus is of interest. The flocculus appears very early in the development of the cerebellum. Mihalkovics states that it appears contempora- neously with the vermis. The fibres which form its core or peduncle begin to meduUate during the fifth month. According to Bruce, Fig. 242. SEAtlC//KViA/f Diagram showing the connection of the flocculus and the roof nuclei of the cerebellum with the nucleus of the sixth nerve and other parts, and also other connections of the sixth nerve. (Bruce.) successive transverse (frontal) sections show that this peduncle passes inward towards the lateral angle of the fourth ventricle, and that the majority of its fibres pass inward and enter into relation with both the external and internal nuclei of the auditory nerve FUNCTIONS AND LESIONS OF THE CEREBELLUM. 381 and with the nucleus of the sixth nerve on the same side. It is also connected with the accessory nucleus, and probably with the dentatum. Bruce believes that the associations of the flocculus point to it as an important structure related to the vestibular branches of the auditory nerve, which are probably not true nerves of hearing, but rather nerves of space. The connections of the flocculus are indicated in the diagram, Pig. 242. The Clinical Phenomena of Cerebellar Disease. — A careful study of a large number of cases of cerebellar disease shows that the most important symptoms and those of most frequent occurrence are headache, vomiting, vertigo, double optic neuritis, unsteadiness of station or gait, tonic spasms or contractures, which may be either paroxysmal, continuous, or nearly continuous, tremor sometimes associated with voluntary movements and seen oftenest in the upper extremities, pleurothotonos, opisthotonos or retraction of the head, and paresis or paralysis of the extremities or of the cranial nerves, usually of one side. The symptoms in carefully recorded cases are, on the whole, in agreement with the results of physiological and histological research, although they may seem at times to conflict. This apparent conflict can be explained. The symptoms are not always to be directly referred to the cerebellum ; they may be due to irritation of the bone or of the membranes, to pressure upon the adjacent parts, to acquired hydrocephalus, and to the reflection or diffusion of irritation, as well as to the cerebellar disease itself. The extreme irritation of the dura in most cerebellar tumors probably chiefly accounts for the headache, as even this symptom is occasion- ally absent when the neoplasm is small and develops within the sub- stance of the cerebellum, as in some cases of glioma. Vomiting and vertigo result from dural irritation, but in cerebellar cases they seem sometimes to have special peculiarities and to be unusually severe. They may be due sometimes to the more or less direct irritation of the pons and oblongata. Disturbances of pulse, respiration, and tem- perature not dependent upon the site of the lesion may be present. A large cerebellar growth, hemorrhage, or abscess may give mani- festations due to pressure upon the quadrigemiual body, pons, oblongata, or cranial nerves. Paresis or paralysis of the extremities has been noted as occurring both on the side of the lesion and on the opposite side. This may be accounted for by pressure on the pyramidal tracts of either side. "When loss of power is noted as having occurred on the same side, it is probable that the symp- tom is of the nature of the ataxia or motor impairment which has been described as occurring in animals. The irregularity in the cranial nerve phenomena can be best accounted for as the effect either of pressure or of invasion. Hydrocephalus, which is acquired in many cases of cerebellar lesion, may give special features to the symptomatology. The apathy or stupor sometimes described, and 382 NERVOUS DISEASES. the affections of the optic and auditory nerves, may in some instances be attributable as much to the hydrocephalus as to the original dis- ease. Knee jerk is commonly affected in cerebellar disease. Cases reported by Dercum and nthers show that it may be differently affected : it may be al)sent ; it may Ije alisent at one period of the atfcction and present at another ; it may be exaggerated ; it may be different on the two sides ; or, as in one case of my own, it may be possilde to elicit a crossed knee jerk. The difference between the elfects of destructi\'e and irritative lesions is imjiortant in endeavor- ing to fix the exact site of a cerebellar lesion : thus, destruction of the cephalic portion of the vermis causes a tendency to fall forward, and irritation a tendency to fall in the opposite direction. Destruction of the caudal portion of the vermis, on the other hand, causes a ten- dency to fall backward, -nhile irritation will bring about the muscu- lar adjustment neci'ssary to counteract this tendency. In like man- ner a destructive lesion in the lateral lol>e may cause a tendency to move in a diiection opposite to that produced by an irritative lesion. It is probable that the effects ohser\ed in man aie more frequently due to destruction of tissue than to irritation. Loss or impairment of sensation in the distribution of the sensory portion of the fifth nerve has sometimes been observed as the result of operatiou on the cerebellar peduncles. Ferrier and Turner during operations on the medipeduncle and postpeduncle found anesthesia and subseipieutly some degeneration of the trigenunal nucleus. These results were undoubtedly due to lesions of the long descending branch of the fifth nerve, usually known as the ascending branch. Cerebellar Affections of Congenital Origin. — A few important cases of cerebellar atrophy or deficiency of congenital origin have been recorded. An old and remarkable case, reported by Combette, is that of Alexandrine Labrosse, a girl who lived to the age of eleven years. Her cerebellum was completely atrojihied, its place being occuijied by a cyst. She was fi^'e years old before she was able to stand, and at the age of seven was Aery insecure upon her legs. Shuttleworth and Taylor and Ferrier ha\e vecoided another remarkable case of an imbecile girl who died at the age of fifteen years. No deficiency existed in her senscuy facilities, but she showed a general muscular weakness and tremor in her hands ,when she was using them, which was attributed to debility associated with a phthisical condition. She could walk well and steadily, though she was ne\'er known to run. The cerebrum was well developed, but tile cerebellum was of the most diminutive character. Xonne and Marie and others ha\-e described a form of hereditary cerebellar ataxia associated with atrophy of the organ and of the spinal cord. The peculiar features of this form of disease will be discussed in connection with the affections with which it may be confounded. CEANIOCEEEBEAL TOPOGRAPHY. 383 CRANIOCEBEBRAL TOPOGRAPHY. Definitions. — Craniocerebral topography is the art of deter- mining tlie relations of certain parts of the brain to definite points on the skull. Its cliief practical purpose is to assist the surgeon in trephining for such affections as intracranial hemorrhage, tumor, abscess, concealed fracture, sinus thrombosis, mastoid al)Sccss, dis- ease of the Gasserian ganglion, purulent leptomeningitis, idiocy, epi- lepsy, and hydrocephalus. Anatomists and surgeons h-.ivt employed various methods of determining craniocerebral relations. Cunning- ham hardened the brain in the skull, remo\ ed portions of the cranial walls, and made casts of the preparations. In Figures 243 and 244 Fig. 243. Drawing of a cast of the head of a newborn mlant 1, central fissure ; 2. fissure of Sylvius ; 3, supertemporal fissure ; 4, parietal (intrapanetal) hssure , 5, parieto-oeeipital Assure ; A, position of parietal eminence ; B, position of frontal eminence. (Cunningham, in Morris's Anatomy.) are shown drawings of specimens prepared in this way, which indi- cate not only the position of the sutures with reference to the parts beneath, but also some of the most important lines and points on the skull. On page 147 (Fig. 134), numerous skull landmarks, mainly after Broca, have been given in connection with a consideration of craniometrical investigations. Some of these landmarks are used by the surgeon in determining proper points for trephining, as, for instance, the glabella, inion, bregma, vertex, auricular point or ex- 384 NERVOUS DISEASES. ternal auditory opening, nasion, and stephanion. Other points or lines are the external angular process of the frontal bone, the parietal eminence, the orbital arch, the zygoma, the mastoid process, and the superior arch of the occipital l)one. The glabella, as already de- fined, is the triangular space between the eyebrows, and the inion is Fig. 244. Drawing of a cast of the head of an adult male : 1, central fissure ; 2, fissure of Sylvius ; 3, super- temporal fissure ; 4, parietal (intraparietal) fissure ; 5, parieto-occipital fissure ; 6, medltemporal (second temporal) fissure ; --1. position of parietal eminence ; B, position of frontal eminence ; C, lateral sinus. (Cunningham, in Morris's Anatomy.) the external occipital protuberance. Usually the cephalocaudal or anteroposterior line of the skull is taken from the glabella to the inion. The stephanions, superior and inferior, are the intersections of the coronal suture with the ridjies for the temporal fascia and the temporal muscle re.spectively. The bregma is at the junction of the coronal and sagittal sutures, and the vertex is the highest point of the skull, a little caudad of the bregma. The auricular point corresponds to the centre of the external auditory orifice, and the nasion, which is close to the glabella, to the junction of the nasal and frontal bones. The parietal eminence, the most prominent part of CRANIOCEREBRAL TOPOGRAPHY. 385 the parietal bone, is often referred to, and is quite evident in the child, but frequently in the adult it is obscure and varies somewhat in position. It is necessary to take it into account, as it enters into the calculations of surgeons in defining certain lines or points for operation. The external angular process of the frontal bone is at its junction with the external portion of the orbit. The line of the orbital arch reaches frona the external angular process of the frontal bone to the internal angular process. The zygoma is the narrow projecting bar of the inferior external border of the temporal bone. The mastoid process, which is the nipple-shaped process of the tem- poral bone behind the ear, is the point of departure for numerous measurements, and is also the position for certain operations. The superior curved line of the occipital bone, or superior nuchal line, reaches from the posterior border of the mastoid process to the occipital protuberance. The Most Important Craniocerebral Determinations. — As it is now possible to localize lesions amenable to operation nearly everywhere within the cranium, and as almost all portions of the brain, except the mid regions of the base, are accessible to the sur- geon, it may be necessary to indicate on the skull almost any fissure, convolution, or special part ; but some fissures, convolutions, and regions are of paramount importance because of their functions, and of the frequency with which they are the seats of disease, and also because, in some instances, they serve as places of departure in mapping out the cranium. Among fissures which may need to be located are the Sylvian, central, precentral, retrocentral, first and second frontal, first and third temporal, intraparietal, parieto-occip- ital, and the transverse fissure between the occipital lobe and the cerebellum. Of these the most important are the Sylvian, the cen- tral, and the parieto-occipital. Among convolutions topographi- cally important in craniocerebral work are the precentral and post- central, the angular, the first, second, and third temporal, the second frontal, and the cuneus. It may also be necessary sometimes to define the position and extent of an entire lobe or a large part of it, as of the prefrontal, the lateral portion of the temi^oral, the occip- ital lobe, or a lateral lobe of the cerebellum. I^umerous methods of determining craniocerebral lines and points are to be found in the textbooks. Some of these are simply slight modifications of others. All have their merits, and nearly all have some defects. Considerable experience in craniometrical measurements, as well as in the neurological aspects of cranial surgery, has convinced me that it is often difficult, if not impossible, to designate upon the scalp some of the well known points of the uncovered skull, such as the bregma, lambda, and parietal eminence. Those methods are therefore the best which select as points of departure landmarks which can always be determined. 25 386 NERVOUS DISEASES. Craniocerebral Variations. — The sutures even of the adult skull do not bear fixed relations to the fissures and convolutions. Con- siderable variations have been noticed. A comparison of Cunning- ham's illustrations with similar illustrations by others will show that the squamous suture is represented as above, below, and nearly on a line with the fissure of Sylvius ; and other similar sutural variations are indicated. Anderson and Makins found that the summit of the parietal eminence had a range of variation in posi- tion half an inch in the vertical and an inch in the horizontal direc- tion. The bregma and lambda have also a considerable range of variation in position from the glabella and inion. According to Foulhouze, in children up to the third or fourth year the Sylvian Fig. 245. Craniocerebral guiding lines traced upon a photograph of one of the casts prepared by Profes- sor Cunningham ; O, glabella ; I, inion ; M, midsagittal point, midway between G and I: A, ex- ternal angular point ; .S, squamosal point, intersection of oblique and frontal lines at jmiction of middle and lower thirds ; P, parietal point, termination of oblique line equidistant with b from squamosal point ; E, preauricular point ; a. " commencement" of fissure of Sylvius, five twelfths of the distance from Ato S; b, bifurcation of fissure of Sylvius, seven twelfths of the distance from A to .S; d, termination of fissure of Sylvius, one half inch (1,25 cm,) above P, in a direction parallel to frontal line ; Ce, central fissure ; C, upper extremity of central fissure, three eighths of an inch (.9375 cm.) behind the midsagittal point; c, lower extremity of central fissure, carried to oblique line in direction of fissure, three eighths of an inch (.937;i cm.) in front of the squamosal point ; 0, parieto-occipital fissure, on sagittal line seven twelfths of the distance from Mto I; the dotted line from O to I is the "sagittal line;" the line from A to Pis the "oblique or squamosal line ;" the line from E to Mis the " frontal line." (After Anderson and Makins.) fissure is more oblique and lies farther above the squamous suture. Dana found that in some young children the fissure lies just under the squamous suture, as in adults, but usually it is a little above it. In children the upper end of the central fissure is generally at or a little cephalad of the point given for adults. Anderson and Makins's Craniometrical Lines. — Anderson and Makins suggest (1) a median sagittal line, from the glabella to CRANIOCEREBRAL TOPOGRAPHY. 387 the inion ; (2) b, frontal line, from the midsagittal point to the depres- sion just in front of the ear at the level of the upper border of the meatus ; (3) a squamosal line, from the most external point of the external angular process, at the level of the superior border of the orbit, to the junction of the middle and lower thirds of the frontal line, and prolonged for about an inch and a half behind the frontal line. The upper extremity of the central fissure was found by them to lie between the midsagittal point and a point three fourths of an inch behind it, and the lower extremity of this fissure they located near the squamosal line, about three fourths of an inch in front of its junction with the frontal line. The commencement of the lateral portion of the Sylvian fissure is not at a definite fixed point, but will usually be hit at a point from one and a half inches to two inches behind the angular process, the course of the horizontal portion of this fissure corresponding closely to the squamosal line. Fig. 246. TOUXXJ Lncas-ChamplonniSre's method of determining the central Assure : AB, horizontal line two and four fifths inches long, drawn from the upper outer angle of the orbit ; BC, perpendicular line one and one fifth inches long, to the position of the lower extremity of the central fissure ; CD, course of central fissure from last point to half an Inch behind the centre of the vertex ; 1, speech centre (Broca's convolution) ; 2, 3, and 4 represent respectively the positions of the arm, leg, and face centres. (Lanphear.) The parieto-occipital notch is placed at a point seven twelfths of the distance from the midsagittal point to the inion. The longitudinal sinus frequently deviates towards the right side in the caudal portion of its course. The points and lines given by Anderson and Matins are shown in Pig. 245. Lucas-Championniere's Method of Determining the Central Fissure.— In Lucas-Championni^re's method of determining the cen- 388 NERVOUS DISEASES. tral fissure, illustrated in Fig. 246, a line is dra\m from the upper outer angle of the orbit, marked A, directly backward for a distance of two and four fifths inches (7 cm.) to the point marked B. Prom this point a perpendicular line is raised to C, and the line CD is drawn to a point half an inch (1.25 cm.) behind the centre of the vertex. This line represents the course of the central fissure within a fraction of an inch. Reid's and Agnew's Landmarks. — Eeid suggests to draw first a base line from the centre of the external auditory meatus to the inferior margin of the orbit. The longitudinal fissure is indicated by the line from the glabella to the inion. The transverse cerebellar Fig. 247. Agnew's diagram showing tlie cranial lines for cerebral localization : CG, Reid's base line drawn from the lower border of the orbit through the external auditory meatus to the base of the mastoid process ; EP, anterior perpendicular line drawn from the sulcus in front of the ear to the top of the head ; GH, posterior perpendicular line drawn from the posterior border of the mastoid process to the top of the head ; X, parietal eminence ; O, position of postcornu, one inch and three quartets below the parietal eminence, and two inches and one quarter from the surface ; IK, line drawn from the upper part of the occipital protuberance to the perpendicular EF, indicating the trans- verse cerebellar fissure ; P, position of the lateral sinus ; L, angular gyrus ; M, parieto-occipital fissure : N, cuneus. fissure is represented by a line drawn from the external occipital protuberance to the external auditory meatus. To determine the line of the fissure of Sylvius, a point is first taken one and one fourth inches (3.125 cm.) behind tlie external angular process of the frontal bone, and another three fourths of an inch (1.875 cm.) below CRANIOCEREBRAL TOPOGEAPHY. 389 Fig. 248. the most prominent part of the parietal eminence, the position of the fissure being indicated by a line di-awn between these points. Two perpen- diculars are drawn to the base line, one through the depres- sion just in front of the ear, and the other through the posterior border of the mastoid process. These are extended to the longi- tudinal fissure, and a line is drawn from the junction of the most posterior of these per- pendiculars with the longitudinal fissure to the junction of the most anterior with the Sylvian line. This represents the posi- tion of the central fissure. Agnew's method is a modifica- tion of that of Eeid, and the lines and Diagram of craniocerebral relations : -t-, parietal eminence : a, convex line forming- lower boundary of parietal lobe ; l.fr.e., first frontal or superfrontal convolution; l.fr.f., first frontal or su- perfrontal fissure ; /.i2., central fissure, fissure of Rolando; s resulting from traumatism will be con- sidered under encephalitis and abscess. In all forms of intracranial traumatisms, according to Phelps, in endea\'oring to make a differ- ential diagnosis the possible multiplicity of lesions must be kept prominently in mind, and the relative as well as the absolute value of symptoms must be estimated. HYPEREMIA OP THE BRAIN AND ITS SOFT MEMBRANES. 431 HYPEREMIA OP THE BRAIN AND ITS SOFT MEMBRANES. Definition and General Considerations. — lu hyperemia of the brain and of its soft membranes, which must be considered together, the encephalic vessels contain, for a time at least, an amount of blood disproportionate to that present in the rest of the system. Its exist- ence as a clinical entity has been doubted ; but certainly a hyper- emia of passive character due to obstruction may occur, and it is almost equally certain that an active hyperemia may affect the brain as the result of anxiety, cerebral overwork, injuries, effects of the sun, and toxic substances circulating in the blood. It is true, how- ever, that the diagnosis of hyperemia or congestion of the brain has too often been made. Eecurring attacks of hyperemia form part of the clinical history of some forms of insanity. Varieties. — Hyperemia may be either acute or chronic, active or passive. Other special varieties are sometimes described, as the light and the severe form, the cephalalgic, the psychic, the convulsive, and the apoplectic form. (Hirt.) Such varieties simply represent dif- ferences in the intensity of the pathological process. Localized and circumscribed hyperemia of the active type may occur in the vicinity of tumors, meningitis, or encephalitis. Symptoms. — The symptoms of acute general hyperemia of the brain are headache, sensations of throbbing or confusion, tinnitus, phosphenes or i)hotopsias, flushing of the scalp and face, and injection of the conjunctiva. The pupils are generally contracted. Insomnia and even delirium with hallucinations and illusions may be present in severe cases. In rare cases congestive apoplectiform attacks, in which consciousness is lost for a time, occur. The pulse is usually slow, hard, and full. The symptoms of static or passive hyperemia, de- pendent upon local obstruction or deficient cardiac and vasal energy, usually come on more slowly, are more continuous, are of less decided character, and are often associated with other evidences of disease, particularly of cardiac and pulmonary involvement. Dull headache, dizziness on exertion, and feelings of fulness in the head are common. Marked tinnitus, throbbings, and visual phenomena are not so fre- quently complained of as in the active forms of congestion. Attacks of spasm, with or without unconsciousness, are among the rare results of brain congestion of the apoplectiform type. The existence of chronic hyperemia is indicated by such symptoms as have just been described as belonging to the acute forms, but these are of less inten- sity and have marked exacerbations. As already stated, it is doubt- ful whether a persistent chronic hyperemia without organic change is present over a long period. Etiology. — Active hyperemia may be the result of organic dis- ease or of functional disturbances of the circulation from causes acting either within or outside of the body. Subacute and chronic 432 NERVOUS DISEASES. hyperemia of the brain, with acute exacerbations under exciting causes, sometimes accompanies hypertrophy of the heart, which in its turn may be dependent upon aortic valvular disease, or upon some extracardiac obstruction to the circulation. Sudden and wide- spread contraction of the arterioles in other parts of the body may cause temporary encephalic hyperemia, as when the vessels of the skin and other organs contract over large areas from exposure to ex- treme cold. A few drugs, as amyl nitrite and nitroglycerin, induce hyperemia of the brain by their action on the vasomotor centres. Some neurotics seem to have an inherent tendency to vasomotor weakness, leading to recurring cerebral hyperemia, generally of a mild type. The transient headaches of children may be accounted for in this way. Many physiological and clinical facts tend to prove that hyperemia of the surface of the brain may be the result of psychical overactivity. Tracings have been made with the sphyg- mograph by Mosso, Batty Tuke, Putnam- Jacobi, and other observers, where the brain has been exposed as the result of disease of the cranial walls, and these cases have shown bulging and increase of blood pressure due to mental activity or excitement. In other words, a functional hyperemia is thus produced, and is due either to direct action of the vasodilator centres or to retardation of inhibition of vasoconstrictor centres. Passive hyperemia of the brain is, as a rule, due to diseases which cause interference with or obstruction to the return of the blood within the capillaries of the brain, as aneu- risms or tumors of the neck, weakness of the heart with fatty de- generation, and disease of the lungs. The playing of wind instru- ments is also a possible cause. Pathology. — The intracranial cavity is closed and practically always filled, but, as shown when considering concussion of the brain, the usual state of balance between blood pressure and brain pressure — that is, the pressure of the cerebrospinal liquid — is at times altered. The fact that brain pressure may be changed makes it possible to have a cerebral hyperemia. According to Eoy and Sherrington, the encephalic circulation is regulated by three factors, — the general arterial pressure, the general venous pressure, and the presence or absence of chemical products of cerebral metabolism contained in the lymph which bathes the walls of the arteries of the brain. These last may sometimes act locally, bringing about dif- ferent degrees of cerebral activity. One of the most important facts observed by them was that the blood sujiply of the brain varies with the pressure in the systemic arteries. In chronic nephritis with in- creased ))lood pressure, cerebral congestion and hemorrhage are well known < x-currences. One explanation of cerebral hyperemia is that it is dependent upon paralysis of the vasomotor nerves, which allows dilatation and overfilling of the bloodvessels. Such a condition of paresis or paralysis might be brought about by the circulation of HYPEREMIA OF THE BRAIN AND ITS SOFT MEMBRANES. 433 toxic agents in the blood, affecting the vasomotor centres either in the bulb or in the cortex. The ingestion of alcohol or other narcotics and products of metabolism in the body may give rise to hyperemia. The condition present in many cases of so-called hyperemia is cer- tainly one of toxemia : the blood retained in the distended capil- laries is changed in quality as well as in quantity. In passive hyper- emia, for instance, the capillaries contain an excessive amount of carbon dioxide, the influence of which on the encephalic centres is more baneful than the mere presence of an undue amount of blood. The blood is not properly oxygenated ; and in other cases special toxic agents may be dammed up in the congested capillaries. The congestion of the brain and its membranes which results from ex- posure to high temperatures is due to a toxic agent in the blood, the toxin being the product of catabolic changes produced by high tem- perature. (Tuke and Woodhead.) It is well known that uric acid increases arterial tension, and in this way conditions conjointly hyper- emic and toxemic may be produced in the head, and in various parts of the nervous system. De Sarlo and Bernardini have recorded experiments on the cerebral circulation during psychical activity and under the action of certain intellectual poisons. The experiments were made upon a patient of a moderat-e degree of intelligence who had a fracture of the skull that permitted instrumental registration of the movements of the brain. The object of the investigation was to determine the relations existing between the cerebral pulse and the emotions. They found that in all emotional conditions there was an increase of the cerebral volume and of the height of the pulsations. The physical pain produced by the electric current always caused vasal spasm, while the pain induced by other means did not specially modify the circulation, or the modifications occurred at the same time with the other emotions. They conclude that the manner of re- action by the cerebral circulation produced by emotions is not altered by the effects of these agents, and that the changes in the cerebral circulation induced by them are of the nature of reflexes, not subject to modification by preexisting conditions. They offer the suggestion that as the psychic phenomena observed by them in their subjects were due to chemical intoxication, and not to circulatory disturb- ances, many forms of mental disease thus have for their cause, in- stead of cerebral hyperemia or anemia, some intoxication, of the real nature of which we are still in ignorance. (Soury. ) Pathological Anatomy. — Hyperemia of the brain is a vital process, and one which does not always leave appearances which can be detected after death, and the records of autopsies have in this respect been often misleading. Engorged veins and capillaries often seen at autopsies are sometimes set down as evidences of congestion. The brain passively congested during life may present an anemic appearance after death. Among the best evidences of cerebral hyper- 28 434 NERVOUS DISEASES. emia is tlie ijresence of minute extravasations in tlie floor of the ven- tricle and scattered throughout the cortex and the centrum ovale. Microscopical examination may show enlarged capillaries. The con- gested appearance of the inner membranes of the brain, particularly- in the occipital region, is sometimes due to gravitation of blood to these parts either before or after death. In hyperemia of the brain an excessive amount of blood is retained within the capillaries, just as in congestion of the lace or any visible portion of the body the abnormal condition is chiefly one in these vessels. In active or flux- ionary hyperemia too much blood is driven from the arteries into these capillaries, while in a static or passive hyperemia the flow from them is obstructed. Diagnosis. — The diagnosis of acut(; fluxionary hyperemia of the brain and its inner membranes may in some instances be made from the appearances presented by the patient, and yet in a large experience I have seen only one or two cases in which this could be done with certainty. In one of these cases the patient was relieved from threat- ened catastrophe by prompt and free bloodletting. He complained of severe headache, throbbing, dizziness, and a sense of peril ; his face was flushed to turgescence, his heart action was rapid and thumping, and his pulse was full and tense. This patient was of ijlethoric habit and addicted to the moderate use of alcohol. Similar evidences of active hyperemia are occasionally observed in cases of focal lesion. The diagnosis of local hyperemia of the brain is often made in chronic cases, and is frequently erroneous. Patients suffering from all sorts of head pains and paresthesias are said to be the victims of chronic hyperemia of the base or other part of the brain ; but such cases bear other interpretations. They may be mild toxemias, or light forms of neuritis of branches of the trigeminal, or perhaps they are instances of neural rather than of cerebral congestion. They may also be simply hysterical, hypochondriacal, or neurasthenic manifestations. The diagnosis of encephalic hyperemia from serious organic focal affections, such as aneurism, embolism, thrombosis, and tumor, is usually readily made by the greater intensity of the symptoms in the latter cases, and by their more focal character, ^o form of persisting paralysis, spasm, anesthesia, or disorder of the special senses can be justly set down to hyperenua, even admitting that it may at times be local ; although temporary aphasias and paretic states may perhaps occasionally be due to local hyperemia of obstructive origin. In uremic attacks the appearance of the patient, his temperature, pulse, and respiration, and the presence of albumen and casts and other evidences of renal disease, are sufiicient to make the diagnosis from congestion. Prognosis. — As a rule, the immediate prognosis of an attack of acute hyperemia of the brain is good. A congestive attack of the apoplectic type may result fatally, capillary or arteriole extravasation HYPEREMIA OF THE BRAIK AND ITS SOFT MEMBRANES. 435 taking place in some vital region, like the floor of the fourth ven- tricle. Under appropriate treatment, most of the fluxionary cases of hyperemia recover, although it may be to have succeeding and more serious attacks. In chronic hyperemia with recurring exacerbations, changes gradually take place in the arachnopia and cortex, so that after a time the case is one of chronic hyperemia plus certain organic degenerative lesions. The soft membranes gradually become more or less opaque, and the vessels undergo changes. The prognosis of pas- sive congestion due to obstruction is practically that of the disease causing the obstruction, although special measures may temxjorarily relieve the hyperemia. Treatment. — Patients with a tendency to active congestion of the brain should carefully regulate their lives so as to avoid the conditions predisposing to such attacks. They should give close attention to the proper regulation of the gastrointestinal tract, should avoid stimu- lants, their diet should not be too luxurious, and they should take sufficient exercise in the open air. The use of the alkaline and cathartic mineral waters, natural or artificial, has a place in the treat- ment of such cases. When an attack of hyperemia is threatened and its coining is announced by tinnitus, throbbing sensations, flushings, and other phenomena, much can be done towards aborting or ren- dering less serious the attack by saline and mercurial purgation, com- plete rest with elevation of the head, and the use of hot foot baths, and of sinapisms and other derivatives to the extremities. If the patient has an overacting or hypertrophied heart, aconite or veratrum may be used, and the bromides and hydrobromic acid are of especial value in this form of hyperemia. Ergot can be administered with advantage unless the attacks occur at the menstrual period or for some other reason it is contraindicated. Venesection, leeches to the temples and mastoid, the application of cold to the head, and the use of enemata are old but useful measures in well chosen cases. As a rule, it is not well to treat the paroxysms of hyperemia which occur in chronic alcoholism and in paretic dementia by general bloodletting. In many cases the treatment will be mainly that of the diseases from which the hyperemia originates ; for example, the use of remedies to regulate a diseased heart ; or the treatment of an obstructing tumor within the cranium, or in the neck or the mediastinum. The under- lying condition in many cases of encephalic hyperemia is one of toxemia ; and venesection, purgation, or the use of diuretics and diaphoretics may relieve the toxic state, as well as unload the vessels ; but in some cases benefit will be derived from the use of remedies directly designed to attack the acute or chronic toxemia. In such cases, for example, sodium salicylate, lithium preparations, or col- chicum may be advantageously combined with the bromides, or the potassium salts may be used for their known powers of changing the quality of the blood. 436 NBEVOTJS DISEASES. ANEMIA OF THE BRAIN AND ITS SOFT ICBMBRANES. Definition and Varieties. — In cerebral anemia, strictly speaking, tlie amount of blood in the vessels of tlie brain and in tlie vessels of the closely investing arachnopia is proportionately less than in other parts of the body ; but, as a rule, the affection is a part of a general condition of anemia and malnutrition. The diagnosis of anemia of the brain and its soft membranes has often been incorrectly made. The cerebral capillaries may contain a deficient supply of blood, just as in hyperemia an excess of blood may be present. Encephalic anemia may be acute or chronic, general or partial. A change in the quality of the blood will affect the entire brain, while a deficiency in the quantity may affect either the whole or a part only. (Gowers.) Symptomatology. — In acute general anemia of the brain the patient is at first dull or drowsy, and may have tinnitus, sensations of confusion, or slight vertigo with feelings of general weakness. The face and conjunctiva are often pallid. If the anemia is extreme, syncope ensues, and the patient falls and remains for a short time unconscious, the skin being cool and moist. The severest forms of acute cerebral anemia are attended with convulsions ; and in very rare cases, as after large hemorrhages, the patient passes into a coma- tose state and dies. In acute recurring cerebral anemia the patient recovering from one attack is comparatively well, but suffers from more or less headache and discomfort in the head. In a short time another and soon still another acute attack may occur. In chronic general anemia the patient usually suffers from dull headache, inca- pacity for cerebral work, mental depression, and irritability. Belief is afforded by the horizontal position in chronic as in acute anemia. The horizontal position favors the afflux of blood towards the brain, while the vertical position has the opposite effect. Verticality im- proves cerebral hyperemia, while the reverse is true of anemia. The symptomatology of partial anemia of the brain is a part of the symp- tomatology of those focal diseases of which it may be one stage, as of embolism, thrombosis, tumor, or meningitis. It will be especially considered when treating of embolism. Marshall Hall first recog- nized an acute form of anemia occurring in infants, to which he gave the name of hydrocephaloid disease. As already stated, the symptomatology of this disease bears some resemblance to that of marantic thrombosis. The little patients, usually after some ex- hausting disease, as an attack of diarrhea or cholera infantum, become stupid or somnolent. The face is pale. In some cases stra- bismus, contracted pupils, and rigidity of the neck are present. The fontanelles are usually depressed. The patient may pass into a comatose state and die, or may recover under appropriate treatment. Etiology. — Acute encephalic anemia is sometimes of abrupt origin, as when it results from an injury to a bloodvessel, from ANEMIA OF THE BRAIN AND ITS SOFT MEMBRANES. 437 hemorrhoids, excessive menstruation, loss of blood during labor, or a profuse diarrhea. It may also be induced by sudden emotion, as when fright interfering with the action of the heart causes syncope. It may result from compression. Some drugs produce either tem- porary or persistent anemia of the brain. Eoy and Sherrington found that chloral produced contraction of the vessels of the brain, which came on gradually and persisted for some time, while alkalies in general caused prompt and decided anemia. Partial anemia of the brain occurs as the result of closure or partial closure of the vessels going to certain brain areas, as in syphilis, and in tubercular and senile inflammations and degenerations. The vascular tubes become more and more narrowed. Complete closure of the artery, as in embolism and thrombosis, may at first cause extreme anemia and later necrosis of the tissue in part of the anemic area. Vaso- motor spasm is still another cause of partial anemia of the brain. Pathological Anatomy. — The anemic brain looks as if its vessels had been thoroughly washed out with water, the medullary substance presenting a dead white appearance which contrasts strongly with that of the gray matter. As a rule, it is of firm consistence. It is important to keep in mind the fact that the appearances of the brain after death are not always indicative of the antemortem conditions, a remark which has peculiar force in connection with the study of hyperemia and anemia. Occasionally the brain substance is ede- matous, and in cases of chronic anemia microscopical examination shows degenerated vessels and nerve cells. Diagnosis. — Ordinarily the diagnosis of cerebral anemia is not difficult. It will be indicated by the manner of onset, the feelings of the patient, the state of the pulse, the jjaUor of the face, and the history of a sufficient cause. Occasionally, especially in subacute and chronic cases, the most important diagnosis is between cerebral anemia and hyperemia. Headache, for instance, is usually more diffuse in hyperemia, while in anemia it is more likely to be localized, especially about the vertex. The mental disturbances in anemia take the form of incapacity to fix the attention or perform any work re- quiring intellectual exertion ; while in hyperemia psychical symptoms of a distinct and striking character, such as hallucinations and great excitement, may be present. Contraction of the pupils is usually indicative of hyperemia, and dilatation of anemia. In the latter the urine is usually limpid and passed in great quantities ; while in hj'peremia it is, as a rule, not increased and is often loaded with phosphates and urates. Prognosis. — The prognosis of acute encephalic anemia is gener- ally favorable, unless its cause cannot be controlled, as when a hem- orrhage or a profxise discharge cannot be stopped. When chronic anemia is not associated with organic disease, and when the life and habits of the patient can be properly directed, the prognosis is good. 438 NERVOUS DISEASES. The form of anemia in children known as hydrocephaloid disease, if recognized early, is amenable to treatment. Treatment. — When anemia is sy^stemic, as it is in most chronic cases, the treatment is that of general anemia, — good food, iron and arsenic, and small doses of mercury to improve the quality of the blood. Arsenic is best given in Fowler' s solution in increasing doses, as a solution of chloride of arsenic, or as arsenous acid in pills. An efficient preparation is one of the "three chloride" or "four chloride" mixtures now so generally in use. In acute cases the patient should at once be placed in a recumbent position with the head low and stimulants should be administered. For syncope, ammonia or nitrite of amyl to the nostrils, cold affusions and mus- tard to the spine, and in extreme cases hypodermatic injections of strychnine and digitalis, will be useful. In severe cases transfusion may be employed. Both in acute and in chronic anemia of the brain, nitroglycerin may be of value ; opium and cannabis indica are other remedii'S which have a deser^•ed reputation. The Weir Mitchell rest treatment thoroughly carried out, with massage, fara- dism, full feeding, and the use of iron, arsenic, and mineral tonics, is often most efficient. When anemia of the brain is due to cardiac weakness or disease of the valves of the heart, one of the first indi- cations is to regulate the circulation by the use of such remedies as digitalis, spartein, strophanthus, cactus grandiflorus, and in some cases preparations of ammonia and alcohol. EDEMA OF THE BRAIN. Edema of the brain is an effusion of serous fluid into or beneath the encephalic membranes, or into the substance of the brain. Formerly it was customary to discuss it as a separate disease ; but in recent years the tendency has been to consider it only in connection with those systemic diseases and focal disturbances of which it is a feature. Its occurrence can, I believe, occasionally be recognized by a certain array of symptoms, although its diag- nosis is not, as a rule, easy. Preston concludes (1) that it should receive recognition both from a clinical and from a pathological standpoint; (2) that it follows the laws of edema elsewhere in the body, with the important exception that these laws must be con- siderably modified by the anatomical arrangement of the lymph spaces of the brain and its membranes ; (3) that the effused serum may exert injurious m(M'hanical pressure and also offer occasions for toxic influences ; (4) that it would be a more common and serious affection were it not for the free communication which exists between tli(^ ^'arious lymph spaces, as shown liy the decided symptoms pro- duced when these cavities arc^ isolated by inflammatory adhesions. The anatomy of the lymf)hatii' nervous system, which it is necessary to understand in order to comprehend the mechanism of cerebral EDEMA OF THE BRAIN. 439 edema, has already been sufficiently considered (pages 98 and 99). The ventricles are great lymph spaces, and many other spaces for this fluid are found in and beneath the membranes of the brain, around its vessels, and even around its cells. Numerous as are these spaces and greatly as they differ in size, they are all in some way connected with one another, — and not only with one another, but with the intracranial sinuses and with the neural and spinal lymph spaces. One important function of this extraordinary lymph system is to equalize brain pressure when overdistention of the vessels takes place. Varieties. — Edema of the brain may be partial or general, acute or chronic. Partial edema is the result of local inflammation, or of pressure from a focal lesion, as a tumor or an aneurism. In this way may occur obliteration of lymph channels, or lymphatic or venous ■obstruction which leads to vascular overdistention and serous effu- sion in limited areas. General edema of the brain and of its mem- branes results most frequently from causes which affect the entire system, as from infectious diseases or diseases which lead to toxe mias, or from the introduction of toxic agents into the blood. Edema is spoken of as inflammatory when it accompanies the ex- treme hyperemia which is a part of local inflammation. It may be found associated with diapedesis at the periphery of focal lesions. Yarieties of edema of the brain based upon etiology — as the con- gestive, uremic, or infectious — might be described. Practically all forms of edema of the brain may be called secondary, as they are nearly always dependent upon systemic or special local conditions. The nearest approach to a primary cerebral edema would be an intracranial effusion dependent upon deflcient vasomotor tone of unknown origin. Clinical History. — The symptomatology of cerebral edema will be commingled with that of the disease -nhich it accompanies or of which it forms a part ; but certain symptoms are due to the edema, and it is with these alone that we are here conceriied. The recogni- tion that these are due to the edema may temporarily guide treat- ment. If the effusion is general and infiltrating, the symptoms will naturally be those of pressure and of irritation, the latter being due largely to distention. The intelligence is obtunded suddenly, rapidly, or slowly, according to the manner of occurrence of the edema. The patient's condition may vary from slight obtuseness to sopor, stupor, or coma. Occasionally general convulsions, agitation, or even de- lirium, are present. Hyperesthesia and a condition of general weah- ness are common. Twitchings and rigidity, with contractures, are occasionally noted. The structural stretching and strain to which the brain tissues are subjected in cases of acute or rapid origin account for these and other symptoms of irritation. Overdistention of the iter and of the fourth ventricle may give rise to cardiac, re- 440 NERVOUS DISEASES. spiratory, and cranioneural symptoms. The old view that in some cases of cerebral edema death occurs as the result of the compres- sion or squeezing to which the brain is subjected is probably cor- rect. In these cases additional symptoms may be general muscular relaxation, paralysis of the sphincters, and abolition or profound alteration of the reflexes. The edema which accompanies senile wasting of the brain, or the local atrophy which occurs in para- lytic dementia and chronic epileptic insanity, does not give a symp- tomatology which can be separated from that of the disease of which it forms a part. Edema of the brain occurring in the course of Bright' s disease and of various dyscrasias may result in death, but more frequently it will recur a number of times before a fatal issue. Obviously nothing can be dogmatically stated as to its dura- tion, which necessarily depends upon a variety of matters, as the strength of the patient, the activity of the treatment, the continu- ance of the cause, and the extent of the effusion. Etiology and Pathogenesis. — Mechanical theories account for the production of encephalic edema in some cases, but not in all. Preston found that clamping or tying one or both jugular veins was not followed by an intracranial edema the evidences of which were present after the death of the animal. Embarrassment of the circu- lation and respiration, and convulsions and spasmodic twitchings, were present. He concluded that simple constriction of the venous circulation is sufficient to cause lasting cerebral edema. Other causes of edema of the brain are alterations in the blood, changes in the vessels, and faulty innervation. These factors must be unusually active or the effusion must be unusually great in order to cause per- sistent edema. The most powerful of these factors is a disturbance of the lymph system. Diseases accompanied by an excess of venous tension, as chronic affections of the heart and lungs, may cause edema, especially when the broken down compensation throws into the cel- lular tissue of the viscera and of the splanchnic cavities the overflow of the venous system. Sometimes the circulatory disturbance is en- tirely local and provoked by an obstacle in the network of the cere- bral veins, and above all at their most important point, the vein of Galen ; this may l)e caused by a tumor of the brain, a focus of men- ingitis, or a neoplasm of the neck or of the mediastinum. (Grasset and Eauzier. ) Pathology and Morbid Anatomy. — During the postmortem examination of an edematous brain much of the fluid usually escapes, but when the autopsy is carefully made a bluish dropsical appearance of the arachnopia is seen over larger or smaller areas of the cerebral surface. If the brain has been infiltrated with serum, it is usually pale and soggy, a ' ' wet brain ;' ' but in old cases of subarachnoid edema even the opposite of this may be the case, tlie convolutions being flattened and separated. On section of the brain substance DISEASES OF THE WALLS OP THE ENCEPHALIC BLOODVESSELS. 441 often a small quantity of serous fluid runs out. The ventricular liquid is increased. The microscope shows dilatation and distention of the perivascular spaces. These lesions differ so little from the phenomena of cadaveric maceration, except in the abundant exuda- tion, that certain authors have attributed this lesion of cerebral edema to a postmortem infiltration of the intraventricular liquid into the cerebral tissue. A circumscribed area compressed by the edema is occasionally softened. (Grasset and Eauzier.) Diagnosis and Prognosis.— The diagnosis of cerebral edema in a given case will be made largely by a knowledge of the disease of which it is an accompaniment or a result. When unconsciousness, with or without convulsions, comes on in the course of chronic nephritis, cerebral edema may be suspected. The determination of lesions which might cause venous obstruction would point to this diagnosis. Aside from the previous history of the patient and of concomitant disease, the diagnosis must be largely made by the exclu- sion of such affections as encephalic hemorrhage or softening, sinus thrombosis, and toxic insensibility. The prognosis as to immediate results is uncertain. The patient often dies ; but if he recovers from the attack it is in the majority of cases only to have succeeding attacks. The real prognosis is dependent upon the nature and severity of the chronic affection which gives rise to the edema. Treatment. — The treatment should be in part to improve the general condition of the patient and favorably atfect the chronic disease from which he is suffering, and in part to relieve immediately the threatening symptoms. In some cases the use of the hot pack, and that of jaborandi internally, or of pilocarpin by hypodermatic injection, may be indicated, or other forms of diaphoretic treatment may be employed. Cathartics and diuretics are of service on the same principles that guide their use in chronic renal diseases with effusion anywhere. Arsenic, iron, and other tonic and constructive remedies are of importance in the continuous treatment of the patients. DISEASES OF THE "WALLS OF THE ENCEPHALIC BLOOD- VESSELS. Diseases of the walls of the encephalic vessels and derangements of the circulation require separate consideration, although the latter are often dependent upon the former. Diseases of the vessel walls should be considered first, because they lead to obstructions and derangements of the circulation. Widespread disease of the ence- phalic bloodvessels may interfere to such an extent with the tone and nutrition of a portion of the entire brain as to give symptom pictures which deserve a nosological place. Before taking ujj these affections it may be well to recall briefiy the constitution of the vessel walls. Arteries are usually regarded as constituted of either three or foiir 442 NEEVOUS DISEASES. coats, which can be readily distinguished in a cross section of an encephalic artery of moderate size. When three tunics are enumer- ated tliey are described as the tunica adventitia, tunica media, and tunica iiitima. When a fourth coat is recognized it is usually made by a subdivision of the intima or inner tunic into an elastic and an endothelial layer. The muscular coat is poorly developed in the larger arteries. The walls of the veins have coats like those of the arteries, but they are somewhat thinner, especially the muscular coat. The capillaries are lacking in the muscular coat, appearing to be simply continuations of the endothelial layer, but they sometimes have an areolar investment. Varieties of Arteritis. — The chief varieties of inflammation of the arteries of the brain are the atheromatous, the ohliterative, aneuris- mal periarteritis, nodose periarteritis, and acute purulent inflammation. Warty or varicose endarteritis, in which excrescences form in the vessels, rarely attacks the arteries of the brain. The so-called malig- nant endarteritis, which has the same character as ulcerative endo- carditis, has some importance in encephalic pathology, because the vegetations which form in the cranial vessels may be carried into the endocranial circulation, although the disease rarely originates in the brain. In rare instancas it attacks the large encephalic vessels. Atheromatous arteritis, the usual predisposing cause of aneurism, is primarily a disease of the inner coats of the bloodvessels. In atheroma the intima first presents a milky opacity in patches, which become elevations, and in the midst of which appear pale yellow spots, visible from the outside. They either ulcerate or calcify. The ulcerations predispose to calcification and aneurismal dilatation, an important fact in connection with cerebral hemorrhage. When they calcify without ulceration the patches form calcareous scales, which are liable to be dissevered fiom their attachments and to be carried off in the blood stream to become emboli. The arteries of the circle of Willis are esj)ecially prone to atheroma. Atheroma is sometimes due to syphilis, and probably also to gout and rheumatism, and is fre- quently associated with disease of the kidneys. It is an accompani- ment of old age and of premature senility. The intima sometimes shows spots of fatty degeneration instead of the atheromatous patches just described. The arterial coats become inflamed, pus forming between them, and cerebral abscesses may be developed around the arteries. Charcot in particular has described a form of periarteritis which especially affects the vessels of the brain and may lead to miliary aneurisms. The disease usually progresses from without inward, the inner coat being seldom affected. It is most marked in small arteries, and the capillaries may be attacked. Syphilitic in- flammation of the arteries presents itself in the form of either an endarteritis or a periarteritis, and both may be present in the same case. Syi)hilitic endarteritis is usually of the obliterative type. DISEASES OP THE WALLS OF THE ENCEPHALIC BLOODVESSELS. 443 Our first exact knowledge of it was largely due to Heubner, It is a matter of radical importance to remeuiber that, while atheroma- tous endarteritis leaves the walls of the vessels unchanged in thickness and leads to fatty de- generation, syphilitic endarteritis augments their thickness. In time even a compara- tively large vessel may become obliterated as the result of gradual encroachment upon its lumen by syphilitic en- darteritis. In Fig. 270 is shown an illustra- tion of endarteritis of the basilar artery. N'e- crotic softening is a fre- quent result of obliter- ative endarteritis, and this, because of the dif- fusion of the process, is likely to be multiple. In some cases the parts may be imperfectly supplied with pabulum through collateral circulation, and hence a deteriorated but not necessarily a softened tissue is the result. Another result of syphilitic en- darteritis, especially in the brain vessels of medium or large size, is the production of aneurisms, which in their turn give rise to intracranial hemorrhage. Next to embolism it is the most frequent cause of aneurisms. In Fig. 271 is shown syphilitic endarteritis of the medicerebral artery with a dis- secting aneurism. All cases of el. massive hemorrhage into the brain substance associated with syphi- litic endarteritis are not, however, the direct results of aneurismal rupture. Several varieties of syphilitic periarteritis are well Syphilitic obliterative endarteritis of the basilar artery : E, lumen, about two thirds obliterated ; D, the muscular coat and adventitia nodulated by inflammatorj' changes ; C, the elastic lamina ; A, inflammatory new formed tissue in the in- tima, composed of large spindle and round (on section) cells, with normal cells of the intima next to the elastic lamina and the lumen of the vessel ; i?, the hyaline substance seen distinctly with a higher power. (Weber.) Fig. 271. Section showing endarteritis and a dissect- ing aneurism of a branch of the left medicere- bral artery : R, R, blood cells heaped together ; EL, elastic layer ; E, E, intima. (Herter.) 444 NERVOUS DISEASES. known. One of the most important of these is nodose periarteritis, which has been described by Kussmaul, Meyer, Bruce, and others. In this affection irregular infiltration of the outer sheath of the vessel occurs. In Fig. 272 is shown in section the appearance of a vessel affected with one of the forms of periarteritis with an organizing thrombus. One form of nodular periarteritis is not due to syphilis, but the recorded cases show that the syphilitic variety attacks the arteries of the brain with great frequency, while just the reverse is true of the nonsyphilitic form, the brain usually escaping although Fig. 272. Microscopical section through a vessel In a case of cerebral syphilis, showing great Inflltration and thickening of the outer coat, and an organizing thrombus In its interior : A, inflammatory products around vessel ; B, thickened outer coat : C, middle coat ; D, inner coat ; £, organized thrombus containing delicate new formed vessels in its interior. (Bramwell.) many organs may be affected. Syphilitic nodose periarteritis attacks particularly the great vessels of the base and their branches ; it may or it may not be associated with obliterative endarteritis. A most im- portant fact for the clinician to bear in mind is that "very frequently vascular changes are associated with a diffuse basal meningomyelitis with foci of softening in the nerve centres, and interstitial cellular infiltrations of the cranial nerves." (Bruce.) These cases of nodose periarteritis may show infiltration of both epineurium and endo- neurium. In one form of syphilitic periarteritis the disease chiefly attacks the minute vessels, and results in sclerosis and atrophy. DISEASES OF THE WALLS OP THE ENCEPHALIC BLOODVESSELS. 445 Porter has described a form of hyaline degeneration due to syphilis, the result of a deposit of proteid substance at first in the walls of the smaller arteries and arteriocapillaries and finally throughout the arterial system. This deposit weakens the walls of the vessel, the lumen of which is sometimes contracted and sometimes ex- panded. Typical miliary aneurisms arise when this thinning and expansion are sharply defined and localized in the smaller vessels. Chronic Endarteritis (Arterial or Arteriocapillary Fibrosis or Sclerosis). — Gull and Sutton in 1872 and again in 1876 and 1877 called attention to a pathological condition of the capillaries, arte- rioles, and interstitial structures of various organs, such as the kid- neys, heart, spleen, brain, spinal cord, and lungs. This was described by them as fibroid degeneration. The degeneration of the blood- vessels observed by others, particularly in connection with contracted kidneys and hypertrophied heart, was regarded by Gull and Sutton as not dependent upon renal disease as had been supposed. They believed that it was rather a part of a general pathological process and one that especially attacked the vessels. According to Meigs, the name fibrosis, or rather arteriocapillary fibrosis, is not well chosen, because the disease is not truly a fibrosis and the capillaries are not necessarily implicated. The same objection would hold against scle- rosis. Meigs believes that the affection is essentially a chronic endar- teritis, inflammatory thickening of the arteries and arterioles being the most constant lesion. Whatever view may be taken of the pathology of this affection, the student of nervous diseases must early learn to recognize its importance, keeping in mind that it is not only a factor in the production of many focal diseases, but may also present a symptomatology of its own, which may be referable to the brain or to other organs. The affection described by Gull and Sutton and by Meigs, and the hyaline degeneration of Oeller, Porter, and others, may represent differing phases of the same general pro- cess, or perhaps somewhat differing morbid processes which lead to similar results in the vessels and viscera. Chronic endarteritis begins in the intima as a simple inflammation, and may or may not extend to the veins and capillaries. While it shows a tendency to invade vessels everjrwhere, it may choose certain organs for its early inroads or to bear the brunt of its assaults. The brain vessels in particular suffer, giving an array of distinctive symptoms. These symptoms cause frequent mistakes in diagnosis. N'eurasthenia, hysteria, chronic meningitis, and brain tumor are some of the affections which may be wrongly supposed to exist. Meigs found chronic endarteritis typi- cally present in a marasmio child who died at the age of five months, and it has been observed and studied at all periods from early infancy to extreme old age, although most frequently it is a disease of ad- vanced years. When cerebral hemorrhage occurs in infancy, child- hood, or youth, its presence may with good reason be suspected. 446 NERVOUS DISEASES. Symptomatology of Encephalic Endarteritis. — Among the symptoms of chronic endarteritis are general muscular weakness, shuffling gait, wasting of the muscles, loss of memory, change of disposition, and mental irritability. Meigs has noted a curious hyperesthesia in old people, not confined to the skin, but caused by movement of any part of the body. Epistaxis, edema of the ankles and fcL't. albumen and casts in the urine, marked irregu- larity of the cardiac Aulves, and lung symptoms such as bronchitis, with or without expectcnation, may be present. The pulmonary symptoms may come on abruptly with fever or may develop insid- iously. One of the most distressing symptoms of chronic endar- teritis or arterial sclerosis is vertigo. Grasset has divided the vertigo which occurs in these cases into simple vertigo, vertigo with epilep- tiform crises, and vertigo with slow pulse and syncopal epileptiform attacks, the terms descriptive of these variations indicating the special characteristics of each. The vertigo usually first presents itself as an attack of sudden faintness or swimming in the head, a feeling of giddiness or of distinct gyration, or of darkness and im- pending death. The attacks occur at intervals and vary consider- ably. Some cases experience a sense of fulness or throbbing in the head, a feeling of heat in the scalp, and blurring of vision. The face may be at first pale and later flushed, and the patient may have a strong desire to get into the open air. When the vertigo is severe he may sink, stagger, or fall to the ground, but consciousness is rarely lost. Careful examination of these cases will generally show a tortuous temporal artery, a stiffened radial, a distinct arcus senilis, a strong or even clanging sound of the heart, increased arterial ten- sion, a pulse slow or arhythmic, and scant urine with a trace of albumen. Exertion or change of position from lying or sitting to standing may cause the attacks. Meniere's disease, or at least aural vertigo, may be wrongly diagnosticated, especially if some tinnitus or impairment of hearing is present. Eecognized in an early stage, potassium iodide, sodium iodide, or hydi'iodic acid may prove of some service in retarding the progress of the disease. The treatment should be continued over a long period. Arsenic and alkaline min- eral waters are advantageously combined with the iodides. ENCEPHALIC ANEURISM. Varieties. — Aneurism of the brain, as of other parts of the body, may be true or f(ilfry is possible, by the stopping of the hemorrhage before the lateral ventricle is reached. A distinctive feature of these cases is the progressive deepening of the serious ENCEPHALIC HEMORRHAGE. 459 phenomena. According to Charcot, next to the striatum, thalamus, and internal capsule, the most frequent seat of hemorrhage is the narrow baud of gray substance in the external capsule called the claustrum, avant-mur, or teniform nucleus. Hemorrhage into the Subcortex and Centrum Ovale. — Occa- sionally a small hemorrhage occurs immediately beneath the cortex, and this in the motor region may give special diagnostic features, as in one of my cases of hemorrhage with subsequent cystic formation just beneath the cortical areas for the leg and arm. The most per- sistent and distinctive symptom in this case was a continued spas- ticity of the paretic arm and leg. The right leg remained in an almost rigid condition, slightly flexed at the knee, and in a state very similar to that of both limbs in many cases of spasmodic tabes. The right arm was also markedly spastic, but the rigidity was not so extreme as in the leg. The fact emphasized by the record of this case is that a motor subcortical lesion partly destructive and partly irritative has for its most characteristic symptom a persisting spastic paresis or paralysis. Hemorrhage into the centrum ovale at points entirely removed from the cortex occurs with some frequency. I have observed cases of this kind in the prefrontal, frontoparietal, and occipital regions. Cerebellar Hemorrhage. — A study of the points given under lesions of the cerebellum in the last chapter will help to make clear the symptomatology and diagnosis of cerebellar hemorrhage. The most usual sites are the vermis, one of the lateral lobes in the vicinity of the dentatum, and the medij)eduncle. These hemorrhages may be difficult of diagnosis in the acute stage ; and cysts which remain after a small hemorrhage may give puzzling symptoms. Hemorrhages into any of the three localities above named may burst into the fourth ventricle and cause a speedy fatal issue. Added to early cerebellar symptoms such as vertigo, vomiting, astasia, or ataxia will be those of a severe ventricular apoplexy, the former being soon over- shadowed by the latter. In one of my cases of cerebellar hemor- rhage with ventricular effusion the blood passed from the metepiccele through the iter into the third and lateral ventricles, an unusual invasion. The patient was fifty-three years old, and the case had been diagnosticated as one of insular sclerosis. Two days before his death he began to feel dizzy and complained of headache. He was perfectly conscious, but he grew gradually worse, and in an hour was completely unconscious. His pulse was 72 and full. He had com- plete paralysis of the left side of his body, and on the chest on the left side fine muscular twitchings were observed. The pupils were slightly contracted and immobile. His temperature at the time of his seizure (one o'clock) was 96° F. ; at two o'clock it was 98.2° F. Before death he was cyanotic, and he evidently died of respiratory failure, the respirations ceasing a considerable time before the pulse. 460 NERVOUS DISEASES. No evidence of meningeal hemorrhage was present, but under the pia covering the posterior and inferior portion of the cerebellum was a slight extravasation of blood. The vessels at the base presented a few atheromatous patches. On opening the lateral ventricles a clot was found on the left side. The fourth ventricle was filled with black tarry blood. The main damage to the brain tissue was in the pons, crura, and cerebellum, which were ploughed up and disorganized. The heart was hypertrophied, but was without valvular lesions. The kidneys showed evidences of chronic parenchymatous nephritis. In several cases of what I believe to have been hemorrhagic cysts of the cerebellum I have seen the diagnosis of hysteria erroneously made. The histories were of apoplectic seizures brief in duration, with or without unconsciousness. One of these patients was left with an astasic and ataxic condition which involved both lower and upper extremities and to a less extent the trunk. She never regained the power of standing or walking without support. She also showed mental weakness and some ataxic disturbance of speech. In another case the symptoms closely simulated those of locomotor ataxia, but the patient had neither sensory nor pupillary changes, and her symp- toms were clearly from a sudden seizure. Contrasting these two cases, in the first the knee jerks were exaggerated and the unsteadi- ness affected both the upper and the lower extremities ; in the second only the lower extremities were weak and unsteady and the knee jerks were abolished. The stigmata of hysteria were absent in both cases. Multiple Encephalic Hemorrhage. — Multiple hemorrhages into the brain are not infrequent. They have been particularly observed in senile brains in which the vessels are more or less degenerated. Forms of focal hemorrhage may occur at successive periods, so that postmortem examinations may reveal a number of ochreous cysts in various parts of the brain and these evidently of different ages. In some autopsies symmetrical or nearly symmetri- cal hemorrhagic foci were found, which may have been either recent extravasations or the cysts left by former hemorrhages. It is com- paratively common to find such symmetrical hemorrhages or the relics of them in the striata. Sometimes a focus of considerable size is found in one thalamus, and another of smaller size in the thalamus of the opposite side. Occ;isionally also such hemorrhages may be found in the centrum ovale in like or nearly similar posi- tions on the two sides. Large and severe hemorrhages in rare instances take place simultaneously in the two hemispheres. In a case of C'hurton's, a large clot was found in the left thalamus and postcornu, and another of considerable size in the callosomarginal fissure invading the gyrus fornicatus and apparently producing complete anesthesia of the left foot. The pons is a not infrequent seat of multiple hemorrhage of small size. Eecently a case of this ENCEPHALIC HEMORRHAGE. 461 kind came under my observation at tlie Philadelpliia Hospital. Three small hemorrhages and three old but minute cysts were found in one lateral half of the pons, and in the lenticula was also a, cj-st of considerable size. In many cases of injury of the head, either with or without fracture, I have noted hemorrhagic foci in various portions of the pia, and in less number in the substance of the brain. Similar minute hemorrhagic foci are sometimes found scattered throughout the brain substance and membranes in cases of very sudden and extensive hemorrhagic apoplexy. In one of my recorded cases of extensive capsuloganglionic hemorrhage with effu- sion of blood into the ventricles, extravasations and ecchymoses were present in other parts of the brain, very similar to those described by Duret, Park, and others in cases of traumatism, although not so numerous nor so extensive as in the latter, and not accompanied by so much contusion and laceration of brain substance. In this case a slight depression or splitting of the floor of the fourth ventricle, similar to that which has been observed in the traumatic cases, was also present. In such cases large masses of blood sometimes find their way to the central regions of the base, enveloping various cranial nerves and infiltrating the membranes and the spaces beneath them far out into the Sylvian, calcarine, and other fissures. Numer- ous punctate hemorrhages may also be found scattered through the substance of the brain. Conditions similar to those which result from external injury are brought about because the interior of the brain receives a violent blow when blood is suddenly poured out into its substance. Some regions seem to be peculiarly liable to extra- vasations, as the pia of the cerebellum and of the pons and oblon- gata and the pia and convolutions opposite to the seat of injury. The subject of multiple hemorrhage is of practical importance, especially when the hemorrhages occur simultaneously. The clini- cian must keep in mind the peculiarities of symptomatology which would result from such multiple lesions. When very decided symp- toms of hemorrhage on one side of the brain are present, and in addition others which indicate pial or cortical irritation and some involvement of the other side, the complex phenomena are probably due to bilateral hemorrhages differing in size. In a case the recent symptomatology of which was that of thalamic and capsulothalamic hemorrhage, I found a hemorrhage in the right thalamus, a small cyst in the right striatum, and a large cyst in the left striatum. The vessels of the circle of Willis and its branches, especially the right medicerebral artery, were highly atheromatous, bluish white plates being seen on their inner coats. In the upper temporal region were a number of dilated vessels. I have found small hem- orrhagic cysts in the striatum in cases which were under obser- vation for several months, the patients never having presented hemiplegic symptoms. 462 NERVOUS DISEASES. Capillary Hemorrhage. — One of the subdivisions of encephalic hemorrhage is into massive and minute. Massive hemorrhages are those which take place from vessels of considerable size, and are such as have just been considered. Minute hemorrhages maj be due to the rupture of arterioles or capillaries, or to transudation through veins. Hemorrhage from the capillaries is not usually classed as a distinct disease with a recognizable symptomatology, but it plays an important part in some cerebral affections. Capillary and arteriole extravasations into vital regions of the oblongata may be the cause of death in not a few chronic affections of the nervous system, as tabes, disseminated sclerosis, epilepsy, and in hydrophobia. Con- gested areas and small extravasations are frequently seen in the ventricular floor, especially in cases which die after convulsive seizures, or in which spasms have been frequently repeated during life. These foci often correspond to the cell nests of the cranial nerves, and especially to those from the fifth to the twelfth. In con- cussion of the brain, either with or without fracture, numerous capil- lary extravasations are found both in the brain substance and in its membranes. In leptomeningitis innumerable punctiform hemor- rhages are often present, and these are supposed by some to be due to the influence of the specific virus of the disease. In the so-called red softening, whether encephalic or spinal, the red color is supposed to be due to capillary hemorrhages. When such hemorrhages are numerous in the same locality the condition is known as capillary apoplexy. A tendency to transudation or extravasation of blood from the capillaries and veins of the brain membranes is present in per- nicious anemia, leucocythemia, and other blood affections. Nothing need be said in detail about the symptomatology, diagnosis, prog- nosis, and treatment of capillary hemorrhages. Their treatment will be that of the affection of which they form a part and in which they occur as episodes. Duration and Complications. — The duration of a hemorrhagic apoplectic attack is variable. It depends upon the site, size, and extensions of the clot. A large hemorrhage into the pons and ob- longata often results in immediate or nearly immediate death, con- stituting the so-called " thunderbolt apoplexy," apoplexie foudroyante. Secondary ventricular hemorrhage is usually fatal. In fatal cases death takes place most frequently on the second or the third day, but in cases in which apparently only one hemorrhage has occurred I haA^e known death to result at any time within six or seven days after the seizure. In cases which last over three or four days bleed- ing usually recurs at the original site. As a rule, in fatal cases the patients do not recover consciousness and the course is consecutively from bad to worse, but occasionally there is partial recovery of con- sciousness with some improvement of the paralytic symptoms. When the patient recovers from the apoplectic attack, in periods varying ENCEPHALIC HEMORRHAGE. 463 from one to several days, he usually begins to improve ; the reflexes change for the better, motion and sensation — if the latter is dis- turbed — improve, consciousness is restored, and control over the evacuations is regained. Various symptoms clear up as the case progresses. In the majority of cases in about ten days or two weeks the patient simply shows the effect of the localized lesion, usually in some paralysis of motion or in loss of speech, and occasionally in some disturbance of sensation or of the special senses. A special section will be devoted in a later portion of this chapter to the hemiplegias, monoplegias, aphasias, and other chronic affections which follow apoplexies and other focal lesions of the brain. Edema of the lungs, or even a pneumonia of local or general type, may complicate an apoplectic attack. Sometimes the nervous symp- toms simulate those of pneumonia and a mistake is made in this way, the shallow breathing being supposed to be due to lung com- plications, whereas it is in reality the result of the loss of cerebral control and is due to the hemorrhage Etiology. — Predisposing Causes. The majority of cases of hemor- rhagic apoplexy probably occur between the ages of thirty-five and fifty-five. It is, however, comparatively frequent in the first year of life, causing some of the cerebral palsies of children. Cerebral apo- plexy occurs more frequently later in life in the rural districts than in cities, owing probably to the differences in modes of life. The curve of cerebral hemorrhage begins rather high, then drops and remains at almost a normal line until the age of fifteen, gradually rising until twenty-five, reaching its greatest height between forty-five and fifty- five, then sinking until the age of seventy -five is reached. (Dana.) Such a curve has only relative value and must be subject to many variations. Hemorrhage is more frequent in the male than in the female sex in the proportion of nearly two to one. It is not sex alone that leads to this disproportion, it is also the differences in life and occupation, which in men predispose to hemorrhage. Occu- pation has some influence. Berger and Schultze have shown that in some parts of Germany the workers in lead have an unusual predis- position to encephalic hemorrhage, as have those also whose occupa- tion leads them to assume peculiar strained positions of the body. Sedentary, indoor occupation probably acts to a moderate degree as a predisposing cause. The influence of race and that of climate have not been well determined. According to some life insurance investigations, encephalic hemorrhage is, on the whole, most fre- quent among the Anglo-Saxon races. It is more common in winter than at other seasons. Among other predisposing causes of ence- phalic hemorrhage are an inherited tendency to arterial disease, acquired or hereditary syphilis, alcoholism, intemperance in eating with sedentary habits, life at high tension, and the introduction of toxic or infectious agents into the blood. It not infrequently 464 NERVOUS DISEASES. occurs in cases of renal, cardiac, or valvular disease, and it may follow the puerperium or infectious diseases. A tendency to ar- terial disease may be present in several generations of the same family. The underlying condition is in some cases a rheumatic, gouty, or other form of inflammatory and degenerative disease of the vessels. While acquired syphilis undoubtedly causes a fair percentage of cases of cerebral hemorrhage, it more frequently leads to thrombosis. Statistics and experience overwhelmingly demon- strate that chronic alcoholism is a strong predisponent to hemor- rhagic apoplexy, although syphilis and alcoholism are so often found in the same cases that it is hard to discriminate as to their relative etiological influence. Exciting Causes. It is well known that many cases of apoplexy occur as the immediate result of a debauch. A small percentage of attacks takes place during some especial bodily or mental stress, as from straining at stool, during coitus, and at times of great emotional excitement. In rare instances a hemorrhage into the brain foUows a severe epileptic fit or a series of fits. Briefly stated, the most fre- quent exciting causes are those which increase blood pressure. The influences above stated are of this character, as are also others, such as attacks of vomiting, coughing, sneezing, straining exertions, and the lifting of great weights. Among other causes which may act differently but to the same end are a full meal, a cold bath, and sudden exposure to great cold or to abrupt variations in temperature. The apoplectic attacks which occur during sleep are more frequently due to thrombosis than to hemorrhage. If cerebral hemorrhage does occur during sleep, this may be due to the fact that gravity does not assist as much in the return of blood from the brain as from other parts of the body during this period. Pathological Anatomy. — Gross Appearances. Much that relates to the pathological anatomy of encephalic hemorrhage has already been given in the discussion of the diseases which affect these intra- cranial vessels. Some opacity of the inner membranes of the brain not infrequently accompanies the widespread disease of the vessels. The amount of havoc wrought by the extravasated blood is to some extent dependent upon the condition of the brain tissues. Gray matter yields more readily than white, the tissues of the old, and those tissues which have undergone degeneration, more readily than those which are normal. The appearances of the clots and of the brain tissue which has been injured by them will therefore vary ac- cording to the size and the diffusion of the extravasation. One hemi- sphere may be distended and fluctuating, if the hemorrhage into its substance has been large. Sometimes the convolutions present a flattened and anemic appearance on the side of the hemorrhage. Small quantities of blood may be extruded into the Sylvian and other fissures from the interior of the brain. Autopsy in recent ENCEPHALIC HEMORRHAGE. 465 cases of hemorrhage usually shows a large mass of blood destroying the middle and posterior portions of the internal capsule and adjoin- ing ganglia, with a passage torn into the flooded ventricles ; but occa- sionally, even in fatal cases, no blood is found in the ventricles or their annexes, although the structures which bound them are evi- dently distended on the side of the clot. Sometimes the appear- ances indicate a recent clot which has not quite broken into the ventricle, still having a thin roof formed by a layer of the caudatum or thalamus. The pia of the convexity may be edematous or opaque, and in spots and patches is often hyperemic. Usually in subpial and gyral hemorrhages the fissures near the seats of the ruptures will be found filled with blood, the convolutions being eroded but not greatly disintegrated. The blood is generally found in part beneath the arachnopia, which is often lifted and torn, and in part in the subdural space. It sometimes finds its way by gravity from the seat of hemorrhage to or nearly to the base. Changes in the Clot. The blood, as indicated in the above records, may be fluid, coagulated, or partly coagulated. In coagulating, at first at least, the clot continues to fill the whole cavity which it has made for itself. Clotting takes place in the same way that blood coagulates in the heart, not as the process proceeds in a cup. (Char- cot.) When death does not take place, granular degeneration of the clot soon begins, its various constituents gradually disappearing. The red corpuscles lose their coloring matter and remain only as hematoidin crystals. Leucocytes and fibrin also disappear. Step by step the clot condenses and separates itself from the fibrous lining membrane which lines the interior of the hemorrhagic cavity. The wall of the cavity undergoes changes, connective tissue increasing at the expense of degenerated nerve tissue. It gradually assumes a yel- lowish or ochreous color. The lining membrane may form as early as one or two weeks after the apoplexy. The clot dwindles more and more, becoming soft and yellowish, and after years it may disappear entirely. The cyst left may be of small or moderate or even of enor- mous size. In old hemiplegics with aphasia and contractures, I have seen cysts large enough to destroy the subcortex of the insula, the ante- rior two thirds of the capsules, the striate bodies, and a portion of the thalamus. These old and large cysts are usually filled with liquid and a small amount of detritus or of clot in the last stages of disin- tegration. They may be crossed by trabeculae. When the hemor- rhage has been very small, only a cicatrix may be left. Secondary degenerations frequently follow. They differ somewhat according to the site and extent of the hemorrhage, but are chiefly descending and of the fibres of the internal capsule and its continuation in the crus, pons, oblongata, and cord. Diagnosis.— The diagnosis of encephalic hemorrhage must be considered with reference both to the apoplectic attack and to the 30 466 NERVOUS DISEASES. paralytic and other consequences of such attack ; but its more or less remote effects will receive special attention later. Before taking up diagnosis proper, it will be well briefly to call attention to the symp- toms which threaten, and those which are supposed to threaten, an apoplectic stroke ; in other words, to describe what might be termed the prodromic diagnosis of encephalic apoplexy. Threatening Symptoms. In the consideration of the clinical his- tory, under the head of premonitory symptoms the phenomena given are sometimes recognized by the patient as the forerunners of an apoplectic or a paralytic attack ; but it is important to remember that these or at least similar symptoms may not be significant of such an event. They are to be regarded as forecasting acute hemor- rhage or softening only when, with other symptoms such as have been detailed under diseases of the encephalic vessels (page 445), they are the evidences of arterial or arteriocapillary fibrosis. Me- niere's disease, or forms of aural vertigo which are not in a strict sense this affection, cause symptoms, such as vertigo, tinnitus, and apprehension, which may call up the spectre of apoplexy ; but, as these disorders will be especially considered elsewhere, their diag- nosis need not here be gone into at length. Mild neuritis or other rheumatic and gouty affections of the nerves and nerve centres may cause paresthesias or even pareses in some instances. The general good health of such patients, the history of a rheumatic or gouty diathesis, and the favorable response to treatment with the sali- cylates, lithium salts, or colchicum, will assist in making the diag- nosis. Gouty disease of the vessels or membranes may after many years lead to apoplexy, but such symptoms cannot in a proper sense be regarded as the immediate i^rodromes of a cerebral attack. The lithemic and gouty, and sometimes the aged or neurasthenic who are not the victims of these diatheses, at times have spells of cardiac palpitation and irregularity with a sense of dissolution or danger, which they often believe to be the precursors of paralysis. The heart beat may be rapid or slow, and occasionally intermittent. Doubtless neither heart, vessels, nor nerves are in perfect condition, but such paroxysms may occur during many years without any more serious consequences than the Aveakness and dread produced by the attacks. Neurasthenics and patients in the early stages of melan- cholia often live in a fear of apoplexy, which is based on their un- comfortable sensations and general distress of mind ; but it is not necessary here to do more than to allude to this subject. Affections to be differentiated from Encephalic Hemor- rhage. — When the physician is confronted by an unconscious patient, and the diagnosis of hemorrhagic apoplexy is fairly presented, in the first place it must be distinguished from insensibility due to a variety of causes, such as alcoholism, uremia, diabetes, opium poison- ing, saturnism, and other toxic conditions, sunstroke or heatstroke, ENCEPHALIC HEMORRHAGE. 467 syncope, postepileptic stupor, hysterical coma, and pure simulation. Secondly, the different varieties of encephalic hemorrhage must be separated from each other, as intracerebral hemorrhage without ven- tricular effusion from ventricular hemorrhage, primary or secondary, intracerebral from meningeal hemorrhage, meningeal from cortical hemorrhage, and the different forms of cortical hemorrhage from each other and from large effusions. In the third place, encephalic hemorrhage must be differentiated from forms of apoplexy due to encephalic lesions, such as acute softening dependent upon embolism or thrombosis, intracranial abscess, or new growths. Toxemias. In a case of uremic coma the patient may have swell- ing of the limbs, edema of the eyelids or of the face, the breath may have a urinous or beef tea odor, the pupils are generally dilated, and, as a rule not wibhout exceptions, one side of the body shows more paralysis than the other. Considerable evidence has been accumulated to show that affections of the nervous system strictly limited to one half of the body occur during the course of some forms of Bright' s disease. In this country Dercum has reported cases of hemichorea, hemiplegia, and unilateral convulsions. Eaymond, Chantemesse, and Tenneson have reported a series of cases of uni- lateral affections, chiefly hemiplegia and epilepsy, apparently of uremic or at least of renal origin. In not one, according to the re- porters, could a trace of a strictly focal lesion be discovered. Chauf- fard has reported a case under the title of uremic convulsions of the Jacksonian form. Such cases can be diagnosticated only by the his- tory of the case and a full consideration of the signs and symptoms which indicate renal disease. Diabetic coma may be suspected if sugar is present in the urine, and especially if the patient has a his- tory of glycosuria. Opium, chloral, lead, and other narcotic drugs or substances give rise to conditions of insensibility. Deep insensi- bility with contraction of both pupils, and the absence of indications of unilateral paralysis, such as conjugate deviation, loss of muscular tone, and absence of drooping of the face on one side, favor the diag- nosis of opium poisoning ; and yet Taylor has reported inequality of the pupils in one case of opium poisoning. Profound narcotism from opium and the coma of serious apoplexy present phenomena which are very similar. McEnroe, in speaking of the differential diagnosis between hemorrhage into the pons and opium poisoning, says that in pontile hemorrhage the coma is more profound. In narcotism it is possible to rouse the patient and to make him answer questions intelligently, as far as he will answer them at all. The pulse is full and strong in the early stages of opium poisoning, while in hemorrhage it is wiry, sometimes slow, sometimes rapid, but not usually fall, strong, and regular. In the former the whole body is bathed in perspiration, and the respirations are less frequent than in hemorrhage. The discussion of the distinction between hemor- 468 NERVOUS DISEASES. rhagic apoplexy and tlie unconsciousness produced by cMoral, can- nal)is indica, chloroform, liyoscyamus, or prussic acid and nitroben- zole, belongs to works on toxicology. A word might here be said about lead poisoning, as coma, convulsions, and other symptoms pointing to profound involvement of the brain are occasionally seen as the result of severe poisoning by lead ; but here the presence of the lead line, the history of other forms of lead disease, and the occu- pation of the patient are of great value, if information with reference to these points can be obtained. Occasionally cases either of deep stupor or of excessive delirium are seen for which no cause can be assigned. These are sometimes due to toxemias of unknown origin. That they are not ordinary apoplexies can be recognized, but exactly what they are may be beyond the pale of diagnosis. In sunstroke, which by some is regarded as a toxemia, the fact that the patient has been exi^osed to excessive heat, the great rise and steady increase of body temperature, the prostrated or collapsed condition of the patient, and the absence of unilateral phenomena serve as differential features. Alcoholism. A case of acute alcoholism may at the same time be one of apoplexy. One suffering from an apoplectic attack may have the smell of liquor on his breath and yet not be intoxicated. The breathing in a case of acute alcoholism, while it may be deep and heavy, is not truly stertorous nor of the Cheyne-Stokes variety, and examina- tion will not reveal paralysis of one side of the body. Conscious- ness may appear to be lost, but this is not absolute, and the patient can generally be aroused, at least for a moment, from his stupor. The pupils are usually equal and dilated. The temperature may be two or three degrees below normal, but it does not show the suc- cessive variations of true apoplexy. Southey has recommended the injection into the rectum of a pint and a half of cold water with a tablespoonful of salt dissolved in it, which in his experience at once restored to consciousness a case of extreme drunkenness. Misci-'nanemts Affections with Real or Apparent Unconsciousness. Asphyxia is to be distinguished by the presence of phenomena which show that the affection is primarily pulmonary and not cerebral. These are, in addition to the loss of consciousness, an embarrassed bi'eatliing, turgescence of the face, and frequently tremors and con- vulsions. Unilateral palsies are, as a rule, absent, as are also other phenomena which point to a lesion of one side of the brain. In fainting the face beconies pale, the patient loses consciousness, and usually sinks to the ground. The pulsations of the heart and the movements of breathing are diminished, and no indications of paral- j'sis are present. A i^atient may l>e found in the deep stupor which commonly follows a severe epileptic paroxysm, and the physician have no knowledge of the preceding convulsion. Such a case may simulate closely hemorrhagic ajioplexy, especially when an exhaus- tion paralysis of one side is present. If possible, a history should ENCEPHALIC HEMORRHAGE. 469 be obtained before giving an opinion. The fact that a patient is in a profound sleep or stupor rather than in an apoplectic coma is usu- ally evident ; conjugate deviation of the head and eyes is commonly absent. That the tongue has been bitten points to an epileptic attack, which may also be indicated by the bruising of the body which has resulted from falls or the violent movements of the patient. In hysterical coma the breathing is not stertorous nor of the Cheyne- Stokes variety, and the face of the patient is usually placid. Hemi- plegia or hemianesthesia, if present, is clearly different in character and depth from that of organic disease. Consciousness is perverted, but not profoundly lost. Inecxuality of the pupils and marked differ- ences of the reflexes of the two sides are not present. Watchful- ness, and the use of sensory tests and measures to throw the patient off guard, will generally suffice to make the diagnosis of simulation. Occasionally even the sleep disorders, such as somnambulism, trance, catalepsy, and the African sleeping disease, have been mistaken for apoplectic attacks with prolonged stupor. In such affections the clinical history, the protraction of the somnific state, the absence of paralysis, and the special phenomena of temperature, respiration, pulse, the state of the pupils, and ocular movements which are sig- nificant of apoplexy, will be of value. The apoplectiform attacks which occur during paralytic dementia are usually less severe and much more transient than ordinary attacks of intracerebral hemor- rhage, but occasionally they are sufficiently serious to make the diag- nosis of hemorrhage debatable. The previous history of such a case as to physical and mental symptoms should be carefully ascertained. Differential Diagnosis of the Varieties of Encephalic Hemorrhage. — The diagnosis of different varieties of encephalic hemorrhage from each other has a value which is sometimes enhanced by the question of the advisability of surgical procedure. It is oc- casionally important, especially in cases which are known or sus- pected to be traumatic in origin, to differentiate between meningeal and ventricular hemorrhage. I have, for instance, known the diag- nostic question chiefly discussed in an important case to be whether the patient was suffering from an intracerebral hemorrhage which had burst into the ventricles, or from an immense supradural or sub- dural clot. Under the symptomatology of primary and of secondary ventricular hemorrhage the chief diagnostic features of each have been ftiUy given. In the secondary form the occurrence of the ven- tricular inundation is announced either abruptly or gradually by an increase and deepening of the phenomena of the attack. A distinct interval may occur between the first symptoms of an intracerebral apoplexy and those of a more pronounced character which announce the ventricular accident ; in other cases the ventricular symptoms appear without any hiatus in the clinical phenomena. Ventricular and Intracerebral Hemorrhage. The following table 470 NERVOUS DISEASES. from Grasset and Eauzier gives the main points of distinction be- tween primary ventricular hemorrhage and intracerebral hemor- rhage, the differential diagnosis of which, according to Gowers, is often practically impossible. Ventricular Hemorrhage. Frequent in the old and the young. Onset rapid and violent. Generally very profound coma dating from the onset. Convulsions frequent. Contractures frequent. Paralysis often wanting ; when present it may be general. Amelioration or a passing remission of the symptoms not rare. Recovery a rare termination. Death rapid, ofteii in a few hours. Intracerebral Hemorrhage. More frequent towards middle age. Onset slower and less violent. Coma generally less profound. Convulsions rare. Contractures rare. Paralysis the rule, and generally of the hemiplegia type. Amelioration much less frequent. Recovery frequent. Even in fatal cases life prolonged ordi- narily for several days. Ventricular and Meningeal Hemorrhage. Epidural or subdural hemorrhage, and in rarer cases cortical or even intracerebral hemor- rhage, may occur as the result of severe injury, either as indepen- dent affections or coincidently with meningeal hemorrhage. The following table has been slightly modified from one given by Gras- set and Eauzier, who included points determined by Eamskill and Nothnagel. Ventricular Hemorrhage. No antecedents to explain the lesion. Premonitory symptoms not rare. Gradually deepening unconsciousness. Cephalalgia rare. Paralysis when present is usually hemi- plegia. Varying pupillary conditions. Deviation of the mouth and tongue very common. Contractures very common. Convulsions maj' be present, but not common. Vomiting not frequent. No symptorns of secondary meningitis with fever. Death rapid. Meningeal Hemorrhage. Antecedents : for the newborn a pro- longed or hard labor ; for the adult a traumatism. Premonitory symptoms generally ab- sent. When traumatic, unconsciousness fol- lowed by partial restoration of con- sciousness and then again by uncon- sciousness. Cephalalgia frequent. Paralysis ordinarily generalized ; hemi- plegia exceptional. Unilateral dilatation of pupil common. Deviation of the mouth and tongue rare. Contractures, although frequent, less common. Con^^llsions the rule. Vomiting frequent. Symptoms of secondary meningitis with high fever towards the third or fourth day. Life, as a rule, prolonged several days. ENCEPHALIC HEMORRHAGE. 471 To make the diagnosis from cerebral hemorrhage of an ordinary type, the history of an injury and its tangible evidences are of first importance. The methods of diagnosticating dural hemor- rhages have already been given on page 270. It will be recalled that unilateral dilatation of the pupil on the side of injury to the head is an important sign in such hemorrhages ; and so also is the occurrence of unconsciousness followed by a period of partial res- toration of consciousness, and this again by unconsciousness. The elevation of temperature which is so important a diagnostic sign in distinguishing hemorrhage from acute softening may occur in almost any form of injury to the head, particularly if the brain substance is lacerated. Sufficient diagnostic points have been given in the preceding pages in the discussion of cortical hemorrhage and of the different varieties of focal hemorrhage. Differentiation of Encephalic Hemorrhage from other Acute Focal Lesions. — The distinction between hemorrhage into the brain and acute softening due either to embolism or to thrombosis may be important both for prognostic and for therapeutic reasons. After embolism and thrombosis have been considered, this diagnosis will be presented in tabular form. Eeference will be made here only to a few points of difference. In favor of hemorrhage is the fact that an attack comes on between forty and sixty-five years ; that the attack is not the sequence of endocarditis ; that atheroma of the vessels is evidently present ; that the seizure is sudden, and attended with loss of consciousness ; and that certain peculiar changes in tempera- ture result. Often the temperature shows an initial fall with subse- quent more or less continuous elevation ; often also the two axillse and the two sides of the head show differences of temperature, it usually being higher on the paralyzed side. In acute softening the rise of temperature does not take place unless the lesion involves the pons or is very extensive. As against some of the points just given, it must be remembered that cerebral hemorrhage may occur a,t any age, that embolism may be sudden, and that disease of the heart and of the vessels is often present in embolic, thrombotic, and hemorrhagic cases. The method of making the diagnosis of encephalic hemorrhage from sinus thrombosis will be made clear by reference to the article on the latter (page 303). Here it is only necessary to call attention to the importance of a previous history of aural or other causative disease, and to the local signs, vascular and neural, of closure of particular sinuses. A brain tumor, so far as its symptoms are concerned, may remain largely latent, attention being first abruptly called to the affection by an attack of stupor or coma with or without paralysis. Frequently in such a case the ophthalmoscope reveals single or double optic neuritis. A history of headache or vertigo, or of other cephalic symptoms which did not 472 NERVOUS DISEASES. fix the attention of the patient, may be obtained on close inquiry. Blood is not infrequently extravasated into some forms of brain tumor, particularly gliomata, and occasionally such a hemorrhagic attack first reveals the presence of the tumor. Sudden paralytic attacks in tumor cases are not, however, usually due to the occurrence of such hemorrhages, but rather to the softening from pressure or the obliterative inflammation of the arteries which takes place around the tumor after it has progressed to some extent. In the differen- tiation of ordinary encephalic hemorrhage from a neoplasm, with intercurrent hemorrhage or with attacks of acute softening, the clinical history of the case and the presence of such distinctive symptoms as severe headache and optic neuritis will usually be suffi- cient to make the diagnosis clear. A patient sulTering from syphilitic disease of the arteries, with gumma or gummatous meningitis, often has stuporous attacks which may be sudden in onset and may closely simulate the occurrence of an ordinary apoplexy. The diagnosis of brain syphilis of this type can be made only by a close study of the previous history of the patient and of his present and recent symp- toms. The absence of the distinctive features — especially of the temperature, respiratory, and ocular phenomena — of an apoplectic attack will be helpful. An encephalic abscess will not often be con- founded with hemorrhage. Occasionally after remaining for a long time more or less latent a large collection of pus may burst through its ordinary boundaries, causing an apoplectiform attack. The patient generally dies in a short time. In such a case careful inves- tigation will reveal at least a few facts which point to abscess, as the history of purulent ear disease or of some suppurative process else- where, and irregular attacks of septic fe\'er. In one of my cases an abscess was found occupying almost exactly the usual site of cere- bral hemorrhage, and here the diagnosis was especially difficult ; but this is a very uncommon site for cerebral abscess. Prognosis. — When a patient is stricken with apoplexy, the two points about which information is usually asked of the i^hysician by friends or relatives are whether the patient is likely to die in the attack, and what will be his probable mental and physical condition if the issue is not fatal. It is difficult to state in general terms the jarospects of recovery in a case of cerebral hemorrhage, the prognosis depending upon the extent and location of the lesion, the previous heallh of the patient, and the care with which he is treated. Among conditions which point to a probable fatal issue are profound unconsciousness, paralytic involvement of both sides of the body, convulsions, great irregularity in the action of the heart, Cheyne-Stokes breathing, and marked initial fall of temperature with correspondingly great subsequent elevation. The formation of a trophic eschar on the buttock is of ominous import. Recovery is doubtful when the patient presents all or most of the above phe- ENCEPHALIC HEMORRHAGE. 473 nomena, which usually indicate a large hemorrhage and one which has by extension become ventricular. When the disturbances of con- sciousness, respiration, pulse, and temperature are less marked, when paralysis is readily made out to be unilateral, and when rigidity and trophic eschars do not appear early, the chances of weathering the attack are better. As early recurrence of the l)leeding takes place in a considerable percentage of cases, an absolute prognosis should, if possible, be withheld for several days. Incautious handling of the patient sometimes leads to fresh hemorrhage. The prognosis can occasionally be influenced by active treatment, particularly by treat- ment directed to the reduction of the blood pressure. The traumatic effect of a hemorrhage, often the most serious factor, is, according to Wernicke, equal to the product of the mass of the effused blood into the square of the rapidity with which it is poured out. The latter depends upon the pressure in the vessels, and can sometimes be par- tially controlled by appropriate treatment. Individuals respond very differently to the influence of cerebral traumatism, whether in- ternal or external ; in some, profound unconsciousness is produced by a much smaller clot than in others, and the prognosis in such cases will be uncertain. As to the exact amount of recovery in non- fatal cases, it is generally impossible during the first two weeks to give even an approximate opinion. Some patients pass through a severe apoplectic attack, recover consciousness and considerable vigor of mind and body, but remain absolutely bedridden for months or even years ; others get so that they can hobble around with scarcely any further use of the paralyzed limbs than that which enables them wearily, and it may be painfully, to stand and walk ; still others to a very large extent regain motor power, speech, and sensation, if the latter be affected. Mental integrity is very differently affected in different cases. Eight hemiplegics are usually more emotional than those suffering from left sided paralysis. A large degree of mental power is often retained, but one who has suffered from an apoplectic seizure is never quite equal to his former self, and often is much below his normal standard in will power and in capacity for intellec- tual effort. A patient who will eventually walk again usually shows considerable improvement at the end of two, three, or four weeks. After a hemiplegic has recovered sufficiently to get about, it is dif- ficult to say to what extent his improvement will progress. Vain and sometimes injurious efforts are made to compel further im- provement, the patient often urgently demanding relief. The treat- ment, if judicious, may do some good, but the prognosis as to the amount of recovery is largely predetermined by the lesions. Apo- plexy is regarded by Dana as a conservative agent, sometimes call- ing a halt to excessive activity and intemperate living and actually prolonging life ; but it is doubtful whether this position is well taken, although it has some force so far as it bears on the change 474 NERVOUS DISEASES. in the personal habits of the patient due to the dread of another attack. Treatment. — Whenever there is good reason to apprehend the occurrence of hemorrhagic apoplexy, the person threatened should lead a most careful life. In the majority of cases chronic degener- ation of the arteries associated with cardiac and renal disease is present, and sometimes there may be syphilitic or gouty disease of the vessels ; close attention should therefore be given to the kidneys, heart, and vessels. Pood should be sufficient, but should be of a kind easily assimilated and digested. Constipation should be care- fully avoided. Laxative mineral waters and lithia waters will be found of value. The patients should not lead lives that are too sedentary, and on the other hand violent exercise should be avoided. Alcohol should not be abused, and in most cases it is well to abstain entirely from its use. If hypertrophy of the heart or some other form of cardiac disease be present, a judicious use of cardiac reme- dies may be instrumental in preventing the apoplectic attacks. Arsenic and small doses of the iodides are of some value if long continued, because of their effects upon the vessels and viscera. High medical authorities hold that the best treatment in a case of encephalic hemorrhage is to let the patient alone, at least so far as either internal or external medication is concerned. Mendel be- lieves that even the ice bag to the head is useless and that nothing should be done but to keep the patient at rest with the head some- what elevated. Hughlings Jackson and others have advised only to administer one or two drops of croton oil. Position certainly counts for something in the treatment of such cases. As taught by Bowles, the turning of the patient to one side and keeping him in this position with some steady support will often prevent or modify the stertorous breathing, which is in part at least due to mechanical causes. A patient suffering from hemorrhagic apoplexy should be moved as little as possible, and when movement is absolutely neces- sary it should be effected with the greatest care, so as not to favor renewed bleeding. When the patient has involuntary evacuations from the bowels or the bladder, or when it is deemed necessary to use cathartics, he should be guarded as much as possible from vio- lent exertion and unnecessary jarring on the part of those who handle him. It may be necessary to make use of urinals which can be attached to the patient. Dawbarn and Thompson recommend the application of the Spanish windlass to the extremities in cases of apoplexies, to lessen intravascular cerebral pressure and promote coagulation by preventing the return of venous blood to the trunk and head. Pormerly the vast majority of cases of cerebral apo- plexy were bled ; now the reverse of this is true. Venesection may be called for in a few cases, when sthenic symptoms such as flushing or turgidity of the face with full, hard pulse are present. ACUTE ENCEPHALIC SOFTENING. 475 In rare instances trephining has been tried for deep seated hem- orrhages. Horsley has advised the tying of the common carotid artery for the ordinary type of cerebral hemorrhage, and Schwarz has recommended arteriotomy of the anterior branch of the tem- poral artery, on both sides if necessary, asserting that this will cause a reduction of the blood pressure in the carotids with less loss of blood than follows venesection. ACUTE ENCEPHALIC SOFTENING. Acute encephalic softening is due to death of the brain tissues, usually the result of occlusion of a vessel or vessels. The lumen of the vessel is obliterated from within by a plug or embolus carried from a distance, or by the gradual closing in of the vessel wall through proliferative disease and the formation of a thrombus. Embolism is from the Greek bix^oXo:;, an embolus, derived from the verb meaning to throw or insert, and thrombosis is from the Greek Bpoii^ot;, a clot of blood. Arteries may be compressed until their channels are obliterated by nodes, tumors, or exudates, necrosis of the tissue resulting. It probably also results from inflammation and manifold minute extravasations of blood ; but, as a rule, the acute softening recognized as a special disease is dependent upon embolism or thrombosis. The popular idea of softening of the brain is largely erroneous. It seems to be believed that in some mysterious way general degeneration and softening of the brain result from strain, anxiety, and various causes which lead to serious nervous and mental disturbances but not to organic changes. Generalized softening prac- tically never occurs, and nearly all softenings are due, as above stated, to the occlusion of vessels, ^^^idely disseminated foci of softening may be present in a brain as the result of widespread arte- rial disease. All forms of acute softening are therefore local, but the affection may be single, diffuse, or midtiple. Arterial obliteration does not always lead to softening. ISTumerous vessels of small size, or a few of considerable dimensions, may be occluded and softening not result. The parts are nourished by neighboring or by anastomosing vessels. The circulation to such parts is disturbed, and anemia and malnutrition may result, but necrosis may not take place or may be postponed until more extensive obliteration of the vessels occurs. The symptomatology of vessel obliteration is in part the sympto- matology of arteriocapillary sclerosis or fibrosis, which has already been considered. In cases of thrombosis of large vessels the symp- tomatology of the focal softening which results is often complicated with that which is due to the diffuse disease of the vessels, many of the finer vessels being obliterated, although the vast majority are not. While obliteration of arteries is the most frequent patho- logical cause of softening, it is not the sole cause. The old writers undoubtedly made the mistake of supposing that it was almost 476 NERVOUS DISEASES. alwaj^s due to inflamuiatioii, but the more recent schools of pathol- ogy have perhaps gone too far in the other direction. Summarizing, brain tissue may disintegrate and soften as the result of vaiious pi'oeesses : lirst l)y occlusion of arteries as the result of embolism or thrombosis, aiul occasionally from the pressure of growths or from compression in other ways ; next comes the softening which accom- panies encephalitis after it has reached a certain grade. Occasion- ally softening may be due to occlusion of veins, but such an origin is rare. Chronic softening results from other processes. "Wernicke and Gowers have both given their allegiance to the view that we may have chronic progressi\'e softening without obliteration of blood- vessels, and each cites cases in support of this doctrine. The cen- trum ovale both of the cerebrum and of the cerebellum was softened over large areas in these cases. It seems most probable, however, that these forms of softening are due to the obliteration of the fine terminal branches of the subcortical and ganglionic systems of ves- sels ; but this can be demonstrated or negatived only by researches conducted with care, and by methods that will enable us to determine the condition of the most minute arteries. SOFTENING FROM EMBOLISM. Cerebral Arteries usually Attacked.— It is one of the best known facts in medicine that emboli more freciuently lodge in arteries of the left than of the right side of the brain, giving tlierefore with similar frequency right sided paralytic affections. The explanation of this, at least so far as the mechanical conditions are concerned, is, that while the left carotid artery comes off nearly in a straight line with the blood current from the arch of the aorta, the right carotid branches from the innominate, which leaves the aorta almost at a right angle. Even in the parts of the brain supplied by the basi- lar arid vertebral arteries, endiolism is rather more likely to occur on the left side than on the light, because the left vertebral artery, which is larger than the right, ai-ises from the highest point of the subchwian. The fact, however, that most of the blood passes by way of tlie basilar, which is a large azygous artery, bel'ore it is dis- tributed from these arteries, makes the direction of the blood cm rent and the peculiarities of the left vertebral supply less intluential as regards intracranial h'sions than are those of the left carotid. Em- bolism, thrond)i>sis, and hemorrhage are all of more frequent occur- renc(^ in the left hemicerebrum. Tlie left half of the brain, the lead- ing half, pays for its supremacy by its greater liability to viiscular disease. Clinical History. — Initial Si/mploms. Embolism is usually of sudden occurrence, and may be initiated with various jihenomena. Occiusioually, but not so often as in hemorrhage and thrombosis, it is preceded by vertiginous sensations. It is usually stated that pro- SOFTENING FROM EMBOLISM. 477 dromata are absent, but this is not strictly true. Embolism often occurs in tlie absence of arterial disease, but chronic endarteritis and cardiac disease may be present, especially in cases in which a second or a third attack has occurred, and the prodromata are chiefly the same disturbances of circulation as precede thrombosis. Earely the attack begins with spasms, usually local, and on the side which is later affected with paralysis. Loss of consciousness is frecpient, its occurrence or nonoccurrence being related to the size of the vessels obstructed. In many cases the apoplectic attack is as sudden and severe as in cerebral hemorrhage, and is attended by as profound un- consciousness, but the coma, except in cases which have fatal issue, is commonly more transient than in hemorrhagic apoplexy. Vomit- ing is infrequent. As a rule, the evidences of vascular tension are not so marked as in hemorrhage. Delirium and fever may soon fol- low tlie attack, but these may be as much due to ulcerative endocar- ditis and to septicemic processes as to the direct effects of embolism. The initial fall of temperature so often observed in hemorrhage does not, as a rule, occur, and the rise of temperature which takes place is not so marked nor so distinctive in its featui'es as it is in hemor- rhage. Temperature observations are often valualjle in the differen- tial diagnosis of the different forms of apoplexy, but because of their complicating causes are not infrequently misleading. In thirty-eight cases of acute softening, Dana rarely found any disturbance of tem- perature on the first day, even in those which terminated fatally. On the second day a slight rise was often observed, so that the average was from 99.5° to 100° P. Dana says there are very few exceptions to the general law that the temperature rises after a serious hemorrhagic laceration of the brain and does not rise after a serious embolic or thrombotic softening of the brain. The rare exceptions to this clinical rule are when the embolic process is extremely large, involving an entire lobe, or when it is situated in the pons or the oblongata, or when it is due to a septic focus. In both embolic and thrombotic softening the temperature on the two sides is usually the same, or the variation is slight. Even during the apoplectic stage certain symptoms and signs may enable the physi- cian to say that the patient is suffering from a focal lesion in a cer- tain locality of the brain. Careful manipulation of the limbs of both sides may show less resistance or a decidedly flaccid paralysis in one arm and leg. The face may be seen by inspection to droop on one side and perhaps to be drawn towards the other. Conjugate devia- tion of the head and eyes may be present, but is not so frequent as in hemorrhage. Loss of sensation due to embolism of the ganglionic vessels, particularly when branches of the posterior cerebral are plugged, can sometimes be determined. The tendon and muscle phe- nomena are usually exaggerated on the side of the paralysis. As the patient rallies, consciousness is regained partially or altogether, 478 NERVOUS DISEASES. generally sooner than in hemorrhage. If the left side of the brain is attacked, aphasia is nearly always present. ('(Hirse. As regards both course and onset, encephalic embolism may be of several types. Most frequently, indeed in the majority of cases, the onset, as already stated, is sudden, and the acute stage short, at least as compared with heinorrliage. Some of these cases which show a lai'gc^ aoK^unt of jmialysis at first largely recover from this paralysis, otiiers reiiiaiii i)eiinanently hemiplegic and it may be aphusic or hemianopsic. A few cases are rapidly fatal. Occasionally both embolic and thrombotic softening may occur without any symp- toms having l)een recognized, or at least without symptoms which have been attributed to disease of the brain. Focal Types of Encephalic Embolism. — .Just as the most fre- quent descri])tioii of ceiebial hemorrhage is founded upon the symp- tomatology of liemorrhage from the lenticulostriate artery, so the usual account of an embolic apoplexy and of tlie acute state follow- ing it is founded upon the symptomatology of the results of occlu- sion of the same deep branches of the Sylvian or medicerebral artery. The acuteness of attack and the progress of a case of embolism must, however, vary with the locality affected ; but to describe in detail eacli form would be simply to repeat much that has already been said in the pages devoted to eoitieal and interior localization. Among central vessels most fn;(juently closed by emboli are then, first, the lenticulostriate, lenticular and other branches of the medi- cerebral aitery ; but chjsure of the lenticulo-optic artery, with soft- ening involving the internal capsule, the posteroexternal portion of the lenticula, the anterior portion of the thalamus, and the tail of the caudatum, is also fre((uent. A gyral area which is a frequent seat of embolic softening is the left third frontal convolution, the insula, and the under- surface of the overhanging pfirtion of the operculum. Softening of the upper temporal convolutions is also comparatively common. In Pig. 278 is shown an immense cyst the result of embolic softening. It is irot necessary to give a list of the different areas which may be isolated l)y processes of softening, as they corraspond to the speeiid vascular- territories already con- sidered. Occlusion of the lenticulostriate gives symptoms similar to those al)-eady given in the general description of the symptoma- tology of embolism; when the hsnticulo-optic is affected, hemianes- thesia and perhaits h('miano])sia may be added to the motor symp- tom picture. When the vessels going to the insula and left third frontal are occlirded (Fig. 279), aphasia will of course be a promi- nent result ; when that supplying the first and the second temporal, word (htafness may ]><: the chief symptom. When large areas of the ])r-efi-ontal lobe are the seat of embolic softening, peculiar psychical changes occur. Softening of the cuneus and of the optic radiations gives amblyopia or hemianopsia. Goldscheider relates a case of SOFTENING FROM EMBOLISM. 479 embolism of the basilar artery, conlii'med by autop.sy, following ulcerative endocarditis, in wbich the main symptom was somno- lence deepening into coma and ending fatally in twenty hours, the only other cerebral symptom being a contraction of the left pupil. Fig. 278. Cyst the result of embolic softenin^^ ; the party involveolioencephalitis, in which som- nolence is also a prominent symptom, is obvious. Etiology. — Sex, age, and probably inherited peculiarities act as predisposing causes. Embolism is said to be of more frequent occur- rence in females than in males ; but this is not in accordance with Fig. 279. Old cyst, probably embolic, involvuig the left third frontal gyre and ojierculum. my own experience. Statistics upon this subject, unless very exten- sive, are of little value. It is more nearly correct to say that sex has little influence in favoring the occurrence of embolism. As compared with hemorrhage and thrombosis, it is more often observed in the young, but it may occur at any age, dependent upon the disease which it accompanies or follows, as rheumatism, endocarditis, or sep- 480 NERVOUS DISEASES. ticemia. As these diseases, particularly the first two, are likely to originate in youth and middle age, so embolism is more common at these periods ; it is of most frequent occurrence between puberty and fifty. Eheumatism, multiple neuritis, endocarditis, phlebitis occur- ring during the puerperium, and various other infectious diseases, such as diphtheria, scarlatina, and variola, act both as predisposing and as exciting causes. A relighting of old endocardial and arterial disease is a frequent exciting cause. A nervous shock may have, in exceptional cases, a tendency to the production of embolism. Thus, fright and violent exertion, particularly in the presence of recent endocarditis, may lead to the detachment of vegetations. A few very rare instances of echinococci plugging the cerebral vessels have been reported. Pathogenesis. — The intruding embolus is usually carried from the heart, which has suffered from endocarditis and some form of mitral or aortic disease. It is derived more frequently from the Adcinity of the aortic than from that of the mitral valves, but it is particiilarly likely to occur with mitral constriction. The slow fiow of blood through the nar- rowed mitral orifice during diastole per- mits the aggregation of white corpuscles on the valve, and the quick flow during the auricular systole tends to detach the masses thus formed. Often there is great dilatation of the auricle, and a clot forms in the auricular appendix, Diagram illustrative of the effects of fragments of wMch are likely to be de- embolic plugging: aa, portion de- , , , ,. -, j_ j-j_ j i.- n priyed of its blood supply by the em- tachcd, Or the clot softcus and particlcs boiufs E ; A, artery ; v, vein filled with from it pass into the blood Current. blood clot. The arrows indicate the mi .cj. j ^ 4. ■ ■ „ collateral channels which lead to a ^he SOftCUed maSS ottcu COUtaiUS miCrO- hyperemic zone around the occluded Organisms. In ulcerative endOCarditiS fldsch.') ^^'™'' ^''™' ^"'' ^^'^' the particles detached, which are usually small, may carry infective micrococci into the cerebral arteries. Minute ^-essels are therefore often plugged and tlie adjacent tissues necrosed. Other sources of emboli, besides a diseased heart, are aneurisms, particulaily of the aorta and caro- tids, phlebitis following labor or of other origin, disease of the pul- monary \'eins, and ulcerati\'e bronchitis and gangrene of the lungs. Minute pigment emboli sometimes block the cerebral capillaries, or fat embolism may follow degi'iicration of large vessels or disease of the bone. Certain xDoisouous substances, as carbon monoxide and phosphoins, aie supposed to induce softening by their effect upon the vess(sls. Pathological Anatomy. —In embolic softening fat crystals and SOFTENING FROM EMBOLISM. 481 granular debris are found on microscopical examination. In addi- tion, leucocytes may be increased and the vessels may show slight inflammatory changes in their vicinity. The diagram, Pig. 280, illustrates the effect of embolic plugging on the neighboring vessels and tissues. Beyond the obstructed artery is the anemic wedge- shaped area of its distribution, and below the embolus are seen swollen branches, which tend to establish a collateral circulation. ' ' If this faUs, we get as a result engorgement of the latter vessels, and a congestive vascular zone surrounding the wedge-shaped area. The tissue here becomes swollen and cedematous, and minute htem- orrhages are apt to occur, whilst the whole central and peripheral textm-e becomes broken up by the effusion, and a true necrosis occurs of the tissue forming the area of distribution of the nutrient branch which has been plugged." (Bevan Lewis.) Diagnosis. — The diagnosis of encephalic embolism, whether con- sidered in respect to the apoplectic attack or with regard to the secondary chronic or paralytic stage, is often difficult, and sometimes must remain a matter of doubt, particularly as to its distinction from hemorrhage or thrombosis. The diagnosis at the time of the apoplexy is important, because the proper treatment differs somewhat from that which should be used in either hemorrhage or thrombosis, and especially in the former. It is important to establish the patho- logical cause of a hemiplegia, a monoplegia, or an aphasia, so as to adopt the best methods of protecting the patient from future attacks of endocardial disease and embolism. Age needs to be considered in arriving at a decision. Comparative youth is in favor of embolism. Here it must never be forgotten that many cases of syphilitic throm- bosis occur before middle life, so that it is not improbable that apo- plectic attacks leading to hemiplegia and occurring before middle age are frequently thrombotic in character and due to syphilitic peri- arteritis or endarteritis. A syphilitic history should be carefully in- quired for, although it is not infrequent to meet with a history of both rheumatism and syphilis in the same case, and here the physi- cian may be compelled to choose as seems to him best. As between embolism and thrombosis, abruptness of onset is one of the most im- portant diagnostic i:>oints. An attack sufficient to cause marked paralysis usually comes on with sudden unconsciousness. As between hemorrhage and embolism in serious attacks, the temperature, as shown under hemorrhage, is a matter of great importance. The tabular presentation of the differential diagnosis of cerebral em- bolism from thrombosis will be given later. Too much stress should not be laid upon valvular disease. In those numerous cases of chronic disease in which nephritis, endarteritis, cardiac hypertrophy, and other pathological conditions are present together, the valves of the heart may also sooner or later become implicated ; but a patient of this kind is just as likely to have paretic or paralytic attacks as 31 482 NERVOUS DISEASES. the result of endarteritis and thrombosis as from cardiac vegetations carried into the circulation. One of my hospital cases, a woman about sixty years old, had cardiac degeneration with both aortic and mitral disease, and widespread atheroma of the vessels. This patient had three attacks of right sided paresis or paralysis, dying after the third one. Postmortem examination showed extensive calcification of the aortic crescents and degeneration of the heart walls. The aorta and the cerebral vessels were atheromatous. Centres of soften- ing were found in the motor zone, in the brain, and also in other regions. Several of the secondary and tertiary branches of the mid- dle cerebral artery were occluded as the result of disease in their walls and the formation of thrombi. In favor of thrombosis would be advanced age, atheroma of the vessels, fatty degeneration of the heart, and a succession of slight paretic attacks. In favor of em- bolism are youth, absence of signs of atheroma, previous history of rheumatism, and a sudden and comparatively severe attack of paralysis. Prognosis. — The prognosis of encephalic embolism needs to be considered with reference to the apoplectic attack, the probability of the recurrence of the affection, and the persistence of the paralysis, aphasia, or other consequences. The prognosis of an embolic attack is better than that of hemorrhage, presuming that vessels of nearly equal size are affected. Even when the attack is severe the patient is more Ukely to recover from it than from a serious encephalic hemor- rhage. As cerebral embolism sometimes takes place during the acute or subacute stage of an endocarditis, the prognosis as to the fatal issue and as to more or less speedy recovery will depend upon the state of the heart. Cases of embolism which at first have the appearance of great seriousness may on the clearing up of the apoplectic attack largely recover from the paralytic, aphasic, and mental symptoms. A patient who during the acute stage was totally hemiplegic and aphasic may in less than three weeks have left only a slight paresis of the arm and of the orolingual muscles ; I have seen many such cases. Moderately severe cases may sometimes recover almost entirely from the paralysis. Most authorities state that attacks of embohsm are not likely to recur, and this is probably true of embolism as compared with thrombosis ; and yet I have somewhat frequently seen two and three attacks in the same patient. A patient who has once had a rheumatic and endocardial attack may as the result have only slight permanent changes, but will always be liable to a recurrence of the original affection in a more Aiolent form and therefore also to a new or recurring embolic seizure. Cases which recover completely or nearly completely from the paralysis usually do so within a few weeks. After the chronic stage has set in, the difference in prog- nosis of the persisting symptoms as between hemorrhage, embolism, and thrombosis is not great. SOFTENING FROM THROMBOSIS. 483 Treatment. — The prophylaxis of encephalic embolism is in the first place the prevention of rheumatism and other infectious diseases which lead to endocarditis and the formation of vegetations, and in the second place the careful treatment of the heart and regulation of the circulation when evidences of old or recent endocarditis and val- vular disease are present. One who has already suffered from rheu- matism and endocardial disease should not be unduly exposed to great variations in temperature or to any depressing conditions likelj^ to renew the old troubles. The remedies to regulate the circulation will of course vary according to the valves affected and the other special conditions present. Strophanthus, digitalis, cactus, on the one hand, or aconite and veratrum, on the other, may be needed. The main- tenance of the general health of the patient by the use of tonics, rest, and careful regimen is important. The treatment of the attack dif- fers somewhat from that called for in hemorrhagic apoplexy ; but in both the patient should be kept perfectly quiet. In serious cases in which the breathing is interfered with the patient may be turned to one side and supported in this position in order to relieve the ster- tor. At the moment that the embolic obstruction occurs, all patent arteries dilate to compensate for the obstructed vessel. As long as this process lasts, a corresponding quantity of blood is used for their dilatation and so is lost to the rest of the cerebral circulation. The circulatory derangement is slighter the greater the force of the heart and the remaining available arterial tension. The greater the pressure in the veins the lighter the coma. A therapeutic deduction is to increase the force of the heart and the venous pressure by the recumbent position. (Geigel.) Hot applications to the extremities and trunk sometimes act favorably. To equalize and support the circulation, ammonium carbonate, digitalis, stro- phanthus, and cactus, with strychnine hypodermatically or by the mouth, may do much good, and alcoholic stimulants, usually in small quantity, may be needed. Venesection should not be used. If the patient is constipated, a quickly acting cathartic can be ad- ministered. The inhalation of oxygen has been used to tide the patient over a period of threatened collapse. SOFTENING- FROM THROMBOSIS. Definitions.— Occlusion of an artery by the process known as thrombosis may, like embolism, also lead to acute softening of the brain tissue. A thrombus is a clot or plug which forms at a certain place in a bloodvessel, either as the result of changes in the blood or in the walls of the vessel, or usually as the result of changes both in the blood and in the vessel walls. Thrombi may form in the heart, sinuses, and veins, as well as in the arteries, but it is only with arterial thrombosis that we are here concerned. Sinus thrombo- sis has already been considered. Absolute obliteration of an artery 484 NERVOUS DISEASES. may take place without the lodgement of a clot, and in a strict sense such cases may not be regarded as instances of thrombosis ; nevertheless, diseases which cause obliteration of bloodvessels by proliferative processes, or by pressure, produce softening and dis- turbances of the circulation. The distinction between a thrombus and an embolus is that in the former the obstructing mass forms at the seat of the occlusion, whereas in the latter the plug is carried from a distance. The disintegration or the partial disintegration of a thrombus may lead to embolism in the circulation at points bej'ond the thrombus, a thrombus again organizing at the original seat of the trouble : so that both processes may be present in the same case, and one may be causative of the other. Pathological Varieties. — The thrombi which are found in ence- phalic vessels are variously subdivided. An obstructing thrombus is one which completely closes the lumen of the vessel ; it may be incomplete or lateral, only partially closing the vessel, the adherent material clinging to its walls but leaving a channel of greater or less extent. Thrombi may again, according to their structure, be stratified or noustratified, the latter being composed in the main of various layers of fibrinous material. Etiological Varieties. — The varieties of thrombosis differ ac- cording to etiology. The term simple thrombosis is sometimes applied to those forms of the disease in which a clot forms in the vessels chiefly as the result of undue coagulability or of other pathological transformation of the blood, caused by depleting and infectious dis- eases, such as anemia, scurvy, the puerperal state, cancer, and by acute infectious and nutritional diseases in general. When disease of the vessel is present, it is sometimes named from the peculiar or special tyi^e of the disease : thus, it may be spoken of as syphilitic, gouty, atheromatous, etc. Pressure thrombosis is sometimes de- scribed, pressure of a tumor or an exudate compressing the vessel and giving rise to disease of its walls. Clinical History. — Premonitory Symptoms. Premonitory symp- toms are more marked in thrombosis than in hemorrhage or embo- lism. The same prodromes may be present in both hemorrhage and thrombosis, for the reason that both are dependent upon similar dis- ease of the arteries. As a result of Avidespread syphilitic or athe- romatous disease, patients may suffer from dull headache, vertigo, apathy, mental weakness, dizziness, and various disturbing and dis- tressing sensations within the cranium. Some of the phenomena set down as prodromes of an attack of thrombosis of a vessel of moderate or large size are themselves due to obliteration of vessels of smaller size in various portions of the brain and at various periods. Among these so-called prodromic phenomena are transient aphasias and pareses, cranial nerve paralyses, partial anesthesias, and various cortical and subcortical phenomena of the special senses. SOFTENING FROM THROMBOSIS. 485 In thrombosis from atlieroma premonitory symptoms are frequent. They depend on disturbances of the circulation caused by disease of the vessels, and may be present at intervals for a few hours, for weeks, or for months before the onset. The most common of these prodromes are dull general headache, giddiness, tingling, numbness, slight weak- ness in one half of the body, sometimes limited to a single limb, and often, but not always, corresponding in seat to the subsequent paraly- sis. Less commonly the patient shows defective articulation or some mental change, failure of memory, or irritability due to the malnu- trition of the brain that is produced by widespread arterial disease. In syphilitic cases, as other lesions besides those of the vessels are present, the premonitory symptoms may be the same as those just described, but in addition more severe and general cerebral symp- toms may be present. Headache is the most frequent ; it is often severe, usually general, and may be worse at night ; it may exist for weeks or only for a day or two before the onset. Sometimes considerable mental dulness or a somnolent condition may last for weeks. (Gowers.) Onset. Hemorrhage and embolism have, as a rule, an abrupt onset, but in occasional cases both may come on slowly. Thrombosis, on the other hand, is usually of gradual onset, but occasionally comes on abruptly. It is commonly of gradual onset, because in the ma- jority of cases the vessel lumen is nearly obliterated before the lodge- ment of the clot and complete closure take place ; but when the blood dyscrasia and the velocity of the blood current play the most important part, a large orifice may be occluded abruptly and give a sudden onset and a comparatively severe apoplexy. As in the ma- jority of cases the closure of the vessel is slow and progressive, that is, spreading from the original site of the occlusion backward until various branches of the first vessel obstructed are also occluded, the changes in the surrounding tissues take place more slowly, and con- sequently the paralytic, aphasic, and other clinical phenomena may come on without unconsciousness and in a less dramatic manner. When large vessels are closed they are none the less serious and per- sistent. In thrombosis, while the onset may be gradual, the progress of the case when once fully established may be rapid, although both gradual onset and gradual march are more common. The initiating symptoms of an attack of thrombosis will vary, of course, with the size of the vessel closed. Making our comparison with hemorrhage and embolism, if the vessel occluded is of considerable size, like a large cortical branch of the Sylvian, or like the lenticulostriate or the lenticular, or like a cerebellar branch of the basilar, the symptoms will be definite but of slow development. Motor paralysis comes on slowly, first in the leg and then in the arm and face, or it may be in the face and arm almost simultaneously, and last in the leg. Apha- sia may be coincident with the lost power in the face or in one or 486 NERVOUS DISEASES. both of the members. Loss of sensation, absent at first, may soon be present and profound, especially if the vessels which go to the poste- rior capsular region are affected. The sequence of phenomena may differ greatly both as to the parts affected and as to the period elapsing between the beginning and the closing of the process. It is hugely because of this peculiar manner of onset that patients are more likely to attribute their trouble to peripheral disease in thrombosis, and to brain disease in embolism and hemorrhage. In proportion to the surprise to which their consciousness is subjected are the patients likely to be affected with foreboding. When smaller vessels are occluded, the onset may be latent or light in phenomena. The patient may be conscious of a slight numbness or weakness in a limb or in the face, of a fugacious scarcely appreciable aphasia, of a tran- sient amnesia for names or faces, or of a transient hemianopsia or amblyopia. Dizziness or a sense of uncertainty, and weakness, or incoordination, is often present. Symptoms during the First Hours or Days of the Attack. As ence- phalic thrombosis — even when a vessel of considerable size is the seat of the occlusion — does not, like embolism and hemorrhage, give very striking apoplectic symptoms during the period of what may be regarded as the acute attack, the patient has not a sudden stroke, but finds himself paralyzed, usually at first partially, and he may succeed in getting to bed by his own efforts, consciousness, as a rule, not being lost. The temperature may fall slightly soon after the onset, and a little later may begin to rise, but the striking temperature variations of hemorrhage are absent. The range of temperature is not so great, the oscillations are not so violent ; differences in both axillary and surface temf)erature on both sides may, however, be present, and are striking. Slight changes in pulse and respiration take place in the majority of cases. "When a large focus of softening results from the obliteration of a large ganglionic vessel, the patient may have more marked disturbances of temperature, pulse, and respiration. Two of the factors which interfere with the \i\n\ functions of the brain in hemorrhage are absent in thrombosis. These are the irritative, dis- tending, and pressure effects of hemorrhage, and, when the blood has passed into the ventricles, its immediate effects upon the impor- tant nuclei in the fioor of the fourth A'entricle. When the vertebral or basilar or any of their larger branches are the seats of thrombo- sis, special symptoms may be present even during the acute stage of the process. A A^'ell reported case with autopsy will sometimes most clearly indicate the symptomatology of thrombosis of a special vessel. Peabody has recorded a ease of thrombosis of the basilar artery due to arteriosclerosis, A^ith softening of the pons, in a woman aged thirty years. She av;is comatose on admission. One week before, she had complained of numbness and tingling in the right arm, and some im- pairment of power was present. Examination showed rigidity and SOFTENING PROM THEOMBOSIS. 487 partial loss of power in the right upper and lower extremities, motor and sensory paralysis on the right side of the face, and dilatation of the right pupil. The heart sounds were feeble, and the temperature was normal on admission, but after four days it rose to 100° P. and at death it was 106° P. Focal Symptoms. It has just been shown that according to the size and to some extent according to the location of a thrombus are the initial and immediate symptoms, general and focal. The early and the persistent phenomena, of course, depend upon the area of the brain necrosed as the result of the thrombosis. These differ in no essential respects frora the phenomena of encephalic hemorrhage or embolism, and therefore do not need special consideration, except perhaps that a few words might be said about occasional cases which present a definite but restricted symptomatology. These are cases in which, usually because of syphilitic disease, vessels are nearly oblit- erated by gradual additions to their walls, and by this jarocess and the lodgement of a thrombus small areas of softening originate. If these areas happen to be so situated as to destroy important nerve nuclei, tracts, or cortical centres, special symptoms may result. Paralysis of the iritic reflex or of accommodative power may be the sole symptom for a considerable time ; more rarely a patient may suffer from total or partial word deafness ; or the symptoms may be referable to lesions of the root fibres of the cranial ner\'es in the pons ; or there may be hemianopsia, or paraphasia, or a special type of amnesia, as a persistent symptom. In brief, such a case may show one or two of the various phenomena which are eventually present in multiple softening to be presently considered. Duration, Course, and Complications. — The active phenomena of the period of attack are fewer in thrombosis than in hemorrhage or embolism, and unless the vessel closed is very large and important the patient rallies in a few days. He may, however, be left with so large a degree of paralysis that he will not be able to get on his feet for several weeks ; and indeed it is best that he should not be allowed to do this too soon. The further course of acute thrombosis differs but little from that of hemorrhage and embolism. The vic- tims of thrombosis are perhaps more likely to show general mental enfeeblement, because their brains are badly nourished by the dis- eased vessels. Partial recovery from paralysis, aphasia, etc., takes place slowly ; complete recovery almost never results. The symp- tomatology of thrombosis may be complicated by symptoms due to the renal, splenic, cardiac, and other diseases and degenerations which are often present. Etiology. — One predisposing cause of thrombosis is age, with its degenerative accompaniments, such as a weak fatty heart, and athe- roma of the vessels. Any constitutional condition, infectious disease, or toxic agentr— rheumatism, gout, syphilis, alcoholism, poisoning by 488 NERVOUS DISEASES. lead or other substances — may lead to changes in the bloodvessels. Syphilis is the most frequent of these causes. Its influence in the production of disease of the vessels is sufficiently considered else- where in this volume. Pathological Anatomy. — The vessels most commonly affected are the internal carotid, medicerebrals, vertebrals, basilar, and post- cerebrals, but thrombosis may occur in any of the vessels of the brain, large or small. In old age minute terminals not infrequently become occluded as the result of obliterating endarteritis, with or without the formation of very small thrombi. Widespread changes in the vessels, often macroscopic, are present, and these may be any of the forms of disease already described in discussing affections of the walls of the encephalic vessels. The arteritis or atheroma may advance until the vessel is no longer pervious, but usually a clot lodges after the lumen of the artery has been much reduced. After closure has taken ijlace, a forward and backward extension of the occluding process often occurs, so as to implicate various branches and con- nections of the original vessel. When the blood is in a pathological state, as during or after childbirth or infectious diseases, coagulation occurs with more readiness than under ordinary circumstances. As in embolism, anemia is one of the first effects of thrombosis, and later a portion of the anemic area usually softens. The appearances presented by the softened areas and their environment are much the same as those observed in embolism. Either red, yeUow, or white softening may be present. The areas deprived of their blood are at first anemic, but after the first day break down. Capillary ex- travasation is the chief cause of the red tint. As the blood degenerates and its pigment is transformed, the yellowish color appears. Eed and yellow softening are more frequent in the gray matter. In white softening, which may be present from the first, and is commonly subcortical, minute hemorrhages have not been so numerous. Diagnosis. — Points in the differential diagnosis of encephalic ar- terial thrombosis have already been given in the discussion of sinus thrombosis and of encephalic hemorrhage and embolism. Hemor- rhage, embolism, and thrombosis can at times be differentiated fi'om one another, although the making of this diagnosis is sometimes dif- ficult and exceptionally is an impossible task. In the diagnosis of thrombosis reliance is often largely on the past history of the patient, although the prodromes, modes of onset, and phenomena of the attack are of some assistance. The last are much the same for embolism and thrombosis ; but previous history, premonitory symptoms, and methods of onset differ somewhat in the three affections. So much has alicady been said in the consideration of symptomatology that it will only be furthei' necessary to summarize the most important differences in the table which follows. SOFTENING FROM THROMBOSIS. 489 Hemorrhage. Most frequent between the ages of forty and sixty-five years, but may occur in in- fancy or at any age. Often a family tendency to arterial disease. History of syphilis and a com- bination of renal, cardiac, and arterial disease com- paratively frequent. Occasional premonitory symp- toms, such as vertigo and temporary amnesia. Onset usually sudden. Complete unconsciousness, sometimes brief, but oftener prolonged, and gradually deepening ; rarely the pa- tient does not lose con- sciousness. Initial spasm very infrequent, but may occur. Conjugate deviation of the eyes and rotation of the head common. Pupils generally fixed and often unequal. Early rigidity frequent. Hemiplegia commonly total and profound. Stertorous and often Cheyne- Stokes breathing. Usually an initial fall with subsequent elevation of temperature. Pulse varying, but often tense, hard, and slow. Embolism. Thrombosis. Most common between pu- Most frequent in the aged, berty and middle age. the prematurely senile, and the syphilitic. Hereditary tendency to arte- Hereditary tendency to ar- rial disease not common. terial disease occasionally present. History of rheumatism, infec- History of syphilis very fre- tious disease, and old or quent. recent cardiac disease. Premonitory symptoms rare. Premonitory symptoms, in- dicative of chronic arterial disease, frequent. Onset almost always sudden. Rarely a sudden stroke; at- tack completed in a few minutes or hours. Unconsciousness commonly Unconsciousness often absent, complete but not prolonged. Sometimes ushered in with spasm or convulsive move- ments. Conjugate deviation less fre- quent than in hemorrhage. Affections of the pupils less frequent. Early rigidity less frequent. Paralysis usually less com- plete and less profound. Breathing less profoundly af- fected. Temperature changes less marked J initial fall often absent. Pulse likely to be weak, arhythmic, and compres- sible. Initial spasm absent. Conjugate deviation, affec- tions of the pupil, early rigidity, paralysis, breath- ing, temperature, and pulse the same as for embolism. Prognosis. — The prognosis varies considerably according to the vessel affected. When a vessel of large size, as the medicerebral, or one going to a vital centre, as a branch of the vertebral, is occluded, the effect produced may be permanent or even fatal. As regards the immediate result to life, thrombosis is ordinarily less serious than either hemorrhage or embolism ; the prognosis as to the recurrence of the attacks is, however, worse in thrombosis than in the other affections. The diffuse disease of the vessels so commonly present 490 NEKVOTJS DISEASES. in the subjects of thrombosis is a constant menace, and is often the cause of more or less mental disturbance and deterioration. Treatment. — The preventive treatment of thrombosis is largely that of the diseases which lead to it, and is considered elsewhere under syphilis of the nervous system, diseases of the vessel walls, and the causal affections of organic diseases of the brain. When any of the forms of syphilitic arteritis and their visceral accompaniments are present or suspected, the patient should be treated with iodides, mercury, and ammonium salts. Arsenic is also beneiicial, either alone or in combination with these drugs. Particular attention should be paid to the condition of the kidneys. An attack of cere- bral thrombosis is rarely as threatening as one of hemorrhage or em- bolism. Often the patient does not take to his bed ; commonly the attack is not attended with unconsciousness, the paralysis coming on gradually. The patient should be immediately put to bed. While this may not assist in removing the thrombus, it will do much towards tranquillizing the disturbed circulation. Probably the best treatment for the cerebral condition is that which has already been recommended under embolism. Efforts should be made to equalize and maintain the circulation, and this can be accomplished by the recumbent position, with the help of strophanthus, digitalis, and other drugs to which attention was called in the last section. Nitro- glycerin, and even alcohol in moderate amoimts, may be of great service. When the patient has rallied from the immediate effects of the attack, which is usually in a very short time, he should not be allowed to get out of bed. The bowels should be carefully regulated. Care should be taken in the use of cathartics in the treatment of thrombosis, for fear that purgation may weaken the heart and cause a tendency to increase in the size of the clot. MULTIPLE ENCEPHALIC SOFTENING. A few or many foci of softening may be found in the same brain. Charcot directed attention to the fact that in the badly irrigated ter- ritory in the interior of the cerebrum, where the terminal vessels of the cortical and central systems ajiproach each other but do not anastomose, little lacunse, or lakelets of softening are likely to occur, especially in the aged. They are due to the obliterati^e atheroma or endarteritis which occurs in the old and broken down, and they are sometimes so small as to be scarcely detectable by the naked eye. Larger patches of softening may be found scattered through the brain and may have given rise to a series of attacks and an irregu- larly developing train of symptoms and conditions. The compara- tively mild yet definite apoplectiform attacks often observed in the aged in the few years preceding death doubtless mark the occurrence of small foci of acute softening or hemorrhage, and other foci may originate without recognizable symptoms. It is not in the aged alone MULTIPLE ENCEPHALIC SOFTENING. 491 that multiple softeninjj is observed. Oases associated with endarte- ritis at various ages have beeu recorded, as one )iy Herter, in a woman thirty-two years of age, without cardiac disease. Patches of softening of considerable extent were found in the prefrontal Fig. 281. lobe, callosum, caudatum, len- ticula, light temporal lobe, and left occipital lobe. Many vessels were examined microscopically and without exception were found to be the seat of endarte- ritis. Three of the foci of soft- ening are shown in the sketch Fig. 281. Kolisco reports that he has found, as the result of carbon monoxide poisoning, small symmetrical areas of soft- ening in the striatum, internal capsule, and thalamus, at isoints in the distribution of the terminal arteries which go to these structures. In Fig. 282 are shown several Fig. 282. Multiple foci of softening, (Herter.) Areas of old and recent embolic softening in the same case : I., small foci of recent softening (A, B, C) in the right temporal lohe ; II., old embolic cyst (A) involving the lenticula (N) and the internal capsule ; T, thalamus ; III., old embolic cyst in the central region of the pons at A. areas of old and recent embolic softening in a case occurring in the service of Dr. Sinkler and the writer at the Philadelphia Hospital and recorded by Dr. E. A. Shumway in Volume III. of the Phila- delphia Hospital Eeports. Symptomatology of Multiple Cerebral Softening. — This must be of varied and irregular character, depending upon the sizes and 492 NERVOUS DISEASES. sites of the affected areas. In a majority of cases the foci are in the centrum ovale and ganglia, but they are sometimes cortical. Mental symptoms, such as amnesia, impairment of attention, emotionality, apathy, and difficulties in orientation, are generally present. These at first are usually of a mild character, increasing in severity as the areas increase in number. They indicate disruption of associating and commissural fibres, — of the paths of communication which tend to preserve the solidarity and integrity of the mind. Lesions dis- seminated in considerable number throughout the cerebrum may give rise to such mental phenomena, although they are probably more marked and more special in character when they destroy pre- frontal areas. As in Herter's case, multiple softening may show itself by a series of apoplectiform attacks with or without prodro- mata and with or without unconsciousness. In one attack the patient may be rendered hemiplegic or monoplegic ; in another, aphasic ; in another, a partial hemianesthesia or sector hemianopsia may occur, and in still another, amnesia and other psychical phenomena. OCCLUSION OF THE ENCEPHALIC CAPILLARIES. Capillary occlusion requires brief notice. Its diagnosis is rarely possible. Such symptoms as diffuse headache, vertigo, nausea, and general tremors and weakness are sometimes due to multiple oc- clusion of capillaries ; and these symptoms may be either acute or chronic, according as they are dependent upon multiple emboli or multiple thrombosis more gradually determined. Occasionally acute delirium is the result of capillary embolisms associated with embo- lisms of the minutest arteries. Decided mental decay comes on as the result of arteriole and capillary occlusions. Among the forms of capillary and arterial embolism to which some attention has been directed are pigmentary embolism observed in the course of mal- aria ; fat embolisms, the emboli having been derived from atheroma- tous vessels or from diseased or injured bones ; and embolisms from pus cells or white blood corpuscles. ENCEPHALIC INFARCTION. The term infarction, derived from the Latin infarcire. to stuff, cram, or fill in, was first applied by Laennec to obstructed areas or infarcts seen in the lungs. Hemorrhagic and anemic infarcts are found in the brain, and have much the same appearance as in- farcts in the spleen, kidneys, and lungs. They are found in all organs which have terminal vessels, in which they are commonly seen as wedge-shaped masses of necrosed tissue in and around which is more or less hemorrhagic infiltration. Pathological infarcts are by some regarded as originating at times simply from the extravasation of 1 ilood without occlusion of vessels. Charcot suggested that the cortex and underlying white matter may be divided into a system of wedge- ENCEPHALIC TUMOES. 493 shaped areas, the apices of which are turned towards the central regions of the brain, and the base towards the surface, an arrange- ment of vascular subterritories which can be demonstrated by injec- tions and by anatomical and microscopical examinations. Many superficial softenings of the cerebrum assume a somewhat wedge- shaped appearance, and infarcts are usually dark red, partly softened areas of this shape. The red color is due to extravasations, and these probably result from efforts of neighboring vessels to reestablish the circulation in parts cut off from their ordinary blood supply. En- cephalic infarcts may be the dii-ect or indirect result of embolism, but embolism and softening may be present without the formation of infarcts. A large area of softening in one place may be coincident with several infarcts in other localities, the latter resulting fiom mul- tiple emboli. When proximal vessels — as branches of the medicere- bral shortly after it is given off from the internal carotid — are plugged, cortical and subcortical areas may soften without infarction, but in- farcts occur when distal branches are plugged, or when branches which deeply penetrate the cerebral interior are the seat of eraboli. ENCEPHALIC TUMORS. Under the designation encephalic or intracranial tumor are in- cluded all new growths within the skull, whether they originate in the brain substance, in its vessels or membranes, in the periosteum, or in the bone, or whether they arise as secondary or metastatic pro- cesses, the primary lesion being in some other organ. Extracranial growths occasionally penetrate the skull and become in part endo- cranial and encephalic. The cranial cavity is the most frequent site of tumors, a greater variety of new growths being found here than in any other portion of the body. Bollinger found one hundred cases of brain tumor in eight thousand four hundred and eighty-eight bodies dissected in the Munich Pathological Institute in fourteen years, being one in eighty -five. Hale White found one in fifty-nine. The subject of brain tumors has become of increased practical importance since the possibility of removing such growths by operation has been demonstrated. The following table, by Starr, shows the percentage of cases probably removable to be about seven per cent. Percentage of Brain Tumors Removable. Author. No. of Cases. Operable. 1. Mills and Lloyd . . 100 10 2. Hale White . . 100 10 3. Starr 300 16 4. Knapp 40 2 5. Gray • 102 10 6. Seydel 100 3 7. Dana 29 5 8. Starr 300 21 9. Byrom Bramwell 50 3 494 NERVOUS DISEASES. The literature of brain tumors is very extensive. The Index Cata- logue of the Library of the Surgeon General's Office, in 1886, con- tained no less than six hundred and thirty-two references to contri- butions on intracranial tumor, and the number of such contributions has greatly increased since that time. Among recent works some of the most valuable aie a prize dissertation by Knapp, a treatise by Bramwell, and monographs by Putnam-Jacobi and Starr. Starr's chapter in the Texfc-Book of N"ervous Diseases by American Authors, edited by Dercum, gives references which bring the literature of the subject well up to date. Etiology. — Heredity plays at least an indirect part in the causa- tion of brain tumors, as when a tuberculoas, sarcomatous, or carci- nomatous taint is present. The frequency of occurrence of differ- ent forms of tumor will be considered under pathological varieties. The habits and occupations of men make them more liable than women to suffer from intracranial tumors : alcoholism, syphilis, and traumatisms, for instance, are more fi-equently present in the former. About two thirds of all cases occur in males. A large majority of cases occur between twenty and fifty ; probably about one fourth of the whole number before the age of twenty. Gliomata and tubercular growths are frequent in children. Gummata develop oftenest from early adult life up to the age of forty-five ; while sarcomatous, car- cinomatous, and the rarer forms of tumor are. more frequent near middle life. The aged are nearly exempt from all forms. While the influence of traumatism as an exciting cause of intracranial growths has probably been overestimated by some, it cannot be ques- tioned that it is an efficient causative agent. The local contusions and extravasations produced by severe blows or falls on the head, even in the absence of fracture, may be the foci from which tumors develop. Frequently in my experience an apparently direct relation has existed between a head injury and the origin of a neoplasm. Certain tumors, as the fibromata, osteomata, and angiomata, appear to be of most frequent occurrence as the direct result of traumatism. Pathological Varieties. — Ordinarily, in the present work, eti- ology, pathology, and morbid anatomy are considered after sympto- matology, but in the case of brain tumors it may be best, for special reasons, to discuss them first. The symptomatology, for example, differs somewhat according to the pathological variety, and therefore some advantage accrues from previous knowledge of the latter. In- tracranial growths are subdivided by Knapp into (1) the infectious granulomata ; (2) connective tissue tumors ; (3) epithelial tumors ; and (4) aneurisms. Aneurisms have been considered in a special section. Under the infectious granulomata are included tubercular growths, gummata, and actinomyces. Following the German authors and Knapp, tubei'cular aggregations and gummata will be considered as tumors, although good pathological reasons might be advanced ENCEPHALIC TUMORS. 495 against placing them under neoplasms. By including them under in- fectious granulomata they are recognized as the results of inflamma- tion which is dependent upon bacterial infection, and therefore they might be relegated to the class of inflammations ; but the products of the inflammation are often so isolated and so aggregated as to con- stitute tumors in the clinical sense. They give rise to both focal and general symptoms, and need to have applied to them the same princi- ples of diagnosis as sarcomata, gliomata, and some of the rarer neo- plasms. It is best, therefore, in a work like the present to regard them as tumors, but it must be understood that in so doing we are not separating them from other inflammations. In the same sense that gummata and tubercular masses are classed as tumors, aneurisms and abscesses can also be so regarded, but, foi' special reasons, they are best discussed separately. In the class of connective tissue tumors are glioma, sarcoma, fibroma, osteoma, enchondroma, neuroma, and lipoma ; while epithelial tumors are subdivided into carcinoma, ade- noma, and cholesteatoma. In a table of one hundred selected cases prepared by Lloyd and the writer, gliomata, sarcomata, and tuber- cular tumors were represented by nearly the same percentages. Ac- cording to Gowers, excluding syphilitic growths, tubercular tumors constitute more than one half the number of cases, and gliomata and sarcomata together about one third, gliomata being rather more fi-e- quent than sarcomata. Knapp, from an analysis of Birch-Hirsch- feld's three hundred and fourteen cases, and of Starr's two hundred and ninety-nine cases occurring in children, and of forty personal cases, concludes that tubercle is the commonest form of intracranial growth ; next the two connective tissue formations, sarcoma and glioma, with their varieties ; and next, with a long interval, gumma, cancer, and parasitic cysts, other forms being exceptional. Experi- ence teaches that the vast majority of new growths within the cranium originate either from the dura or from the arachnopia. Often the two membranes become so agglutinated that it is difficult to tell from which membrane the growth springs. Tubercular Tumors. Tubercular tumors are often multiple, and may be present in widely separated regions of the brain, and in this way give rise to a puzzling symptomatology. As a rule, they are found in the membranes or along the cortical distributions of some of the larger arteries, as the Sylvian and postcerebrals, or their main branches. Occasionally they are observed in the ventricles or in the substance of the brain, probably here also originating from vessels, the bacilli being carried by the blood current to the infected spot. They are often irregular in shape, and may be constituted by a conglomeration of tubercular deposits. Their central portions often undergo cheesy metamorphosis, and the brain substance around them may be necrotic or sclerosed. On section they are commonly of a reddish hue in their more recently organized peripheral zones, 496 NERVOUS DISEASES. and yellowisli or even greenish yellow in their older central portions. Under the microscope a few bacilli can sometimes be detected. It is sometimes difficult to distinguish a tubercular from a syphilitic growth, but the former, according to Bramwell, presents a marked difference from most syphilitic neoplasms, in that it is developed in the substance of the nervous tissue, while this is very rarely the case with the latter. Adjacent meningitis is frequently present. Giimmata. Most authorities hold that gummata do not develop as the result of inherited disease ; certainly in the vast majority of cases, if not in all, the specific disease has been acquired. They differ much in size and appearance ; thus, they may be nearly round, wedge-shaped, or of irregular contour. They also differ greatly in consistence, and Heubner has described two characteristic forms : the first a not sharply defined, com- FiG- 283. paratively soft, moist, grayish or grayish red mass, which on sec- tion exudes a scanty juice ; the second a well demarcated, firm, almost cartilaginous mass, which is often dry and friable. On sec- tion of the latter the interior is often found cheesy and broken down, while the periphery is red- dish and translucent, the appear- ances being strikingly like those presented by some tubercular Gumma of the striatum, showing gummatous grOwthS. Connective tiSSUe in infiltration, and the hyaline metamorphosis of ^„^„g. nrnmints mav Tinvp dpvpl- an artery with concentric infiltration of the ^^^^^ amOUntS maj naVC QCVei- cerebral tissue around the vessel. (Porter.) Oped in these grOWthS. VeSSelS and nerve trunks in the vicinity of a gumma are not infrequently involved in the lesion. A gumma of the striatum with one of these forms of coincident involvement is shown in Pig. 283. Gummata are often multiple. They may develop at any time from a few months to a score of years after the primary infection. If recognized early they are amenable to active specific treatment. Most frequently the gumma is situated on the surface of the brain, originating from its inner or outer membranes, often having an adjacent zone of meningeal inflammation. Although growing from the membranes, it usually invades the brain itself, a process well represented in Pig. 284, from Bramwell. In Pig. 285 are shown the microscopical appearances of a gumma and its vessels, and also the infiltration of the surrounding tissues. In rare instances gummata develop in the substance of the brain, originating irom the vessels. Bramwell has recorded two such cases. Aciinomyces. The parasitic fungoid organism called actinomyces in extremely rare cases directly or indirectly invades the brain. ENCEPHALIC TUMOKS. 497 Actinomycosis is the disease caused by this fungus. It often forms granulations which give rise to inflammations of the teeth, jaws, ears, neck, and face. Cases are reported of extension of the disease to the occipital foramen and into the brain, causing purulent inflammation and even abscess. Bollinger has reported an actinomycotic tumor as occurring in the third ventricle, the peculiar nodules of the specific microorganism having been found. In a case described by Del6pine multiple tumors and abscesses in the cerebral hemispheres were caused by actinomyces. Fig. 284. Transection through the left hemicerebrum in a case of gummatous syphilis : E, thickened and adherent dura ; F, gummatous and inflammatory products between the membranes and the sur- face of the brain ; O, surface of the brain at a point where it is being invaded by the syphilitic lesion. (Bramwell.) Sarcomata. All varieties of sarcomata, as the round- celled, spin- dle-celled, giant-celled, alveolar, and melanotic, may occur in the brain. Commonly they originate from the bone, periosteum, or mem- branes, and gradually invade the cerebral substance. They are usu- ally single, but may be multiple, in the latter case especially appear- ing as scattered melanotic nodules. Occasionally they are subcortical and infiltrating. Weir and Seguin have reported a case of this kind 32 498 NERVOUS DISEASES. in which a sarcomatous growth was found beneath the surface in the neighborhood of the facial centre. In the majority of cases sarco- FiG. 285. ©ilS^'v.^c/'^ Microscopical section through a gumma of the brain : C and D, enlarged connective tissue cells ; E, infiltration of the inten^ening tissue with corpuscular elements ; A, transversely and B, longi- tudinally divided vessels. (Bramwell.) mata not only are isolated but are also encapsulated. The macro- scopic appearances, external and internal, and the microscopic struc- ture, differ according to the variety. The spindle-shaped form is Fig. 286. Large sarcomii iif (lie left frontal lobe. (Morrison.) generally tirni and ledilish ; the melanotic is nodular and usually hard ; while other \'aiieties are soft, vascular, and sometimes gelati- nous. In Fig. 286 is shown a sarcoma of large size, the case having been reported by Morrison. The growth proved to be a spindle- ENCEPHALIC TUMORS. 499 shaped sarcoma, which was two and a half to three and one fourth inches in its greatest dimensions, and weighed five ounces after sev- eral months' immersion in alcohol. It was a dural tumor occupying the left anterior fossa of the skull, causing absorption of the brain substance as the growth advanced. It illustrates the great size at- tained by these neoplasms, the fact that they are usually encapsulated, and also one of their most common methods of invading the brain, by compressing its substance. At an early stage it might have been suc- cessfully removed. According to the relative preponderance of their constituent tissues the sarcomata found in the brain and elsewhere are classed as fibrosarcomata, gliosarcomata, myxosarcomata, and cysto- sarcomata. The endothelioma is a variety of sarcoma occasionally found in the brain. A tumor of this kind consisting largely of cal- cified cell nests, described by Hamilton, was as large as a walnut and Fig. 287. I^^m Microscopical section of an endothelioma of the left hemicerebrum : a, endothelial cells seen as small spindles between the cell nests, c, c: b, edge of a large mass of the tumor not shown in the figure. (McDowall and Bram well. ) occupied the head of the striatum. In Fig. 287 is shown an unusu- ally fine example of endothelioma from Bramwell's "Intracranial Tumors," the case having been recorded by McDowall. This tumor was situated at the under surface of the tip of the frontal lobe. Myxo- mata, or mucous tumors, are usually in part sarcomatous or glioma- tous. The myxosarcoma is a comparatively rare form. Similarly angiomata are fundamentally either sarcomatous or gliomatous in nature. A view once held, but now not generally received, is that hemorrhagic pachymeningitis is a species of angiomatous neoplasm. The angioma is in reality an exceedingly vascular variety of sarcoma. 500 NERVOUS DISEASES. the angiosarcoma. Even the psammoma, or sand tumor, is in most cases a form of sarcoma, and has been called by Woodhead the an- giolithic sarcoma. It has been found to contain spindle cells, but is largely composed of dark, gritty, calcareous material. Psammomata are most frequently found in the conarium, the choroid plexus, and the dura. Large calcareous plates are sometimes found in the latter membrane. In Fig. 288 are shown the microscopical appearances presented by the superficial part of a sarcoma removed by Prof. Fig, 288. Microscopic appearances of the superficial part of a sarcoma removed by Prof. Annandale from the motor area of the cerebrum. (Gibson.) Annandale from a case under the care of Dr. Gibson of Edinburgh. This growth was situated in the motor region of the cerebrum, appar- ently growing from its inner membranes. It was of large size, and was mainly a soft sarcomatous mass, denser and older in the centre, presenting the usual characteristics of sarcomata found on the sm-face of the brain. It was interesting etiologically because it had appar- ently grown from a cicatrix the result of a traumatism received years before. The case is also interesting becaiise the patient was greatly improved by the operation. GJiomata. The gliomata occur with about the same frequency as sarcomata. They are of peculiar interest in the study of encephalic pathology, as they develop from the neuroglia of the brain substance, while the, majority of encephalic neoplasms originate from the mem- branes, from vessels, or from glandular structures. They have been frequently observed in the cerebellum, pons, and oblongata, and in the cerebral hemispheres, and they occasionally develop in the retina. They originate oftener in the white than in the gray substance. The fbroglioma, mi/jrogJioma, and gllomvcomn are common intracranial varieties. A glioma is often so ill defined from the brain substance ENCEPHALIC TUMORS. 501 that on careless examination it is at first overlooked. Fatty degen- eration may occur in the central (older) portions of the mass. The more vascular forms are peculiarly liable to intercurrent hemorrhage, giving rise to misleading apoplexies. Gliomata may be either soft or hard : the soft varieties are those which are most nearly allied to sarcomata. Osier found that giiomatous tumors studied by him con- tained very large spindle cells and coarse fibres. The hard varieties are more closely allied to the fibromata. Fibromata. While fibromata are also of rare occurrence, one of the largest and most interesting intracranial growths recorded by the writer was of this character. The tumor had destroyed a large por- tion of the frontal lobe and other structures. Keen has also described a case of fibroma which was removed by him, the writer having been present at the operation. Fibromata are generally of a bluish or yellowish white color, of spheroidal shape and firm consistence. A vascular zone separates the tumor from the healthy tissue. They can be readily enucleated from the surrounding brain substance. Histo- logically they are composed of small fusiform cells, parallel to one another, with compact fibrillary intercellular tissue. They sometimes originate as the result of traumatisms. Osteomata ami Enchondromata. Osteomata, or true bony growths, are rare, and most commonly are projections from the inner table of the cranium ; but the deposition of calcareous plates has been re- corded as occurring in a variety of positions, as in the falx, tentorium, and other portions of the dura, and in very rare instances even in the substance of the brain. Enchondromata, or cartilaginous tumors, have been observed in the brain. They usually spring from the base of the cranium in the form of flattened masses arising either from the bones or from the dura and lying like plates upon the brain. They are composed of ordinary cartilage, and sometimes are in jjart bony, constituting the osteo-enchondromata. Neuromata. True intracranial neuromata originate in the sub- stance of the cranial nerves. False neuromata are fibrous growths springing irom the nerve sheaths. The form of heterotopia de- scribed by Virchow as originating in the brain substance is not a neuroma, but a variety of glioma, sometimes designated as neuro- glioma ganglionare. Lipomata. Lipomata, or fatty tumors, are rare within the cra- nium ; but Taubner has recorded the occurrence of one the size of a hazelnut which grew from the quadrigeminal body. Bernhardt has also recorded a case. Carcinomata. Oarcinomata are epithelial neoplasms, and are not uncommon in the brain. They are often secondary. Bramwell has seen encephalic carcinoma follow cancer of the breast. Primary car- cinoma has in rare instances been observed in the brain, usually having originated in the meninges or lining membrane of the ven- 502 NEEVOUS DISEASES. tricles. Dural carcinoma is comparatively common. Carcinoma may be multijile, showing itself as scattered nodules in the brain or its membranes. Of its thi-ee varieties, the scirrhous, encephaloid, and colloid, the encephaloid is the most common encephalic form. Carcinomata are soft, elastic, fluctuating, and are not encapsulated. They are very vascular, and are made up largely of epithelial cells, presenting a stroma forming alveolar spaces in which are contained nests of epithelial cells, the so-called cancer nests. The evolution of an encephalic carcinoma may be very rapid. In a carcinoma of the base Wernicke observed a cancerous infiltration of the network of nerves situated in the neighborhood of the tumor. Adenomata. The glandular tumors or adenomata in the brain are of course found either in the conaiium or in the pituitary body (hypophysis). They are usually soft and spongy in structure. In one variety the tubules are lined with cylindrical epithelium, and an- other consists of acini lined with spheroidal epithelium containing a Fig. 289. •i.«#?^l *V? '/). nif[ \ o\''V' V>^J Adenomatnus timv r llio piliiitary buily. (Blacklmrn.) varying amount of coiniccth'c tissue. Blackburn has described an interesting case of adcnomaof the pituitary body (Fig. 289) which was nearly an inch and a quarter in its a\'erage diameter and almost globular in shape. It had ex(>rcised ]iressure upon the optic nerves, chiasm, cavernous siuus, and ciixie of Willis, had caused absorption of the posterior clinoid processes and other structures, and had pro- ENCEPHALIC TUMORS. 503 duced a depression in the under surface of the brain. On section the growth was found to be soft, reddish gray, and moist, and proved to be chieiiy an overgrowth of the epithelial portion of the hypophy- sis. The case was one of chronic dementia, the patient having been blind for some time ; shortly before death she had a severe convulsion. Cholesteatoniata. Tumors of pearly lustre containing cholesterin, and called cholesteatomata, are found in various positions in the membranes of the brain, and more rarely in its substance. They are usually composed of proliferated endothelial cells of the arachnopia which have undergone a sort of fatty degeneration. They occur either solitary or as multiple nodules, and in some cases appear to be the remains of hydatid cysts. Dercum has recorded a case of un- usual interest in which pearly bodies were found in the midst of a sarcoma. The microscopical appearance of a section of the tumor is shown in Fig. 290. The concentric onion-like structure of the cholesteatoma is readily seen. Fig. 290. Microscopical section of a tumor of the brain, siiowing a cholesteatoma in the midst of sarco- matous tissue. (Dercum.) Tuhemis Sclerosis. An interesting form of sclerotic pseudotumor is sometimes found in the brain, especially among the idiotic, imbe- cile, insane, and epileptic. It attains various sizes, from that of a pea to that of a walnut, or it may be as large as an entire convolu- tion or a lobule. It is described by some authorities as tuberous sclerosis. The first examples of this affection seen by me were in brains obtained fi^-om the Pennsylvania Training School for Feeble- Minded Children. The sclerotic masses or nodules are sometimes 504 NERVOUS DISEASES. very distinctly defined, projecting from the brain like excrescences. They are due to an increase of glia. Cysts and Cystic Degeneration. — Cysts found in the brain are usually porencephalic, the cysts of old hemorrhages, or small retention cysts in the vascular plexuses. Porencephaly will be con- sidered later. In rare instances dermoid cysts have been found within the cranium. Kruse has reported an interesting case of this kind, the cyst not having caused any symptoms. The fourth ven- tricle was almost filled with a mass of hairs surrounded by a shiny, pasty substance. The tumor extended from the lower end of the ventricle to above the acoustic strife. Kruse could find only two other cases in literature, — one in the cerebellum of a child of seven with paraplegia, the other in the right striatum. A form of dis seminated cystic degeneration of the brain is occasionally seen Pick has recorded his observations on eight cases of this kind Three were from cases of progressive paralysis, two from tabetics, one fi'om a case of melancholia, and the other two showed no brain symptoms. The size of the cysts varied from that of a point barely visible up to that of a pea, and no lining membrane was detectable. Irregular compound cysts, formed by the coalescence of smaller ones, were found not only in the cortex but in the centrum ovale and gan- glia. Most authors agree in referring these cysts to dilatations of the perivascular lymph channels. Occasionally a cystic tumor of large size is found in the ventricles, as In a case reported by Hirsch, in which the left ventricle contained a cystic tumor covering the thalamus, being eight centimetres long and six centimetres broad. The tumor, which was a typical spindle- celled sarcoma, had devel- oped from the choroid plexus and had destroyed the posterior part of the caudatum and the posterolateral portions of the left thalamus. Parasites of the Brain. — Varieties. Parasitic growths within the cranium include eysticerci and hydatid cysts, the most important class of the latter being the echinocoeei. These parasitic growths have been most observed in Germany, and seem from reported cases to be com- mon also in Australia ; in this country they are comparatively rare. Cyst ice reus CeUulosw. The term cysticercus cellulosse is applied to the cystlike formations of the tenia solium in a certain stage of its development. These parasites enter the circulation from the intes- tines and are carried into the vessels of the brain. They vary greatly in size. The entire surface of the brain has been found thickly studded with them. Occasionally softening or iniiammatory action takes place around them, particularly after the death of the para- site. By its series of hooklets the cysticercus attaches itself to the inner surface of a vessel, or to other tissues and organs. After having been located for a short time the hooklets fall off, and there is left a cyst or bunch of cysts. The symptomatology of cysticercus of the brain presents a few special features. The symptoms may ENCEPHALIC TUMORS. 505 be of extremely varied character. The diagno8is will largely de- pend upon the history of the patient,— for instance, as to whether he is in the habit of eating uncooked meat, especially pork. In four cases recorded by Hirt all the patients suffered from epilep- tiform convulsions, and between the seizures they presented symp- toms of mental confusion which were regarded as the psychical equivalents of the motor attack. All complained of headache and vertigo. A number of cases have been rejjorted in which the i^ara- site was found after death, but in which no symptoms were noticed during life, but the i>arasites were small, and they were located where active symptoms are not usually i^roduced by lesions. Hydrocephalus has resulted from the i)resence of cysticerci which have been found floating free in the ventricles. Cases have been observed which in a general way presented the course and symptoms of paralytic de- mentia. Matignon has reported the case of a female found in the street aphasic and in collapse, who on admission to the h(jspital had generalized convulsions lasting fiom three quarters of an hour to an houi'. The following day right hemip)legia with aphasia and relaxa- tion of the anal sjjhincter was evident. In the third left frontal convolution a tenia cyst was found ; on the anterior extremity of the left first frontal another ; and on the inferior face of the cerebellum a third. The right temporal lobe contained a degenerated cyst the size of a walnut, with cartilaginous walls. In Pig. 291 is an illustra- tion of a case of cysticercus cellu- losEe at the base of the brain ob- served by Herdman. Early symx)- toms were paresis of the upper and, a little later, of the lower extremi- ties. Knee jerks were exaggerated, and other motor, sensory, and ocu- lar symptoms gradually developed. After a succession of chills fol- lowed by unconsciousness and a series of fits of short duration, the patient died. The autopsy showed a growth at the base of the brain in the middle region extending from the chiasm to the pons and spreading laterally on each side of the temporal lobes. The growth had the appearance of boiled sago, and was of pearly lustre, each individual portion being distinct. It seemed to originate in the meshes of the pia, and was adherent to the basilar artery and the arteries of the circle of Willis. Such a case might possibly be confounded with disseminated sclerosis of the pons, and this was one of the diagnoses made in this case, because Cystif LFf us cellulnscf of the < entr il rt^'iun ot the bahe uf the brain. (Herdman.) 506 NERVOUS DISEASES. of the peculiar interferences with motion in the extremities, and the peculiar disturbances of speech. EcMnococcus. The echinococcus somewhat frequently invades the brain. It is usually found in an isolated mass, but may be multiple or diffuse. It is a hydatid, the tenia echinococcus of the dog, and is the most unevenly distributed of all the hydatids, being found in the liver and other organs of many animals. Its diagnosis is made from the history of the case. In some of the recorded cases many of the cysts in the brain penetrated to the outside. The most important symj)toins of two cases were summarized in a collection of one hun- dred cases of brain tumor by Lloyd and the writer. In the first, re- corded by Visconti, the parasitic cysts having been situated in the right occipital lobe, the symptoms were periodical headaches, pains in the scalp, neck, and vertebral column, staggering gait, diplopia, confused sounds in the right ear, and tetanoid contractions in the neck. In the second case, reported by Yates, an echinococcus cyst filled the whole of the left lateral ventricle, and the symptoms were periodical headaches, unsteady gait, left hemijDaresis, peculiar swell- ing of the face, delirium, convulsions, and badly smelling discharge from the nose. Long and J. B. Hamilton have recorded a case of pedunculated polycystic hydatid found lying loose on the floor of the lateral ventricles but attached to the choroid plexus by a long pedicle. The patient was a right hemiplegic and aphasic, and the day before his death had what appeared to be an apoplectic fit ushered in by a severe convulsion. The effects of hydatids are chiefly those of irritation and pressure. In the brain after a time the hydatid dies and the sac sometimes dries up into a cheesy mass, which, however, can be identified by the booklets, which may remain for a long time. Common Sites of Certain Varieties of Brain Tumor. — It might be well to emi)hasize the fact that certain varieties of intra- cranial tumor are most likely to occur in special regions of the brain. When surgical i^rocedure is contemplated the decision as to operation must depend, in part at least, upon the conclusion reached as to the nature of the growth. In my experience gliomatous tumors are most frecjuently cerebellar and occur especially in children. According to Brannvell, tumors of the pons are usually either scrofulous (tuber- cular), gliomatous, or syphilitic ; tumors of the surface of the hem- isphere, syphilitic, sarchalic tumor — by which are meant symjitoms common to growths of all kinds and in nearly all positions — are headache, vomiting, vertigo, insomnia, and double optic neuritis. ENCEPHALIC TUMOES. 509 Mental changes, convulsions, temperature, and other febrile phe- nomena ma J' be either general or focal symptoms according as they are due to lesions of special centres or to the influence of the neo- plasms on the brain as a whole. ^^^i ^^^■ Headache. Head- ache varies much in character, but it is usually intense and often agoniz- ing. Sometimes it is paroxysmal, but more ii'equently it is nearly continu- ous, with periods of great exacerba- tion. It is more constantly present than any other gen- eral symptom. Ten- derness on percus- sion is of some ser- vice in fixing the site of a meningeal or cortical tumor, but even in these cases it may be misleading, and subjective localization of the pain is of little value for the pur- poses of focal diagnosis. Headache is somewhat less frequent in children. This is in part due to the fact that the growths in chil- dren are often gliomatous, and tumors of this class do not always cause headache. In very young children before the fontanelles have closed, headaches are not so likely to be present, or at least to be so violent, because, owing to the yielding of the cranial walls, the in- crease of tension is less. Syphilitic headaches are sometimes worse at night. In one hundred cases collected by Lloyd and the writer, headache was recorded in sixty-six, and in some of the others it was doubtless present but was not recorded. In only five cases was it stated not to have been present ; and three of these were said to be gliomata. Putnam- Jacobi obtained nearly the same percentage by a tabulation of the cases of Ladame and Bernhardt. Headache was present in four hundred and one out of six hundred and fourteen cases. The chief causes of the pain are irritation of the nerves of the dura and stretching of this membrane. Vomiting. Vomiting is present in a large percentage of cases. It may occur at any time and be unassociated with any disorder of the gastrointestinal tract. In cerebellar cases it is very commonly present, and sometimes of unusual severity. It is more paroxysmal. Ventral view of gliomatous tumor (same as Fig. 292) involving the pons, oblongata, and cerebellar peduncles : T, tumor mass ; 0, post- oblongata, somewhat changed in shape from pressure : P, pons. 510 NERVOUS DISEASES. occurring especially with exacerbation of the headache, and it may be brought on by movements of the head and body. Nausea with- out vomiting is occasionally present. In Putnam- Jacobi's tabulated cases vomiting was noticed in one hundred and sixty -two out of five hundred and seventy-eight cases. Verfif/o. Vertigo is present in about one third of all cases, and, like headache and vomiting, is usually due to some irritation of the dura. In some instances it is ocular, in others it is due to irritation transmitted to the labyrinth from the cerebral cavities. Under the general designation of vertigo are included dizziness, giddiness, reel- ing, and feelings of insecurity not dependent upon true ataxia. Insomnia. Insomnia, although often present, can hardly be re- garded as one of the distinctive general symptoms of encephalic tumor. Like restlessness, emotionality, and irritability, it is often dependent upon the suffering caused by the disease. It is more frequently present in adults than in children, and is more likely to accompany certain forms of growths, as the syphilitic and the sar- comatous, than others. In rare instances the patient suffers from unusual somnolence instead of sleeplessness. This is especially true in intracranial syphilis, in which, in addition to the isolated growth or growths, diffuse lesions are present. PapiUitis. OiJtic neuritis or papillitis is a most important symp- tom of brain tumor. Following von Graefe, many writers on oph- thalmology and neurology recognize two forms of oi^tic nerve disease associated with intracranial tumors, one the so-called choked disk, the other a descending neuritis. The term neuroretinitis simply indi- cates that both nerve head and retina are implicated. As it is often impossible to separate the so-called varieties of neuritis from one another, it is probably better, as has been suggested, to include them all under the non-committal term papillitis. Of the various attempts to explain the production of this affection, the Leber-Deutschmann theory seems to have most in its favor. According to this view, papillitis is a true inflammation caused by the action of the irritant or infecting agent of the disease, which finds its way into the cere- brospinal fluid. In like manner it originates from the infection of a meningitis. Increased intracranial pressure serves to intensify and multiply the effects of this inflammation. IS^euritis is probalily present on both sides in from sixty to eighty per cent, of all the cases, but statistics on this subject are somewhat conflicting. Its presence is of great value in settling the diagnosis ; its absence may prove nothing. Out of one hundred and seven cas(>s of intracranial tumor tabulated by Ednuinds and Lawford, sixty-eight showed optic neuritis. It is more frequent when the encephalic growth is in certain locations. More than one half of Edmunds and Lawford's cases were associated with tumors at the base or in the cerebellum. It has been noted in only al)0ut fifty per cent, in tumors of the motor cortex, and is rarely ENCEPHALIC TUMORS. 511 present when the growths ;ue confined to the hypophysis. Pituitary tumors do, however, sometimes cause neuritis and atrophy b>' their direct effects upon the chiasm and optic nerves. Single or monocular papillitis is rare, and when present is commonly due to a unilateral growth cephalad of the chiasm. Marked differences in the degree of neuritis present on each side are comparatively frequent. Vision is not always impaired at first, nor even for a long time, so that the ophthalmoscope should be resorted to when tumor is suspected, al- Fimdus oculi (indirect image) in a case of well marked papillitis. (BramwelL) though the patient does not complain of his eyes. When blindness comes on with apparently great rapidity, papillitis may have existed unrecognized. Occasionally it is the only symptom of encephalic tumor discovered during the entire progress of the disease. A few cases of this kind with autopsies are on record, as one recorded by Morrow in which the patient had no symptoms except weakness, malaise, and occasional dizziness when walking, but the ophthal- moscope revealed double optic neuritis in the swollen stage with numerous retinal hemorrhages near the disk. A pear-shaped glioma was found in the right temporal lobe. In tumors of the prefrontal region papillitis may be the only positive symptom. Papillitis usu- 512 NERVOUS DISEASES. ally goes on from bad to worse, sometimes rapidly, but more often slowly. A partial recovery may take place, but the most common result, if the patient does not die while active neuritis is still present, is consecutive or postneuritic atrophy. Under diagnosis attention will be called to some of the difficulties met with in arriving at a decision as to the disease indicated, even when papillitis is present. Commonly, this is tumor of the brain, but it may be associated with other affections, such as leptomeningitis, encephalitis and abscess, and nephritis with albuminuric neuroretinitis. Mental Disturbances and Deteriorations. Mental changes both gen- eral and focal are usually present in every case of encephalic tumor. Our concern here is with the former, although necessarily the psychic disorders caused by tumors in different localities will need to be referred to in order to make the subject clear. Among symptoms which rank as general are the mental disturbances due to the patient's suffering, and yet, as the pain may be caused by irritation of special branches of the fifth nerve, these symptoms are often indirectly local in origin. The patient is often highly emotional, restless, fretful, irascible, and easily affronted. After the disease has existed for some time he often becomes despondent, indifferent, and apathetic. Somnolence or semi-stupor, continuous or recui-rent, is sometimes properly included among the general sj^mptoms, but may be also due to the focal effects of large growths, especially when these are situ- ated in the prefrontal lobes. Subcortical growths, which destroy cerebral association systems, often give rise to amnesia, defects in orientation, and inability to respond quickly to ideas or to peripheral stimuli. The symptoms thus induced are general in the sense that they interfere with the solidarity of brain action, — with the working of the brain as a whole. The brain is thrown into a more or less cha- otic condition, causing disorderly psychic and other manifestations. Hallucinations, illusions, and delu- sions are most commonly due to the effects of tumors on S]jecial regions of the brain cortex or subcortex. Acute mania on the one hand, and profound depression or apathy on the other, is present in rare cases, and may obscure the diagnosis of brain tumor, especially if the pa- tient is observed for a short j)eriod only. Hysterical and neurasthenic states are sometimes induced by tumors, and it may be by one the presence of which is not suspected until papillitis is discovered by Regressive neuroretinitis of intracranial tumor. (Oowers.) ENCEPHALIC TUMORS. 513 the ophthalmoscope. The diagnosis between hysteria and tumor of the brain, as will be presently shown, is not always easy. In chil- dren the mental changes vary with the age and intellectual develop- ment of the patients. Eestlessness, fretfulness, irritability, apathy, and inability to concentrate attention and to pursue systematic study are frequently noted. In adults as well as in children, in studying the mental disturbances and deteriorations produced by a neoplasm, just as in the investigation of a case of insanity, the recent and pre- vious mental status of the individual must be taken into account. He must be compared with his former normal self. Patients of little edu- cation and low intelligence, like many of those found in hospitals and infirmaries, do not show the fine differences and striking departures of a psychical character exhibited by the educated and intellectual. Convulsions. General convulsions are common, and occur with special frequency in children. Although the convulsion is general, it often starts locally, but the local initiation of the spasm may be overlooked, or even when observed it may not be accorded its just significance as a localizing phenomenon. Such focally initiated gen- eral spasms are often the result of local irritation, as of some part of the cortical motor area, or of a sensory nerve in the dura. It is probable that the vast majority of cases have this mechanism ; but it must be remembered that general convulsions, closely simulating ordinary grave epileptic attacks, may be due to tumors situated in any region of the brain. The irritation is radiated in all directions, eliciting or failing to elicit spasmodic phenomena, according to the resistance offered by the tracts which jiass from the focus of disease to the motor cortex or bulb, and the stability or instability of these regions, stimulation of which gives rise to motor phenomena. Local spasms and the so-called Jacksonian epilepsies have received some consideration under cerebral localization, and will be again referred to when focal symptoms are discussed. False, Respiration, and Temperature. Aberrations of pulse, respi- ration, and temperature usually classed as febrile are common in encephalic tumors, although they may be absent or not attract atten- tion except in the last stages of the disease. These febrile phenomena tend to come and go, and may even show some periodicity. The fever is doubtless due in some instances either to meningitis or to the toxemia which is an accompaniment of infectious neoplasms. The pulse shows great variations, these probably being conditioned by the size, character, and situation of the growth. It is often slow and arhythmic, especially in the early and middle stages of a slowly growing tumor. It not infrequently falls to less than fifty beats a minute. Towards the end of life it may become weak and rapid. When associated with meningitis, it may for a time be tense, hard, full, and frequent. Cerebellar, pontile, and oblongatal growths cause irregularities of the pulse through their more direct 33 514 NERVOUS DISEASES. influence upon the centres of the vagi nerves. Now and then an extremely slow pulse is noted. Respiration, like pulse and tem- perature, may be very diff'erently afi'ected. In the terminal stages stertorous or Cheyne-Stokes breathing is common ; the latter may be observed long before this stage is reached, occasionally as a recur- ring phenomenon, and especially with ventricular, basal, and cere- bellar growths. As already stated, lesions of the tuber and its vicinity should give rise to rapid or to slow breathing, according as the lesion is destructive or irritative. Such respiratory phenomena belong rather to focal than to general manifestations. Unilateral differences in respiration are rare. Buccal, rectal, axillary, and sur- face temperatures all show departures from the normal during the progress of a case. If the entire course of the case except its ter- minal period is considered, the temperature is a little below the normal, but at irregular intervals the temperature shows marked ele- vations or vacillations. Sudden or rapid changes in temperature are sometimes due to increase of intracranial pressure, to aggrava- tions of meningeal inflammation, or to an intercurrent extravasation of blood into the tumor. Differences in the temperature on the two sides of the body may be present and are occasionally quite marked. In one of my cases, a twin tumor in front of the chiasm, various in- teresting observations were made. The temperature was taken regu- larly twice daily in the right and left axillae for eleven weeks before death, and gave an average for the right axilla in the morning of 99.1° F. and in the evening of 100° P. ; for the left axilla 99.4° F. for the morning, and for the evening 101.4° F. On some days remarkable falls of temperature took place, as to 96° F., 95° F., and even to 94° F. and 93° F. The average head temperatures were above the normal ; for stations on the right side of the head averaging about 97° F., and for the left side about 94.3° F. Elevation of the temperature of the head and scalp is occasionally present in large tumors. Lloyd and the writer concluded that in brain tumors the average temperature of the whole head is elevated several degrees above the normal, and that the elevation of temperature is generally greatest at the station nearest the seat of growth. Changes in the IntraeraniaJ Percussion Note. In a few cases a pro- cedure practised by Macewen may be of value in diagnosticating and locating a brain tumor, especially if of considerable size and situ- ated at or near the surface. The method suggested is to tap the skull with the finger or percussion hammer and listen with the stethoscope placed upon the patient's forehead, pterion, or some other portion of his head. I have long practised percussion without the use of the stethoscope, holding my ear close to the head. Undoubtedly a peculiar note is present in many cases of hydrocephalus, the dis- covery of which may point to the presence of associated brain tumor. My experience does not lead me to rely with any certainty upon the ENCEPHALIC TUMOES. 515 difference between the ordinary cranial note and that which is pro- duced immediately over a new growth. The resonance is increased in hydrocephalus, and it may be found to be so decreased imme- diately over a meningeal or cortical tumor that the difference is recognizable. Sachs has noted this increased dulness in a few cases of encephalic tumor in children. Macewen regards the changed percussion note as also of value in the diagnosis of abscess. Miscellaneous General Phenomena. Besides the general symptoms which have just been discussed in detail, others of more or less in- terest, and occurring with more or less frequency, may be present. Among these are constipation and other digestive disturbances, re- traction of the abdomen, anemia, enlargement of the head, and thin- PiG. 296. Thinning of the calvarium in a case of cerebral tumor, (W. Hale White.) ning of the bones of the skull. Constipation is very frequent, and is possibly due to the inhibitory influence of the tumor and the en- forced inactivity of the patient. Other digestive disturbances may be present ; the appetite may fail, or, on the other hand, it may be ravenous and a true bulimia may be present. As a rule, the patient emaciates. Children after a time become marasmic in appearance, wasting until they seem to be little more than skin and bones. The blood often shows on examination a true anemia. Great retraction of the abdomen may be present, as in a case reported by Hale White of gliomatous tumor in front of the chiasm in a child nine years old. This retraction is not due entirely to the loss of intra-abdominal fat, although this may account for it in part. It is a condition similar to 516 NERVOUS DISEASES. the scaphoid belly so often present in tubercular meningitis. In young children in whom the sutures and fontaneUes are not fully closed, the head sometimes enlarges, owing to the increased intra- cranial pressure and consequent separation of the bones. The en- largement is due more to the hydrocephalus which accompanies the tumor than to any distention caused by the growth itself. In Hale "White's case, although the patient was nine years old, the roof of each orbit was driven down a little, so that the upper eyelids became more vertical than normal, as is sometimes observed in hydrocepha- lus. The bones of the skull are occasionally thinned as the result of excessive and continued intracranial pressure. In Pig. 296 is shown a thin calvarium from a case of cerebral tumor reported by Hale White. The bones were transparent, and when held to the light showed their vessels as a beautiful arborescent network. The same writer refers to a specimen in the Museum of Guy's Hospital in which the thinning of the bone in a case of brain tumor actually laid open the tympanum. The thinning may in rare cases be so marked that the bones can be pressed in and will rebound like the "bottom of an oil can." Hyperesthesia is a comparatively common symptom. It is often present in the paralyzed limbs, and appears sometimes to be due to a secondary neuritis, and at other times to the central effects of the growth. The head also is frequently hyperesthetic. Focal Symptoms. — General BemarJcs. The focal symptoms of an encephalic neoplasm — by which we mean those symptoms indi- cating destruction or irritation of a limited area of the brain with known functions which are capable of being interpreted by the effects of disease — may sometimes outweigh in importance, both for diag- nostic and for prognostic purposes, the general symptoms, to the elucidation of which our attention has up to this point been directed. General symptoms, such as headache, papillitis, vertigo, vomiting, and convulsions, may tell us in no uncertain tones that a tumor is present, and yet may throw no light upon its location or its patho- logical character. The mere absence of focal symptoms is not suffi- cient to enable the diagnosis of the location to be reached by exclu- sion ; for a growth located in any one of three or four extensive re- gions of the brain may give rise to no focal symptoms, or at least to none which attract attention. Such regions are the orbital surface of the prefrontal lobe, the right temporal lobe, or the lateral lobe of the cerebellum. Physiological and other studies in localization have been of practical service in establishing the focal symptomatology of brain tumors, and, on the other hand, much has been learned ia regard to the functions of special regions of the brain through well studied and well reported tumor cases. Under cerebral localization, and in other sections of Chapter IV., the focal symptomatology of lesions of all kinds has been so fully presented that it will not be necessary again to consider the subject in much detail. ENCEPHALIC TUMORS. 517 Cortical Tumors. Brain tumors may g:row in or from any of the physiological subdivisions of the cortex given in the diagrams Figs. 228 and 229 (page 333), which represent the zones and centres of the lateral and mesal aspects of the cerebrum. These symptoms must therefore be considered according as they affect the prefiontal, the motor, the postparietal and limbic, the occipital, supertemporal, mid- temporal, uncinate, and preorbital regions, or their known subdi- visions. Careful study of the recorded tumors of the prefrontal lobe shows that they are nsu.ally accompanied l)y mental degrada- tion or deterioration and special perversions of the higher psychical faculties. These cases need most careful study, particular attention being given to the previous history as regards intellectual capacity. "When the growth is small it may be impossible to detect any focal symptoms, and when it occupies the orbital surface few distinct symptoms may be present, unless it extends caudad so as to involve the olfactory bulb and chiasm, in which case disorders of smell and sight may result. Bruus from a study of four cases of his own, and of cases of Oppenheim, Bernhardt, and others, concludes that dis- turbance of equilibrium, identical with the so-called cerebellar ataxia, occurs very frequently in tumors of the frontal lobes. This symptom he believes is much rarer in tumors of other parts of the brain and is absent with considerable regularity in tumors of the Eolandic region. The accompanying psychical symptoms and those due to pressure and irritation will usually enable a diagnosis to be made between cere- bellar and frontal tumors when ataxia is present. Starr suggests that, as the prefrontal lobes are known to be connected with the cerebellum by special tracts, this symptom when present may be due to irritation conveyed by these tracts to the cerebellum. In my own experience this symptom has not often been present. In the central or Eolandic region the chief focal symptoms are monospasm or unilateral convul- sions, with increasing paralysis of varying type according to the lo- cation and extension of the lesion. The spasmodic symptoms usually precede the paralysis in these cases. The spasm is often local, and generally begins in the same part in different attacks, as in the fingers, the toes, or the face on one side. Invasions of the hinder portion of the left third frontal and of the second frontal convolu- tion give motor aphasia and motor agraphia which may be partial or complete according to the extent of the lesion. In the posteroparie- tal and limbic regions disorders of muscular and cutaneous sensibility are sometimes present, and can be looked for with certainty when the lesions are deep or when they are bilateral. When the gyrus forni- catus or the quadrate lobule is involved, in addition to anesthesia local vasomotor and trophic phenomena are also sometimes observed. (Savill.) Tumors of the anterior portion of the lateral occipital lobe, where it merges with the parietal lobe (angular region), give word blindness, and, if situated a little more posteriorly, apraxia, or soul 518 NERVOUS DISEASES. blindness. Lesions of the cuneus and of the oalcarine region cause hemianopsia or quadrant or sector visual defects. When the tumor is situated in the superior temporal convolutions, partial or complete word deafness, and sometimes other affections of hearing, are present ; while tumors of the third temporal convolution, as in one of my own cases, may give verbal amnesia with or without other symptoms (see pages 345-347). Tumors when located in tlie fifth temporal convo- lution and its vicinity cause disorders of smell, while affections of taste are supposed to be caused by tumors and other lesions of the fourth temporal convolution ; but this point is not yet settled. The above summary is chiefly applicable, excei)t for the motor region and the calcarine cortex, to lesions of the left hemisphere, and it must be un- derstood that disturbances of psychical activity, motion, sensation, vision, audition, taste, and smell, include phenomena of irritation, destruction, and pressure. The phenomena of pressure and of irri- tation at a distance from a growth are sometimes spoken of as indirect symptoms. Tumors of Special Regions heloio the Cortex. For the symptoms of tumors confined to the basal ganglia or invading special portions of the capsules and centrum ovale, the crura, conarium, hypojjhysis, quadrigeminal body, pons, and oblongata, it will simply be necessary to consult the preceding special sections on localization, and the sec- tions and chapters which follow on diseases of the pons, oblongata, and cranial nerves. Tumors of the basal ganglia of the brain are seldom strictly localized to one or other of these bodies. Growths occurring in this region usually involve one or more of the ganglia and adjacent tracts, and can be localized only by a process of careful exclusion, as well as by the few special symi^toms which they are known to give and which have already been discussed. With refer- ence to tumors of such structures as the pineal and pituitary bodies, it is, as already stated, of great importance to bear in mind their effects uj)on neighboring parts. Symptoms referable to lesion of the chiasm, tuber ciuereum, circle of Willis, and third ventricle are often present in pituitary tumors, while a growth involving the cona- rium may give symptoms showing invasion of the thalamus, midbrain, and other parts (see pages 367 and 368). Tlie cerebellum is a fre- quent site of tumor. I do not belie^'c it to be in any part a latent region, as is sometimes stated, and yet slowly growing gliomata, and probably some other forms of neoplasm, when they originate in the lateral lobes of the cerelidlum may for a long time not j)resent recog- nizable symptoms. Und(>r "Fiuictions and Lesions of the Cere- bellum" (pages 373-382) the symptoms of tumor as of other cere- bellar lesions are fully gi\-en ; but one or two points might be re-emphasized. In tumors of this region some of the general symp- toms of encephalic growths receive a special cerebellar stamp. The vomiting, vertigo, and optic neuritis, for example, are commonly of ENCEPHALIC TUMOES. 519 an aggravated type, and symptoms referable to compression or inva- sion of the bulb or of the quadrigeminal body are frequently exhibited. The headache is often of occipital type, and nystagmus and other dis- orders of ocular movement are frequent. Tumors of the callosum, in accordance with what has been stated under cerebral localization, may give unilateral monoplegia, or hemiplegia developing into bilat- eral monoplegia or hemiplegia, spasms irregularly bilateral, hebetude, slowness of speech, and irregular gait. The bilaterality of the symp- toms will sometimes assist in the diagnosis. Dementia is frequent, and the general symptoms of encephalic tumor are nearly always present. Multiple Tumors. — The possibility of multiple tumors should never be forgotten. They have been reported as occurring in any num- ber from two to a score. Tumors most frequently multiple are the tubercular, the syphilitic, and the sarcomatous. Occasionally neo- plasms show a tendency to be symmetrically located on the two sides of the brain. Multiple tumors may, of course, give phenomena referable to various parts of the brain, symptoms and signs so con- flicting as to make local diagnosis impossible, and even to confuse the expert as to general diagnosis. In other oases, however, one growth of large size or in an active region takes command of the situation, and leads clearly to its diagnosis in spite of other less significant tumors. In one of my cases not only was the presence of a large tumor of the motor cortex diagnosticated, but its exact location was indicated during life. Postmortem examination, however, showed a smaller tumor at the inferior angle of the right lobe of the cerebel- lum, and also some basal meningitis with effusion, which had not been suspected. When operation is in question, the possibility of the co- existence of another tumor should be carefully weighed. In one case three gummata were found by me, — one in the j)refrontal region, an- other in the retrocentral fissure, and a third in the supramargiual convolution. The general symptoms of brain tumor were present, but no localization was possible. Occasionally all the ventricles are invaded by sarcomatous growths. Duration. — "So very positive statements can be made as to the du- ration and course of encephalic tumors. The duration may depend on various factors, such as the nature of the growth, the age and general health of the patient, and the care which can be given him. Gliomata and encapsulated sarcomata are often of long duration. (Bramwell. ) In thirty-two cases of brain tumor studied by Knapp the duration of the shortest— measuring duration from the time of the first recognition of the symptoms — was twenty-five days, that of the longest twelve years ; the average duration being sixteen months. A case of cerebellar tumor recorded by Seguin had definite symptoms for eighteen years. Andral has recorded a case which lasted fifteen years, and other cases lasting ten or twelve years have been put on record ; but these are exceptional. 520 NERVOUS DISEASES. General Course and Stages. — Both the general and the focal symptoms of encephalic tumor vary considerably according to the stage of the disease. Early recognition of the meaning of the symp- toms is of the greatest importance. With regard to the course and duration, the clinical history of encephalic tumors may, as a rule, be divided into an initial or early stage, a stage of the fully developed disease, and a terminal period. Headache, vertigo, and vomiting, slight mental changes, and disturbances of vision with the formative changes of optic neuritis, are among the first recognizal ile symptoms, and these are i^resent with increased severity and greater constancy in the fully developed disease. The focal symptoms then become more definite and pronounced. Paresis deepens and passes into paralysis ; spasms and contractures develoi) ; and hemianesthesia and special disorders of hearing, taste, smell, and temperature show themselves according to the position and extension of the growth. The neuroretinitis may now be of the most phenomenal character, the papillae being enormously swollen. In the terminal period the condition of the patient is often most distressing. The symptoms indicating destruction of the brain tissue have increased until the patient is often not only helpless and bedridden but may also be deaf and blind. Evacuations are involuntary, and loss of mental power may have advanced to almost complete dementia. Headache may persist, although in some instances, and especially in syphilitic cases, it abates or disappears with the onset of the paralysis or after the paralysis has reached a certain intensitj^, — probably because the intracranial tension is relieved with the breaking down of the brain tissue around the growth. As already stated, when considering brain pressure, one cause of headache is stretching of the dura, and this tension is relieved when the tissue surrounding the tumor softens. The patient may suff'er less from head pains also because of his changed mental condition. In the majority of cases the general pre- cede the focal symptoms, but occasionally this order is reversed, and some motor, visual, or auditory or other focal manifestations may appear first. Occasionally brain tumors progress with great rapid- ity, more frequently with fits or spurts of rapid progress. Either spontaneously or under the influence of rest, care, and good hygiene, or under the use of such remedies as the iodides, bromides, and ergot, remissions may take place in the severe sj'uiptoms of intracranial tumor. Under active treatment, especially in syphilitic cases, the symjitoms may subside, and a cure, or at least an approximate cure, may be achieved ; or, again, in exceptional cases the tumor may be successfully removed by surgical operation. Eare cases occur in which after attaining a certain intensity the symptoms subside and the patient continues in a quiescent and comparatively comfortable state for years. Termination and Mode of Death. — Brain tumor cases terminate ENCEPHALIC TUMORS. 521 by apoplexies, by intercurrent diseases, by general exhavistion, by the effects of brain pressure exerted on the oblongata, and occasionally in other ways, as from septicemia developing from an abscess which arises adjacent to the tumor. In the majority of cases death comes on slowly at the end of a protracted terminal stage, but in a con- siderable percentage of cases — usually when the disease is well ad- vanced — the patients die suddenly. Hale White mentions fourteen cases of sudden death out of a total of thirty-one observed. My experience does not confirm this high percentage, but in a number of cases I have observed either the sudden or the very rapid oncoming of death. White mentions one case of a woman who while peeling potatoes, and another of a man who when lifted to be gi\'en a drinlc, suddenly fell back dead. These sudden deaths may be due to abrupt changes in the intracranial pressure and local increase of this press- ure in vital regions, like the floor of the ventricle, the changes prob- ably being brought about by the sudden shifting of the head and body. The pulse has been observed to continue beating for at least half an hour after respirations have stopped. General Diagnosis. — The diagnosis of the existence of an intra- cranial tumor is, in the first place, to be made by a close considera- tion of the general symptoms, but it will at once be recognized that some or all of these symptoms may also be present in other affections, organic and fanctional. Among such organic diseases are encepha- lopathies due to toxic agents ; chronic endarteritis with nephritis ; meningitis, acute or chronic ; some forms of insanity, encephalic abscess or hemorrhage, and brain syphilis which has not assumed the form of a neoplasm. Among functional affections are headache and other symptom complexes due to eyestrain, grave hysteria, and migraine. The diagnosis of brain tumor from other organic affec- tions of the central nervous system is in each case usually to be made by a close study of a few points. The focal diagnosis has been sufficiently presented under the functions and lesions of different por- tions of the brain, and under focal symptoms in the present section. Toxemias. In cases of lead encephalopathy the presence of a blue line on the gums and of lead in the urine, and the occupation and previous history of the patient, will be of most service in clear- ing up the diagnosis. Profound malaria may in rare instances cause severe headache, general convulsions, hemianopsia, and papillitis, but in such cases most of the general and focal symptoms of brain tumor are absent, and the history of the case will help to a decision. The psychical and general symptoms which result from lithemia or gout are occasionally mistaken for those of brain tumor. Atrophy of the optic nerves in chronic alcoholism, nicotinism, or saturnism, particularly when the patients have such accomjianying symptoms as chronic headache, vomiting, and vertigo, may also wrongly lead to the diagnosis of brain tumor. 522 NERVOUS DISEASES. Endarteritis tvith Nephritis. In several instances I have known the mistake to be made of confounding chronic endarteritis associated with nephritis with tumor of the brain. In one of these cases the jtropriety of operation at the site of an old scar was discussed. The patient died at the close of a series of uremic convulsions, and the autopsy sliowed the case to be one of Bright's disease with cardiac degeneration and widespread endarteritis. The correct diagnosis was finally made in this case by an examination of the urine, by a study of the accessible vessels, and by the discovery of a typical retinitis albuminurica which at first had been legarded as ordinary optic neuritis. Headache, vomiting, vertigo, and mental changes are not infrequently present in these nephritic cases, and the con- vulsions occasionally assume the Jacksonian type. Headache, as a rule, is not so severe. Youth would be in favor of tumor. In Pig. 297 are shown the ordinary appearances of the fundus in albumi- FiG. 297. Fundus oculi in a case of albuminuric, retinitis. (Bramwell.) nuric retinitis, whicli can be compared with those in the illustra- tions Figs. 294 and 295. De Schweinitz calls attention to the fact that brain tumor (usually cerebellar) may cause choked disk witli a star-shaped figure of whitish color in the macular region, exactly simulating the appearances usually considered characteristic of a type of albuminuric retinitis, he having seen this in a number of cases in the Philadelphia Hospital and at the Infirmary for Nervous Diseases. ENCEPHALIC TUMORS. 523 Meningitis. Almost aoy of the forms of meningitis already con- sidered may at times need to be differentiated from tumor of the brain, or, as so many neoplasms grow from the membranes and are accompanied by some adjacent meningitis, the fact that both diseases are present in the same case may require to be determined. Usually the diagnosis is between some variety of leptomeningitis and tumor (see page 293). Subacute or chronic meningitis needs the attention of the diagnostician oftener than the acute form of inflammation. A careful study of causation, although at times misleading, may be of service. Meningitis is a result of tuberculosis, syphilis, trauma- tism, etc. ; but tumors likewise with less frequency are traceable to the same causes. On the whole, the more focal character of the symptoms and the early presence and severity of the papillitis are among the most distinctive characteristics of tumor. In syphilitic and tuberculous subjects the diagnosis is sometimes practically im- possible. In children the distinction most frequently needs to be made between tumor and tuberculous meningitis, and in adults be- tween tumor and syphilitic meningitis. The facts that gliomata are of comparatively frequent occurrence in children, and that head- ache is absent in some cases of glioma, must be borne in mind. In the following table are given a few of the most useful points of distinction between encephalic tumor and tubercular meningitis : Encephalic Tumor. Tubercular Meningitis. Previous history of syphilis, injury, or History of syphilis, injury, or other otiier cause than tuberculosis. cause than tuberculosis absent. Hereditary history usually wanting. Hereditary history of tuberculosis com- mon. Onset generally slower, but exceptions Onset usually somewhat rapid, with to this rule. irregularities. Papillitis comes on earlier and is usu- Papillitis of later development and ally of higher grade. lower grade, or may be absent. Definite and regular focal symptoms Focal symptoms, suth as palsies, and more common. disorders of sensation and of the special senses, irregular in type and development. Headache usually of higher grade and Headache more dilfused and some- more localized. times of duller cliaracter. Local head temperature sometimes sig- Local head temperature of little or no nificant. value. Course more regular, and duration usu- Course irregular, and duration usually ally of several months or years. limited to days or weeks. Febrile phenomena paroxysmal or Febrile symptoms usually persistent, wanting. but irregular. While the points given in this table will answer for many cases, for others they may fail or even be misleading. Headache, for example, may be far more severe in meningitis than in tumor, and may even be absent in the latter in rare cases, as already stated. Tumors of 524 NERVOUS DISEASES. the brain occasionally are rapidly fatal, and tlie course of a menin- gitis even of the tubercular variety may be protracted. Tumor and meningitis are not infrequently associated in the same case, as when a solitary tubercle or tubercular tumor is present in one part of the brain while tubercular meningitis attacks the membranes of an adja- cent or a distant region. Much stress is usually laid upon the pre- dominance of basal symptoms in meningitis, but both tubercular and syphilitic meningitis of the convexity are not uncommon, and, as already shown, the base of the brain is one of the frequent seats of tumor. Tubercular or syphilitic meningitis of the convexity may give psychical disturbances, palsies, local spasms, general convul- sions, sensory disturbances, and peculiar disorders of the special senses. Tubercular meningitis of the base can be readily dis- tinguished from cases of tumor Ijy the fact that one cranial nerve after the other is likely to become involved in the diffusing inflam- matory process. Chronic Hydrocephalus. Hydrocephalus, with or without enlarge- ment of the head, is a frequent accomijaniment of brain tumors, and especially of cerebellar, quadrigeminal, pontile, and other growths, which may by pressure or adjacent inflammation lead to obstruction of the foramens or channels of communication between the different ventricles. It may therefore become necessary to distinguish between these secondary forms and primary hydrocephalus. In chronic hy- drocephalus not associated with tumor the case usually advances more slowly, and it often dates from birth or is even prenatal in origin. Although convulsions are often present, symptoms of focal irritation are not so common as in cases of tumor. Diplegias of the spastic and ataxic forms are often present in hydrocephalus, but strictly localized or unilateral spastic and paralytic phenomena are less common. Optic neuritis and atrophy may be present in hydro- cephalus, but are absent oftener than in tumor, and symptoms of meningeal irritation such as headache, vertigo, and vomiting are not nearly so frequent as in ordinary hydrocephalus. While the diag- nosis between the two affections can often be made, in some cases it is exceedingly difficult, as when a cerebellar or a pontile glioma is accompanied by hydrocephalus. Abscess. The diagnosis of tumor from abscess of the brain is im- portant, and may l)e difficult. It will be more fully considered after the symptomatology of the latter disease has been discussed. A few of the points to be remembered are the frequent association of ab- scess with aural disease, the tendency which abscess has to remain for a considerable time latent, and the more uniform and steady progress of tumor. Apoplexji and the BcsuJts of Apoplexy. In rare instances it is neces- sary to distinguish between a recent apoplexy and a brain tumor. Intercurrent hemorrhage may occur during the progress of different ENCEPHALIC TUMORS. 525 forms of neoplasms, and in a number of instances such a hemorrhage has first called attention to the existence of a glioma. Cases are ob- served which during life present clinical features of apoplexy, but in which the autopsy shows no trace of hemorrhage, recent or re- mote. Kuttner reports two such cases from the practice of Ewald. In one the tumor was a large cystic glioma of the occipital lobe ; in the other it was a secondary carcinoma of the left temporal lobe, the latter growth being surrounded by an extensive area of softening. In ten of eleven cases recorded by Ladame, softening had occurred around the tumor. Many similar cases have been observed by the writer and others. Acute softening may therefore be regarded as the explanation of most cases of this kind. The points of distinction in the chronic stages of those cases of cerebral hemorrhage, embolism, or thrombosis which leave conditions of paralysis and other symp- toms simulating the permanent condition caused by tumors have been given in full by Lloyd and the writer. Hemorrhage has usu- ally a precedent history of diseased kidneys, hypertrophied heart, or atheromatous bloodvessels, and occurs generally in advanced life ; in embolism the previous record is of rheumatism and valvular disease of the heart, and the attack occurs at any period of life, early or late. In brain tumor the history is usually one of traumatism, of constitutional infection, or of a special predisposing diathesis ; and falls upon the head are common antecedents. A history of syphilis, tuberculosis, scrofula, or cancer is present. Tumor, like embolism and unlike hemorrhage, may occur at any time of life. The severe and often agonizing headache which precedes the paralytic and other phenomena of tumor is more distinctive of the latter than of the former. Papillitis is much more likely to occur in tumor than in the other affections. Chronic Degenerative Diseases. Occasionally a brain tumor is at first supposed to be present in cases which prove to be locomotor ataxia, disseminated sclerosis, nodular or tuberous sclerosis, syringo- myelia, or some other form of degenerative disease of the encephalo- spinal axis. These affections are diagnosticated by a careful con- sideration of the history and symptoms in each case. It may occasionally be necessary in the early stages of these diseases to postpone positive diagnosis. Among the most difBicult cases are those in which diffuse sclerosis of the cerebellum has occurred ; but such cases are rare. The ocular, sensory, ataxic, paretic, tendon, and muscle phenomena must all be carefully studied and properly referred. Insanity. The diagnosis of brain tumor from some of the forms of insanity, such as paretic dementia, mania, and melancholia, may now and then present difficulties. The history of the onset and progress of the case, and the development of the more or less typical psychical and mental symptoms of paretic dementia, will be most 526 NERvotrs diseases. helpful in differentiating this affection. Pierce Clark has reported two cases of tumors of the brain — one of multiple gummata and the other of multiple sarcomata — in which the diagnosis of dementia paralytica had been made, and the writer and his colleagues of the Neurological Staff of the Philadeljjhia Hospital have in a number of instances been confronted by cases presenting the same problem of diagnosis. The subject will receive fuller consideration when gen- eral paralysis of the insane and so-called syphilitic pseudoparesis are discussed. Usually delusions of grandeur are absent in these cases, but what adds to the difficulty is the fact that in some cases of true paralytic dementia the patient is depressed, or does not present mental exaltation. In a few cases of brain tumor the patients have outbursts of acute mania or frenzy, but in true mania the general and focal symptoms of tumor are nearly always absent, although, according to Lautenbach, optic neuritis occurs in a high percentage of cases. The delusions of melancholies may lead them to believe almost anything with reference to themselves : they insist at times that they have tumors or abscesses in their brains. Xo difficulty need arise in uncomplicated cases. Headache. It is not improbable that the headache of brain tumor and that of at least some cases of migraine have the same intra- cranial mechanism. Both may be caused by distention and irrita- tion of the dura. In most cases, however, the diagnosis of these affections is not difficult. In migraine, symptoms absolutely dis- tinctive of tumor, such as neuroretinitis and such focal phenomena as palsy or spasm, are not present. It must be remembered that in migraine hemianopsia, photopsia, fortification lines, and aural, gus- tatory, olfactory, and even aphasic disturbances may be temporarily present. Migraine is usually hereditary, and its victims have longer or shorter intervals of entire freedom from symptoms. The most difficulty will be presented when a tumor in the brain develops in a suiferer from migraine, a possibility which should be always borne in mind. Eijestmin. In the anemic, or in those in whom from any cause the general health is impaired, eyestrain may give rise not only to head- ache more or less severe, but also to conditions of the optic disk and retina which are much like optic neuritis of organic origin. Even genuine and serious optic neuritis, with consequent atrophy and blindness, is said by high authorities to be due in rare instances to eyestrain ; but my own experience and that of my ophthalmological friends would lead me to doubt the correctness of this opinion. It is more likely that eyestrain in these cases is associated with some local intracranial mischief or constitutional disease. The diagnosis of eye- strain from brain tumor is made by a study of the history of the case, by exclusion, and by a careful consideration of the ophthalmoscopic appearances. ENCEPHALIC TUMORS. 527 Hyfiteria. Hysteria is frequently present in organic nervous dis- eases, and especially in those which, like brain tumor, cause great suifering. A decision in these cases is largely a question of keen perception and close analysis of symptoms. Double optic neuritis is of great value in deciding in favor of tumor, but occasionally conditions of the fundus are present in hysteria which are very similar to those of a low grade neuritis. In one of my own cases of grave hysteria an ophthalmologist's report upon the eyes led to an erroneous diagnosis. The fact that in grave hysteria such symp- toms as monoplegia, hemianesthesia, amblyopia, and even hemian- opsia and severe hystero-epileptic convulsions may be present adds to the difficulties of diagnosis. Pathological Diagnosis. — Although the diagnosis of the patho- logical nature of a neoplasm in the brain is often difficult, it may sometimes be made with reasonable certainty. When considering the pathological varieties of tumor, most of the facts necessary to be borne in mind in making this differentiation were given. The de- termination of the nature of such growths has become much more important since surgical procedures have been adopted for the relief of brain tumors. A history of syphilis will of course be in favor of gummata ; but it must be remembered on the one hand that such history cannot always be obtained, and on the other that tubercular, sarcomatous, and other neoplasms are occasionally found in syphi- litic subjects. Evidences of carcinoma, sarcoma, or tuberculosis in other parts of the body than the brain may point to the correct pathological diagnosis. Tumors in young children are most fre- quently tubercular, although gliomata are not uncommon. Syphi- litic growths are, of course, common in adults, and carcinomata beyond middle life. The effects of mercury and of the iodides may indicate that a growth is syphilitic, and yet favorable results are sometimes obtained from the use of these remedies in other cere- bral tumors. If the situation of the growth can be determined, its pathological nature may be suggested. Tuberculous and gliomatous tumors are common in the cerebellum and the pons. Tumors of the surface are most frequently gummata, sarcomata, or tubercular de- posits ; while the centrum ovale and the callosum are usually attacked by gliomata or sarcomata. At the base a tumor may be of almost any variety. Prognosis. — The prognosis is unfavorable. Eecoveries even in syphilitic cases are rare. Bramwell states that he has come across the remains of only one old cured tumor in at least a thousand autopsies, excluding from this enumeration old syphilitic lesions. Even in syphilitic cases the growths are, as a rule, only partially removed, the connective tissue elements remaining. Tubercular and other growths sometimes become encapsulated and cease to grow or to do much harm. In rare instances intracranial tumors may be 628 NEEVOUS DISEASES. entirely removed by operation, but, with the exception of fibromata, old inert gummata, and probably some cases of isolated tubercular growths, the neoplasms are likely to reappear. Uncertainty as to the size of a growth will often throw doubt upon the prognosis when operation is in question. Medical Treatment. — Remedies to relieve Particular Symptoms. The agonizing headache of tumor of the brain sometimes can be re- lieved only by large doses of analgesics and sedatives. The suffer- ing may be so great that if unrelieved the patient may have a mani- acal attack or be driven to suicide. Opium and its salts are needed, the most valuable preparations being the salts of morphine and of codeine. Codeine sulphate or phosphate can be given, beginning with an average dose, say one grain, and rapidly increasing it if the exigencies of the case demand. Morphine sulphate or muriate may also be used in full doses. Hypodermatic injection is the most prompt and efficient method, but, when once resorted to, usually lias to be continued. Next to morphine or codeine, phenacetin is the most ef&cient remedy : in some instances it is even preferable to those drugs. It can be given in doses ranging from five to fifteen grains : the effect upon the patient must be studied when its ad- ministration is begun. Large doses will generally be tolerated, but occasionally the depressing effects of the drug are markedly shown. Caffeine or strychnine may be used with it to counteract these effects. Acetanilid and antipyrin may be used instead of phenacetin. The former can be given in doses of from five to ten grains, and antipyrin in doses of from ten to twenty grains. Cannabis indica can be ad- ministered, and is most efficient when combined with the bromides and chloral, neither of which will serve to relieve the pain when given alone, but they are valuable adjuvants to the true analgesics. Either very hot or very cold applications to the head, and espe- cially the former, may prove soothing. For the insomnia the pain- relieving remedies are of course demanded, but with them may be given special hypnotics, such as chloralamid and trional. Chloral- aniid in doses of about thirty grains has proved particularly useful in some of my cases. The papillitis or optic neuritis present is bene fited most by treatment directed to the absorption of the tumor and the relief of intracranial tension. Horsley has shown that a remark- able improvement in the optic neuritis is sometimes produced by merely opening the slcull, the swelling of the disk greatly subsiding. The eyc^s may need to be protected from bright glares, or even from the ordinary light ; although it is remarkable that some patients suf- fering from double optic neuritis of high grade are unaffected by light. For the vertigo, nausea, and vomiting, when clearly due to the intracranial irritation caused by the tumor, the measures em- ployed for the relief of headache are in the main useful. Large doses of the bromides either with or without chloral are most service- ENCEPHALIC TUMOES. 529 able for the relief of spasms, local or general. ISTelther elevation nor depression of temperature of moderate degree calls for special treat- ment, but when great elevation is present, phenacetin, antifebrin, or antipyrin may prove useful in reducing it, ^\'hile at the same time the pain in the head and the general irritability of the patient are relieved. Sponging with tepid water will occasionally be found com- forting to the patient. Leeches to the temples or to the ma.st(nd, wet or dry cups, counterirritauts to the back of the neck, and deriva- tives to the limbs may do something towards mitigating the intense suffering. In rare cases, especially when sthenic and congestive symptoms are present, venesection should be employed. Cystitis, paralysis of the bowels, bedsores, and other complications must receive careful attention. Remedies to promote Absorption and relieve Inflammation. When a gumma is suspected, mercury and iodide of potassium or of sodium should be promptly used, after the methods described under general therapeutics and under intracranial syphilis. In order of i^reference are mercurial inunction, with or without iodides, frequently repeated doses of calomel or of biniodide of mercury, and the iodide either of potassium or of sodium alone. Just how long to continue such treat- ment before resorting to operation or giving up the case as hopeless is often difficult to decide. Most patients should be given an active medicinal treatment for at least two or three months. Syphilitic growths are not the only forms of neoplasm which respond favorably to the iodide treatment. Sarcomata, gliomata, and fibromata have been known to make considerable improvement under their use. IsTo cures, however, have been accomplished in these cases, and even in syphilitic cases only an approximate cure may be obtained. The most recent products of the infection are removed and adjacent men- ingitis is relieved, but older portions of the neoplasm which have be- come inert remain. Even when much relief and apparent cure have been obtained by the use of specific remedies, these should be re- sorted to again and again at intervals of two or three months for a period of at least two years. Surgical Treatment. — A small percentage of cases of intra- cranial tumor can be successfully removed by trephining and abla- tion or enucleation. Fibromata and osteofibromata are among the most favorable cases for operation, but these include only a small percentage of the entire number. Isolated and encapsulated sarco- mata are also comparatively favorable cases for operation ; and gum- mata which have resisted specific treatment, and tubercular growths which are apparently isolated and unassociated with tuberculosis in other organs, may both caU for operation. Before operating, the exact position of the growth, that it is in an accessible area, and that it is probably solitary, should be decided. Infiltrating tumors and those secondary to disease elsewhere do not call for operation 34 530 NERVOUS DISEASES. unless it is simply to relieve the sufferings of the patient. Oper- ation to relieve intracranial pressure and thereby mitigate extreme suffering is justifiable if its object is explained to the patient and a false hope of cure is not held out. While surgical interference should not be hastily resorted to, on the other hand it is often too long postponed. Occasionally the question of operating a second time on a case of brain tumor may be presented, either because the tumor has not been properly located by the first operation or because it has been only partially removed and the trouble recurs again at the primary site of the lesion. Such an operation is sometimes jus- tifiable to afford temporary relief, or because of additional light as to focal diagnosis. When the situation of small cysts can be fixed, they may be opened and their cicatrization favored. Large poren- cephalic cysts cannot respond favorably to operation, as reaccumula- tion of the fluid takes place. ENCEPHALITIS. Encephalitis or cerebritis is an inflammation of the substance of the brain. In times not very remote, encephalitis and softening of the brain were regarded as practically synonymous, the profession in those days being largely influenced by the teachings of Duraud- Fardel and his disciples. Acute inflammation of the brain was then regarded as the chief or only cause of acute softening, and chronic inflammation of chronic softening ; but after embolism and throm- bosis were understood, these views of the relationship of encephalitis and softening were seen to need revision. Hughlings Jackson was one of the first to show clearly that brain softening is usually a local process due to occlusion of vessels. — a necrosis rather than a result of inflammation. Similar views are now claiming more atten- tion in connection with disease of the spinal cord. Much that has been classed as myelitis is necrotic softening, and it is quite probable that nerve trunks are at times the seat of noninflammatory necrotic processes. Nonsuppurative encephalitis has a real existence, and may be of several varieties. It is also true that it may give rise to processes of disintegration and softening on the one hand, or of hard- ening and atrophy on the other. In these days of frequent surgical procedure for intracranial affections, a knowledge of encephalitis may occasionally prevent serious mistakes. Varieties. — Encephalitis, like inflammation of other organs, may be either parenchymatous or interstitial, but in most cases both par- enchyma and connective tissue are consecutively or conjointly im- plicated. It may be either acute or chronic, the acute variety with our present knowledge being of the most clinical importance. It may also be primary or secondari/ and suppurative or notisuppurative. The secondary forms are those due to metastasis, or those associated with or consecutive to other lesion-i. Tumors of the brain, hemor- ENCEPHALITIS. 531 rhagic apoplexies, injuries of the skull or brain, and even emboli or infarcts, may have surrounding zones of secondary meningitis and encephalitis or meningoencephalitis. Our concern will first be with the acute and chronic forms of primary encephalitis. Acute primary encephalitis may be either focal, diffuse, or disseminated; chronic primary encephalitis is usually diffuse, but some forms of it are localized to lobes or lobules. Acute focal encephalitis has been de- scribed as of different forms according to its location — in the cortex, subcortex, pons, or oblongata. Cortical polioencephalitis was sug- gested by Striimpell in 1884. While acute primary encephalitis may be limited to the gray matter of the brain, and thus be entitled to the designation polioencephalitis, a number of cases have been re- ported which show that this disease may attack either limited or comparatively large areas and may in its immediate effects involve both gray and white matter and both parenchymatous and inter- stitial tissues. It is best, therefore, to discuss simply primary acute focal encephalitis, leaving the question of its polioencephalitic char- acter in some cases unsettled. Cases of focal encephalitis, usually hemorrhagic, and similar in their pathological findings, have been observed in all portions of the brain. The terms which have been introduced in describing some of the best known, or at least the most frequently discussed, of these forms are certainly calculated to mislead, a remark which applies not only to Striimpell's polioen- cephalitis, but also to the polioencephalitis superior and the polioencepha- litis inferior of "Wernicke. Polioencephalitis superior is described by Wernicke as an affection of abrupt origin which attacks respectively the nuclei and adjacent fibres of the aqueduct and preoblongata, — structures chiefly related to the ocular nerves and muscles. Some form of ophthalmoplegia is the predominating clinical feature. In polioencephalitis inferior the nuclei and other structures of the post- oblongata are attacked, giving labioglossolaryngeal paralysis with or without respiratory and cardiac involvement. These affections will need to be considered again under diseases of the pons, oblongata, and cranial nerves. The names used above to designate them have become so engrafted into the literature of the subject that it is better to make use of them in discussing encephalic inflammation, at least as synonyms. The terms "superior" and "inferior" are, however, misleading, as they might just as well be applied to cortical and sub- cortical focal encephalitis, or to cerebral and subcerebral varieties of the disease. A general encephalitis is clinically unknown, for the simple reason that death must ensue before the inflammation involves the entire brain ; but forms of diffuse inflammation, both acute and chronic, are well observed clinical and pathological types. A lobe or almost an entire hemisphere may be involved in the inflamma- tory process, which is usually subcortical, but may be conjointly cortical and subcortical. A diffuse periencephalitis or inflammation 532 NERVOUS DISEASES. limited to tlie surface of tlie brain may be almost general, and the soft membranes of the brain are often implicated in such inflamma- tion, as would be expected from the intimate connection between the arachnopia and the brain. This associated inflammation of mem- branes and brain surface constitutes a meningoencephalitis. In para- lytic dementia or general paralysis of the insane, periencephalitis or meningoencephalitis is present with other lesions. Disseminated encephalitis has been described, and may be of a widely distributed miliary form, or may occur in patches of varying size. Etiological varieties of encephalitis, such as the luetic, alcoholic, saturnine, puerperal, and postfebrile, are sometimes recognized, but these need here only this general reference. ACUTE FOCAL ENCEPHALITIS. As stated in the last paragraph, Striimpell at first contended for the existence of a form of localized cortical polioencephalitis, analo- gous in causation and nature to poliomyelitis and the bulbar types of polioencephalitis of Wernicke. Much opposition has been shown to this suggestion, and some writers have made sweeping assertions denying even the possibility of its occurrence. I can see no reason why an inflammatory process due to infection or other cause might not attack the gray matter of the cerebrum if it attacks that of the bulb or the spinal cord ; but the weight of recent observations is in favor of the view that the inflammatory lesions, as a rule, are not strictly confined to the gray matter, although they may be so limited in rare instances. In support of Striimpell' s original view, Moebius has given the history of two children in one family who were stricken down with fever, one of whom developed a tj3)ical poliomyelitic paralysis of the upper extremity, and the other a spastic hemiplegia. Striimpell has recorded cases of apoplexy in adults simulating closely in their clinical history attacks of embolism, but revealing on autopsy hemorrhagic encephalitis of both gray and white matter. Other observers have reported similar cases, some of them having been observed during the recent epidemics of influenza. Schmidt has recorded one such case in which the autopsy revealed in the head of the left caudatum and lenticula an isolated mass of bloody detritus, and in other localities, on both sides of the brain, hemorrhagic fis- sures and punctiform hemorrhages. Fiirbringer and Koenigsdorf have corroborated the existence of this affection. The term acute focal encephalitis is to be preferred to cortical polioencephalitis, as the lesions have been found to affect both gray and white matter. It is a disease both of adults and of children, and it is not improb- able, as lias been held, that it is the cause of some of the cases of infantile cc>rcl)ral paralysis, both hemiplegic and diplegic. At the time of the acute symptoms the patient may be supposed to be suf- fering from typhoid fever, malarial fever, influenza, or some other ACUTE FOCAL ENCEPHALITIS. 533 form of infectious disease ; or the enceplialitis may originate in tlie course of such febrile affections. Clinical History. — The disease as observed in young childi-en usually comes on acutely, vomiting, convulsions, and fever being prominent symptoms. Headache, irritability, vertigo, and drowsi- ness may be present for a few days. The child then i)asses into an aj)athetic or comatose state, which may alternate with i)eriods of restlessness or even of delirium. Fever of varying grade is present ; chills may or may not be among the manifestations ; tetanoid symp- toms and oj)isthotonos may be present early, or may be entirely ab- sent. If cranial nerve symptoms are present, the probabilities are that the encephalitis has become diftuse, or that basal structures are coincidently involved with the cortex. In most severe cases the mental and physical conditions become aggravated, respiration is interfered with, Cheyne-Stokes breathing may be present, and the patient dies in a week or two ; but the acute symptoms not infre- quently pass away, leaving residual affections of more or less severe type. Paralyses, contractures, atrophies, monochoreas or hemicho- reas, hemiathetosis, chronic convulsions, often of the unilateral type, and a greater or less grade of imbecility, are the most persistent of these residual affections. The duration of the disease as an acute affection may vary from a few days to several weelcs. Eemissions and exacerbations in the acute symptoms are observed in some cases. Few children who are attacked with the disease pass scathless through it ; something in the form of paralysis, with or without spastic phe- nomena, is generally left behind. When acute focal encephalitis at- tacks the adult brain, the symptoms do not differ markedly from those observed in the young. Irritative phenomena, as headache, fever, and convulsions, are on the whole less severe, and the residual paralyses, contractures, and other conditions may be less extensive. When the inflammation attacks parts chiefly below the cortex, the focal symptoms will of course differ with the location of the lesion. More or less localized forms have been recorded in the centrum ovale, basal ganglia, and capsules. A sharp distinction cannot always be made between focal and diffuse encephalitis. Probably at first the inflammation is more or less diffuse in most cases, but its destructive effects become concentrated in small areas, the disease in this way having striking analogies to the so-called poliomyelitis, which at first is often a diffuse myelitis. The symptomatology may therefore at first be that of a diffuse inflammation, the focal mani- festations becoming evident as the acute stage subsides. Etiology. — Acute focal encephalitis usually arises after or during the course of some acute infectious disease, as influenza, typhoid fever, diphtheria, or the eruptive fevers. Like anterior poliomye- litis, it would appear at times to have an infection peculiarly its own ; that is, none of the known infectious diseases are recognized 534 NERVOTTS DISEASES. as present. Sji:iliilis, alcoholism, and traumatism are occasional causes of both cortical and subcortical focal inflammations, but more fre(|uently they give rise to diffuse encephalitis. Pathological Anatomy.— In a few recorded cases with autopsies, circumscribed and usually small areas of softened tissue, which have a red appearance due to punctiform or capillary hemorrhages, have been found. The microscope shows distended and ruptured vessels, leucocytes, and granular cells. jSTeuroglia cells are proliferated, and the destruction of true nerve elements is greater or less according to the extent and intensity of the pathological process. Whether the inflammation in infectious cases is the direct or indirect result of the infecting microbes has not yet been determined. In some in- stances comparatively large hemorrhagic and broken down areas are present. Diagnosis. — As in poliomyelitis, the patient in the acute stage of this disease is often supposed to be suffering simply from an ephemeral, intermittent, remittent, typhoid, or other fever, the presence of the encephalitis not being recognized. Attention to the cerebral symptoms, and to the progress of the disease and its effects, is necessary to make the diagnosis clear. Often the true nature of the affection is not recognized until after several weeks, when a palsy of the limbs or of the face is discovered. The patient is often supposed to be suifering from one of the forms of meningitis, and it is diificult to separate the two affections. The presence of rheumatism and endocarditis, and the abrupt origin of the paralysis, will assist in making the diagnosis from embolism. When the cere- bral and spinal palsies of children are considered, the methods of ditferentiating the residual affections of focal encephalitis will claim attention. Prognosis. — The prognosis as to the acute attack varies, and is dependent largely on the virulence of the infection which leads to the encephalitis. If the issue is fatal, death may be due not directly to the encephalitis, but to the general toxemia of which the en- cephalitis is one of the serious results. The prognosis as to resid- ual affections also varies. Occasionally patients recover completely from a paralysis. In a larger number of cases partial recovery takes place, the patient being left more or less mouoplegic, hemiplegic, or diplegic. Some improvement may continue for several mouths after the acute attack. Treatment. — Little need be said as to treatment. Often, the focal encephalitis not being suspected, treatment is simply directed to the acute febrile disorder from which the patient is suffering or supposed to be suffering. When encei)halitis is suspected, the treat- ment should l)e similar to that of acute meningitis, ^ — absolute quiet, sedatives, analgesics, cold a])plications to the head, and the adminis- tration of purgati^'cs, especially of calomel or other mercurials. ACUTE DIFFUSE NONSUPPURATIVE ENCEPHALITIS. 535 ACUTE DIFFUSE NONSUPPURATIVE ENCEPHALITIS. Diffuse encephalitis may be acute, subacute, or chronic. A case beginning acutely may soon terminate fatally, or before death or partial recovery takes place it may be so prolonged as to become either subacute or chronic. A clear separation, therefore, cannot always be made between these forms. Probably the term subacute is most applicable in the majority of cases. Diffuse encephalitis may also be nonsuppurative or suppurative ; and in this section attention will be directed to the former. As already stated, a sharp distinction cannot always be made between focal and diffuse encephalitis ; but a few recorded cases clearly show that a severe inflammation sometimes involves large continuous areas of the interior as well as of the sur- face of the brain, leaving effects that can be referred only to exteu- sive destruction and degeneration. Either softening or hardening of the brain substance may be the ultimate result of diffuse encephalitis, softening being more likely to follow an acute or a subacute inflam- mation, and hardening a chronic inflammation. In some extensive and severe cases the affected areas are reduced to a semipurulent mass. When the subject of tumors of the brain was under consid- eration, it was stated that, properly speaking, both gummata and tubercular tumors are acknowledged to be the result of inflammation, but for clinical reasons they were regarded as tumors, the products of the inflammation being so aggregated and so isolated as to give definite focal symiDtoms. A few special words may here be said about syphilitic encephalitis. The syphilitic virus acts chiefly on the bloodvessels, lymphatics, and connective tissue. Parenchyma- tous lesions, whether cerebral or spinal, are, as a rule, secondary. The tissues react to the irritant much as in other inflammations. The products of the syphilitic inflammation may be a true gumma or a dif- fuse infiltration, the latter being so distributed as to constitute a dif- fuse or disseminated encephalitis. Eecent pathological investigations of syphilitic and tuberculous myelitis throw considerable light upon the nature of all forms of inflammation of the central nervous sys- tem. Any sufficiently virulent infection or toxic agent, or a serious traumatism, may produce inflammatory and necrotic changes similar to those which have been demonstrated as occurring in the spinal cord and brain, especially in the former, as the result of syphilis. In central syphilitic disease the process is a diffuse and irregular one, giving a certain stamp to most cases of specific origin. Whatever be the cause of the inflammation, the parenchyma, although it is rarely primarily involved, is always sooner or later implicated in the inflam- mation, or becomes the seat of degeneration through deprivation of nourishment. The softening of the brain in all forms of encephalitis is usually in reality necrotic, at least so far as the parenchyma is concerned, being due to obliterative inflammation of the vessels or to 536 NERVOUS DLSEASES. their occlusion by exudates or growths. So far as the noVjle elements of the brain are concerned, the softening or degeneration is the result of infiamniation rather than inflarnrnation itself: but the interstitial and parenchyjjjatous tissue becomes so blended and disintegrated in the complicated morbid jjrocess that the whole is best regarded as a diffuse inflaiiimatory lesion. Because of its comparatively distinctive features, and for otlicr practical reasons, syx^hilitic enceplialitis will be treated at greater length when intracranial syjjhilis is separately considered. The following brief discussion of diffuse norLSujjftura- tive euceijhalitLs is concernee ab- sent, and piaralysis was present on both sides, but was much more comjdete on the right than on the left. The superficial reflexes were absent, but knee jerks were normal and equal. He had a numl^erof convulsions, and from time to time variou.s local spastic phenomena, * In Brain, vol. xvi., 1803, paK? 21.5-229, Knaggs and Brown have made a valuable contribution to the subject of diffusa encephalitLs. which I ha%-e freely u.=ed in the pr<-]>aration of this section. The report of the ca.=e is accompanied by details of an autop-y and microscopical examination. ACUTE DIFFUSE NONSUPPURATIVE ENCEPHALITIS. 537 such as trismus, turning- of the eyes, and incessant twitchings of the muscles of the face, tongue, jaw, and neck. The temperature during the acute or subacute stages varies considerably, usually at first being moderately elevated ; but during the progress of the affection it is more likely to be subnormal or to range close to the normal. When one hemisphere is affected, the temperature has been found in a few cases to be subnormal on the side of the paralysis, — that is, the side opposite to the lesion. The pulse, like the temperature, is often subnormal, but varies according to the stage or intensity of the pro- cess. Involuntary evacuations, as a rule, are present. Optic neuritis is not so common as in meningitis or purulent encephalitis, and it may be unilateral. Duration and Course. — The duration is usually from twenty-four hours to four or five weeks. A few cases are rapidly fatal ; the ma- jority linger for several weeks, and some become chronic. A very few cases have been recorded in which acute or at le;ist active symp- toms persisted for several months with remissions and exacerbations. The course of the disease, even when short, is usually somewhat irregular, symptoms of irritation taking the lead at one time, and states of apathy and torpor predominating at another. Etiology. — The disease, except when syphilitic or alcoholic, usually occurs in infancy and childhood ; the cases collected by Knaggs and Brown were all under twenty years. Inherited weak- nesses of various kinds act as predisposing causes, and traumatism is the most frequent exciting cause. Alcoholism, or any infectious disease or toxic agent, is a possible cause. Both diffuse and focal encephalitis have been recorded as occurring during epidemics of influenza. Pathological Anatomy. — In the early stages of diffuse inflam- mation of the brain, vessels are distended and dilated, and capillary and arteriole extravasations probably take place. In cases of severe type in which autopsies have been made, after the inflammation has existed for a comparatively short period, softening of the brain sub- stance has been the chief pathological feature. In the more chronic cases induration has been found. The changes may involve nearly an entire hemisphere or extensive areas of both hemispheres, or they may be more restricted. The right hemisphere which was the seat of widespread inflammation in the case reported by Knaggs and Brown was found at the autopsy fluctuating and tremulous to the touch. The ventricles and their horns were enormously dilated. Careful examination of the brain after hardening showed the lining membranes of the ventricles much thickened, and the right striatum and other parts of the hemicerebrum sclerosed and greatly atrophied. The left lateral ventricle and its horns were also dilated, but not neurly to the same extent as on the right. The inflammation had been lim- ited to the right hemisphere, but dilatation of the connected Aentricu- 638 NERVOUS DISEASES. lar cavities had resulted, probably because of closure of the iter from obliterative inflammation. In Pigs. 298 and 299 are shown the ap- pearances of the ventricles and hemispheres from sections and draw- ings made by Dr. Brown after the specimens had been hardened. In some cases, perhaps in the majority, evidences of more or less exten- sive inflammation are seen in the membranes. Sometimes, although extensive inflammation of the brain substance has been present, the appearances to the naked eye are not such as to enable a positive opinion to be given. In Sharkey's case, for example, the macro- FiG. 298. Fig. 299. Longitudinal section of right liemicere- brum (after liardening), showing the appear- ances of the enlarged lateral ventricle and the surrounding diseased areas, in a ca.se of suVj- acute diffuse nonsuppurative encephalitis fol- lowing traumatism. (Knaggs and Brown.) Longitudinal section of left hemicerebruia (after hardening), showing enlarged lateral ventricle, but without surrounding inflamma- tory and degenerative changes ; same case as Fig. 298. (Knaggs and Brown.) scopic postmortem examination was regarded as practically nega- tive, but the microscope showed dilated vessels, leucocytes, and other evidences of true inflammation. Microscopically all traces of nerve structure may be lost in the parts which have been the seat of the most active inflammation, and the neuroglia is condensed and infil- trated with inflammatory products. Perivascular spaces are enlarged. Descending degeneration may be found in cases which have survived the inflammation for a short time. Diagnosis. — It is certainly difficult, with our present knowledge of the subject, to distinguish between some cases of diffuse menin- gitis or meningoencephalitis and diffuse subcortical encephalitis. A symptom which was present in all the cases collected by Knaggs and Brown, and which is therefore of diagnostic importance, is the state of vacuity and lielplessness in which the patients lay for long periods. These writers believe that long continued torpor of mind and body is the most salient feature of chronic diffuse encephalitis ; but, as this condition may not develop in acute cases of brief duration, its diagnostic value for such cases is imj)aired. Even in the acute cases, when the brain is very extensively involved, the torpor is present, and tlie symptoms are those which show involvement of large sub- cortical areas. The symptoms as detailed in the clinical history are DISSEMINATED ENCEPHALITIS. . 539 largely the same as those given under focal encephalitis, the focal cases being at first more or less diffuse, or the diffuse cases in other instances having at first been focal. In the diffuse form of inflam- mation, especially when it is largely subcortical, states of vacuity and torpor and symptoms which show dissociation of cerebral faculties are more x)roininent. In focal cases the acute stage is briefer and the residual conditions, while very definite and distinctive, are not so serious. After a focal encephalitis of limited extent, only moderate monoplegia or hemiplegia, with little or no mental deterioration, is left. When diffuse encephalitis does not result fatally, it always leaves severe and extensive residual affections. Prognosis. — The prognosis as to complete recovery is always bad. When the diffuse inflammation attacks both hemispheres, and when it is due to a very severe traumatism or to a virulent infection, death may occur in a few days. In other cases the patient lives for several weeks or months, and then dies from exhaustion or lingers for years deteriorated in mind and a sufferer from some one of the forms of hemiplegia or diplegia. According to Oppenheim, in acute nonsup- purative encephalitis, A'ery abrupt onset and severe symptoms, in- cluding high temperature, are signs of danger, while a slow onset, low temperature, and protracted course are of good omen. The cases referred to by Oppenheim were probably more focal than diffuse, but the remarks apply equally to both varieties. Treatment. — During the acute stage the treatment should be that employed for other forms of acute inflammation, — mercury, iodides, bromides, ergot, local and in rare cases general bloodletting, and ice bags to the head. Absolute rest should be enforced. Special symp- toms should receive attention. Convulsions, for instance, may call for the use of the bromides, antipyrin, antifebrin, sulphonal, or similar remedies. DISSEMINATED ENCEPHALITIS. While disseminated encephalitis of several forms has been de- scribed by different authors, no well defined clinical type of this affection is known. Occasionally disseminated encephalitis, like dis- seminated myelitis, is an acute affection ; and such cases so far as known are due to syphilis or to some of the well known infectious diseases. Various acute diseases of infectious or contagious charac- ter, as diphtheria, scarlet fever, variola, influenza, typhoid or typhus fever, and erysipelas, may set up a disseminated encephalitis of pecu- liar character. Little foci of inflammation are scattered here and there throughout the brain. This form of disseminated encephalitis may also be present in septicemia. What has been termed mycosis of the brain is a form of disseminated inflammation, — an affection in which little colonies of micrococci are found scattered throughout the brain. Charcot and Gombault studied and described a form of cerebrospinal syphilitic inflammation which is chronic and results in 540 NERVOUS DISEASES. the formation of sclerotic patches, some of which undergo caseation. The lesions of this disease are more frequently spinal than encephalic, but they may be confined to the encephalon. Doubtless nodose peri- arteritis and some of the forms of chronic syphilitic meningitis are allied to and associated with this variety of disseminated encephalitis. Danillo has described a form of miliary encephalitis in newborn chil- dren due to septic causes, such as suppuration of the umbilicus. In some cases, at least, insular or disseminated sclerosis of the brain is of inflammatory origin. Some forms of focal sclerosis of the nerve centres are due to syphilis. According to Lancereaux, the syphilitic forms of sclerosis can be diagnosticated from the nonsyphilitic by the greater tendency of the neur(jglia to fatty degenerations, and by the occurrence of foci of softening in their neighborhood. The symp- tomatology of disseminated encephalitis, acute or clironic. must of course be very irregular and variable in character, depending upon the number, size, and location of the points or patches of inflamma- tion. 'No symptom picture of the acute cases can well be given. It may be as multiform and irregular as the lesions. Paresis, anesthe- sias, amnesias, cranial nerve disordeis of slight or marked character, and visual, auditory, and other phenomena of the special senses, may be among the symptoms. CHRONIC ENCEPHALITIS. The forms of focal, diffuse, and disseminated encephalitis which have been described usually run an acute or a subacute course, but occasionally the inflammatory stage is so prolonged as to justify the application of the term chronic. The term chronic encephalitis is, however, more commonly applied to several other forms of in- flammation, although these have not yet attained a well defined position as the result of either clinical or pathological study. Ac- cording to Gowers, certain rare forms of chronic softening of the brain are probaijly inflammatory in nature. He also believes that a chronic focal inflammation of the brain substance is sometimes ob- served in patients with a gouty diathesis, the symptoms being those of focal lesions of the cortex, such as convulsions beginning locally, hemiparesis, partial aphasia, delirium, and slight pyrexia. Optic neuritis is absent, and headache is not prominent, but in other re- spects the symptoms are like those of brain tumor. In stUl other rare instances cases are observed which simulate brain tumor even more closely, such symptoms sis headache, vomiting, and even well marked papillitis being present. Hughlings Jackson has reported such a case in which the severe symptoms lasted for six months, and in which the microscope showed slight diffuse inflammatory changes throughout the substance of the brain. Inflammatory hypertrophy of the brain cortex has been described with a symptomatology which includes epileptiform convulsions and some arrest of mental develop- CHEONIC ENCEPHALITIS. 541 ment. The different forms of so-called sclerosis of the brain are regarded by some authorities as primarily varieties of interstitial inflammation, and it is probable that in some instances they are inflammatory in origin, in others simply reparative and degenera- tive, or that the changes are due to some irritant morbid process, usually the result of infection, the process standing in some way inter- mediate between true inflammation and simple degeneration. It has been shown in the section on diffuse encephalitis that one of the re- sults of an active acute inflammation is a hardening of the brain substance throughout a lobe, or it may be throughout almost an entire hemisphere ; but this is to be ranked not as a chronic encephalitis, but as the sequel of an acute or a subacute encephalitis. In that form of insanity known as paralytic dementia, a more or less diffuse in- flammation of the surface of the brain is one of the most constant lesions. It constitutes a periencephalitis, but the arachnopia is also inflamed and thickened, and is usually adherent in many places to the cortex, so that the inflammation presents itself rather as a men- ingoencephalitis. Various grades of inflammation are also present in the dura ; the vessels are seriously diseased ; and nerve cells and fibres are atrophied so that convolutions and even lobules or lobes may present an irregularly shrunken appearance. According to one view, the disease is primarily an interstitial inflammation beginning in the vascular apparatus, soon involving the connective tissue, and event- ually by secondary processes implicating and destroying the true nerve elements. According to another view, the disease is primarily parenchymatous and noninflammatory. N"erve cells and processes first disappear, and later the vessels 'are diseased, and neurogliar hyperplasia takes place. A chronic meningoencephalitis, however, is present at some stage of the disease, according to either view. The encephalitis is not strictly confined to the cortex, but may invade the brain substance to various depths. Ependymitis is often present. Paralytic dementia will be considered more fully elsewhere, attention being directed to it here simply to make more complete our survey of the entire subject of encephalitis. It is necessary to bear in mind also in this connection that a meningoencephalitis or periencepha- litis may be present and not result in this disease, which is probably one which is due to a toxin produced in the system usually following syphilitic infection, a general assault being made upon the entire nervous system. The periencephalitis is simply an important part of the morbid processes which are set up in the interstitial and paren- chymatous tissues of brain, cord, and peripheral nerves. Eaymond considers syphilitic general paralysis to be a chronic interstitial in- flammation, having its point of departure particularly in the cor- tical capillaries, the lesion being termed by him diffuse embryonic meningoencephalitis or diffuse vascular meningoencephalitis. 542 NERVOUS DISEASES. DIFFUSE SUPPURATIVE ENCEPHALITIS. Suppurative encephalitis and abscess of tlie brain, althougli usu- ally considered together, are not strictly synonymous, as a diffuse suppurative encephalitis may be present without the formation of an abscess in the clinical sense — a localized collection of pus with defi- nite boundaries. On the other hand, a circumscribed accumulation of pus may be found within the brain without evidences of adjacent or remote intracranial inflammation. In like manner suppurative meningitis may be present without the formation of an abscess ; but an abscess may form either outside or within the brain membranes as the result of meningitis, or of purulent disease in some remote posi- tion in the cranium or elsewhere in the body. It is therefore neces- sary for the purposes of diagnosis and treatment to regard abscess as a focal affection, and suppurative encephalitis as either focal or dif- fuse and as possibly occurring without the formation of true abscess. The symptomatology of acute suppurative encephalitis is in general terms that of the nonsuppurative forms, with the addition of symp- toms due to septic infection. It is chiefly that of more or less diffose ii-ritation and compression. Distinctive focal symptoms are wanttag. Fever of irregular type is present. The temperature is sometimes below normal, but varies according to the degree and character of the involvement of the brain, sudden oscillations being comparatively common. The variations in pulse and respiration are similar to those of temperature. Chills or chilly sensations are common. Dull head- ache, delirium or stupor, local or general spasms, irregular paralytic phenomena, and disturbances' of speech, of sensation, or of the special senses, may be present. Optic neuritis is comparatively common. Meningitis, and particularly leptomeningitis, often accompanies sup- purative encephalitis. When an abscess does not form for a long period, or when the final condition is one in which the brain substance is converted into a semipurulent mass, sometimes termed a cold abscess, a few symptoms are present over a long period, the most important of which are pain, dizziness, mental confusion, torpor, athetoid or choreic movements, convulsions and gradual loss of motor power, speech, or sensation, according to the parts invaded. It is not necessary to go into special details as to the etiology, pathology, diagnosis, and treatment of those forms of suppurative encephalitis which do not result in localized collections of pus, as these will he given under abscess. Postmortem examination shows great destruc- tion and disintegration of the nerve elements. The parts swarm with leucocytes, the brain mass being reduced in some places to a soft pulpy state, in others being fluid and semipurulent. Various patho- genic microorganisms are present. The possibility of the occurrence of suppurative encephalitis should be borne in mind in the treatment of injuries and of serious cases of infectious disease. ENCEPHALIC ABSCESS. 543 ENCEPHALIC ABSCESS. An encephalic abscess is a circumscribed collection of pus any- where within the cranial cavity ; but experience shows that it is much more frequent in certain situations, as in the temporal lobe and the cerebellum, these being the most frequent locations of brain abscess, because they are so commonly associated with disease of the ear. The following summary from a table by AUport shows the most common locations of intracranial abscesses, and their relative frequency in different sites. Location of Ninety- Eight Cases of Intracranial Abscess. Temporal lobe 40 Parietal lobe 7 Occipital lobe 1 Frontal lobe 2 Cerebellum 31 Pons 3 Cerebellar peduncle : 1 Middle cranial fossa 1 Posterior cranial fossa 2 Superior frontal convolution .1 Apex of the petrous bone ..... .1 Beneath the dura on the outer surface of the petrous bone . . 3 Diffuse subdural abscess 5 Clinical History. — Active and Latent Periods. The symptoms of brain abscess vary according as the affection runs a chronic or an acute course. An abscess may remain encapsulated and latent, or nearly so, for months or years. Even when abscess is suspected the symptoms are often for a long time obscure. Sooner or later, in cases of chronic abscess, active terminal symptoms show themselves, and these are usually similar to those of an acute abscess which runs a somewhat rapid course from the start. Owing to these facts, the clinical history can sometimes be divided into a latent or semilatent stage and a period of active manifestations. The entire course may be sharply acute, terminating in a few weeks ; or, after an active initiatory period, the symptoms may become partially or completely latent, the disease again clearly manifesting itself by slow degrees or by abrupt transition. An injury sometimes calls the acute symptoms into activity. In thirty-six cases of traumatic abscess recorded by Beck the time between injury and operation in fourteen instances was counted by weeks, by months in sixteen, and by years in six. In the latent stage, such general symptoms as mental disturbances, headache, occasional vomiting, and vertigo, may be present for a longer or shorter time, with free intervals. General Symptoms of the Active Period. The general symptoms of the active stage of abscess are much the same as those of brain 544 NERVOUS DISEASES. tumor ; but they vary somewhat with the location and extent of the suppurative process ; also according as it is superficial and associated with meningitis or is isolated and deep seated in the substance of the brain. The most important of these general symptoms are headache, nausea or vomiting, vertigo, hebetude, and convulsions. Optic neu- ritis is occasionally present, but not so often as in tumor of the brain. At'cording to Knies, the most frequent form of papillitis is what he terms "obstructive neuritis," in which the swelling is slighter but the inflammatory phenomena are more pronounced than in typical choked disk. He considers this the most characteristic ophthalmo- scopic finding in abscess of the brain, it being usually bilateral, al- though more marked on one side. When unilateral it is generally on the same side as the abscess, which is usually located in the frontal or the temporal lobe. Delirium may be present even in uncomplicated cases, but is more marked when there is associated meningitis. At some stages the symptoms are chiefly such as indicate a suppurative process, as fever with rigors followed by sweating. When the abscess is for a long time latent, its probable presence is sometimes indicated by such irregularly recurring septic phenomena. The temperature changes usually point to septic infection rather than to a focal en- cephalic lesion, although at times differences in temperature may be due, in part at least, to differences in the sites of the abscesses. The temperature, after an initial rise, usually falls and remains below normal. In cases observed by Esk ridge the temperature taken in the axilla was found to be from one half to three degrees higher on the paralyzed than on the unaffected side. After evacuation of the abscess it becomes nearly equal on the two sides. The pulse is usually slow, and of fair volume unless meningitis is present, when it may be both rai^id and irregular. It may fall as low as forty or fifty beats in the minute, or even less. The Ijowels are often obsti- nately constipated until just before death. Inhibited or sluggish cerebral action is often a significant feature ; and rapid emaciation is a symptom of considerable value, especially when it cannot be explained liy diarrhea, vomiting, and fever. The pupils show many variations, so that nothing definite can be determined from their study. Local tenderness of the scalp is sometimes present, even in temporal and cerebellar cases, but it is not a symptom upon which reliance can be placed, excejit when indicative of mastoid disease. Hymptoms due to tlw A,ssoei((tiiin of Encephalic Abscess with other Intraenniiiil Affeetions. When leptomeningitis is associated with eucejihalic abscess, the focal and other symptoms of a circumscribed collection of pus may be the first to appear, and then follow symp- toms of meningeal involvement. These symptoms are such as gen- eral irritability, local or diffuse spasms, high temperature without decided remissions, and rapid pulse. On the other hand, the symp- toms of an active and acute purulent meningitis may mark the first ENCEPHALIC ABSCESS. 545 stages, and the focal and other symptoms of abscess be added ; the symp- tom picture then becomes very confusing. Sinus thrombosis may be associated with abscess, but from the confused and extensive array of phenomena it may sometimes be possible to pick out those of both abscess and thrombosis. The symptoms of secondary thrombosis as given on page 306 should be studied. Usually when this association occurs the patient suffers from frequent rigors, the pulse becomes weak and rapid, and the temperature high with decided remissions. Some of the local evidences of thrombosis in the posterior cervical triangle, tenderness along the jugular of the affected side, and pul- monary infarcts may be present. The cranial and intracranial mani- festations due to accompanying suppurative aural disease are of course important, and include such symptoms as j)ain in the ear, deafness, facial paralysis, tinnitus, and local changes in and around the ear. AUport has tabulated the symptoms present in one hundred and sixty-nine cases of purulent brain deposits and accumulations follow- ing ear disease. They included ninety-eight cases of abscess proper, the others being mostly cases of purulent thrombosis and menin- gitis. The table given below is modified from his tabular statement. Most Important Symptoms in One Hundred and Sixty-Nine Cases of Intracranial Purulent Deposits or Accumidations. Head pain Nausea and vomiting . . Vertigo Optic neuritis Delirium Con-vulsions ... Stupor Unconsciousness Coma .... Insomnia Somnolence . . Chills Temperature high . Temperature medium Temperature subnormal . . Sudden rise and fall of temperature Pulse high . . Pulse medium Pulse subnormal Diarrhea Constipation Incontinence of urine .... Amblyopia or amaurosis .... Pupils dilated Pupils contracted Pupils sluggish Nystagmus Ptosis Exophthalmus . . . Diplopia Strabismus. ... Aphasia . . . Pacial paresis or paralysis . Paresis or paralysis of limbs Spasms of limbs ... Spasms of facial muscles . Paralysis of auditory nerve Neuralgia of trigeminus Opisthotonos . . . Ear pain Deafness Tinnitus aurium . Tympanic necrosis . . Tympanic granulations Tympanic polypus . . Swelling in front of ear Swelling over ear . . . Swelling under ear . . Mastoid swollen and tender Pus in mastoid opening . . Pue not in mastoid opening Spontaneous mastoid opening Edema of eyelids . . Facial veins enlarged . . . Facial edema . . ... Edema of the neck . . 4 2 10 8 28 19 7 4 2 2 3 35 11 3 6 6 7 3 4 4 35 16 7 5 1 2 2 3 35 546 NERVOUS DISEASES. Symptoms due to the Association of Abscess with Disease of the Inings or other Organs. The symptomatology of abscess of the brain may be confused not only by its frequent association with leptomeningitis, sinus thrombosis, and local affections of the ear and cranial nerves, but also because it may be complicated with symptoms due to the in- fectious morbid processes, and diseases which are present in other organs and some of which may be the septic sources of the brain affection. The febrile phenomena, the emaciation, and the general prostration or even typhoid state sometimes present may be depend- ent as much upon serious inflammatory and suppurative disease of the lungs as upon the purulent accumulation within the cranium. In a case reported by Eskridge and Parkhill, the two abscesses which were found in the brain were caused by septic emboli from an old gunshot wound in the right lung. This lung in its lower third was a solid mass of fibrous tissue, and the bronchi here and in the middle lobe presented cavities filled with mucus and pus. The lungs or other organs may be the seat of multiple abscesses. In such cases the symptoms strictly referable to the intracranial lesions must be carefully separated from those due to general septicemia or to local disease in organs other than the brain. Less reliance in these com- plicated cases can be placed upon peculiarities of temperature and pulse, upon rigors followed by sweats, and upon emaciation and exhaustion. Serious disease of the lungs may almost mask the brain disease. Focal Symptoms. The focal symptoms of abscess, like those of hemorrhage, softening, and tumor, vary, of course, with the location of the abscess and with its extension and radiation from a given loca- tion. These symf)toms will be readily understood liy a consideration of what has already been taught under encephalic localization and other focal diseases. Abscesses of the motor cortex or subcortex are not common, but when present give varying grades of paresis or paralysis and spasms of a more or less limited character, but these are less frequent than in brain tumor, and when they are present are not likely to have such definite initial or signal symptoms. When, as occurs in rare instances, an abscess involves the internal cai^sule, hemiplegic and even hemianesthetic s^niiptoms may be pres- ent, and they will vary according to the extent of the lesion. Hemi- paresis is sometimes present in a case of temj^oral abscess, and the symptom may be misleading. The loss of power which is usually on the oj)posite side of tht' body is due to x^ressure exerted from the temporal to the frontoparietal region across the Sylvian fossa. When th(^ al)scess is of the diffuse subdural variety, the pus may invade the Sylvian fossa and t'xcn-t its influence directly upon the central and third frontal con\'olutious, as well as upon the tem- poral lobe. True motor aphasia, as well as paresis or paralysis, may be then present. A more or less circumscribed abscess of the ENCEPHALIC ABSCESS. 547 superior temporal region of the left side gives partial or complete word deafness and paraphasia, and in some instances verbal amnesia. Paralysis of the third nerve on the same side as the abscess, due to pressure, is another not infrequent association symptom, and occa- sionally the fifth and sixth nerves also suffer. When the abscess is in the occipital lobe visual symptoms will be caused, and similarly in other cortical and subcortical positions the symptoms will be those of irritation or destruction, or such as have been described in detail under localization and phenomena the result of pressure and invasion of adjoining districts. Prefrontal abscesses are hard to locate by special symptoms. Frontal headache and an indifferent or apathetic mental state, and the peculiar psychical phenomena such as have been detailed both under localization and under brain tumors, are significant, and, according to Paget, great thirst and voracious appe- tite are often present. Extension backward of a prefi-ontal abscess, when on the left side, causes motor aphasia or agraphia, while in other rare instances abscesses are circumscribed in the region of Broca. Symptoms of Cerebellar Abscess. An abscess of the cerebellum is usually situated in one of its lateral lobes, and may give rise to focal symptoms due to pressure upon the bulbar region, as well as to true cerebellar symptoms, such as ataxia and nystagmus. Eigidity of the neck and occipital headache are comparatively com- mon, and vomiting is frequent. Facial paralysis, deafness, ear pains, and mastoid swelling may be present in cases due to aural disease. In twenty-three cases of cerebellar abscess collected by Deanesly the summarized symptomatology was as follows. Optic neuritis was definitely stated to have been absent in three out of twenty -three eases, and in eight the point was not recorded. Headache was pres- ent in all ; vomiting was present in fourteen, absent in three, and not mentioned in the remaining cases. In nearly all the cases the temperature was raised above the normal in the early stages, but in all, with one exception, it sank to normal or subnormal before opera- tion or death. Other symptoms sometimes present were slowing of the respiration, Cheyne-Stokes breathing, repeated yawnings, slow- ness of cerebration and general apathy, irritability and intolerance of light, delirium, rigidity of the neck and retraction of the head, nystagmus, giddiness, unsteadiness in standing, and a staggering gait with a tendency to fall laterally or forward. Excluding paralysis or irritation of the facial muscles on the same side as the ear disease, in only seven cases was motor or sensory paralysis observed. In advanced cases of cerebellar abscess, great depression and prostra- tion, with extremely slow pulse and respiration and low temperature, are common symptoms. Unilateral paralysis due to pressure on the pons or oblongata may be present upon the same or upon the oppo- site side, according as the pressure is exerted above or below the 548 NERVOUS DISEASES. decussation. In rare instances bilateral paralysis or paresis due to pressure has been observed. Symptoms of Diffuse Abscesses in the Cranial Fossce. Diffuse ab- scesses sometimes occupy the various cranial fossse between the dura and the brain. The pus may accumulate in these spaces as the re- sult of disease of the bone or membranes ; or it may be derived from abscesses iu the substance of the brain but near its surface, and the symptoms will differ according as the abscess originates in one or the other of these ways. When the brain substance is directly involved the symptoms will be those already described as belonging to ab- scesses of the cerebellum, temporal lobe, or prefrontal lobe, with the addition of others indicative of diffuse basal involvement. A dif- fuse abscess of the anterior cranial fossa, for instance, may give dis- orders of smell and of the nasal branch of the fifth nerve. Pus may be so diffused in and beyond the middle fossa as to involve the fourth, fifth, sixth, and seventh nerves, or any one of them, while diffuse abscess of the posterior cranial fossa may give cerebellar and other symptoms referable to the implication of the nerves derived from the pons and oblongata, or of other structures in these portions of the brain. As the pus accumulates in one cranial fossa, it may overflow into other fossse of the same side, into the midregions of the base, and even into the fossse on the opposite side of the skull ; so that the symptoms may show widespread implication of nerves and other structures at the base, and these may in some instances be irregularly bilateral. Etiology. — Abscess of the brain is much more frequent in males than in females, some statistics showing a proportion of nearly two to one in favor of the former. It is most frequent between seventeen and thirty years. In children between the ages of three and ten it is infrequent, while iii those under three years of age it occurs mod- erately often because of the tendency to middle ear disease, the thin- ness of the cranial bones, and the difiiculty of treating aural disease in infants. From one third to one half of the whole number of cases of intracranial abscess can be traced to aural disease, and especially to suppurative affections of the middle ear. Barker and von Berg- mann consider fifty per cent, to be due to otorrhea ; and yet only a small percentage of the miscellaneous affections of the ear result in brain abscess. Jansen found only seven cases of cerebral abscess clearly traceable to disease of the ear in thirteen thousand cases of aural disease of all sorts. Nearly all cases of temporal and cere- bellar abscess are associated with aural disease. Brain abscess is more frequent in association with chronic than with acute ear disease. A brain abscess seems sometimes to result from tubercular disease of the ear and tlie temporal bones, but generally when tuberculous dis- ease is present the infection is mixed. Traumatism in the etiology of brain abscess ranks next to aural disease. While fracture is usu- ENCEPHALIC ABSCESS. 549 ally present, abscesses are occasionally observed after injuries which have not resulted in fracture. Traumatic abscesses are most frequent in the frontal and parietal regions, especially in the former. When the result of a gunshot wound, suppuration may follow the entire track of the ball, or the abscess may form only where the ball has lodged. The abscess may be more or less remote from the wound of entrance ; or different collections of pus may be present in one or both hemispheres. In Pig. 300 is shown an encapsulated abscess in the track of a ball in a case reported by Porter. This track ex- tended through the right and left hemispheres. The abscess was Fig. 300. Transverse section of an abscess, and track of the ball : a represents a section through the ab- scess with the contents in situ; b shows the ball encapsulated just underneath the pia at the bottom of the bullet track ; ( shows the cicatrized wall of the open track of the bullet from the point of entrance down to the abscess. (Porter.) chiefly in the left hemisphere, but reached above and in front of the callosum to the right. The track of the ball in the right hemisphere had healed. In one case which fell under my observation a circum- scribed abscess in the prefrontal lobe resulted from a wound in the brain by the wire rib of an umbrella, which had penetrated the floor of the skull by way of the nose. The healed track of the wire could be traced, the abscess being at its termination. Erysipelas or cellu- litis of the face and scalp, and suppurative processes anywhere about the head, as in the nose or the nasopharynx, in the orbits, and along the sinuses, may be the source of the abscess. It may occur also as the result of suppurative disease situated anywhere in the body, — 550 NERVOUS DISEASES. from ulcerative endocarditis or endarteritis, or from purulent disease of the lungs, or even from similar disease in remote localities, as in the abdominal cavity, the pelvis, or the limbs. Pathogenesis. — All abscesses of the brain are formed secondarily to a primary focus of infectious disease located elsewhere, the chief infectious foci being found in connection with middle ear disease. The microorganisms which give rise to abscess of the brain, as to other purulent intracranial affections, are chiefly the streptococcus pyogenes, the staphylococcus pyogenes aureus, the intracellular diplococcus, and the pneumococcus (see page 287). The parasitic fungus, oidium albicans, has been found in a few cases. In two cases of thrush recorded by Zenker many small abscesses were scattered through the brain, and the oidium albicans was found in the blood- vessels. In very rare instances the disease seems to have originated in actinomyces. Pathological Anatomy. — Encephalic abscesses are usually in the white matter of the brain, or between the bone and the dura. In chronic cases suppuration is very commonly diffuse, whUe in the acute cases it is more liable to follow the sinuses. Abscesses associ- ated with disease of the middle ear are more frequently on the right side than on the left. An unusually located abscess was observed in the Philadelphia Hospital wards of Dr. Sinkler and the writer, involving the internal capsule, lenticula, and thalamus, and extending forward slightly into the white matter of the prefrontal region. In cases of chronic abscess the pus is usually green and fetid, and a limiting membrane is commonly present. The greenish yellow color is prob- ably dependent upon the bacillus pyocyaneus. Occasionally the pus is brownish or brownish red in appearance, this tint being due to hemorrhagic extravasations. In recent cases the pus is generally yellow. Brain abscesses are usually surrounded by a zone of broken down cerebral substance. The pulpy environing zone is often in a more or less inflammatory condition, and sometimes the walls of the abscess cavity are jagged and irregular and show shreds of sloughing tissue. In other cases the abscess is circumscribed and demarcated by a firm membrane. To this encapsulating pyogenic membrane the terin pyophijlaetic has been apj)lied. It is comjiosed of condensed in- flammatory tissue which in some cases forms as the active suppurative stage subsides. It may liecome firmer and thicker as time progresses, and it is owing to the protection afforded by it that abscesses so often remain stationary and more or less latent. Occasionally some- thing like absorption may occur, the pyophylactic membrane be- coming vascularized, and phagocytic action tending to dispose of the contents of the aliseess. In other cases vigorous granulation tissue displaces the membiane, and the abscess augments in volume from within outward until it bursts and gives rise to severe acute symp- toms, the case soon terminating fatally. (Park.) ENCEPHALIC ABSCESS. 551 Diagnosis. — Intracranial abscess may be confounded with menin- gitis, secondary sinus thrombosis, tumor, and occasionally with hem- orrhage, with encephalitis without abscess, and with thrombotic softening. It may also be necessary to distinguish it from disease of the ear and mastoid without intracranial complications. 3Ieningitls. In the diagnosis of intracranial abscess from menin- gitis the cause and course of the two affections must be kept promi- nently in view. Abscess and meningitis may be due to the same causes, as to ear disease and injury. The two are often associated, in which case the existence of meningitis may be recognized and the abscess overlooked, but the latter can sometimes be diagnosticated if focal symptoms are present and receive attention. Its acute and rapid course in some cases, and in others its explosional manifesta- tions when the disease has been for a time latent, will assist in diag- nosticating an abscess from meningitis. Meningitis more frequently than abscess and also in a more irregular manner involves the intra- cranial nerves. The symptoms of abscess are oftener unilateral than are those of meningitis, and in this connection the existence in cases of abscess of exaggerated tendon and muscle phenomena on one side may be of value. While meningitis and abscess often have the same origin, the former has a wider range of causation. It may originate from tuberculosis or syphilis, or from any of the infectious diseases. On the whole, the presence of symptoms indicating suppuration and focal disease is most serviceable in reaching a conclusion. When pulse and temperature are persistentlj' subnormal, an abscess should be suspected. All destructive symptoms are sometimes absent in a case of prefrontal abscess, which, however, may be suggested by the history of a traumatism or by the existence of disease of the frontal sinuses. Smus Thrombosis. Uncomplicated sinus thrombosis is diagnosti- cated from encephalic abscess chiefly by the local painful areas and edemas, and by paralyses of cranial nerves and other focal symptoms which point to closure of the special sinuses, as the lateral, petrosal, and cavernous. These symptoms have been discussed sufficiently to make the diagnosis clear, under sinus thrombosis. Attention has been called in the present section, under symptomatology, to the clinical manifestations of coexisting abscess and sinus thrombosis. When meningitis, abscess, and sinus thrombosis are all present at the same time, the confusion is increased, but even then the diag- nosis can be made by close scrutiny of the external evidences of thrombosis, of the focal symptoms of the abscess, and of the symp- toms of meningocortical irritation. The symptoms of thrombosis become the most prominent. General septicemia is usually present. A reddish brown discharge is regarded as diagnostic of suppurative thrombosis of the lateral sinus. Tumor. In the diagnosis of intracranial abscess from tumor the 552 NERVOUS DISEASES. history is of most value. Aural disease points to abscess, and trau- matism is a more frequent direct cause than of tumor. The symp- toms are more regular and uniformly progressive in tumor, and when spasm is present signal symptoms are not so common as in the latter. These and other points of distinction are summarized in the follow- ing tabular statement of the differential diagnosis of brain tumor and abscess : Abscess. Tumor. Suppurative disease in the ear or else- Suppurative disease usually absent. where common. History of traumatism frequent. History of traumatism not uncommon, but not so frequent. Onset of active symptoms either abrupt Onset usually slow. or slow. Headache usually dull. Headache of great intensity. Papillitis may be present, but oftener Papillitis more commonly present and absent. usually of higher grade. Febrilesymptomsoften those of pyemic Febrile symptoms not those of puru- infection. lent disease. Rigors and sweating frequent. Rigors and sweating usually absent. Temperature and pulse medium or sub- Temperature and pulse variable. normal. Diffuse meningitis often associated. Meningitis less common, and usually localized around the growth. Phlebitis and sinus thrombosis fre- Phlebitis and sinus thrombosis usually quent accompaniments. absent. When spasm occurs, signal symptoms Signal symptoms frequent. not common. Focal symptoms most frequently indi- Focal symptoms most frequently motor, cate the temporal lobe or the cere- but may indicate any part of the bellum. brain. EncepTialic Hemorrhage. Occasionally the diagnosis between ab- scess and encephalic hemorrhage may present difficulties, as when an abscess which has been apparently quiescent suddenly rupttu'es and gives rise to symptoms of an acute apoplectic attack. The pres- ence of suppurative disease in the ear or elsewhere, the occurrence of rigors, and the conditions of temperature and pulse indicative of purulent affections will here be of value. As abscesses do not usually occupy the position in which hemorrhages are found, motor symptoms are often not prominent ; but, as already stated under focal symptoms, paresis or paralysis may be due to the pressure exerted by a temporal abscess. An abscess which bursts into the ventricles from any quarter may gi\(' symptoms like those of secondary ven- tricular hemorrhage. In one of my cases referred to under patho- logical anatomy, in which an abscess was found occupying the tisual seat of intracranial hemorrhage, the patient, a woman, twenty-five years old, had purulent disease of the left ear. She complained of pain in the right side of the head and neck. Her temperature was ENCEPHALIC ABSCESS. 553 102.4° P., and two days later it rose to 103° F., and she soon passed into a stuporous state. She had mastoid tenderness upon the right side, with edema of the neck in the vicinity. Later a purulent dis- charge took place in the left ear. The right pupil was contracted, and both pupils reacted to light. The left face, arm, and leg were paretic at first, and later the limbs showed well marked paralysis with spasticity. In both leg and arm at one stage were scattered areas of partial or delayed sensation which in some places amounted to com- plete anesthesia. The knee and muscle phenomena and cutaneous reflexes were exaggerated on the left side. Edema of both optic disks was present. The patient was irritable, restless, at times de- Urious, and at others stuporous. She showed considerable variations in her general condition during the three months preceding her death ; but the hemiplegia persisted. Pulse and temperature were some- times subnormal. The symptom picture in this case was confusing, but the history was not that of a sudden attack. This case is re- corded by Dr. E. A. Shumway in Vol. III. of the Philadelphia Hos- pital Eeports. Acute softening from either embolism or thrombosis might in rare instances be confounded with abscess of the brain, but the diagnosis can be made by a consideration of the etiology, by the presence of symptoms indicating suppuration, and by a study of the points given in the table of the differential diagnosis of hemorrhage, embolism, and thrombosis on page 489. Encephalitis. Acute nonsuppurative encephalitis, either focal or diffuse, is wanting in the symptoms of septic infection, and runs a definite and often rapidly progressive course without intervals of latency or partial latency. Focal encephalitis is more frequently than abscess an affection of the motor regions of the brain. Diffuse subcortical encephalitis has mental vacuity or torpor as a more per- sistent and distinctive symptom. Diffuse suppurative encephalitis, without circumscribed accumulations of pus, as distinguished from abscess as a focal disease, is briefly considered on page 542. Suppurative Aural Disease, tuithout Abscess. The local or peripheral irritation caused by a diseased ear may give rise to symptoms which closely resemble those of intracranial abscess. Dizziness, giving with tinnitus and deafness Meniere's symptom complex, may be present, as also headache and vomiting. In such cases the physician should carefully weigh all the manifestations in the case, laying particular stress upon papillitis, aphasia, ataxia, hebetude, delirium, or other symptoms, especially focal manifestations of intracranial disease. Prognosis. — The prognosis is always grave. The acute cases, while usually rapidly fatal, are the most amenable to treatment. Occasionally striking successes are obtained by surgical interference, and much attention has been paid to this subject by neurologists and surgeons in recent years. Eecovery is more frequent from temporal than from other forms of encephalic abscess. In a very few cases 554 NERVOUS DISEASES. abscesses of small size become firmly encapsulated, and partially dis- appear by absorption or by phagocytosis, the patient dying of some other affection. In exceedingly rare cases abscesses have evacuated themselves spontaneously. In fatal cases death results in various ways. It may in some cases be due as much to a widespread menin- gitis or to sinus thrombosis as to the abscess. The abscess may rup- ture into the ventricles, leading to a speedy fatal issue ; the centres of the bulb may become involved ; or the end may come through general pyemia or exhaustion. Treatment. — Medical Treatment. In every case of purulent dis- ease of the ear — indeed, in every case of chronic aural disease with a recurring tendency to suppuration — the possibility of intracranial abscess should be borne in mind, careful attention to such affec- tions constituting one of the most important prophylactic measures against abscess of the brain. The general health should be sustained. Tonics, nutrients, fresh air, and the avoidance of exposure and in- jury should form a part of the management of the case. For acute symptoms the treatment is practically the same as that for menin- gitis or encephalitis, or for any irritative disease of the brain. It includes counterirritation, local depletion, the application of cold or heat to the head, and the use of remedies to subdue the fever, control pain, and counteract septic infection. Surgical Treatment. Like cranial fractures and intracranial hem- orrhage, abscess of the brain often calls for prompt trephining. It is an interesting historical fact that in 1871 Paul Broca, through speech disturbances, localized a cerebral abscess over the left third frontal convolution, and on trephining found pus between the bone and the dura. The patient subsequently died of meningoencephalitis, a fatal issue that would probably not occur in these days of aseptic and antiseptic surgery. Barker makes a broad assertion, which is nearly true, that nine tenths of all encephalic abscesses are situated within a circle three fourths of an inch in diameter, the centre of which is an inch and a half above and behind the centre of the meatus. The most important points for trephining are given in the section on craniocerebral topography. If the presence of an abscess is determined and it is accessible, it should be operated upon as speedily as possible. When the symptoms indicate the locality of the lesion, tlic dutv of the surgeon is to operate guided by them ; if they arc more general and unrelieved by medical treatment, an exploratory opening should be made at some point where no important intracra- nial vessel or sinus is likely to be injured, and if pus is obtained a second or counter opening should be made. It is important to remem- ber cases such as that recorded by Drummond which indicate how erratic and anomalous the symptom picture of encephalic abscess may be, and also how a mistake in operating may occur. The patient, a girl nin(3 years old, had for se\'eral years a purulent discharge from the right MULTIPLE ENCEPHALIC ABSCESS. 555 ear. Headache, vomiting, right-sided convulsions, and paralysis of the right arm gradually passing into right hemiplegia, rather suddenly developed. Later she was aphemic and optic neuritis was present. Cotton introduced into the right meatus was quickly moistened with a purulent fluid, although there was no active discharge on either side. A trephine opening without result was made over the left tcmjjoral lobe. A second opening was made over the arm centre, and a third over the left lobe of the cerebellum, but with equally negative results. The autopsy revealed nothing in the left hemisphere except the evi- dences of the operation, but an abscess cavity holding about an ounce of pus was found in the right lobe of the cerebellum near the surface. MULTIPLE BNOBPHALIO ABSCESS. The possibility of multiple abscess is important from both medi- cal and surgical points of view. General pyemia or septicemia may give rise to multiple abscesses, one or more of which may be within the cranial cavity, and even from a single source of infection a number of abscesses may originate. Finley and Adami have reported a case in which half a dozen pus cavities were found in the white and gray matter of the brain, the source of infection having been a suppu- rating bronchial gland secondary to pneumonia, a not infrequent source of cerebral abscess. Nauwerck has reported another case with depression and perforation of the right temporal bone, defect of the underlying convolutions, and multiple abscess and hydrocephalic softening of the hemisphere. Corresponding to the traumatic de- pression of the bone, eight distinct abscesses were found filled with thick green pus. Twenty-eight years elapsed between the reception of the injury and the final fatal result, probably the longest recorded time of quiescence in cases of traumatic intracranial abscess. Esk- ridge and Parkhill have reported a case in which two abscesses were present in the same hemisphere, one of which was successfully opened and the other was overlooked. Both were encapsulated, and no connection existed between them. Multiple abscesses are very common in the same half of the brain, or they may be multiple in the cerebrum, the cerebellum escaping, or the reverse. It may be difficult or impossible to determine that a second or a third abscess is present in the brain after one has been evacuated, and especially when cerebral symptoms are complicated by those of the primary morbid condition in the ear, lungs, or elsewhere. Occasionally fresh abscesses form in the neighborhood of one that is encapsulated, the tissues being in an unhealthy condition and liable to inflammation. A new abscess or new abscesses may result from infection due to leakage from the original purulent focus. A case is described by Macewen in which an extradural abscess formed so completely around the old one that the capsule containing pus was found float- ing in the secondary abscess. CHAPTEE VI. RESIDUAL ENCEPHALIC LESIONS, DEGENERATIONS, AND DISEASES. Acute focal diseases of the brain, sucli as hemorrhage, softening, tumor, and abscess, when they do not result fatally, leave cystic, necrosed, or sclerosed areas, and these lead to progressive degenera- tions of the central and peripheral nervous systems. Special symp- toms and syndromes are also developed, and these, although they preserve from the first some of their characteristic features, are modified in accordance with the progressive pathological changes. To some of these changes attention has been already directed, as when reference was made to the consecutive alterations in a clot after hemorrhage into the brain. Allusion has also been made to secondary degenerations, but these and their concomitant clinical phenomena — the hemiplegias, monoplegias, anesthesias, spastic disorders, aphasias, hemianopsias, and other residual affections — require further and special consideration. These conditions often persist for years, and it is with them that the physician frequently has to deal, rather than with the primary and causal affections. SECONDARY DEGENERATIONS CHIEFLY AS OCCURRING AFTER ACUTE FOCAL LESIONS IN ADULTS. Cruveilhier in 1832 observed diminution in size of the pyramidal tract in a case of hemiplegia. Tiirck, from 1851 to 1855, first system- atically described the secondary spinal degenerations following cere- bral lesions ; since that period, and especially during the last ten years, the subject has been much advanced by physiological and histologi- cal researches. One of the most important clinico-histological con- tributions to the subject is Tooth's Gulstonian Lectures on Secondary Degeneration of the Spinal Cord, published in 1889. ^\Tiile investi- gations with the Golgi and Jlarehi methods of staining are changing in detail the former views with reference to secondary degenerations, some of the most important theories regarding degeneration which follows focal cerebral lesions remain as advanced by Tiirck, Charcot, and Bouchard. The distinctive bands of secondary degeneration caused by the acute focal diseases of the brain can be readily isolated and studied. The diffuse affections of the encephalon, as chronic meningitis, encephalitis, and even (Midarteritis, also lead to secondary changes, but these are of an unsystematic character. Such degener- ations result when meningitis and lesions of the surface of the brain cause cortical destruction deep enough to involve the ambiguous and great pyramidal layers. Tumors do not give rise to secondary de- 556 .SECONDARY DEGENERATIONS. 557 geueratioDS as the result of pressure, but after they have produced some destruction of brain substance. Secondary degeneration is set up and progresses chiefly in the conducting tracts along the lines in which they transmit motor, sensory, or other impulses. In the motor system the degeneration is descending or centrifugal — from the forebrain towards the pons and oblongata, from these structures towards the spinal cord, and from the spinal cord towards the periphery. In the sensory systems it is ascending or centripetal — from the peripheral sense organs to the dorsal ganglia or cord, and from the cord to the brain ; from the organs of 'special sense in the primary basal centres, and from these and their tracts to the higher regions of the cerebrum. Initiation and Progress of Secondary Degeneration. — Prob- ably as soon as a nerve fibre is totally separated from its trophic centre it begins to degenerate ; but the changes which take place are not appreciable for several days. Homen placed the earliest time at which such alterations could be recognized at about the third day. Tooth found evidences of degeneration in the spinal cords of lower animals and of man after six days ; and the presence of secondary degeneration cannot be affirmed by a study of clinical phenomena or by microscopical appearances until about this time. Boyce, whose investigations were made upon the hemicerebrums of cats by Marchi's osmic acid method, discovered traces of degeneration five days after the excision of the hemispheres. Histological investigations would seem to show that secondary degenerations cannot be appreciated quite as early in the adult human being as in the lower animals. Just when the process of secondary degeneration in a given tract is completed it is difficult to say. It certainly continues for six months or more, and may in some instances not be completed for one or two years. Different tracts probably have different rates of progressive degeneration. Inflammatory Degeneration. — It is equally important to the histologist and to the clinician to remember that near the initial lesion, especially if it is irritative in character, these changes, which are partly degenerative, must be distinguished from those of second- ary degeneration proper. Under the name of traumatic degeneration, these changes have been particularly studied by Schiefferdecker, Homen, and Tooth. This inflamed and degenerated tissue is found both above and below the lesion, for the distance of one centimetre or more. Doubtless some of the peculiarities in the early symptom- atology of cases of hemiplegia are due to the presence of this tissue. While the studies of the changes present near the initial lesion have been chiefly made upon traumatic spinal cases, the facts determined are equally applicable when encephalic lesions are of an irritative character, such as tumors, traumatisms, hemorrhages, abscesses, and encephalitis. 558 NERVOUS DISEASES. Distinction between True Secondary Degeneration and In- volution. — Secondary degeneration is commonly due to the separa- tion of the nerve fibres or processes from their trophic centres, the cell bodies. A distinction must be made between true secondary de- generation and involution. The former extends only to the extreme limits of the fibres which are cut off from their trophic centres. When, for example, a destructive lesion is in the cerebral cortex, centrum ovale, or internal capsule, true secondary degeneration can be traced throughout the pyramidal tract to the nuclei of the cranial motor nerves in the bulb, and to the nuclei of the spinal motor nerves in the central horns of the cord, but not into these gray masses them- selves nor iuto their distal processes. The same is true of ascending secondary degeneration, which extends from a peripheral lesion to the dorsal ganglia, or from a lesion in the cord to the gray masses inter- posed in the sensory tracts at the lower extremity of the oblongata. The process of disappearance or partial disappearance of intra- spinal and intraencephalic centres and tracts, known as involution, is somewhat different. Involution is a retrogression which certain structures undergo as the result of disuse. The tracts and centres in this process atrophy because they have ceased to function, not because the trophic centres from which their fibres originate have been cut off or destroyed. After evulsion or destructive lesions of the peripheral nerves, the parts related to these nerves, both in the spinal cord and in the brain, undergo more or less involution. After amputation of a limb, areas in the opposite cerebral hemisphere, particularly in the motor region, have been found greatly atrophied. After removal of the eyeball, or after long continued blindness, re- lated central parts as far as the occipital lobe undergo involution. In like manner, after destruction of the aural apparatus or after long continued deafness, a similar involution is noted in the ence- phalic auditory tracts and centres as far as the temporal cortex. Involutions of the cerebral visual area have been described by me as occurring in the brain of a woman who was blind for more than twenty-five years, the occipital lobes having been xevy small, and of the cerebral auditory areas in the brain of a man deaf for thirty years, the supertemporal convolution having been unusually small and smooth. The brain of the blind deaf mute Laura Bridgman, thoroughly investigated by Donaldson, showed iuA'olutions of por- tions of the occipital and temporal lobes and other regions of the brain. Ascending secondary degenerations from transverse lesions of the spinal coi'd extend as far ;is the clavate and cuneate nuclei, but when such cases are of long standing, involution takes place in the sensory centres and tracts, basal and cerebral, above these nuclei. Motor cerebral areas because of disuse undergo involution after diseases such as anterior poliomyelitis, which destroy spinal centres and lead to neural degeneration and paralysis. A striking SECONDARY DEGENERATIONS. 559 illustration of involution is that of an entire lateral lobe of the cere- bellum after a large destructive lesion or arrest of development of the opposite hemicerebrum. Destruction of one occipital lolje leads to involution not only of the optic radiations, pregeniculum, prc- geminum, and optic tracts, but also of special association tracts con- necting this lobe with the parietal and other regions of the cortex. Excision or destruction by disease of the superior temporal convo- lutions is, in like manner, followed by degeneration and involution of the intracerebral centres and tracts concerned with hearing and speech. Secondary Degeneration of the Crossed Pyramidal Tracts. — The great pyramidal tract is the seat of the most important form of secondary degeneration following encephalic lesions. A destructive focal lesion of any portion of the motor cortex or subcortex causes degeneration in this tract below the focus of disease, which degener- ation is greater or less according to the extent and destructiveness of the originating lesion. The ganglion cells of the central or Rolandic region are the chief trophic centres for the fibres of the upper levels of this great tract. Tiirck believed that degeneration of this tract also originated from destruction of the basal ganglia, and especially of the striatum, and it may be that the tract is fed by some fibres from the basal ganglia. As far caudad as the pyramidal decussation, secondary degeneration following unilateral lesions of the motor por- tion of the cerebrum is confined to one pyramidal tract, that of the side of the lesion. It has been long known that below the decus- sation the degeneration continues through the entire length of the lateral columns of the spinal cord, on the side opposite to that of the lesion in the brain, the so-called crossed pyramidal tract. It has also long been known that descending degeneration of the direct pyram- idal fasciculus in the anterior column takes place ; but this is of limited extent. More recently it has been demonstrated that degen- eration of the lateral pyramidal tract on both sides is present, and usually of a marked character. These bilateral degenerations will be next considered. Secondary Bilateral Degeneration of Motor Tracts.— Charcot early observed bilateral degeneration, and it has since claimed the attention of many others. Pitres in 1884 found that of ten cases, in six the bilateral degeneration was symmetrical in the pyramidal bundles of the lateral columns of both sides, while in four it was greater on the side opposite the lesion. Tiirck' s direct fasciculus in the anterior column, in two of the four cases in which the pyramidal degeneration was unequal, was normal on both sides. Sherrington, in 1885, from a series of experiments on the cortex of the dog, con- cluded that injury of the "cord area" (motor area) of one hemicere- brum caused degeneration in both halves of the spinal cord in the dorsal angle of the lateral columns, and held that the anatomical 660 NERVOUS DISEASES. changes were the results of the clinical symptoms becoming bilateral. He also showed that bilateral degeneration takes place in the pons and oblongata after a unilateral focal lesion. Many advances have been made upon these investigations, and even on those of later date. The researches of Muratoff, Boyce, and Melius place beyond doubt the fact that the fibres of each pyramid spUt into two sets. One of these, the larger of the two, goes to the lateral tract of the opposite side, the other to the corresponding tract on the same side. As the result of some experiments on cortical centres it was found that bundles of degenerated fibres on the side of the lesion were present in amounts varying from one tenth to one third of those in the crossed tracts, the conclusion being that the bilateral degeneration observed by previous investigators indicates a general bilateral descent of fibres from one hemisphere. A few degenerated fibres were found in the direct tracts of the anterior columns. The pyramidal tracts in the cord, it will be seen, are therefore composed in part of fibres of heteromeral and in part of those of hecatomeral cells (see pages 92 and 93). Secondary degenerations of the motor tract sometimes show great peculiarities and striking departures from the ordinary rules. Most of them are best ac.counted for by congenital absence, deficien- cies, or aberrations of this tract, or by fetal lesions, or by affections occurring at or near the time of birth. Sometimes the degeneration is irregular, and in rare instances no crossing takes place. In some cases of hydrocephalus the crossed pyramidal tracts have been found entirely wanting ; but in these instances they may have been con- genitally absent. Degeneration following Encephalic Lesions variously lo- cated. — Various more or less isolated tracts of degeneration besides those so long known in their entirety in the pyramidal bundles have been traced in the lower animals and in man by a few observers, but as yet not much light has been thrown upon the lunctions of these tracts. Sherrington found that, in addition to the pyramidal tract degeneration, other regions of the pons, oblongata, and cord degen- erated or involuted after unilateral encephalic lesions, as the central gray and ventral horns of the cord ; the lateral horns of the cord ; islanded gray masses in the pons lying close to the fibre bundles of the crustal tract in the deep transverse fibres ; a gray mass in the mesal third of the crusta ; and the intercalatum or substantia nigra, especially its ventral jwrtion. In Fig. 301 is shown the relative preservation of the anterolateral gray matter of the cord on the two sides in a case of unilateral lesion of the brain resulting in hemiplegia with some atrophy, crossed pyramidal degeneration being also shown. Such a case is in accord with some of Sherrington's experiments on lower animals. In a case recorded by Bechterew, the substantia nigra was markedly degenerated ;is the result of a lesion which involved the cortex, centrum ovale, capsules, and ganglia. This degeneration was, SECONDARY DEGENERATIONS. 561 however, part of a general secondary process which caused a shrink- age of the entire pes and the same side of the pons. In the oblongata Fig. 301. Section of the spinal cord in tiie cervical region in a case of left hemiplegia accompanied by amyotrophy : A, anterior cell groups ; L, lateral cell groups ; P, degenerated crossed pyramidal tract. In the anterior horn of the left side some cells of the anterior group, A, and of the lateral group, i, are alone preserved ; all the others are atrophied or have undergone involution. (Marie, after Pitres.) it was restricted chiefly to the pyramidal bundles of the same side, and in the spinal cord to the pyramidal tract of the opposite side. Bechterew attributed the degeneration of the intercalatum to the de- structive lesion of the basal ganglia, and particularly of the striatum. Fig. 302. Section at the level of the postgeminum showing secondary degeneration of the pyramidal tract and other structures of the same side, in a case of large lesion of the thalamus and partial de- struction of the posterior portion of the posterior limb of the internal capsule. The illustrations (Figs. 302, 303, 304, 305) show the most important degenerated tracts following a large thalamic and capsular lesion in a patient who was for many years before her death under my care in the Philadelphia Hospital. She had an apoplectic attack in 1877, and died in 1892. The summarized symptomatology of the case was 36 562 NERVOUS DISEASES. hemiparesis with contractures, and liemianesthesia with inability to recognize the position of the affected limbs. Hemianopsia and all affections of the special senses were absent, as were also athetoid and choreoid movements. Autopsy showed an old hemorrhagic cyst, Fig. 303. Fig. 304. Fig. 305. Fig. 303.— Section of the oblongata, showing secondary degeneration of the pyramidal tract, changes in the olivary body, and general shrinkage of the entire oblongata on the side of the lesion (same ease as in Fig. 302). Fig. 304. — Section through the pyramidal decussation, showing marked degeneration of the pyramidal tract of both right and left sides (same case as Fig. 30i). Fig. 305. — Section just below the decussation, showing marked degeneration of the crossed pyramidal tract of the left side, and slight degeneration of the direct psTamidal tract of the right side (same case as Fig. 302). which had destroyed about two thirds of the substance of the thala- mus, including the entire external tubercle and a large portion of the pulvinar, the anterior extremity and the internal and inferior surfaces of the thalamus being intact. The lesion had also invaded the posterior half of the posterior limb of the capsule. The sections all show marked degenerations of the great pyramidal tract. De- generation of the central tegmental tract of the right side was also present. This tract, first described by Bechterew, has been chiefly demonstrated by developmental investigations. Appearing on the posterior and external aspect of the olive, it gradually increases in size from the middle of the olive ujiward. The section through the oblongata (Fig. 303) shows marked degeneration of the pyramidal bundle, changes in the inferior olive, and shrinkage of the entire ob- longata on the side of the lesion. The other sections (Figs. 304, 305) show marked degenerations lioth at and just below the decussation. Traefs of Bifieneration in the Cms. From a study of different cortical lesions Zacher differentiated various tracts in the cms. He divided the peduncle from without inward into four nearly equal parts. The filnes wliich run in the outer fourth were found to come from the occipital and temporal lobes, and to reach the upper levels SECONDARY DEGENERATIONS. 563 of the pons, in which they probably terminate. In an instructive case of congenital atrophy of the occipital lobe recorded by Kreu- ser, this tract and other important structures were lacking. The second fourth of the cms from without inward was found by Zacher to be in great part occupied by the pyramidal tract, which is in ac- cord with the observations of Plechsig and of others. In the crus it is the chief seat of the intraencephalic degeneration described in the last paragraphs. According to Zacher, the fibres of the third fourth of the pes, measuring from the external border, probably arise in part in the body of the striatum, and also in part from the ascending frontal convolution. Plechsig supposed that the median or inner fourth of the crus received its fibres from the prefrontal lobe, which is the view generally held. While degeneration of this band seems to cease in the pons, it is probable that through the intermediation of pontile cell nests it is connected with the cerebellum, and its fibres are therefore sometimes termed frontocerebellar. Secondary degen- eration of this tract has also been found after disease of the most anterior portion of the internal capsule. Zacher' s view of the origin of these fibres of the innermost fourth of the crus is diff'erent. Ac- cording to him, they are derived from the neighborhood of the insula and base of the lenticula. Degeneration of the Lemniscus and of Various Special Tracts. Bruce has recorded the careful microscopical study of a case in which, in addition to degeneration of the pyramidal tracts, dorsal longitudinal bundle, and other structures of the oblongata, there was marked de- generation of the lemniscus after an old and extensive lesion of the cerebrum, the parts destroyed being large portions of the internal cap- sule and of the basal ganglia. The cephalic two thirds of the callosum and a large area of the centrum ovale were atrophied. The nucleus cuneatus and the nucleus gracilis on the opposite side of the lesion were considerably less than the same structures on the same side. Bruce believes from his observations in this case that the nucleus cuneatus is more directly connected than the nucleus gracilis with those fibres of the fillet that end in the cerebrum, which is in harmony with the results obtained in the embryo. While the fillet has thus been shown to degenerate downward, it is known that the posterior columns do not degenerate in this direction. A unilateral destruc- tive lesion at about the level of the postgeminum and nuclei of the third nerve was found by Boyce to cause a peculiar form of bilateral degeneration simulating closely the appearances of two degenerated pyramidal tracts. He found that these degenerated fibres near their origin cross to about the position of the fillet, and continue down the cord close to and partially intermingled with the fibres of the pyra- mid after their decussation. They pass down the cord as far as the upper dorsal region, lying forward and close to the middle line of the anterior column, in the position of the so-called direct pyramidal 664 NERVOUS DISEASES. tract. After lesions destroying either the superficial or the deep transverse fibres of the pons, secondary degenerations have been ob- served in the fibres on both sides of the lesion. This is what might be expected, as these fibres connect the cerebellar lobes, or one lobe or lobule of the cerebellum with the cortex or ganglia of the opposite hemicerebrum. In one of my cases a hemorrhagic cyst, which was small, but large enough to have caused destruction of numerous transverse fibres near the middle of one half of the pons, was pres- ent, and one cerebral and the opposite cerebellar hemisphere were markedly atrophied. The patient was hemiplegic for many years. Ascending Secondary Degeneration. — The study of ascending secondary degeneration belongs in the main to the study of spinal lesions, primary and secondary. It should be glanced at here in connection with intraencephalic secondary degeneration, as some of these degenerative and involutional processes which begin at various levels of the cord do not cease until they have passed cephalad con- siderably beyond the foramen magnum. After reaching certain levels they cease to be true secondary degenerations, but beyond these points in some instances they are continuous to the mantle of the forebrain and cerebellum as involutions secondary to lesions and degenerations of lower levels. It has been clearly shown that after transverse lesions of the cord ascending secondary degenera- tions take place in at least four localities — in two triangular areas at the most posterior and mesal parts of the posterior columns, in the direct cerebellar tract, and in the anterolateral tract of Gowers. The degenerations in all these tracts become more restricted as they ap- proach the brain. In the dorsal or posterior region the degeneration appears as a steadily narrowing band in the columns of Goll, as far as the termination of the latter in the nucleus gracilis and nucleus cuneatus. The direct cerebellar tract much condensed can be traced as far as the restis ; and Tooth has traced secondary degeneration in the anterolateral tract of Gowers to the exit of the sixth and seventh cranial nerves. This column is supposed to end in the lateral nucleus. Secondary Degenerations after Cerebellar Lesions. — In a previous section (pages 71 and 72) attention has been directed to the course of the conducting tracts of the cerebellum and of the cere- bellar peduncles. After ablation of the middle lobe of the cerebellum in dogs, Pelizzi found (1) complete degeneration of the prepeduncle ; (2) degeneration of the raedipeduncle and of the pons, that in the pons being most considerable in the deep stratum ; (3) partial degenera- tion of the restiform body ; (4) degeneration of the fillet or lem- niscus, most intense in the lateral or inferior fillet ; (5) degeneration of Deiters's nucleus; (6) degeneration of the posterior longitudinal bundle ; (7) degeneration of the anterior root bundles of the spinal nerves. CHRONIC HEMIPLEGIAS AND MONOPLEGIAS. 565 CHRONIC HEMIPLEGIAS AND MONOPLEG-IAS— THEIR CLINI- CAL FEATURES, INCIDENTS, AND ACCIDENTS. The lesions are commonly of the motor regions of the brain, and paralysis more or less complete of one side of the body is usually the result of an apoplectic attack, and according to its extent this is termed a hemiplegia or a monox)Jf(jia. As the paralysis and the condi- tions -which accompany it at the time of an apoplectic attack and Immediately afterwards have already been described, the phenomena now to be especially considered are those of the residual or chronic affection. A chronic hemiplegia is left after an acute apoplectic attack ; or it is a progressive affection, which comes on step by step, as in a slowly developing meningitis or brain tumor, or when one vessel after another closes from time to time ; or a progressive hemi- plegia associated with aural disease may be due to a gradually forming abscess. It may be well to define here more explicitly than hitherto the meanings of the terms most commonly used in describing these paralytic affections. In the section on symptomatology and methods of investigation (see pages 165, 166) hemiplegia A\'as defined as a form of paralysis which attacks the most of one half of the body. A mono- plegia is a paralysis limited to one arm or one leg or to one side of the face, or, it may be, to certain groups of muscles in any one of these parts. When the monoplegia is of the face it is called facial ; when of the arm, brachial ; when of the leg, crural ; and when of the tongue, Ungual; or it may be brachiocrural, brachiofacial, faciolingual, or some other form of combined monoplegia. Monoplegias and hemi- plegias are not always of encephalic origin ; but our concern here is with those which are due only to brain disease. A distinction must occasionally be made between a hemiplegia and a double nionoplegia. The entire paralysis in a hemiplegia is, as a rule, due to a single lesion, which may be large or of moderate size. In a double mono- plegia the paralyses of different parts are due to distinct lesions. It is illustrated by a case in which the paralysis is in a leg, or in a leg and the face on the same side, and is due to separate lesions which have occurred at the same time or at different times ; but of two attacks of cortical or subcortical embolism one might lead to paraly- sis of the arm or the face or of both, and the other to paralysis of the lower extremity. The diplegias or double hemiplegias which affect a large portion of both halves of the body are usually due to lesions on both sides of the brain, and constitute one variety of infantile cerebral palsies, which will presently be considered. In rare in- stances they may come on in adult life. The Most Important Hemiplegic Phenomena. — Chronic "hemiplegics," as the cases just defined are usually classed, present special clinical concomitants, incidents, and accidents. The most important of these, after the paralysis, are certain disorders of move- 566 NERVOUS DISEASES. ment, of reflex action, of sensation ; of vasomotor, secretory, and trophic functions ; and of mentality. These hemiplegic phenomena are due, in the first place, to the persistence of the original focal lesions ; secondly, to certain consecutive pathological changes, and especially to the secondary degenerations discussed in the last section ; thirdly, to inflammatory, nutritive, or other local changes in the par- alyzed parts. These last are sometimes accidents rather than true concomitants or incidents. The phenomena of secondary degenera- tion develop step by step during weeks, months, and perhaps years after the apoplectic seizure. Amount and Order of Recovery in Paralyzed Parts. — Occa- sionally a case of hemiplegia remains for months and years almost totally paralyzed in the extremities, and with a large degree of loss of power in the lower face, no restoration of power taking place ex- cept during the first few weeks after the apoplectic seizure ; but such cases are exceptional, some improvement usually showing itself as time progresses, this in some instances becoming very considerable. As a rule, improvement in the lower extremity precedes that in the upper, and the proximal portions of the limbs regain power sooner and to a much larger extent than the distal. While the tendency is for the leg to recover some power sooner, and eventually to recover to a larger extent, than the arm, occasionally cases are seen in which the latter recovers more rapidly than the former. This was the order of events in seven out of two hundred cases observed by Bastian. Trousseau taught that cases in which the arm tended to recover before the leg were usually of ill omen, and this view has crept extensively into neurological literature. He believed that dementia and a fatal issue were much more likely to occur in these cases. Like Bastian, I have seen some cases in which recovery in the arm has taken place sooner and to a greater extent than in the leg. Bastian inclines to the view that in these cases the lesion is likely to be below the cap- sule, and especially in the pons. While this may be true, a small lesion of the centrum ovale or of the internal capsule might be so situated as to cause destruction only of the projection fibres related to the lower extremity, such a lesion at first affecting by pressure the arm and the face fibres, the paralysis in these parts passing away as the pressure disappears. IMovements of the shoulder and upper arm and those of the muscles of the pelvis and thigh are regained earlier and more largely than those of the forearm and hand or of the leg and foot. The exceptions to this rule are few. The reasons for this order of recovery are to be sought for not so much in the site and ramifications of the persisting lesions as in the part played by the undamaged hemisphere. Movements of both shoulders and of the hip and thigh— proximal limb movements generally — are represented in each hemisphere to a greater extent than are distal movements, so that one hemicerebrum learns to act for both sides, CHRONIC HEMIPLEGIAS AND MONOPLEGIAS. 567 as it does under normal conditions to a larger degree for the trunkal, laryngeal, and other movements which have an almost equal bilat- eral representation. Relative Involvement of Different Parts. — As already inti- mated, the term hemiiilegia is not strictly correct in an etymological sense. The paralysis is one-sided, but does not implicate an entire half of the body. As a rule, the muscles of the trunk and abdomen, the masticatory and the laryngeal muscles, and in general those of both sides of the body which habitually act together, escape in whole or in large part. Some of the reasons for this have been already indicated under cerebral localization (pp. 339, 340). Muscles which act synchronously, and which have a bilateral representation in each cerebrum, are completely paralyzed only as the result of bilateral lesions. Usually, therefore, a hemiplegia is chiefly of the arm and leg, and of those muscles of the face which are in the main unilater- ally innervated by cortical centres. The bilaterally innervated mus- cles, however, do not always escape. In early infancy the unilateral differentiation of cortical centres is comparatively slight. In one of my cases, an infant who died of cerebral hemorrhage, the muscles of the trunk and face were almost equally paralyzed with those of the limbs. Even in adults, particularly in some of the severe types of hemiplegia, close inspection, especially during the apoplectic period, will sometimes show diminished power in the trunkal muscles of the paralyzed side. This may be observed in movements of respiration. No respiratory movement, or only a slight one, is seen on the para- lyzed side of the chest even on forced inspiration. Broadbent was the first to suggest a satisfactory explanation of the mechanism of this retention of power, relatively or absolutely, in certain groups of muscles on the paralyzed side. He believed that the structural con- nections which allowed both sides to be excited from one hemisphere were between the lower centres, bulbar and spinal. According to this hypothesis, impulses coming from one side of the brain are conveyed to the lower centres on the opposite side, and the im- pulses designed for muscles which act habitually together are trans- mitted by well worn and easily traversed pathways to the homol- ogous centres of the opposite side. Such an explanation, while sufficient for some of the phenomena, will not answer for all. Bear- ing upon this question is the fact that a large amount of degener- ation takes place in the lateral columns of both sides after unilateral cerebral lesions, showing that each hemisphere is directly related by special fibres with the oblongatal and spinal centres on both sides. Sherrington advanced the view that some of the fibres after crossing at the pyramidal decussation recross at lower levels of the cord ; but experiments show that the pyramidal fibres split into two sets, one for each side. This subject has been already discussed under secondary degenerations of the motor tracts (pages 559 and 560). 568 NERVOUS DISEASES. Clinical Types of Hemiplegia. — Numerous clinical types of hemiplegia can be described in accordance with the degree and special characteristics of the paralysis. As has been stated, the hemiplegias arrange themselves into preponderating arm types or leg types, and also into distal and proximal types, the upper extremity and distal types being by far the most frequent. A few special remarks might be made here about the cases met with now and then which differ markedly from the usual types, particularly as regards the proximal and distal distribution of the paralysis, and the peculiarities of other motor disturbances present, such as spasm, contractures, and ataxic or athetoid phenomena. A case, for instance, may present a paralysis of common type in the leg, more distal than proximal, and without any unusual characteristics, while in the upper extremity the paral- ysis is pronounced or more marked in the shoulder or the upper arm, the movements of the forearm, hand, and fingers bemg relatively weU preserved, but showing greater incoordination and grotesqueness. Phenomena of this kind should suggest that the lesions are not those usually present in hemiplegics. They may be cortical or subcorti- cal growths. Inquiry will often show that convulsions of unilateral type occur at intervals in such cases. A departure from the hemi- plegic type usually seen should cause the physician to direct his attention to the possibility of a lesion of unusual character ; and this is one of the ways in which the study of clinical t\'pes of hemiplegia and monoplegia may be of considerable practical value. Clinical types of hemiplegia which are due to the association of the paral- ysis with other important manifestations are somewhat frequently observed. Partial or complete anesthesia may be present. When anesthesia is present the motor paralysis may preponderate in the lower extremity or it may be associated with nearly equal paralysis of both leg and arm, the face escaping in whole or in part. Partial or complete aphasia of sensory, motor, or sensorimotor form may be combined with the paralysis. In still other cases the association may be of hemiparesis or hemiparalysis with hemianesthesia and hemi- anoj)sia, and also sometimes with hemiataxia. Such combinations are sometimes spoken of as the leg-sensory type, the hemipIegic-apMsic tyije, the sensory-hemlanopmc type, the hemianestheilc-hemianopsk type, etc. The most conunon types of hemiplegia are due to capsulogangli- onic lesions. Cortical lesions most frequently give rise to monople- gias, and to abortive, imxicileet, and dissociated types of hemiplegia. After an attaclv-of cortical hemorrhage or embolism, the patient, for instance, at first may show some involvement of face, arm, or leg, but most of the paralysis speedily passes off, leaving only a facial, an orolingual, a brachial, or a crural monoplegia, or one of the combined varieties of monoplegia. Occasionally in cortical cases the paralysis preponderates in the proximal portions of the limbs, although even in such cases some loss is generally present in the distal portions. CHEONIC HEMIPLEGIAS AND MONOPLEGIAS. 569 Often the condition left is one of heiniparesis (Fig. 306) rather than hemiparalysis, but in some part of the partially paralyzed member or face the loss of power will be found to jiiepon- derate. Temporary and partial aphasias often accompany cortical monoplegias, particularly of the facial and facio- brachial types. Hemiplegia occurs some- what more frequently on the right side than on the left. Sixty cases studied in the Philadelpliia Hospital show thirty- three cases of right and twenty-seven of left hemiplegia ; and I believe that the percentage of a larger number of cases would prove to be higher than this in favor of the right side.* It was held by Brown-Sequard, and the opinion has been accepted by Bastian and others, that le- sions of the right hemicerebrum are more severe and fatal than those of the left ; but my experience has not taught any- thing of positive value regarding this question. Hughliugs Jackson has ex- pressed the opinion that double papillitis is more often associated with disease of the right than with disease of the left hemicerebrum. The illustration Fig. 307 shows the mechanism of hemiplegia from lesions in different parts of the cerebrum. Facial and Lingual Paralysis in Hemiplegics. — In the most common form of hemiplegia paralysis of the arm and leg is more complete than in the face, and when the latter is affected the lower portion is usually more decidedly paralyzed than the upper, all facial Henuparesis with slight contrac- tures of the hands ; marked atrophy in the upper extremity, none in the lower : unilateral sweating on para- lyzed side ; loss of thermic sensation and allochiria ; affection of nine months' standing. * In 1895 Dr. Helen Baldwin, one of the internes of the Philadelphia Hos- pital, under my supervision made an examination of sixty hemiplegics, oljtain- ing many interesting facts as to the side of the body affected by the paralysis ; its completeness ; its preponderance in the lower or in the upper extremity, or in the proximal or the distal portions of the limbs, and the association witli the paralysis of partial or complete apliasia. Other observations were made on rigidity, contractures, athetosis or athetoid movements, and other spastic phe- nomena ; on associated and substitutional movements ; on tendon and muscle phenomena ; on vasomotor conditions ; on atrophy and other trophic changes ; and on pain, hyperesthesia, and anesthesia. A study was also made of the non- paralyzed side. Reference will be made to this investigation in different portions of this section. 570 NERVOUS DISEASES. movementB having a larger bilateral representation in each cerebral hemisphere than do those of the limbs. In rare cases of hemiplegia due Fig. 307. Diagram showing the arrangement of the motor tracts for both sides of the face, the left arm, and the left leg ; also the mechanism of hemiplegia from lesions in different parts of the cerebrum : B and B', right and left hemicerebrums ; P, pons ; M, oblongata ; S, S, spinal cord ; V, V, lateral ven- tricles ; NC, caudatum ; LN, lenticula ; CO, crus ; T'S', left temporal lobe ; F, A, L, cortical centres for the face, arm, and leg in right hemisphere ; F', cortical centre for the face in left hemisphere ; 1, 1', right and left facial nerve nuclei ; 2, 2', right and left nerve nuclei for upper extremity ; 3, 3', right and left nerve nuclei for lower extremity ; fm and fm, right and left facial muscles ; a'm, muscles of the left upper limb ; I'm, muscles of the left lower limb ; 4, localized lesion in the cor- tex, producing paralysis of the opposite leg ; 5, lesion of tlie pyramidal tract as it enters the inter- nal capsule, producing hemiplegia on the opposite side of the body (paralysis of the face, arm, and leg). (Bramwell.) CHRONIC HEMIPLEGIAS AND MONOPLEGIAS. 571 to unilateral cerebral lesion the face is relatively as much paralyzed as the limbs. These cases can perhaps be accounted for in se\'eral ways. The control over the paralyzed side of the face may have been less normally than that over the other. "When lesions destroy the region of the knee and the more anterior portion of the posterior limb of the capsule, the paralysis of the face and tongue will be more marked. Probably also lesions in the cephalic portion of the pons which de- stroy the tracts for the limbs, and the facial tracts just before their decussation, leave more decided loss of power in the face. On care- less inspection a hemiplegic may apparently be able to use the para- lyzed as well as the unparalyzed side of the face, when closer scrutiny will show some diminution of power. He may perhaps be able to close both eyes, but the eye of the paralyzed side will not be so tightly shut as the other, as shown by the lesser depth of the radiating fur- rows which indicate the contraction of the orbiculopalpebral muscle. After the zygomatic movements have largely recovered, the move- ments of the depressors and levators and of the orbicular muscle of the mouth and lips remain decidedly affected. These may be regarded as the most distal movements of the face. The tongue in hemiplegics shows many variations in the degree of paralysis. Sometimes it can- not be thrust out of the mouth at all, or it may at first be caught by the lips and teeth, the patient by a renewed effort getting it outside of the mouth. It may be deflected to one side or the other, and occasionally it tends to be retracted or to fall back into the pharynx. Pathological Significance of Different Hemiplegic Types. — The type or subtype of paralysis presented in a case of chronic hemi- plegia is largely dependent upon the position and extent of the origi- nal lesion, or at least of so much of it as persists. Early in the his- tory of such cases the effects of pressure, of inhibition, and even of adjoining inflammation must be taken into account, but after the acute symptoms have subsided, and partial absorption has taken place, the lesion in a varying time acquires the dimensions which it will retain permanently unless another apoplexy occurs at the same site. A study of the diagrams Pigs. 235 and 236, on pages 359 and 360, will serve to make clear some of the reasons for the variations in the distribution of the paralysis. In the majority of cases, as stated, the loss of power in the upper extremities preponderates over that in the lower, which is in accordance with the fact that the destructive effects of lesions are most frequently visited upon the middle portions of the posterior limb of the internal capsule, a region supplied largely by the lenticulostriate artery. A lesion situated more caudad may give preponderating leg paralysis, and this may be associated with anesthesia, owing to the involvement of the neighboring sensory tract. In the anesthetic-ataxic-hemianopsic type the lesion certainly in- volves the most posterior portion of the posterior limb of the internal capsule and the optic radiations. In some cases of this kind, as in 572 NEKVOUS DISEASES. those recorded by Seguin, de Schweinitz, and the writer, the lesion is probably located at a position where the optic radiations and the internal capsule are in juxtaposition, and the thalamus may be in- volved in some instances. Differences in the site and extent of the lesion must not be regarded as the only or even the chief explanation of the differences in some of the clinical features of hemiplegia, as has already been sufficiently shown when discussing the reasons for the fre- quent preponderance of distal paralysis. Now and then a case of iso- lated capsular lesion has been put on record, as one by Parisot, — a case of facial monoplegia, the only muscle involved being the depres- sor of the left angle of the mouth. An old hemorrhagic cicatrix was found in the anterior part of the internal capsule, extending transversely across the lenticula just posterior to the geniculate fas- ciculus. Most frequently, so far as recorded cases show, limited pal- sies are of cortical origin, or at the most involve • the cortex and the immediate subcortex. Alternate Hemiplegias. — The alternate hemiplegias are types which will be more fully considered under diseases of the crus, pons, and oblongata. Often in lesions of the ventral portions of the pons the cranial nerves at or near their superficial origins are involved. In lesion of the lower ventral third, or conjointly of the ventral and lateral thirds, the alternate hemiplegia is of the arm and leg of the opposite side, and of the face on the same side ; or facial, abducens, a,nd auditory nerve paralysis may be present with contralateral paralysis of the extremities. In the middle of the ventral thirds, especially if the lesion extends laterally, paralysis of the leg and face of the opposite side may be associated with both motor and sen- sory paralysis in the distribution of the fifth nerve. In the cephalo- ventral segment the lesions may extend so as to implicate the crus and the third nerve, giving the oculomotor type of alternate hemi- plegia ; or some paralysis of both the third and foui-th nerves may show on the same side. Hemiplegia on the same Side as the Lesion in the Brain. — In the vast majority of cases the hemiplegia is contralateral to the brain lesion, — on the side opposite to the half of the brain which is diseased, — in accordance with well known anatomical and physiologi- cal facts. In rare instances, however, the paralysis is on the side of the lesion. Many years ago Brown-Sequard made a considerable col- lection of such cases, using them as arguments against the doctrine of cerebral localization, which wsxs just beginning to find a firm footing. In my own experience I have known of only two cases confirmed by autopsy in which decided hemiplegia was present on the side of the lesion of the brain. One of these was an old case of capsulogan- glionic softening, and the other was a case of recent hematoma of the dura. The usual explanation offered for these cases is the absence of the ordinaiy decussation of the pyramidal tract. Flechsig first and CHRONIC HEMIPLEGIAS AND MONOPLEGIAS. 573 a numbei- of others more recently have shown that this decussation is liable to very considerable variations ; but, as Gowers suggests, this explanation will not answer in all cases, as the decussation may take place below its usual position. Although such cases are rare, they may occasionally be of great practical importance ; if, for instance, in the case of hematoma mentioned above, trephining had been decided upon, the operation would naturally have been performed on the side opposite to the paralysis, which would not have been that of the lesion. Disorders of Position and Movement in Hemiplegics. — The most important disorders of position and movement on the paralyzed side are contractures and rigidities ; tremors, twitchiugs, and clonic spasms ; athetosis and athetoid, choreic, and ataxic phenomena ; and associated, substituted, and forced movements. While these need to be considered separately, it must not be forgotten that several of them may constitute parts of a condition which cannot be pathologi- cally or clinically separated. Eigidity, contractures, coarse tremors, athetoid, choreoid, and ataxic phenomena, may all be closely amalga- mated manifestations having a common origin. Contractures and Rigidities. — Flaccid and Spastic Paralysis. The paralysis in hemiplegia may be of a flaccid or relaxed character, or it may present spastic or cramp-like features. The limbs may be from the first relaxed and totally helpless, a not unusual condition during the apoplectic attack. Instead of this flabby or flail-like paralysis, however, certain phenomena of spasm, contracture, and rigidity may be present in the limbs. Contractures and rigidities must be considered together, as they go hand in hand, and one may be and usually is dependent upon the other. The term contracture is applied to spastic muscular shortening ; rigidity, to the more or less rigid and inflexible position in which the paralyzed extremity or any portion of it is held. Characteristics of HemipJegic Contracture. In contractured limbs flexions usually predominate over extensions, the result being certain peculiarities of attitude and gait. In some hemiplegics with decided paralysis in both the upper and lower extremities the contractures are pronounced and affect all parts of the limbs. The arm in some of these cases is drawn forcibly to the side, and the forearm, bent nearly at right angles to the arm, is carried over the chest and ab- domen. Marked flexures are also commonly present in the wrist and fingers. The thigh is strongly adducted and sometimes slightly flexed ; the leg is flexed on the thigh at a right angle or less. At the ankle and toes the contractures are also usually of a marked charac- ter. Irregularities in the contractures often cause grotesque positions to be assumed by the hand and fingers. In the illustrations Pigs. 308, 309, and 310 various forms of contracture with rigidity are shown. Except when local structural changes are great, the contrac- 574 NERVOUS DISEASES. tures can be overcome by careful traction, the parts resuming their abnormal positions again when the force is removed. It is surprising how frequently the joints remain supple, allowing these contractures to be overcome by such persistent traction, even when strong con- tractures have persisted for months and years. The patients some- times complain of a sensa- FiQ. 308. tion of tension in the parts, and they can often be seen rubbing or working with _ ,.v»™__^_ *^® limbs to relieve this *' jlX^ " /^^^KB^M feeling. A contracture be- FiG. 309. Hemix)leffia with strong contractures In- volvinfi: all parts of the affected limbs ; marked atrophy in tlie upjjer extremity ; right oculo- motor paralysis, with left divergent squint and inward limitations ; paralysis of nine years' duration. Hemiplegia with partial apha- sia : marked contractures of the shoulder, wrist, , and hand; marked atrophy on paralyzed side ; paralysis of thirty-five years' duration. ginning in one set of muscles tends to be diffused to associated mus- clt'S, or to become general through the limb. The contractures dis- appear under ether or chloroform narcosis. Usually in all cases in \\liicli marked contractures are present the tendon and muscle phe- nomena are exaggerated. Besides true rigidity and contracture, the neuromuscular apparatus is often in a state which Brissaud has de- scribed as one of "imminence of contracture," — ready to contract or to exhibit other silastic phenomena on the slightest provocation. CHRONIC HEMIPLEGIAS AND MONOPLEGIAS. 575 Contractures were present in forty-three out of the sixty cases at the Philadelphia Hospital, and these were in the upper extremity alone in about two thirds of the cases. In rare instances contractures of the face are present in old hemiplegics; but both contractures aud twitchings are more frequent aud more diagnostic in peripheral facial paralysis than when the affection is part of a hemiplegia and due to a central lesion. Mechanism of Secondary Contractures. The occurrence of secondary contractures has been variously exi^lained. They have been attributed simply to retraction of the muscles and of the soft parts, a manifestly insufficient explanation. The spreading of motor impulses from the healthy to the paralyzed side, exaggeration of muscle tonus, and permanent muscular activity due to the irritable condition of the spinal cord are among other insufficient hypoth- eses which have been advanced. Ac- cording to Marie, the pyramidal bundle plays a role of arrest, analogous to that exerted by the pneumogastric on the heart ; and, as one mission of the pyramidal bundle is to restrain and regulate the gray matter of the bulb aud cord, contracture takes place and persists because the inhibitory action of the higher cerebral centres is impaired by the destruction of the fibres of this bundle. Rigidities and Fseudocontractures. The rigidity of the paralyzed limbs may be either earJy or late. One form of early rigidity is some- times designated initial rigidity, which comes on at the time of the apoplexy and may pass away in a few hours. A more persistent early rigidity usually develops a few hours after the beginning of the apo- plectic attack, and lasts for several days or weeks. The initial rigid- ity, which is probably dependent upon the immediate irritating effects of the apoplectic seizure, is frequently absent. Initial rigidity may pass into early rigidity, and the latter may merge into late rigidity. Late rigidity, however, commonly shows itself after several weeks, the paralysis having been up to the time of its appearance of a flaccid character, or having shown only a slight tendency to contracture. When contracture and late rigidity have persisted for a long time, certain changes take place in the parts affected, these being in part due to fixity of position and disuse, and in part to central degenera- tive changes ; but in my own experience this structural rigidity is rare even in cases of long duration. All forms of rigidity are, as a rule, more marked in the arm than in the leg, and in the distal rather than Hemiplegia with marked con- tracture at elbow and wrist ; paral- ysis of several years' standing. 576 NERVOUS DISEASES. in the proximal portions of the limbs. In the development of spas- modic contractui-e, in certain cases retraction of the tendons, prob- ably due to rupture and cicatrization of tendinous fibres, results in malformations. Pseudocoutractures are observed as the results of traumatisms and inflammations of the muscles. In Parkinson's dis- ease, and in primary amyotrophies, contractures are characterized clinically by special rigidity to touch, by their irregular distribution, by the absence of any tendency to become general, by the non- exaggeration of the reflexes, and by their nondisappearance during chloroform narcosis. Ischemic pseudocontracture follows prolonged deprivation of arterial blood, is characterized by coldness and rigidity of the limb, and is due to a morbid change in the muscular fibres. (Blocq.) Associated and Substituted Movements. — The term asso- ciated movement, as used in describing hemiplegic phenomena, is commonly applied to an involuntary movement in one part as a result of a voluntary movement in another. Substituted movements are those which take the place of movements that the patient intends or tries to perform. Associated and substituted movements can be conveniently subdivided into (1) movements in the muscles of the nonparalyzed side, with or instead of an intended movement ; (2) similar movements in paralyzed muscles ; and (3) involuntary origi- nal movements with involuntary associated and substituted move- ments. (Senator.) These associated movements are most frequently observed in the upper extremity. Twenty-five of the sixty hemi- plegics studied in the Philadelphia Hospital showed associated or substituted movements. In ten of these cases volitional movements on the unaffected side caused involuntary movements of the paralyzed side, and in eleven cases movements or attempted movements of the paralyzed limb caused involuntary movements on the other side; while in four cases the movements were of special character. Jfearly all the results were obtained from the upper extremities. In one case, however, attempts to use the paralyzed arm caused movements in the paralyzed leg. In another case coughing caused the paralyzed hand to be moved to the face. In a third yawning was followed by an extension of the paralyzed fingers and raising the hand towards the head ; and in a fourth yawning or taking deep breaths caused the forearm of the paralyzed side to be flexed, the index finger to be extended, and the lower extremity to be extended and to become rigid. Beer has recordetl a case of hemiplegia with contractures of the arm in which passive movement was almost impossible. When the patient extended his right (sound) arm, the movement was slight ; but the result of a yawn was surprising. The contracted muscles relaxed so completely that extreme dorsal flexion of the wrist and fingers occurred, while the arm w;is lifted and abducted, the shoulder being almost rigid before. Similar results were obtained in a second CHRONIC HEMIPLEGIAS AND MONOPLEGIAS. 577 case. Various explanations of the origin of associated movements have been suggested. Increased excitability of the centres and di- minished resistance of the tracts connecting the centres through which these movements are produced, transference of reflexes, the overflow of normal impulses, and the loss of inhibitory power, have been evoked in their explanation. The structural connections through which these movements are effected can be understood by what has been already stated as to the splitting of the fibres M^hich go to the lateral pyramidal tracts, and the probable commissural connections between the centres of both sides of the spinal cord. As Senator has shown, the cause of associated movements may be situated alto- gether outside of the central nervous system. One of his patients had received a compound fracture of the skull twelve years before coming under observation, and one year after had become hemiplegic and aphasic. After the fracture, on swallowing he experienced pain in the angle of the jaw upon the right side. Excitement and irrita- tion brought on choreic movements. On protruding the tongue, the paralyzed arm became flexed, the index finger extended, the others clenched, and the hand was raised to a level with the ear as in a mil- itary salute. The same movements were produced by pressure along the painful area at the angle of the jaw, and along the anterior edge of the upper third of the sternomastoid muscle. Senator believed this to be due to an inflammatory infiltration aiound the nerves of the cervical plexus, extending up to the root of the tongue, regarding the movement as reflex and not due to direct ii-ritation. Associated movements may result from cutaneous stimulation, as in a case re- corded by Nothnagel, in which moderate pinching of the paralyzed arm caused muscular contraction in the sound arm ; when the pinch- ing was a little stronger the contractions extended to the sound leg ; and when the irritation was still stronger, to the leg on the hemi- plegic side. The limb pinched always remained quiet. Forced Movements. — Forced movements, or movements which the patient tends to make in spite of his will, are not often seen among chronic hemiplegics, and when present are commonly indica- tive of unusual irritation at the site of the lesion. They may be of peculiar character according to the location of the lesion, as will be understood by reference to what has already been said about the eflfects of destruction or irritation of the cerebellum or cerebellar peduncles. They are occasionally seen during the early stage of hemorrhagic apoplexy, but are more common in tumors. They may he of a violent and almost uncontrollable character. Ewald reports a case of disseminated miliary tuberculosis in a boy, in which the patient showed decided jerking of the left arm and shoulder, so that he was compelled to hold the left arm forcibly against his side with the right to keep it still. When the left arm was released, it was immediately extended backward from the shoulder at an angle of 37 578 NERVOUS DISEASES. forty-five degrees, and was affected with jerkings in all its joints. A solitary tubercular mass, about an inch in diameter, was found in the right thalamus, surrounded by a red ring of inflammation or de- generation, involving a part of the posterior limb of the internal capsule. Forced movements have been attributed to unilateral in- complete paralysis ; to excessive activity of one side of the body the resiilt of unusual central stimulation ; and to vertigo and giddiness. Conjugate deviation of the eyes and rotation of the head constitute one form of forced positions and movements. Athetosis and Athetoid Phenomena. — The word athetosis, which is derived from a Greek word meaning " without fixed posi- tion," is applied to a peciiliar form of grotesque recurring mobile si^asm sometimes observed in adult hemiplegics, although when or- ganic and of cerebral origin it is usually congenital or the result of an affection occurring in early childhood. It is a somewhat frecxuent phenomenon in the cerebral palsies of children, in connection with which it will be again considered. Strictly speaking, it is not a dis- ease, but a part of a symptom group. In hemiplegics it may be de- pendent upon lesions of the motor tract. In Fig. 311 are shown the arm and hand of a Fig- 311. patient who suffered from a marked form of athetosis on the paralyzed side. In the section on the cerebral palsies of children other illus- trations of athetosis Position of the hand and fingers in one of the forms of athetosis. '^^"® Showu lU Several figures. In adult hemiplegics athetosis or athetoid mobile spasm is nearly always asso- ciated with a greater or less degree of permanent rigidity with con- tracture. Tremors, Twitchings, and other Abnormal Movements. — Tremor in the i^aralyzed limbs is not common, but iu rare instances a tremor somewhat similar to that of paralysis agitaus has been ob- served, as in a case reported by Bastian in which the patient was affected with tremors in the right hand and wrist after she had re- gained some motor power. The lesion was probably situated in the cms. Twitchings of various kinds are fret^uently observed, and are sometimes readily induced by handling the limb or by the unavailing efforts of the patient to use it. Rhythmical movements, such as alternate flexions and extensions, are occasionally noted, and are almost exclusively confined to the upper extremity. Choreoid and ataxic movements are also occasional phenomena ; and a posthemi- plegic chorea lias been described, but the mo\'ements in these cases CHRONIC HEMIPLEGIAS AND MONOPLEGIAS. 579 are not strictly of a choreic character. They are usually a com- mingling of a clonic spasm and of tremulous, choreoid, athetoid, and forced movements. Movements of this kind were present in eleven out of sixty cases. It is interesting in this connection to note the curious effect that a hemiplegia may have on the tremor of insular sclerosis. Sinkler has recorded a case of insular sclerosis in which, as the result of an apoplexy, the intention tremor disappeared on the paralyzed side. Cutaneous Reflexes. — During the apoplectic period the cuta- neous reflexes, as a rule, are abolished, and if the patient recovers to become a chronic hemiplegic they may be absent or much diminished for a long time or altogether. The cremasteric and abdominal re- flexes in particular may be absent, even if the plantar reflex is present or has returned after it has been lost for a time. The early loss of cutaneous reflex action is occasionally important from a diag- nostic point of view. The explanation of the diminished or abol- ished skin reflexes is somewhat difftcult, particularly in the light of the fact that muscle and tendon phenomena are usually exaggerated, suggesting the idea that the mechanisms which control the two sets of phenomena are different. It has been held by some that the spinal centres are controlled by lower encephalic centres, and the latter by centres still higher, and that the abolition of the cutaneous reflexes is due to the eifect of lesions which prevent the inhibitory influence exerted by the higher upon the lower encephalic centres. In rare instances the cutaneous reflexes are increased. Tendon and Muscle Phenomena. — As a rule, knee jerk, muscle jerk, and tendon and muscle phenomena in the upper extremity are exaggerated on the paralyzed side ; the front tap phenomenon and ankle clonus can often be readily elicited, and the toe jerk also in rare instances. In some cases the entire paralyzed limb can be thrown into grotesque twitchings, jerkings, or oscillations by slight percussion over the muscles, tendons, or bones, or such local spas- modic phenomena may occur spontaneously, or may seem to be of spontaneous origin, being in reality due to accidental irritation of the parts. In rare cases the muscle and tendon phenomena may be below the normal or even absent, and in these the question of cerebellar disease or of lesions somewhere outside of the cerebrum needs to be taken into consideration. The following results were obtained for the paralyzed side in the sixty cases examined by Dr. Baldwin : Knee jerk exaggerated 45 casea. Knee jerk absent 4 Muscle jerk exaggerated . 43 Muscle jerk absent . . 5 Ankle clonus present 20 Front tap present 35 580 NERVOUS DISEASES. Sensory Disorders. — The sensory disorders of hemiplegics may be (1) pain and hyperesthesia ; (2) paresthesia ; and (3) anesthesia, local or of one half of the body. The perversions may be of one or of several of the different varieties of sensation. Pain and Hyperesthesia. Pain of a severe character may precede an apoplectic attack which results in hemiplegia, may occur during such an attack, or may follow i^iQ attack, constituting part of the hemiplegic state. Weir Mitchell has described what he calls pre- hemiplegic and posthemiplegic pains. In rare cases acute pain in the musculature of the affected side is an immediate prodrome of an attack of hemiplegia, being present from twenty-four to forty-eight hours before the occurrence of the attack. Mitchell records the case of a woman who was seized with violent pain in the leg and arm without joint lesions, and who within thirty-six hours had a quite comj)lete attack of hemiplegia on the same side, after which the pain soon faded away. In some cases unilateral fibroid pain and sore- ness may be persistently present, or may recur at short intervals for a long time, before the hemiplegic state, and similar pains may be present after the patient has become hemiiilegic. These pains are often associated with the joint disorders to which attention is called in another paragraph. A true neuritis, either of accidental origin or a part of the organic affection, may be present in hemiplegics. In some of the instances in which pain has been present it was caused by a subinflammatory hypertrophy of the nerves and their sheaths. Hyperesthesia and tenderness are sometimes to be ex- plained in this way ; in other cases the pain and paresthesia are probably of cortical or cerebral origin. In sixty cases pain was complained of in thirty-one, and in eighteen of these it was in both upper and lower extremities. Hyperesthesia was present in ten cases. Paresthesias. Paresthesias or perverted sensations of various kinds are somewhat common in hemiplegics, who frequently comi^lain of feelings of numbness, burning, itching, heaviness, deadness, etc., in the paralyzed half of the body. These symptoms are sometimes local in origin, due to nutritive or inflammatory changes in the limbs, as the result of disease or of accident. Doubtless also they are some- times due to the cortical or subcortical disease. As Bremer has shown, pain, itching, and other sensations may be of cortical origin. Painful Nodes. Painful periosteal nodes are now and then ob- served in hemiplegic limbs, and attention has been called to them by Weir Mitchell. He records the case of a man, forty-five years old, who two or three months after an apoplectic attack developed joint lesions with rigidity and contracture. An elongated tender node about an inch wide was found three inches above the ankle, and at the insertion of the deltoid another one still more prominent. No history nor evidences of syphilis could be discovered, and the patient, who was a plumber, showed no signs of lead poisoning. CHRONIC HEMIPLEGIAS AND MONOPLEGIAS. 581 Anesthesias. Hemianesthesia of organic origin without loss of power on the affected side is of very rare occurrence, but is occasion- ally seen, and is commonly due to a limited lesion of the most poste- rior portion of the posterior limb of the internal capsule, or to a lesion of the thalamus. Recent investigations have brought neurolo- gists back to the view largely held in former years, and esijccially by the British school, that the thalamus is a sensory organ ; never- theless, the theory that a portion of the sensory tract is contained in the hinder limb of the internal capsule cannot be regarded as over- thrown, or as necessarily inconsistent with the view that the thalamus is the basal terminus of many of the incoming sensory tracts. A ma- jority of cases of chronic hemiplegia do not show any impairment or Fig. 312. Diagram showing the area of retained sensation on the face in a patient otherwise totally hemianesthetic ; anesthesia shown by the shading; hemiplegia and hemianesthesia due to a destructive lesion of the thalamus and posterior extremity of the internal capsule. disorder of sensation even on close investigation, although such sen- sory disturbances are more frequent than is supposed, and are some- times overlooked. In all cases an examination should be made for perversions or losses of the different varieties of cutaneous and mus- cular sensation— for changes in tactile, pathic, and thermic sensi- bility, and in the senses of pressure, locality, and all the varieties of sensation which enter into the so-called muscular sense. Hemianes- thesia may be present with extensive paralysis of the leg, arm, and face, or the paralysis may preponderate in the leg, giving the leg- sensory type. An anesthetic area confined to one limb or to one part of it is occasionally discovered, but such cases are rare. It should be understood, however, that all such cases are not of hys- 582 NERVOUS DISEASES. terical origin, even when they are not confined to particular nerve distributions. Savill has reported several cases which apparently demonstrate that lesions of the gyrus fornicatus and its immediate subcortex will cause more or less limited anesthesia of the opposite extremities according to the exact site and dimensions of the lesion (see page 341). What is supposed to be a complete hemianesthesia sometimes on examination proves to be incomplete. In one of my cases of lesion of the thalamus and internal capsule the patient was totally anesthetic over one half of the body, except in one limited region of the face. This area of retained sensation included the orbital region, the side of the nose, and the left cheek within a line drawn from the external angular process of the frontal bone to the ala of the nose. The mucous membrane of the mouth was sensitive in an area which corresponded, so far as could be determined, to the cutaneous region of retained sensation. (Fig. 312.) In organic cer- ebral hemiplegias some forms of sensation may be lost and others retained, although such cases are rare. Some form of anesthesia was present in five out of sixty cases. Occasionally hemiplegics show a loss of the sense of position of the limbs. This symptom is not common, and is usually associated with hemianesthesia. Disorders of the Special Senses. — Disorders of hearing, smell, and taste are not common in hemiplegia, but are observed in special cases which are to be explained by unusual extensions of the lesions causing the paralysis to the tracts and centres for these special senses, or by the presence of two or more lesions. A hemiijaresis with cere- bral deafness and paraphasia may be caused by a large lesion of the temporal lobe, the loss of power being due to pressure on the motor region or tracts, and the auditory disturbances to the destructive effects of the lesion. Affections of sight are of more frequent occur- rence, and especially hemianopsia, which is present in one of the types to which attention has already been directed, in which the symptom complex is hemiplegia or hemiparesis with hemianesthesia, hemiataxia, and hemianopsia. Hemianopsia will be further consid- ered when affections of the optic nerve and its correlated encephalic structures are discussed. Besides hemianopsia, other disturbances of vision are occasionally i^resent, such as central amblyopia, phos- phcnes, and visual hallucinations. Vasomotor, Secretory, and other Allied Phenomena.— The vasomotor changes in the paralyzed limbs may be of varying, and even of opposite, character. In the early period of hemiplegia the limbs may be warmer, and may present a somewhat hyperemic ap- pearance. Later the parts usually become colder and are often pur- plish or livid. Edema is occasionally present in the paralyzed ex- tremities, and is usually confined to their proximal portions. It may be an early phenomenon, coming on during the apoplectic attack, and disappearing largely or altogether as the attack passes off. As CHRONIC HEMIPLEGIAS AND MONOPLEGIAS. 583 chronic nephritis is a comparatively common accompaniment of apoplexy and hemiplegia, the edema or anasarca of renal disease may also be present. When such renal disease is present, the edema may be more marked in the paralyzed extremities. Edema with glossy skin is sometimes observed over a large portion of the limbs ; and in these cases pain and hyperesthesia, witli other evidences of neuritis, are usually also present. Edema was present in seven out of our sixty cases, and local or unilateral sweating also in seven cases. Surface Temperature. — In the apoplectic j)eriod both axillary and surface temperatures are usually somewhat increased on the paralyzed side, but after a lapse of two or three weeks the tem- perature will be found to be decreased on this side, and in chronic hemiplegics the surface temperatures are almost invariably found to he less on the paralyzed than on the nonparalyzed side. A careful examination of the surface temperature in sixty cases was made by Dr. Baldwin. The average temperature on the sound side was 95.4° P., and on the paralyzed side it was 93.5° P. The actual temperatures taken in thirty of these cases are given in the following table : * Case. NONPAKALYZED SiDE. Pabalyzed Side. Diffeeence. Duration of Disease. 1. 95.4 91.8 3.6 3 years. 2. 93.8 93.4 .4 3 ' 3. 96.5 95.8 .7 4 ' 4. 95.2 91.0 4.2 4 ' 5. 93.5 92.3 1.2 4 ' 6. 96.2 91.5 4.7 5 ' 7. 93.8 93.8 5 ' 8. 96.3 96.1 '.2 6 ' 9. 95.7 95.2 .5 6 ' 10. 96.9 96.0 .9 6 ' 11. 94.8 93.6 1.2 6 ' 12. 95.0 94.1 .9 6 ' 13. 95.6 86.8 8.8 7 ' 14. 95.2 93.4 1.8 7 ' 15. 95.0 92.8 2.2 7 ' 16. 94.0 92.4 1.6 7 ' 17. 94.5 93.8 .7 8 ' 18. 96.5 94.9 1.6 9 ' 19. 96.0 96.0 • • 10 ' 20. 95.6 92.0 3.6 10 ' 21. 93.2 91.2 2.0 11 ' 22. 93.6 93.6 13 ' 23. 94.9 93.5 1.4 15 ' 24. 93.2 87.5 5.7 15 ' 25. 94.7 92.5 2.2 18 ' 26. 96.0 96.0 18 ' 27. 94.5 93.0 1.5 20 ' 28. 93.7 91.7 2.0 23 ' 29. 93.0 92.5 .5 25 ' 30. 95.8 94.0 1.8 35 ' * The thermometers used were carefully tested. They were of the flat spiral bulb variety and most approved pattern. A number of preliminary trials showed that they never continued to register after the lapse of five minutes. The ther- mometer was in all cases placed over the supinator longus muscle. 584 NERVOUS DISEASES. Hemiplegic Atrophy. — In hemiplegias and monoplegias which are the result of acute lesions occurring after adult life has been reached, wasting of the affected limbs and face is not so marked as when the lesion is congenital or originates in infancy and early child- hood. At one time it was thought that atrophy was very seldom present in adult cerebral palsies ; but a careful study of a large number of hemiplegics shows that some atrophy is not infrequent, and usually it is more marked in the distal portions of the limbs. Fig, 313. Hemiplegia with aphasia, contractures, and marked atmphy on the paralyzed side. (Dercum.) The little muscles of the hands, and the muscles of the forearm par- ticularly, often suffer. Occasionally atrophy is quite noticeable in the muscles of the foot and fac«. It is more than the diminution in bulk due to disuse. These atrophies are to be attributed to degen- erations of the pyramitlal tracts and involution of the anterior horns, and to degenerations subsequent to peripheral neuritis occurring in the paralyzed limbs. The atrophy may in some instances be due CHRONIC HEMIPLEGIAS AND MONOPLEGIAS. 585 to the destruction of trophic centres in the cerebrum. Savill, for example, has suggested on the basis of a clini- copathological observa- tion that such centres may be situated in the limbic lobe. An illus- tration of a case of hemi- plegia with well marked atrophy is given in Fig. 313. Moderate atrophy of the arm is also ex- hibited in Pig. 314 ; and in other illustrations al- ready given more or less decided atrophy appears (Figs. 306, 308, 309). In all cases in which hemi- plegia occurs at a very early age, after a few years the entire para- lyzed half of the body presents an arrested or atrophied appearance. These cases will be more fuUy considered under infantile cerebral palsies. Atrophy was present on the paralyzed side in thirty- five of sixty cases, being marked in the seventeen cases shown in the following table. Hemiplegia and aphasia, witla some atrophy of the right arra ; no contractures. SiBE PaEALYZED. FOEEA KM JUST BELOW ELBOW. Middle of Leg below Knee. Sound. Paralyzed. Diflference. Sound, Paralyzed, Difference, Eight. 11,00 9.50 1.50 14,50 14,25 ,25 Right. 10,00 8.00 2.00 No difference. Left. 10,50 9.50 1.00 f ( it Eight. 10,50 9.50 1,00 ti 11 Left. 10.00 9.25 ,75 12,25 11,50 .75 Left. 9.50 9.00 ,50 No difference. Left. 8.25 6.75 1,50 12,25 11,00 1,25 Left. 10.50 9.25 1,25 No difference. Left. 9.25 8.25 1,00 1.3,50 12,50 1,00 Left. 10.00 9.25 ,75 No difference. Eight. 8.50 7.50 1,00 " " Eight. 13.00 10,00 3,00 U (< Left. 9.00 8,00 1.00 12,00 10,00 2,00 Eight. 10.50 9.50 1.00 14,00 12,00 2,00 Left. 10.00 9.50 .50 No difference. Right. 10.00 9.00 1.00 13,00 12,,50 .50 Right. 10.50 9.00 1.50 No difference. Measurements in inclies. 586 NERVOUS DISEASES. Miscellaneous Trophic Phenomena. — During grave apoplectic attacks gluteal escliars or bedsores sometimes form on the paralyzed side. They were first particularly described by Charcot, who re- garded them as most inauspicious signs, the cases in which they were present often terminating fatally. When the patient recovers, such escliars are troublesome for a long time. During the apoplectic at- tack, and sometimes later, the skin in exposed positions may become sore, and it sloughs more readily than on the nonparalyzed side. Sometimes the trophic and other eschars form late in the history of the hemiplegia, when the patient is stricken in his last illness by a recurrence of the cerebral trouble or by some intercurrent or con- comitant affection, as pneumonia, nephritis, or endocarditis. Chronic hemiplegics may also show a tendency to ulcerations and other trophic disturbances in the paralyzed limbs. The skin may be thickened or scaly, or in rare instances it may be smoother and finer than on the paralyzed side. The occurrence of a furunculous erup- tion limited to the paralyzed side of the face has been noted in hemiplegics. Changes in the nails, such as groovings and other markings, brittleness, roughness, increased thickness, peculiar incur- vations and twistings, and alterations in color, often to a yellowish hue, are somewhat common. The nails may show a tendency to dif- ferent rates of growth on the paralyzed side and on the nonparalyzed side. These changes can readily be observed on the finger nails, and are often especially marked on the nails of the great toes. Some abnormalities of the nails were observed in more than half the cases studied in the Philadelphia Hospital. The growth of the hair may be really or apparently increased, and it may be of a coarser charac- ter than on the healthy side. The alterations both in nails and hair may be due to the local neuritis which is so often present in the limbs, and to which attention has been called when speaking of pain and hyperesthesia, rather than to the disease of the brain. It is well known that in variovis forms of neuritis and in spinal disease unassociated with encephalic lesions such trophic changes are pres- ent. Due consideration, however, must be given to encephalic trophic centres both cortical and basal. Joint Affections. — Joint affections or arthropathies, like painful disorders of the limbs, may precede an attack which causes hemi- plegia, or may be manifested at various periods in the history of the hemiplcgic. Weir Mitchell records cases in which repeated attacks of tenderness and swelling of the joints were present, which were strictly limited to one side, this side subsequently becoming paralyzed. In such cases the lesions in the joints sometimes increase after the palsy is established, and may persist as chronic affections. In other cases joint lesions follow closely on the apoplectic attack. Mitchell mentions four c;ises in which, with right sided cerebral lesion, such affections of the joints followed within four days. In other cases CHRONIC HEMIPLEGIAS AND MONOPLEGIAS. 587 arthropathies occur at irregular periods in the history of the hemi- plegic. These joint affections are not to be dismissed simply ;is instances of unilateral rheumatism, for while it is of course possible for a true hemiplegio to be attacked with rheumatism, it is uncom- mon. More commonly joint inflammations appear in from three to six weeks after the apoplectic onset. They are referred by some to the period of inflammatory reaction. The arthropathies are in some cases to be referred to hypertrophic neuritis, and in others to the influence of central lesions ; or both causes may sometimes be opera- tive. When arthropathies occur during the acute stage of an apo- plexy, while any joint may be selected, the articulations most fre- quently affected are the shoulder, wrist, elbow, those of the hand and fingers, the knee, and the foot. Severe arthropathies, like the gluteal eschars with which they may simultaneously appear, are often of evil omen. In chronic hemiplegia they may be evidences of local trouble, or they may develop with a fresh apoplectic attack. Autopsies have shown that the joints possess all the characteristics of a subacute synovitis. In some instances the articulatory affections are so slight as almost to escape notice. Paralysis of the Sphincters. — During the apoplectic state in- voluntary evacuations of feces and urine are the rule. If, however, the patient recovers from the attack to become a chronic hemiplegic, control over the sphincters is usually regained, although it is often weakened. Occasionally the incontinence of urine continues for weeks or months, and it may be a persistent symptom. In large lesions of the cerebellum loss of control over the sphincters is somewhat common. Frequent seminal emissions with imijerfect erections, and failure in coition, are sometimes present for many months after the onset of a hemiplegic attack. Sexual desire and power may be permanently impaired. Disorders of Mentality. — While chronic hemiplegics often" re- tain a large amount of intellectual energy and ability, some weaken- ing or disturbance of mentality is comparatively common. This may be influenced by the age of the patient, by his previous intellectual vigor, or by the presence of chronic disease. Patients advanced in life and those who are prematurely senile usually show the most marked changes. After a second or a third attack the mental de- ficiency and disturbance become more decided ; they are especially marked when the lesions are multiple, and when large areas of the cortex are implicated. The destruction of important subcortical associating tracts also gives rise to confusion and slowness in men- tal action. If the prefrontal lobe is involved, the psychical disorders which are present may have the special characteristic already de- tailed. Seguin believed that left hemiplegics showed a greater ten- dency to emotional disturbances than right hemiplegics. In almost aU hemiplegics more or less emotionality on the one hand, or an 588 KERVOUS DISEASES. indiiferent and apathetic state on the other, is after a time present. The emotional manifestations may be indirect in origin. The patient, finding himself helpless or handicapped, is often restive under his hard yoke. Disturbances of speech may mask or confuse his real mental state. Phenomena on the Nonparalyzed Side. — Interesting clinical phenomena are to be noted on the unparalyzed side, these corre- sponding with what would be expected in the light of what has been said regarding bilateral secondary degenerations. As early as 1875 Westphal noted that in some hemiplegics foot clonus could be elicited on the healthy side. Dignat has shown that muscular force is often diminished fifty per cent, in the lower limbs, and also in the upper, but not to the same extent. The healtliy limbs suffer partly because of the disruption of coordination between the two sides of the body. Friedlander observed that the diminution of strength in the left upper limb was greater in right hemiplegics than that of the right in left hemiplegics. In the late stages of a long continued hemiplegia, es- pecially if the patient is advanced in years, the loss of power may be so great that the patient is almost paraplegic. More or less in- coordination is commonly present. All the tendon and muscle phe- nomena may be exaggerated on the healthy side, although not to the same extent as on the affected side. Even a species of contracture or pseudocontracture may be present, and forced movements are some- times observed. The following are a few of the points regarding the nonparalyzed side brought out by a study of the sixty cases in the Philadelphia Hospital : Considerable loss of power present .31 cases. Increased muscular irritability . .... 7 " Tremor, slight clonic spasm, or cboreoid movements . 7 " Associated movements on nonparalyzed side from move- ments on paralyzed side 14 " Associated movements on paralyzed side from movements on nonparalyzed side ... .... 8 " Knee jerk increased . 16 " Knee jerk abolislied . . . • 2 " Muscle jerk increased 15 " Muscle jerk abolished 2 " Ankle clonus present 6 " Front tap present . ... 11 " Bilateral or Double Hemiplegia. — A bilateral or double hemi- plegia is occasionally observed in adiilts, and may be due to successive or simultaneous lesions of the same character as those which produce ordinary hemiplegia. The diplegias of children constitute a special class, to which no reference is made here. A bilateral case may simply give on both sides the clinical features which have been de- scribed for the ordinary forms of hemiplegia. The patient is likely to succumb to the attack which duplicates his paralysis. In a special CHRONIC HEMIPLEGIAS AND MONOPLEGIAS. 589 form of bilateral hemiplegia described by various writers, the glosso- labia.l syndrome is present and prominent, the affection constituting one of the forms of so-called pseudobulbar paralysis. The lesions may be cortical, chiefly occupying the lower extremities of the central convolutions, where are located the centres for the lips, tongue, larynx, masticatory muscles, and pharynx. They are, however, sometimes intrahemispheric, and in reported cases have been found chiefly in the inferior part of the putamen, or external segment of the lenticula ; but in some cases also they ha^e been present in the orolingual and speech tracts. The predominating symptoms in these cases are disturbances of the organs of articulation, associated with greater or less degree of paralysis in other parts. Some reference has already been made, on page 353, to iDseudobulbar j)aralysis. In exceptional cases a unilateral lesion has been sufficient to cause the bilateral pseudobulbar syndrome. In these cases one hemisphere may have sufficed in the particular individual for the representation of the bilateral movements affected, the corresponding centres in the other hemisphere having had little or no functional importance. Diagnosis. — Etiological Diagnosis. The etiological diagnosis of a hemiplegia or monoplegia may be of the highest importance. The etiological varieties of hemiplegia can be classified under those due to organic diseases of the nervous centres ; those due to intoxi- cations and infections ; and those associated with the so-called neu- roses. The organic nervous affections include traumatic and spon- taneous cranioencephalic lesions, focal diseases of the brain, and some of the cerebrospinal degenerations. Traumatisms, meningeal hemorrhages, pachymeningitis, the different varieties of leptomen- ingitis, hemorrhage, softening, tumor, and abscess, have already been considered. Hemiplegia may also occur in the course of such cerebrospinal diseases as tabes, disseminated sclerosis, and paralj'tic dementia. Some of the intoxications of which hemiplegia may be the result are uremia, diabetes, alcoholism, lead poisoning, and other metallic or gaseous poisonings. It may accompany or immediately follow such affections as pneumonia or pleurisy, malarial, typhoid, and eruptive fevers, diphtheria, and the puerperal state ; or it may be a concomitant of such chronic infections as syphilis and tuberculosis. Hemiplegia or hemiparesis may also be present in general affections of the nervous system, like paralysis agitans, hysteria, and chorea. It is clear that the diagnosis of hemiplegia in many of these affec- tions will confront the physician at the time of its onset or during the acute stages of the disease of which it is a part. It is only neces- sary to mention here these numerous etiological forms of hemiplegia, in order that the physician may be on his guard in studying the more usual types which have just engaged our attention. Points in the Diagnosis of Chronic Hemiplegia. As a hemiplegic often' comes under the physician's notice after the case has become chronic, 590 NEEVOTJS DISEASES. the pathological cause of the paralysis may be overlooked or misun- derstood. Both in hospital and in private practice old hemiplegics are often passed by as hopeless, it being taken for granted that the syn- dromes presented are due to old hemorrhagic or embolic cysts, when in fact a tumor, an abscess, or some other lesion more or less amenable to treatment may be present. The mistake is the more likely to be made because tumors, so far as paralysis is concerned, may remain latent for a long period, and because the paralysis may come on suddenly with an apoi:)lectio seizure, the result of the intercurrent hemorrhage or of the rapid breakdown of the tissue near the growth. Abscesses may also remain for a long time latent. In every case, therefore, a careful study should be made of the type of the paralysis, and of the concomitant symj)toms and conditions. The ophthal- moscope may be of great service by showing that papillitis is or is not present. Septic symptoms may point the way to the diagnosis of a chronic abscess. Diffuse syphilis of the brain or general paral- ysis of the insane may at times present features closely resembling those of some of the usual or unusual types of hemiplegia due to focal lesions. The attitude and gait of a hemiplegic may vary considerably, but in the usual types it is often characteristic. The patient carries himself somewhat towards the sound side, projecting the paralyzed limb forward, the paralyzed foot and leg being often made to describe the arc of a circle. This characteristic gait was first described by Todd. Charcot suggested calling it the helicopod walk, from words meaning to walk in a half circle ; in contradistinction to the helcopod walk or dragging gait of hysterics. In some organic cases, however, the leg is also distinctly dragged. Diagnostic Importance of Jacksonian Epilepsy and, General Convul- sions. In chronic as in acute hemiplegia, either Jacksonian epilepsy or general convulsions are occasional features. Local or Jacksonian epileijsy is characterized by an admixtui'e of clonic and tonic spasm in groups of muscles related to definite centres and areas of the cortex, these being commonly characterized by signal symptoms and a serial order in the motor phenomena (see pages 351, 352). The spasm often shows a tendency to diffuse to many muscles of the same side, and less frequently to those of the other half of the body. The epilepsy may be either facial, brachial, or crural in type. The first gives a unilateral spasm which spreads from the face to the upper and then to the lower limb ; in the brachial type the spasm diffuses from the u]iper limb to the face and next to the lower extremity; while in th(i ci-ural type the most common order of diffusion is from the lower limb to the upper, and from the latter to the face. Not only the nature but the probable location of the lesion may be indi- cated by such spasm. The occurrence of Jacksonian epilepsy fre- quently indicates that the chronic hemiplegia is due not to hemor- rhage or softening in some of the usual sites of such lesions, but to CHRONIC HEMIPLEGIAS AND MONOPLEGIAS. 591 tumor, abscess, meningitis, or diffuse syphilitic disease. General convulsions in hemiplegics may be due to focal lesions, the spasm, at first local, diffusing so rapidly that its probable focal nature is not recognized ; in other cases they may be due to dural irritation, or to toxic causes, as when the hemiplegic suffers either from uremia or diabetes or is the victim of some intercurrent intoxication or infec- tion. While, therefore, either Jacksonian epiU'i)sy or general con- vulsions may occur in any of the more usual forms of hemiplegia or monoplegia, their presence should lead to carefid examinations for the symptoms of other affections like those enumerated. Prognosis . — The prognosis of chronic hemiplegia cannot well be generalized, owing to the great difference in the individual cases. A certain limit of improvement is soon reached in cases due to focal destructive lesions, such as hemorrhage and softening, but these -nill sometimes improve for a year or more. If removed from all sources of physical and mental strain, hemiplegics may live for years. Many of the hospital cases survive from ten to fifteen years and even much longer. The age and general health of the patient are important elements in the prognosis as to length of life. The hemiplegic syn- drome is more serious in the old, in the very young, and in those suffering from diseases which cause constitutional infirmity. Apo- plectic attacks are occasionally repeated, adding to the gravity of the prognosis. The condition of the heart, kidneys, and vessels is of especial prognostic importance. These remarks apply to the prog- nosis of chronic hemiplegia of the most common types. When the paralysis is due to tumor, diffuse syphilis, intoxication, infection, or hysteria, the prognosis is more favorable ; but these diseases do not require to be especially considered in this connection, nor are we here concerned with the prognosis of cases associated with degener- ative diseases or with the so-called neuroses. Treatment. — Prophylaxis and Internal Medication. The prophy- laxis of hemiplegia is, of course, usually that of the apoplexies from which it originates ; but, as isatients rarely expect such attacks, little, as a rule, is done for their prevention. As the hemiplegic, how- ever, is often anxious about second attacks, it is not so difficult to have him carry out rules of careful living that may be of value in warding them off. Whenever there is good reason to apprehend the occurrence of hemorrhagic apoplexy, those threatened should lead most careful lives. In the majority of cases chronic degeneration of the arteries, associated with cardiac and renal disease, is present, and sometimes there may be a syphilitic or a gouty disease of the vessels. Strict attention should therefore be paid to the kidneys, heart, and vessels. Mild diuretics, especially the alkaline mineral waters, can be used in moderation. Constipation should not be permitted. The well known pills of aloin, strychnine, and belladonna, with an occa- sional mercurial and saline, are of service. If hypertrophy of the 592 NERVOUS DISEASES. heart or some other form of cardiac disease be present, a judicious use of cardiac remedies may be instrumental in preventing the apo- plexy. Arsenic and small doses of the iodides are of some value, if long continued, because of their effects upon the vessels and viscera. The food should be sufdcient in amount, but of such a character as to be easily digested and assimilated. Alcohol should not be abused, and in most cases it is well to abstain entirely from its use. Overwork, worry, and exposure to sudden alterna- tions of heat and cold may act as predisposing as well as exciting causes of an apoplectic attack. While violent exercise should be carefally avoided, the hemiplegio should not lead a life that is too sedentary. All sources of physical and mental strain should as far as possible be removed, and exjposure to excesses of temperature should be avoided. If patients have a syphilitic history they shoiild be treated for chronic syphilis. Sodium and potassium iodide are valuable for their effects on the vessels and viscera. Lithium and col- chicum preparations should be used in gouty cases. Occasionally it may be possible to prevent a hemiplegic attack, as when a syphilitic patient is troubled with numbness and formications or with slight spasms and twitchings, when active specific treatment may prevent the threatened attack. For most cases of hemiplegia and monoplegia of organic origin little can be done to affect the lesion responsible for the paralysis and the accompanying conditions. In cases of hemor- rhage some absorption takes place as time progresses, and, in the hope of assisting this process, ammonium preparations and iodides may be used in moderation for a few weeks or months after the patient has rallied from the apoplectic attack. These drugs do some good also by their effect on the chronic disease of the vessels which is so commonly present. Necrosed tissues cannot be removed nor improved by drugs, so that in cases following embolism or thrombosis alteratiA'es and a) isorbents are of value only for their effects upon the vessels. If a hemiplegia is found to be due to a tumor or diffuse syphilis, or to an intoxication, the patient should be treated accordingly. Close atten- tion should be paid by the physician to the sufferings of hemiplegics. The pains in their limbs may be due to neuritis, and this should be treated by rest, hot applications, and internal remedies, like the sali- cylates, iodides, and bromides. Counterirritation and anodyne lini- ments may afford some relief Electrical Treatment. The question of the use of electricity for the treatment of organic hemiplegias is one of considerable interest. Some writers, like Hirt, seem to give it too much importance ; others pass it by with neglect or even contempt. By its careful and judi- cious use a certain amount of good can be accomplished. The lesion cannot be removed by it, nor can secondary degenerations be pre- -s'cnted or benefited. It may, however, stimulate a palsied limb to do all that it is capable of performing, the amount of paralysis CHRONIC HEMIPLEGIAS AND MONOPLEGIAS. 593 present being sometimes out of proportion to the lesion causing it. The patient is paralyzed not only because of the destructive cerebral lesion which is present, but because of disuse, indifference, or psy- chical impression. Electrical stimulation leads the patient to efforts which he might otherwise neglect. Some of the incidents and acci- dents of hemiplegia may be benefited by electricity. It may be of service, for example, in the treatment of the secondary neuritis to which reference has been made, especially when it has become sub- acute and chronic ; or it may promote absorption in the joints or improve the circulation and nutrition. The faradic current answers for most purposes in the treatment of the paralysis itself ; but for chronic neuritis and arthropathies the galvanic current of moderate strength is more useful. Strong currents carelessly applied to para- lyzed limbs may do harm, not only by undue stimulation of nerves and muscles, but occasionally by reflexly exciting the nervous cen- tres. Electricity should not be used at all after an apoplectic attack for at least four weeks, and it may be wise to wait even longer than this. Treatment should not be begun as long as any evidences of brain irritation are present. As regards the treatment of contrac- tures, in my experience, neither the application of galvanism to the muscles spasmodically affected, nor that of faradism or galvanism to their antagonists, has ever done any permanent good. Massage and other Forms of Local Treatment. Massage, Swedish movements, and systematized exercises have some place in the treat- ment of residual hemiplegias ; but too much should not be expected from them, and patients should not be turned over wholly to mas- seurs and masseuses, as they often believe that they can accomplish more than is possible. Massage and movement treatment, if violent, may be injurious rather than beneficial, but carried out with discre- tion and under the advice and control of the physician they may be of considerable service. It is sometimes a comfort to old hemiplegics with marked contractures to have them temporarily overcome, and patients may be seen straightening their fingers and hands with the unaffected hands. For the purpose of giving such temporary relief, sphnts may be carefully applied to the upper extremity, a small cylinder or rubber ball being placed in the hand ; or instead of this an Esmarch bandage may be applied for a short time. Gymnastic exercises for the fingers and hand, as on a typewriter or a dumb piano keyboard, have been recommended for the athetoid and ataxic movements; but little can be expected from their use. The non- paralyzed as well as the paralyzed side of the body should receive local treatment, for, as has been shown, this side is often considerably affected, and the loss of power and of coordination may be improved by skilful and well regulated passive and active exercises. Surgical treatment for the contractures is sometimes practised, but, as a rule, should not be undertaken. 38 694 NBRVOTJS DISEASES. HYPERTROPHY OP THE BRAIN. Some of the malformations of the brain and its envelopes have been considered in Chapter III. (pages 313 to 320), and, as there stated, most of these have but little clinical interest, while some, such as microcephalus, will be more conveniently discussed under idiocy and insanity. Before considering the cerebral palsies of chil- dren, however, a few of the more important cerebral defects, such as hypertrophy of the brain, heterotopia, atrophy of the brain, and porencephaly, should receive attention, as they are in some instances the pathological causes of these affections. Hypertrophy of the brain, or macrencephalia, is an enlargement or overgrowth of the whole or of a portion of the brain, although the partial hypertrophies usually receive special designations. It is to be understood that the increase in bulk is not due to abscess, tumor, or other acquired lesions, focal or diffuse. The condition is usually of congenital origin. It may give rise to macrocephalus, or enlargement of the head, but it may be present, for a time at least, without increase in the general bulk of the head, and macrocephalus may be due to hydrocephalus and other causes besides hypertrophy of the brain. In a strict sense hyper- trophy refers to overnourishment, and the word auxesis, which is derived from the Greek au^w and means increase in size or bulk, would be more correct for these cases. Partial hypertrophy of the brain is a very rare affection. A few well authenticated cases of general enlargement of the brain with increase in the size of the head have been reported. Many years since, with Dr. F. X. Dercum, I assisted in making an autopsy on a child who had been supposed to have hydrocephalus, in which the brain was generally hyper- trophied. In a case reported by Tuke, the patient having attained adult age, the right hemisphere of the cerebrum was very much en- larged, was tough, and weighed only twenty-three and a half ounces. The specific gravity of the two hemisi)heres was the same. The basal ganglia did not appear to have participated in the enlargement. Symptomatology. — The principal symptoms in cases of congen- ital infantile hypertrophy are headache, tinnitus, apathy, at times great excitement followed l»y coma, mental deficiency, difficulty in walking, and convulsions. In eight cases under Beach's care, four died of convulsions, two in a comatose condition, and the remaining two of diarrhea and bronchitis. Idiotic and imbecile children suf- fering from hypertrophy of tlie brain usually die between the ages of five and fifteen years. Down gi^'es the following description of the peculiarities presented by one of these cases : ' ' He walks circum- spectly, and when in the at't of prehension does it in a slow deliberate manner ; even the temptation of taking food to his mouth (and he is particularly fond of eating) does not induce him to feed himself in other than the most deliberate way. He talks, but it is in the same HYPERTROPHY OF THE BRAIN. 596 slow manner, and only in response to questions. His sentences are short and their utterance tardy. Even when excited by promise of reward he speaks with only slightly increased utterance. His pro- gression is by slow walking, and no inducement makes him run. He is rather below the ordinary stature ; has no deformity, except that his fingers are shorter than normal. His face is largely de- veloped, and his nose correspondingly so. When questioned he fre- quently makes feeble movements of the lips without utterance of sound, and only gives audible responses when stimulated to do so. He is seventeen years of age, and the signs of puberty are not want- ing." When the head is very much increased in size, the patient is sometimes unable to carry it without support. Etiology and Pathology. — The causes are obscure, but probably tuberculoiis, syphilitic, alcoholic, or other degenerative heredity is more efficient than anything else. Andral and some early observers have attributed hypertrophy to lead poison, but the proofs of this relationship are, to say the least, uncertain. According to Virchow, who wrote on this subject as early as 1856, the increase in the bulk of the brain is due to overgrowth of the neuroglia ; and most sub- sequent observers agree with this view. Eokitansky believed that increase in size was probably due to an albuminoid infiltration of the brain structure. According to Fletcher Beach, the disease as seen in imbeciles is due to what appears to be granular matter ; but this appearance may be dependent upon the increased amount of con- nective tissue which has broken down as the result of postmortem changes. The brain is anemic, and the bloodvessels are attenuated, but in rare cases they are increased, and a large number of leuco- cytes may be present. It has been suggested that the anemia which is so constant may occur only during the last stages of life, as the result of the final compression of the brain within the skiill. The skull cap may be thinned or thickened. The dura is adherent to the cranium, and the convolutions are flattened and pressed together. The white matter is usually in excess. Cerebrospinal fluid is de- ficient or absolutely lacking in the membranous spaces, and absent or in small quantities in the ventricles. Some cases have been recorded in which local enlargements have been present in the peripheral nerves, in the ganglia, and in the central nervous system. A ten- dency to enlargement of the head unassociated with hydrocephalus has been observed in several generations. The consistency of the brain is nearly always markedly changed. It has been described as tough like the boiled white of an egg, or like cheese or rubber. Increase in the bulk and weight of the brain is sometimes very great. In one reported case it reached nineteen hundred and eleven grammes, or 65.7 ounces. (Virchow.) This brain is one of the heaviest on record, but several cases have been reported in which the weight has reached from sixteen hundred to nineteen hundred grammes. 596 NERVOUS DISEASES. The following table is slightly modified from one by Beach : Weight in Ounces of Seven Hypertrophied Brains, and Average Weight of Brains of Individuals of the Same Age. Age. Weight of hypeetkophied Average weight of brains Average weight of brains BRAINS. (Dr. Boyd's tables). (Dk. Beach's tables). 5 49.5 40.2.3 40.5 8 53 45.96 39 10 55 45.96 40 11 49 45.96 41 11 49.5 45.96 41 14 52 45.96 41 15 62 48.54 42 Diagnosis, Prognosis, and Treatment. — The diagnosis is chiefly to be made from chronic hydrocephalus, this resting on the history of the case and a careful examination of the head. The following table shows the points of difference as given by Beach : Hypeeteophy of the Beain. Head increased in size, but not so much as in hydrocephalus. Increase is most marked above the su- perciliary ridges. The head approaches a square shape. No elasticity over the fontanelles. Often depressions in the position of the fontanelles. Distance between the eyes not in- creased. Hydeocephalus. The head more increased in size. The size of the head most marked at the temples. Head more globular. Elasticity over the closed fontanelles. No depressions in the position of the fontanelles. Distance between the eyes increased. The prognosis is of course bad, and, so far as the affection is known, no treatment is available. HETEROTOPIA. The term heterotopia, as used in neurology, is applied to the mis- placement or the development in unusual positions of either the gray or the white matter of the brain and spinal cord. Numerous cases of heterotopia of the brain have been recorded. Although a true spinal heterotopia is sometimes found. Van Gieson has shown that many cases of so-called heterotopia of the cord may be due to post- mortem manipulations. Heterotopia is to be classed as a peculiar developmental aberration rather than as a special hypertrophy. It has little clinical importance. The observed cases have been found in connection with idiocy and imbecility. Cerebellar heterotopia has been discovered after death, the individual not having shown abnormal manifestations during life. Cerebral heterotopia is almost invariably associated with mental or physical arrest, and is usually a part of some more general congenital morbid condition. It has been found in the brains of those suffering from some forms of infantile ATROPHY OF THE BRAIN ATROPHY AND SCLEROSIS. 597 cerebral palsy with idiocy and epilepsy. The isolated masses of cinerea, when cerebral, are commonly found near the basal ganglia or the walls of the ventricles, especially of the lateral ventricles. They are also somewhat frequently located in the white matter of the cere- bellum. They have practically the same structure as the cerebral cortex, from which they are regarded as having been detached. MateU has reported the case of a woman, a low grade imbecile, who died at the age of twenty -five years, and who had suffered since her sixth year from epilepsy. The patient's head was small, and showed abnormalities. The forebrain was small, and its fissuration reduced and aberrant. A strip of gray matter was present in the centrum ovale. The area in structure was like that of the cortical substance, with which it was connected here and there by bridge-like formations of cinerea. MateU regarded the anomaly as dependent either on an interruption of the development of the brain, or on a complete stand- stiU of its growth at an early period, as at the sixth month of fetal life. The condition was present in both hemispheres. This case is especially referred to here because the investigation seemed clearly to show its cortical origin. In other cases the insular masses are so far removed from the cortex as apparently to have no connection with it, and yet these, like the striatum itself, are from an embryonal standpoint probably cortical structures. It is a matter of dispute among anatomists and morphologists whether the heterotopia is due to aberrant or abnormal development of nerve fibres causing detach- ment of cortical or ganglionic cinerea, or whether the gray masses develop primarily in unusual positions and are subsequently en- trapped by the fibres. Heterotoi^ia of the white matter has been observed in the oblongata. Heard, in 1894, collected the obser- vations of this kind, which, including his own, amounted to nine in all. In the majority of these cases anomalous bundles of white matter have been found unilaterally situated. One was observed by Cramer upon the side of the lesion in a case of cerebellar hemi- atrophy. Kronthal discovered two anomalous unilateral bundles in a case of bulbar paralysis. Heard concludes that the most frequent and fairly constant anomaly in these cases appears to be the presence of a column of white nerve fibres arising at the level of the decus- sation and thence proceeding cephalad in a position internal to the substantia gelatinosa. Klob found a mass of white cerebral sub- stance the size of a bean hanging from a pedicle between the two optic nerves. ATROPHY OF THE BRAIN— ATROPHY AND SCLEROSIS. Anencephaly, or absence of the brain, when total, is without clinical interest, but certain forms of atrophy of the brain give rise to partial anencephaly and to affections which may call for diagnosis and in a few cases for treatment. The more generalized forms of 598 NERVOUS DISEASES. encephalic atrophy are usually congenital. Partial or diffuse atrophy may be congenitai, may be initiated at the time of birth, or may be acquired after birth. When postnatal it commonly originates in the very earliest years of life. In partial anencephaly due to atrophy both hemispheres may be in part wanting, or one may be present and the other practically absent, or one or both hemispheres may be the seat of defects of varying size. Porencephaly is in a general sense a form of partial anencephaly, but in the cases to which reference is made in this section, although a large portion of the brain may be Fig. 315. Coronal aspect of the brain, showing marked atrophy of the right hemisphere and of its con- volutions, from a girl of nineteen, with left hemiplegia, moderate contractures in the paralyzed limbs, epilepsy, and imbecility. (Shaw.) absent, a circumscribed hole or cavity is not formed. In general atrophy brain and skull are both small. When any one consider- able portion of the brain is absent, other functionally associated regions are also found to be more or less atrophied or involuted, as when atrophy of one cerebral hemisphere is associated with marked diminution in bulk of the opposite olive and opposite lateral lobe of the cerebellum. Occasionally the entire cerebellum or a very large portion of it is atrophied or undeveloped. Eeference was made in Chapter IV. to these cerebellar cases, and to the absence or atrophy of such important structuies as the callosum. ATROPHY OF THE BEAIN ATROPHY AND SCLEROSIS. 599 Etiology and Pathology.— Among the causes of partial con- genital atrophy of the brain are pathological conditions of the amnion, as adhesions of this membrane to the embryo, or constric- tions of the cephalic extremity of the embryo. Such adhesions and constrictions may be caused by pressure either from within or from without, and they occasionally result from abdominal traumatisms received by the mother. Acquired atrophy may be due to meningeal hemorrhage, to meningitis or encephalitis, or to any cause injuriously Fig. 316. Basal aspect of the brain shown in Fig. 315 : extreme atrophy of the right hemisphere, decided atrophy of the right half of the pons, and small left lateral lobe of the cerebellum. (Shaw. ) affecting the nutrition of the infantile cortex. In rare cases the atrophied brain is less consistent than normal, but usually it is firmer and is made up largely of connective tissue. In other words, atrophy and sclerosis are commonly associated. Osier found wasting and induration in fifty cases. This was either in groups of convolu- tions or involved an entire lobe or in some cases the whole hemi- sphere. The sclerosis in most of these cases is secondary to atrophy of the true nerve elements. When sclerosis is the primary lesion a diminution in bulk is not likely to be present. The causes already detailed, and others, may lead to an arrest of development of the 600 NERVOUS DISEASES. nerve elements, and consequent overgrowth of connective tissue. Under various names, sucli as lobar sclerosis, tuberous sclerosis, and diffuse sclerosis, much attention has been paid to this subject, espe- cially by French observers in recent years, prominent among them being Bourneville and Cotard. Now and then, instead of being lobar and diffuse, the sclerosis may be in nodules or patches, and these may be scattered over the surface of the brain. "The affected convolu- tions are small, of a grayish yellow color, often with a stippled, pitted surface, to which the pia adheres firmly. In contrast with the neighboring normal gyri, the appearance is very striking and FiQ. 317. Coronal aspect of the brain in a case of extreme atropliy of tiie right hemicerebrum. (Shaw.) characteristic. The reduction in size of the affected hemisphere may amount to one third of the bulk. In one case the atrophied hemisphere weighed two hundred and sixty grains, the normal ten hundred and seven grains. The tissue may be a mere shell over a dilated lateral ventricle, as in the cases of Baud and Piorry. In many cases anfractuosities and small cysts have been found in and about the sclerosed tissue." (Osier.) In Figs. 315 and 316 are shown the appearances presented by the superior and inferior aspects of the brain from a case of atrophy reported by Shaw. The right lateral lobi^ of the cerebellum is exposed ; and, as shown in Fig. 316, the right half of the pons and the left cerebellar lobe are decidedly reduced in size. The brain was taken from a girl of nine- teen, who was imbecile and epileptic and had marked left hemiplegia POKENCEPHALY. 601 with moderate contractures in the paralyzed limb. In Fig. 317 is shown the brain from another remarkable case of cerebral atrophy reported by Shaw. The right hemicerebrum is extremely atro- phied, so that both the cerebellum and the quadrigemiual body are uncovered. The patient from whom the specimen was taken was an imbecile with paralysis and extreme atrophy of the trunk and limbs, and was subject to convulsions. (Pig. 318.) The diagnosis, prognosis, and treatment of atrophy of the brain, general or partial, are Fig. 318. considered under imbecility, infan- tile cerebral paralysis, and other affections of which it is the patho- logical cause. Symptomatology. — The symp- toms of atrophy of the brain will vary according as it is general or partial, and to some extent according to its location. Almost invariably mental defect is present, and this is not infrequently a low grade of idi- ocy. Some of the forms of cerebral palsy in children are associated with unilateral and bilateral atrophies. PORENCEPHALY. The term porencephaly is derived from the Greek words r.opoq^ a cavity, and eyxicpaXo^j brain, meaning a hole or cavity in the brain, and has been used in describing somewhat differ- ent conditions. Heschl, who sug- gested the name, applied it only to congenital cases, the defect, as de- scribed by him, being one in which, because of an absence of cortical and subcortical substance, a large hole, usually somewhat funnel-shaped, was found. This cavity in some instances communicates with the ventricles. The term is applied by some authors to acquired as well as to con- genital cases ; others would restrict it to the latter. Besides the many cases which are clearly traceable to the fetal period, a few have been recorded in which cavities of considerable size have originated after birth, some of them as the result of meningeal hem- orrhage, or from intracerebral hemorrhage, embolism, or throm- bosis. As Sachs has suggested, some of the so-called congenital Infuiuile cerebral hemiplegia, with marked atrophy of the limlj« and trunk ; the patient imbecile and epileptic. The brain from this case is shown in Fig. 317. (Shaw.) 602 NERVOUS DISEASES. cases may be regarded as acquired in the sense that they have re- sulted from influences acting on the fetal brain. Cases acquired after birth are sometimes spoken of as spurious porencephaly. The mech- anism of the production of porencephaly is not entirely clear. Proba- bly in cases of hemorrhagic origin the effused blood by compi^ession causes atrophy and arrest of development in the cortex and subcortex ; and when vessels are occluded a necrosis of the tissues results, with some additional arrest of development in adjacent regions. The blood is absorbed in hemorrhagic cases, and the cavity formed by the loss of brain substance is filled with cerebrospinal fluid. Cases of acquired porencephalus have been reported by Peterson, Willard and Lloyd, and others. Certain characteristics seem to belong to all the cases of porencephaly of congenital origin. When the defect is intracere- bral the overhanging cortex is depressed and roofed in by the arach- FiG. 319. Lateral aspect of the right hemicerebrum from a case of porencephaly in a man fifty-seven years of age : the patient's body observed to be unsymmetrical at birth ; arrested development of the left side ; asymmetry of the skull ; history of a fall and of intemperance and sunstroke ; absent knee jerk and unequal pupils ; general paresis late in the history of the case. (Brush.) noid, the pia closely investing the convolutions. When the sub- arachnoid space forms a part of the cavity or communicates with it, the arachnoid terminates along the edges of the cavity, while the pia invests the brain for some distance into the cavity. According to Kundrat, one of the most characteristic features of the congenital cases is a peculiar radiating arrangement of the flssures and convolu- tions around the cavity. An important point bearing on the time of initiation of the porencephalic lesion is the fact that the permanent primary fissures are never entirely absent, although they may he considerably changed in extent and direction. Porencephaly attacks both hemispheres in about one third of the cases. When only one side of the brain is affected, this is somewhat more frequently the right than the left hemisphere. The convexity of the parietal lobe is its most frequent seat, but it has been found in all parts of the PORENCEPHALY. 603 brain. According to Brill, no case has been reported in wbicb the mesal surface of tbe hemisphere has been implicated ; but, in con- tradiction to this, a case reported by Briish (Figs. 319 and 320) shows distinct involvement of the mesal surface. The cavity, it will be observed, occupies the position of the parietal lobe, and encroaches upon the occipital and temporal lobes. On the inner surface of the hemisphere the cuneus is represented by a shell of brain substance, and nothing remains of the quadrate lobule but a thin stratum of brain substance at its anterior portion. The symp- toms of both congenital and acquired porencephaly are those which are described as belonging to some forms of diplegia and hemi- plegia. Mental disorder is always prominent. Various grades of idiocy are present ; this may be of such an extreme character that the patient leads little more than a vegetative life. Mutism is some- times absolute, and, as a rule, speech is greatly impaired ; deafness and in rare instances blindness are present. Strabismus is common. -f. 111-.*.- Mesal aspect of the right hemicerebrum in a case of porencephaly. Same case as Fig. 319. (Brush.) Epilepsy occurs in a fair percentage of cases. The most constant manifestations besides the mental deficiency are, however, in the trophic and motor spheres. Extreme conditions of spastic paraly- sis with contractures, athetoid and choreoid movements, and atro- phy and malformations of the limbs, trunk, and head, are frequently present. "While the above statements summarize the symptoma- tology of the vast majority of cases of porencephaly, this defect may exist and be of considerable size without extreme conditions of paralysis and imbecility. The diagnosis of porencephaly is in the main that of the infantile diplegias and hemiplegias, which will be considered in the next section. It is occasionally important to differentiate porencephaly from tumor, meningitis, or other more active lesion, as the former is less amenable to treatment. The prognosis of porencephalic cases is necessarily bad, although many of them reach adult life. 604 NEEVOUS DISEASES. THE CEREBRAL PARALYSES OP CHILDREN, AND AFFEC- TIONS ALLIED IN PATHOLOGICAL CAUSATION. Under tlie general designation " cerebral paralyses of children" or " infantile cerebral palsies" are included several affections differing somewhat in their clinical features, but agreeing in that their symp- toms are due to lesions which involve chiefly the corticospinal portion of the motor subdivision of the nervous system. While paralysis, rigidity, and other phenomena are the predominating features, other manifestations, such as defective intelligence often amounting to im- becility or even idiocy, disturbances of the special senses, and vaso- motor and trophic disorders, are frequently present. Paralysis may indeed be absent, and yet the case may pathologically belong to the general type classed as cerebral palsies, the lesions being so situated as not to destroy those parts of the brain which are related to motor functions. The literature of the subject has advanced with rapid strides during the last ten years. For its full discussion special monographs should be consulted, among the most important of which are contributions by Cotard, Kundrat, Striimpell, Marie, Eoss, Mc- Nutt, Knapp, Osier, Freud, Eosenthal, and Sachs and Peterson, although many others almost equally valuable have been published. An important pioneer communication was by Little, in 1853, on the spastic paralyses and rigidities occurring in children, this writer first clearly relating some of these affections to abnormal parturition, difficult labors, and premature birth. Dr. Sarah McNutt was the first to show the relations of meningeal hemorrhages to these affec- tions. As early as 1879 the author, in a lecture published in the 'New York Medical Becord, reported several cases of infantile diplegia and hemiplegia, discussing the question of their cerebral origin. Gee had previously reported similar cases. Freud and Eie and Eosen- thal have recently done much towards systematizing and making more complete our knowledge of the diplegias. The cases are usu- ally considered under the heads of diplegias, paraplegias, hemiplegias, and monoplegias. These terms, embodying the idea of paralysis, are strictly applicable to a majority of cases, but are not descriptive of all. The motor phenomena are frequently of the nature of rigidities, choreas, athetoses, ataxias, or other affections characterized by in- creased muscular activity, and these may be associated with paresis and jjaralysis, but in other instances real loss of power is absent. They are liyperldneses, disorders in which motility is exaggerated, rather than akineses, or paralyses, in which motion is impaired or lost. In the present state of our knowledge, however, little would be gained by an attempt to classify the hyperkineses apart from the paralyses. Hemiplegias constitute a large majority of the whole number of cases, although diplegias are by no means rare. An analysis of two hundred and twenty-five cases made by Sachs and CEREBRAL PARALYSES OP CHILDREN. 605 Fig. .Wl Peterson shows eighty- one cases of right hemiplegia, seventy-five of left hemiplegia, thirty-nine of diplegia, and thirty of paraplegia. Piire monoplegias are very rare. Varieties of Diplegia.— The cerebral diplegias exhibit consider- able clinical diversity iu their symptomatology, bnt a fliir practical basis for the study of these affections is afforded by the four types suggested by Freud, namely, (1^ generalized rigidity ; (2) paraplegic rigidity ; (3) double spasmodic hemiplegia ; and (4) generalized bi- lateral chorea and double athetosis. These designations aptly describe the dominating features in each set of cases. Generalized rigidity is sometimes spoken of as Little's disease. A more or less rigid con- dition is presented by the muscles of the trunk and extremities, and in some cases even hj those of the neck and face. In the tj'pical para- plegic cases rigidity is confined to the lower extremities. (Fig. 321.) In both of these varieties true paral- ysis is not a marked feature, or may be absent. When rigidity and con- tractures are general and are of a decided character, it is sometimes difScult to determine how much real paralysis is present. In the double spasmodic hemiplegias true paral- ysis is clearly associated with the spastic state, and not infrequently the limbs exhibit more or less atrophy. Instead of typical cases of generalized rigidity or double spasmodic hemiplegia, my own investigations have shown that a con- dition of rigidity or a spasmodic hemiplegia is often present on one side while on the other side one extremity only may be markedly affected, this being usually the leg. (Figs. 322 and 323.) While the arm may escape in large part, however, examination will usually show some impairment of power and some hypertonia. In cases of generalized bilateral chorea and double athetosis the hyperkinesia is usually most marked in the upper half of the body, the movements often affecting the upper extremities, trunk, head, and face. These so-called types are often irregular and are seen shading into one another. Great differences in the degree of impairment of intelli- gence may be present, the relative amounts of rigidity and paralysis may vary considerably, and the prominent features of any one variety Infantile spastic paraplegia. (Willard.) 606 NERVOUS DISEASES. Fig. 322 may be exhibited in some degree by any otlier. Paraplegic rigidity is of course j)resent in generalized rigidity, and chorea and athetosis often have some place in other types than the fourth. In Little's dis- ease the rigidity may be extreme, moderate, or slight, or practically almost latent, some cases approaching closely to the normal. Strabis- mus, convulsions, or a greater or less degree of paralysis maybe present in any form. Between the types of generalized rigidity and of para- plegic rigidity occur transitional forms. In the paraplegic cases, for example, traces of rigidity may be present in the upper limbs, such patients show- ing feeble contractures, slight involuntary movements, and a little awkwardness in using their hands. Between generalized rigidity and double spasmodic hemiplegia are also transitional forms. It may be in- teresting to record in this connection the chief features of two diplegic cases re- ported by me in 1879. Summarized, they were as follows : dilated pupils and in- ternal strabismus ; weakened intelligence ; in one case convulsions in infancy ; ap- parent weakness of the muscles of the back in both cases ; marked spasticity of the lower extremities, chiefly aifecting the flexors and adductors ; a similar spastic condition in the arms in one case, and a tendency to spasmodic contraction in the other ; inability to stand or walk alone ; tendon reflexes increased ; no paralysis of IJB ^^^^1 ^^^ bladder or bowels ; retention of electro- MML I^^I contractility and sensibility ; and absence ',mmh. JEU *^^ vasomotor changes or joint troubles. m \ jJT^H Varieties of Hemiplegia. — Many of W \ Mi^^M the cases of infantile cerebral hemiplegia differ from each other in especial but easily determined particulars. Hemiplegia with spasticity and marked contracture is com- mon ; but instances of flaccid paralysis are met with, although they are rare. The hemiplegia may be associated with athe- tosis or athetoid movements, with chorea or choreiform inovements, or with coarse tremors or tremulous move- ments of special character ; or it may be combined with general arrest of development of the same half of the body, or with local arrest in a limb or limbs, as wlien confined to the distal portion of the arm. Instead of atrophy more or less diffuse hypertrophy may in rare Idiocy v,\th spastic dipli^^ia chiefly afTtctim, Inith legs and tbi. rifiht arm , A\lth rachitic dclurm- itiUiS. CEREBRAL PARALYSES OF CHILDREN. 607 FiQ. 323. instances be present. Two of these types of hemiplegia are shown in Figs. 324 and 325. In other cases it may be associated with a motor or sensory aphasia, with hemianopsia, or with mirror writing. In a few cases the associated mental state is normal or nearly normal ; in others the condition is one of feeble-mindedness or retarded intel- lectual development ; and in still others, which constitute the largest number, true idiocy or imbecility is present. As in adults, the arm is more seriously and more frequently affected than the leg, and the paralysis is more marked in the distal than in the proximal portions of the limb. Compared with adult hemiple- gias, motor aphasia occurs relatively oftener with left-sided paralysis, dis- orders of movement are more frequent, and arrest of development on the par- alyzed side is decidedly more prom- inent. The face, and especially the lower face, may be involved, but it often escapes. This involvement of the face is much more common as a persistent phenomenon in the diple- gias, and especially in the double spas- modic hemiplegias and in the bilateral choreas and double athetoses. The facial muscles in the latter cases are sometimes the seat of bizarre grimaces. One side of the face may show paresis and the other side contractures. Symptoms of the Period of Onset. — The published accounts of the clinical history of cases of infantile and juvenile cerebral paralyses have, for manifest reasons, been based chiefly upon a study of the residual symp- toms. A fetal symptomatology is un- known, as intra-uterine manifestations can be surmised only through the complaints of the mother. Cases which originate during labor or very early in infancy are frequently not recognized immediately as instances either of mental defect or of paralysis. In the so-called birth palsies, usually after a prolonged or dif&cult first labor, the child may be born asphyxiated, or may have a convulsion or a series of convulsions immediately or a short time after birth. While often present, asphyxia or convulsions are not invariable. The infant may exhibit simply a condition of extreme feebleness. When the causes have acted before birth, symptoms like coma or convulsions may call attention to the child at the time of birth. Labor may not Irregular type of diplegia : low grade imbecile ; unable to walk or talk ; para- plegic rigidity ; considerable rigidity of the shoulders, but arms freely movable below the elbows; athetoid movements in the upper extremities. 608 NERVOUS DISEASES. Fig. .324. liave been especially difficult. The appearance of the child may be such as to attract attention or to arouse suspicion ; but it may be difficult or almost impossible to judge of the existence of mental arrest or of paralysis from the conditions present at or soon after birth. In a short time it may be noticed that the limbs are not used with the oi'dinary freedom, and that they tend to remain flexed or in unusual positions. General, paraplegic, or localized rigidity, gro- tesque facial expression, a tendency to keep the mouth open, drool- ing, and strabismus may be observed. Efforts are not made to walk or talk at the usual age ; and the infant does not fix its attention or show purposive actions like normal children. As the hemiplegias as well as the diplegias acquired after birth are due to meningeal hemorrhage, intracerebral hemorrhage, embo- lism, thrombosis, focal encei^halitis, acute or chronic meningitis, and hydrocephalus, the symptomatology of the onset must difier ac- cording to the causative affection. When the lesion is a meningeal hemorrhage the attacks are most frequently ushered in by loss of con- sciousness and convulsions. Coma is nearly always i^rofound, and may vary in duration from a few hoiirs to several days. Changes in temperature have been recorded and are probably usually present, but they have not yet been studied as carefully as in the apo- plexies of adults. Delirium, vomiting, re- traction or tossing of the head, or screaming spells may be present, and paralysis of one half of the body may in some cases be made out during the apoplectic attack. It is a point of interest that the hemiplegia may be of more complete character than in older pa- tients. Unilateral disturbance of the respi- ratory muscles may be evident, and the paralysis is likely at first to be marked in the face as well as in the limbs. The reader is referred to Chapter V. for the discussion of the symptomatology and differ- ential diagnosis of intracerebral hemorrhage, embolism, and throm- bosis as they occur in adults, and to the various sections of Chapter III. for the symptoms of marantic and secondary thrombosis, of focal encephalitis, of the different varieties of acute or chronic meningitis, and of h>^drocephaJns. Symptoms and Conditions accompanying the Residual Pa- ralysis. — After the symptoms of the acute attack have passed off, the residual symptoms presented by different cases, which have Spastic heiiiipleK'ia with imbecility : markud arrest uf development of the entire right side. CEREBRAL PARALYSES OF CHir.DREN. G09 been enumerated under the varieties of diplegia and heiiiiplegia, will depend largely upon the position, extent, and character of the lesions which remain. In a few cases monosyllabic speech, nystagmus, dys- phagia, a peculiar dyspnea, stridulous respiration, and arrest of laryngeal growth have been noted. As already stated, rigidity is the characteristic feature of two of the most important types of diplegia, but it may be present in other varieties, and also in the hemiplegias. It may be of any degree, from the lightest hyper- tonia which offers scarcely any ob- stacle to passive movements, to a rigidity which fixes the limb in an almost immovable position. Rigidity may be present with but little loss of power, or it may coincide with most pronounced paralysis. The differ- ence between rigidity and paralysis is sometimes made apparent by the station and walk of the patients. When paralysis is present, the limbs give way and the patient may be un- able to stand ; when the condi tion is chiefly that of rigidity, both standing and walking may be possible, attitude and gait being of the silastic type. Contractures are probably present in three fourths of the cases of diplegia, and in a large but less percentage of cases of hemiplegia. Some of the characteristic attitudes and methods of progression are shown in Figs. 326 and 327. Adductions and flexions predominate, giving forms of the ad- ductor or close-legged and of cross- legged progression. Equinus and equinovarus are among the most com- mon deformities, but valgus is some- times observed. Occasionally the deformities are due to secondary conditions in the tendons and joints rather than to spasms and contrac- tures. The hyperkineses of hemiplegia and diplegia are sometimes spoken of as " postparaplegic" and "posthemiplegic" disorders of movement, and these terms are correct enough as applied to some cases ; but the affections may be independent of any paralysis, as when we have choreiform or athetoid movements in the fourth of Freud's diplegic types. In other instances they are concomitant and Sf astic mon rk.,n flating from six >carh of age. con\ulbions from birth; atropliy and contractures of the left upper extremity ; lower extremity but little affected. 610 NERVOUS DISEASES. Fig. 326. associated phenomena rather than sequential to the paralyses. The general characteristics of these disorders of movement have been considered in the section on adult hemiplegias. Choreic and athe- toid movements are not infrequently mingled in the same case, but examples of pure athetosis are occasionally observed. In Fig. 328 is an illustration of bilateral chorea and double athetosis, and in Pigs. 326 and 329, of unilateral athe- tosis. Peterson has described a mor- bid movement to which he gives the name of posthemiplegic polymyo- clonus. The movements consist of constant clonic contractions in the muscles of the limbs affected, not oc- curring synchronously, the rhythm being that of paralysis agitaus. In one of the cases now in the Phila- delphia Hospital a distinct athetosis is present in the fingers and hand, and at the same time the limb from the shoulder is in a constant state of slight movement, the arm being held downward in the position in which it is usually carried on standing or walking. la this case also slight twitchings are almost constantly pres- ent in the muscles about the mouth and the lower part of the face on both sides. In some cases the arm is twisted or distorted at the joints, and is carried around and held against the back, palm outward, to keep it at rest. Associated movements are fre- quently observed, especially among diplegics. Forced movements are less common, but forced attitudes which are compelled by the paralysis, spasm, and rigidity that are present, and it may be in some instances by the mental status of the patient, are frequent. Knee jerk and muscle jerk are usually exaggerated : and ankle clonus and front tap move- ments can often be elicited. If the knee jerk should be absent, the possibility of a spinal complication should be borne in mind. It may apj)ear to be absent when it is not, the limb being simply held S]>asmodically fixed. Strabismus occurs with moderate frequency. The muscles in diplegia and heniiijlegia respond to the electrical current. The parts affected, however, are arrested in growth. In the hemiplegie cases, especially in those which have lasted some Irregular type of diplegia in a low grade demi-microcephalic idiot : both legs spastic ; right leg smaller and weaker than the left ; rigidity, paresis, and atrophy of right arm ; left arm unaffected or but slightly involved ; method of progression and athetoid movements on using the right arm shown. CEREBRAL PARALYSES OF CHILDREN. 611 years, not only are the limbs shorter and smaller, but the trunk and head and in fact the entire half of the body are distinctly di- minished in size. This is evident iu some of the illustrations. The unparalyzed as well as the paralyzed side may be retarded in growth. In extreme cases of diplegia the limbs sometimes present a wasted appearance ; often they are of fair bulk and firm and hard. In choreoid and athetoid cases occasionally the muscles are hyper- trophied. In the case shown in Fig. 328 the entire upper half of the body seems to be overdeveloped. In many cases of infantile cerebral palsy the cranium shows defects and asymmetries which are often attributed to the use of instruments in difficult labors, and Fig. 327. in rare cases cranial deformities are thus produced. Not infrequently the skulls are smaller than nor- mal, being demimicrocephalic. The skull may be too long, or too short, or oblique, or may present any of the peculiarities described in the section on symptomatology and methods of investigation. In the hemiplegic cases the skull is often notably flattened on the side oppo- site the paralysis. Other of the so-called stigmata of degeneration, such as abnormalities of the face or of the palate, teeth, ears, or hair, may be present. On page 149 is given a table which shows the com- parative measurements of twenty cases of infantile spastic hemiplegia studied by Peterson and Fisher. They indicate marked deviations from the normal. Epilepsy. — A few of the symp- toms or associated conditions need special consideration. No convulsions were present in about one half the cases reported by Eosenthal. Sachs records epilepsy in forty-five per cent, of all his cases. All oases with a history of con- vulsions are not to be regarded as epileptic, as such convulsions may occur daily once or twice at or near the time of onset of the paralysis, and may be due to the immediate exciting effects of the lesion. Marie, Freud, Sachs, and others have directed attention to the important practical point that some of the cases regarded as examples of ordinary epilepsy will be found on close examination to belong properly to the diplegias or hemiplegias, only conditions Diplegia showing cross- progression. 612 NERVOUS DISEASES. of slight paresis or rigidity being present and overlooked. Such cases are not benefited as much by bromide treatment as are epi- leptics of the more usual types. The spasms may be general or Fig. 328. Bilateral chorea and dnulile athetosis : face, trunk, and upx)er extremities chiefly affected ; patient a deaf mute and mentally deficient ; convulsions the third day after birth ; walked at the age of nine years ; movements said to have begun at about the age of twelve years ; mother had a severe fall during ninth month of pregnancy. (Dercum.) of the Jaclvsonian form, and, when the latter, may in time become more and more generalized. Sometimes the convulsions are re- CEREBRAL PARALYSES OP CHILDREN. 613 Fi(, 329 garcled as a cause of the paralysis rather than as a result or even a concomitant ; and, as Dei'cum suggests, it is conceivable that a toxemia may give rise to severe convulsions, and that these may in turn so affect the nutrition of the brain as to lead to x>aralysis. Defects in the Visual Fields, and Mirror Writing. — Hemian- opsia and sector or irregular defects in the visual held are occasion- ally observed in infantile hemiplegias ; or such visual defects may be present in cases which should be included under the class of cei'ebral palsies although no motor loss may be present. The initial and residual lesions in these cases are outside of the motor areas and tracts. In the case reported by Brush, Figs. 319 and 320, such visual changes may have been i^resent. as the cuneus was simply represented by a shell of brain substance. In one case studied by me at the Vineland Training School the patient, who was at the time sixteen years old, could read, write, and draw, had fair powers of memory and attention, but was nervous, excitable, and obstinate, and at irregular intervals had severe convul- sions, in which the head and eyes were turned to the right and the face and limbs of the right side were in violent spasm both tonic and clonic. Before the con- vulsions he passed into a dreamy state, and on other occasions had visual hallu- cinations. He had hyperopic astigmatism of both eyes. Ophthalmoscopic examina- tion by Dr. S. D. Risley showed woolly choroid and the general eyeground of a fluffy red color. The field in the right eye was contracted. In the left^ eye the nasal field was cut off abruptly in a ver- tical line three to five inches to the right of fixation point. Mirror writing is some- times present in infantile cerebral hemiplegia. An interesting case at the Vineland Training School when eighteen months old had an illness attended with convulsions and resulting in partial right hemi- plegia. The boy ranked with the highest grade of imbeciles. He could repeat the alphabet, and spell and read words of one syllable. Eight sided partial paralysis with atrophy was present, as shown in Pig. 330. When efforts were made to teach him to wi-ite with his left hand from a copy it was discovered that he always made Ms attempts at writing from left to right. He copied slowly, but always began without hesitation to write in mirror fashion. Hemiplegia with atrophy and athetosis in a patient forty-four years old ■, the paralysis dating from early childhood. Marked depres- sion in the right frontoparietal re- gion. 614 NERVOUS DISEASES. Etiology and Pathogenesis. — The etiology of a certain number of cases of infantile cerebral palsies can only be surmised. The causes have been traced in a larger percentage of dijilegias and paraplegias than of hemiplegias, one reason for this being that trau- matism during labor is a more frequent cause of the former than of the latter. Both diplegias and hemiplegias can be classified from the etiological standpoint into cases which originate during the iutra- iiterine period, cases due to traumatism during labor, and cases due to various causes acting after [^f"" • ■ ■ ■ y ' i'^i fBB ^HBl^Bm oirtn. Prenatal Causes. With re- gard to prenatal or intra- uterine causation, it is now well established that certain special causes, such as trau- matisms, infectious diseases, and flight and other maternal impressions, may act through the mother. Several cases have been recorded in which autopsies have shown actual evidences of injury to the brain of the child during pregnancy. Eecent clots or older cysts have occasionaUy been discovered. In one case, cited by Cotard, the mother had received a blow on the abdomen, and an old lesion was found in the brain of the child, which was stillborn and showed hemiplegic contrac- tures. Gibbs has recorded another case of fetal cerebral hemorrhage apparently due to a blow received by the mother. All authorities are in accord as to the effects of a serious illness of the mother, such as infecti(ins and septic diseases like typhoid fever, severe influenza, pneiimonia, nephritis, and the exanthematous fevers. Osier records a case in wliich a large recent clot was found in the brain of a fetus six months old, the mother having died of typhoid fever. In some cases tlie child may suffer coinci- dently with the mother frojn infectious or toxic disease. Fright or any powerful emotional impression made iipon the mother during pregnancy is a cause often alleged and occasionally effective, and the doctrine of maternal impressions recei^'es some support from the records of rare cases of infantile cerebral paralysis. Hemor- Infautile cerebral hemiplegia with feeble-minded ness ; the patient being a mirror writer. CEBEBRAI^ PARALYSES OF CIIILDKEN. 615 phage into the brain, and softening from occlusion of vessels, while rare, are occasional fetal lesions. Fetal encephalitis and ependy- mitis have been suggested, but their occurrence has not as yet been fully demonstrated. Besides these more or less active prenatal causes, not a few of the cases are due to developmental arrests. The brain fails to develop because it lacks embryonal potentiality. Hereditary taint undoubtedly plays its part. In some instances several children in the same family are affected, although here certain mechanical conditions presented by the mother may have something to do with the production of the cases. While many of the cases seem to be clearly traceable to such causes as maternal impressions, injuries during pregnancy, birth before full term, diffi- cult labor, and asphyxia, many children who are subjected to causes of this kind escape all forms of infantile rigidity and paralysis. The inherited weakness or predisposition being present, the exciting causes which have just been discussed must be given their proper weight. Inherited syphilis does not seem to play an important direct r61e in the development of these cases, although authorities differ upon this subject. Sachs traces hereditary syphilis in only one of the many cases whicli have fallen under his notice. It is not improbable that in some cases syphilis in the grandparents or in more remote ancestors may have some influence. Etiology of Birth Palsies. Prolonged and difficult labor, partic- ularly with firstborn children, is one of the most clearly demon- strated causes of cerebral palsies. While the direct application of force by instruments may inflict injuries upon the head and brain, these cerebral affections are far more frequently due to compression of the child's head in the pelvic strait, and to the asphyxia which results from protracted labor. Skilfully api^lied forceps, indeed, in some cases prevents the occurrence of these unfortunate palsies. As first clearly shown by McNutt, the actual lesion in most of the birth cases is meningeal hemorrhage, which is likely to be at the base of the brain in vertex i^resentations, and on the convexity in breech presentations. According to Peterson, spinal lesions, usually hemor- rhage, in rare cases give rise to diplegias. Etiology of Postnatal Cases. Among the causes most frequently operative after birth, the acute infectious diseases of infancy and childhood take first rank. Cases have been recorded as occurring during or after diphtheria, scarlet fever, measles, variola, varicella, whooping cough, mumi^s, tj'phoid fever, pneumonia, cerebrospinal fever, and influenza, — after almost every known febrile affection of childhood. In whooping cough hemorrhage may occasionally take place because of the violence of the paroxysms of coughing. Although the view of Striimpell as to focal polioencephalitis being a comparatively frequent cause of infantile cerebral palsies has re- ceived but little support, much can be said in its favor. Cases have 616 NERVOUS DISEASES. fallen under my notice in wMch the history of the attack preceding the occurrence of the paralysis certainly pointed to some acute cere- bral inflammatory affection. In not a few cases close investigation shows a history of coma and convulsions, and fever is frequently present. Injuries to the skull and brain from falls and blows or wounds of various kinds are comparatively common causes. Some of the j)ostnatal cases liave been attributed to fright. As has been shown, convulsions aie frequently present both in diplegias and in hemiplegias. Often they aie concomitants, resulting from irritation or from the cerebral instability caused by the lesions which produce the paralysis and other phenomena of the disease. In compara- tively rare instances the convulsions may give rise to hemiplegia or diplegia. When, for instance, they are due to severe peripheral irritation, like that of dentition, or to toxemia, as duriug infectious diseases, the influence of the convulsive attack may cause an actual destructive focal lesion of the biain, such as a hemorrhage, or it may inhibit the development of the brain. Sachs and Osier both attribute to convulsions this etiological influence. Etiology of Hpecial Clinical Types. Efforts have been made, and with some success, to relate particular clinical types to a special etiology. The hemii^legias as compared with the diplegias are cer- tainly most frequently due to postnatal causes. Generalized rigidity has been shown in a large number of cases to be due to traumatisms during birth and to asphyxia ; while paraplegic rigidity, which is in reality only a subtype of generalized rigidity, frequently follows birth before term. A number of these cases of rigiditj- have been found to be associated with meningeal hemorrhage situated along the median border of the cerebral hemispheres. The fact that meningeal hemorrhages are thus situated and affect both hemispheres, and that the centres for the lower extremities are near and on the mesal sur- face, accoiints for the diplegias and for the frequent preponderance of rigidity and spastic paralysis in the lower extremities. While the arms are often affected, they are usually much less so than the legs. One arm is frequently much less aflected than the other. These facts are to be exi)lained by the degree of diffusion of the hemorrhage towards the Sylvian fossa, which diffusion is often greater on the one side than on the other. The face frequently escapes because of the lower position of its centres on the lateral aspect of the brain. The hemorrhage is usually due to rupture of small vessels, and especially of veins which empty into the longitudinal sinus, which accounts for the locality of the hemorrhage. When the effects of the hemorrhage are confined to the surface of the brain, rigidity largely predominates over paralysis. The depth of the cerebral injury in cases of traumatic origin chiefly determines the form of hemiplegia or diplegia. The deeper the destruction the more profound is the paralysis. When the hemorrhage is intraceiel)ral and in the motor region, paralysis alwaj'S CEEEBEAL PARALYSES OP CHILDREN. 617 results. The choreic and athetoid C'a.scs, and particularly the former, are not often directly traceable to birth before term, difficnlt labor, or asphyxia. They are proliably, in some cases at least, dei)eudcnt upon fright to the mother during pregnancy, ^^"hen the cases are of prenatal origin, the movements may be pi-eseut with little or no real paralysis. In some cases the movements are imjjosed upon double hemiplegias or monoplegias, and are to be classed with those gener- ally described as posthemixjlegic disorders of movement. In a few cases a traumatism to the mother during pregnancy has apparently been the cause. Bilateral or double hemiplegia usually residts from lesions occurring after birth. Cases Avith epilepsy are not often of intra-uterine origin, and when prenatal are probably, like the choreas, in some instances at least, dej)endent upon fright or other maternal influence. As has already been stated, epilepsies are more common in the hemiplegic than in the diplegic varieties of infantile cerebral palsies. Pathological Anatomy. — Many of the facts regarding the general pathology and pathological anatomy of the affections under consid- eration have already been given when speaking of the varieties of diplegia and hemiplegia and of their etiology and pathogenesis, and also in the sections on hyj)ertrophy, atrophy, and porencephaly, which includes the most important residual lesions present in the infantile cerebral palsies. The opportunity of determining the exact character and appearances of the intra-uterine initial lesions in the cerebral paralyses is seldom afforded. In rare instances, as in the cases recorded by Cotard, Gibbs, and Osier, gross fetal lesions, as clots or cysts, are discovered. In these prenatal cases congenital porencephaly (page 601) and forms of cerebral hypertrophy or atrophy, general or partial, are common (pages 594, 597). In some cases the fetal brain is unusually small and presents marked fissural and gyral peculiarities. Incomplete and defective development of the cells of the cortex may be everywhere present in some cases, con- stituting cortical agenesis, and, although all the layers and strata of the cortex may be largely lacking, the layer of great pyramidal cells is especially deficient when motor as well as mental arrest is promi- nent. It is not improbable, although not yet proved, that either infection or traumatism may give rise to focal or diffuse prenatal encephalitis. 'Eo facts have been recorded indicating the actual appearances of the initial lesions in such cases. They would probably be softened and hemorrhagic areas with ruptured vessels, leucocytes, granular cells, and neurogliar proliferations. In one case of cerebral diplegia and bilateral athetosis, recorded by Putnam, the pathologi- cal conditions found on autopsy were two purulent cavities, caseous degeneration, softening, and sclerosis. Such residual lesions point to previous diffuse iniiammation as at least a portion of the initial morbid process. In the birth palsies which terminate fatally, clots 618 NERVOUS DISEASES. are usually found covering a large part of either the convexity or the base of the brain. Several years since, I made an autopsy in a case of stillbirth, three successive children of the same mother having died during or immediately after delivery. In this case a large meningeal hemorrhage was found occupying the longitudinal fissure and covering most of the convexity of both hemispheres. In one of McNutt's cases the autopsy showed a large clot covering the convexity of the pos- terior half of the left hemicerebrum, and in another of her cases the right hemicerebrum was found covered by a clot which spread into the central fissure and had destroyed the cerebral tissues as far as the ependyma of the lateral ventricle. Kundrat has described the occurrence of minute venous hemorrhages which he refers to com- pression of the longitudinal sinus, but Sachs doubts whether such hemorrhages can be connected with the production of infantile cere- bral palsies. It has been suggested that compression of the head in prolonged labor causes hyaline degeneration in the vessels. On microscopical examination, fattj' degeneration of the walls of the encephalic vessels, a condition first described by Eecklinghausen, is sometimes found. Such diseases of the bloodvessels should always be looked for microscopically. As stated on page 445, Meigs found typical chronic endarteritis in a marasmic child who died at the age of five months. In a specimen of brain cortex removed for Sachs by Dr. Gerster — the case having been one of hemiplegia with epilepsy in a child twelve years old — microscopical examination showed thick- ening of the pia, an increased number of thickened arteries, and large pyramidal cells, misshapen, granular, and diminished in num- ber. Out of seventy-eight cases of infantile hemiplegia with autop- sies, studied and tabulated by Sachs and Peterson, twenty-three were attributed to hemorrhage, seven to embolism, and fi-\'e to thrombosis. These included cases occurring at and after birth. Osier has sum- marized some of the more important facts regarding hemorrhage, embolism, and thrombosis as initial lesions. In fi^e cases heart dis- ease was associated with embolism of the right medicerebral artery ; in four cases hemorrhage was present ; the right Sylvian artery was plugged by a firm thrombus in one case ; in another a hemorrhage into the longitudinal fissure had been caused by a rupture of an aneurism of the right precerebral artery ; and ventricular hemorrhage was found in still another case. The appearances presented by acute softening from embolism or thrombosis are similar to those which have alrt'udy been described in discussing arterial embolism and thrombosis in adults, qualified somewhat by the different texture of the fetal and infantile brain. Disseminated foci of tuberculosis have been found in some comparatively recent cases. With regard to the appearances presented by cases with focal or diffuse encepha- litis, the remarks on the itathological anatomy of these affections should be consulted (page 534 and pages 5.'57, 538). CEREBRAL PARALYSES OF CHILDREN. 619 Diagnosis. — Differentiation of Cerebral and Spinal Gases. The diagnosis of cerebral infantile palsies must in the first places be made from those which are of spinal origin. Most important helps are afforded by the history of the onset, the distribution of the paralysis, the mental condition of the patient, the presence or absence of tonic and clonic spastic phenomena, and a study of the electrical reactions. The cerebral cases frequently originate before birth or during labor, while spinal cases are rarely congenital and still more rarely occur at the time of birth. In the cerebral birth cases, and in those which are postnatal, usually the history of the onset is one of asphyxia, convulsions, and coma, with pronounced hemiplegia or diplegia if paralysis can be determined. Hemiplegias occurring during the early years of life have the history of some form of apoplectic attack, which may be that of hemorrhage, embolism, thrombosis, abscess, tumor, or even localized tubercular meningitis, the symptoms of which affections have already been considered. In poliomyelitis of spinal origin the history is more likely to be that of an acute febrile attack of greater or less severity ; but it is true, as noted by Striimpell, that spinal and cerebral cases are sometimes ushered in by similar symptoms, which is perhaps to be explained by the fact that they are often due to infections or toxemias which act on the nervous system, exerting their destructive influences only on localized areas in the interior of the brain and the spinal cord. In the cerebral cases the paralysis is of one of the diplegic or hemiplegic types ; while in spinal cases it is more frequently limited to one or two limbs, or to groups of muscles in one limb, at least so far as the persistent symptoms are concerned. In cerebral cases spastic phenomena largely pre- dominate, in spinal poliomyelitic cases the paralysis is flaccid. In deciding between the spinal and the cerebral cases stress should be laid on the mental condition of the patient, which is absolutely or comparatively good in the former. Choreic and athetoid phenomena point to a cerebral disease. Convulsions are occasionally present at the onset of a case of infantile spinal paralysis, but they are not likely to recur. Convulsions are of frequent occurrence at the onset and during the course of cerebral cases. The tendon and muscle phe- nomena are exaggerated in cerebral cases, and, as a rule, diminished or lost in spinal cases. In the spinal poliomyelitic cases the electrical reactions are those of degeneration. The presence of such reactions indicates spinal or neural disease. Vasomotor disturbance, muscular atrophy, and other trophic changes are more marked in paralysis due to anterior poliomyelitis ; but groups of muscles, a limb, or the entire half of the body may be much diminished in size in cerebral cases. Erb and others at one time held that most of the spastic paraplegias were of spinal origin, and the fact that in rare cases they may be of this origin is generally recognized. Differentiation of the Family Forms of Spastic Paralyses. In the 620 NERVOUS DISEASES. spinal family cases spastic paralyses are probably, as a rule, depend- ent upon arrest of development of the spinal portions of the pyrami- dal tract. Of the family forms of spastic paraplegia, to be hereafter considered, some are cerebral, some S]nnal, and some cerebrospinal. In two cases, brother and sister, which came under my observation, the girl ])reseiited symptoms of spastic paraplegia from birth, while her brother 1 legan to show evidences of the affection only after the age of puberty, and did not lose the use of his lower limbs entirely until he was almost thirty years old. In both of these cases the in- telligence was unimpaired. Occasionally a sporadic case of spinal spastic paraplegia is oliserved, as one recorded by Sachs. This child, who was four years old when first examined, presented paresis and rigidity of both lower extremities, increased knee jerk on both sides, slight double ankle clonus, normal electrical reaction, no disturbances of sensation, and fair intelligence. Striimpell has described one form of hereditary spastic paralysis, the symptoms of which do not usually show themselves until the third decade of life ; but these, of course, need not be considered in connection with the infantile cerebral diplegias, except to note the fact of their occurrence, and to remark that they may be related to the forms which occur congenitally or earlier, the pathology being similar. Association of Cerebral and Spinal Lesions in tlie Same Case. When the case is apparently of cerebral origin and the conditions which belong to spinal cases are present, careful inquiry should be made in order to discover whether the child has not suffered from a spinal instead of or in addition to a cerebral affection. In one case recorded by Sachs the reflexes were increased in the upper extremities and decreased in the lower, although the case was one of right hemiplegia. On close examination it was discovered that two years after the onset of the cerebral palsy the child had suffered from an attack of polio- myelitis. A cerebral and a spinal paralysis may be present in the same case ; or both forms of paralysis may originate or appear to origi- nate from the same causes. In one of my own cases a typical spinal paralysis was present although the history and symptoms seemed to point to a cerebral lesion. The birth of this child was instrumental, and two hours after birth it was seized with convulsions which per- sisted for twelve hours. At the points where the forceps had been applied, evidences of injiiry were present in the frontal bones in the form of marked depressions, which have remained. When the child was nine months old it was for the first time noted that the left leg was smaller and was not properly used. The child had a second attack of convulsions when he was sixteen months old, and another at the age of three >'ears. He was five years old when brought to my Tolyclinic service'. In the left leg all the muscles supplied by the iifternal popliteal nerve were paralyzed or their movements much impaired. The limb below the knee was atrophied, with loss of CEREBRAL PARALYSES OF CHILDREN. 621 faradocontractility in the affected muscles. The tciido Achillis was a thin narrow ribbon, and the foot assumed the talipi-s calcaneus position. The skin over the paralyzed muscles was scurfy and cold. Knee jerk was absent. Ko sensory changes were present. Differentiation of Fseudoparali/tic I^igiditi/ and Bpastie Biplegki. The diplegias need sometimes to be differentiated from forms of pseudo- paralytic rigidity. This is an affection which is often associated with rickets or other constitutional disturbances. Osier has tabu- lated the chief differences, as follows : Pseudoparalytic Rigidity. Spastic Diplegia and Paraplegia. Follows a prolonged illness. Is often Usually exist from birth. History of associated with rickets, laryngismus difficult labor, of asphyxia neonato- stridulus, and the so-called hydro- rum, or of convulsions. cephaloid state. Begins in hands as carpopedal spasm ; Arms rarely involved without legs, and often confined to hands and arms. not in such marked degree. Spasms painful, and attempts at exten- Usually painless. sion cause pain. Intermittent and of transient duration. Variable in intensity, but continuous. Baehitic Pseudoparaplegia and Tetany. Under the designation rachitic pseudoparaplegia Berg has described an affection in which the patients are often unable to walk or are extremely weak, and it may be supposed that these cases of diplegia or ]3araplegia are due to destructive central lesions. The diagnosis will be assisted by the discovery of the fact that these pseudoparaplegics have the signs of rachitis, as shown in the sternum, siiine, liver, spleen, and other tissues and organs. Close examination shows that the muscles are not really paralyzed or atrophied. The electrical reactions are normal, and these patients usually improve and become able to walk under the influence of fresh air, good food, and the adminis- tration of cod liver oil, and preparations containing iodine, such as Lugol's solution, syrup of iodide of iron, and hydriodic acid. While rachitic cases of this type may improve or recover, it must, how- ever, be remembered that some true diplegics are also rachitic, so that the presence of rachitis is not a proof that the patient is not also a sufferer from an organic cerebral lesion. All the facts in such a case must be carefully weighed before advancing a positive opinion. Tetany, which is sometimes associated with rachitis, for a brief time may suggest one form of spastic diplegia, but such an error is not likely to be made and would probably soon be corrected. A con- sideration of the previous history of the patient, the paroxysmal character of the affection, the suddenness of its onset, the peculi- arities of the spasm, and the etiological points serve to make the diagnosis of tetany clear. Infectious and Postinfectious Paralyses. As infectious paralyses may be either of cerebral, spinal, or peripheral origin, or may 622 NERVOUS DISEASES. represent various combinations of cerebral, spinal, or peripheral disease, it may be at times difficult to differentiate the types of organic diplegia and hemixilegia under consideration from other forms of infectious or postinfectious paralysis. These infectious paralyses have been thoroughly considered in a paper by Bassette, who has shown that they occur in connection with measles, diph- theria, scarlet fever, whooping cough, mumps, influenza, malaria, and typhoid fever, and include cases of myelitis, multiple neuritis, diffuse or limited neuritis, and neuritis combined with myelitis, besides a few cases of distinctly cerebral type commonly due to embolism, hemorrhage, or thrombosis. As is well known, some of these postinfectious cases may show widespread paralysis, involving both upper and lower extremities and the ocular muscles, and such cases might without due consideration be regarded as more intrac- table types of diplegia. In most of them the age of the patient, the history of the acute infectious attack, and the evidences of periph- eral or spinal involvement as shown by the electrical reactions, the tendon and muscle phenomena, and other signs of neuromuscular inflammation or degeneration, are sufficient to make the diagnosis. Tumors. A case of infantile cerebral paralysis may of course be due to tumor, a localized meningitis, an abscess, or other active lesion moi-e or less amenable to treatment, and it is therefore impor- tant to separate these cases from the forms of diplegia and hemiplegia now under consideration, which are commonly due to other causes. The rules of diagnosis given in the previous sections for tumors, abscess, etc., will answer here, but it is desirable to remember a few special points. Tumors of the quadiigeminal body, of the pons, or of the cerebellum sometimes give rise to diplegic rigidity of more or less regular form, the cerebellar cases in which these manifes- tations are present being usually so situated that they compress or irritate the pons or postoblongata. Bilateral neoplasms symmetri- cal or nearly symmetrical in situation, and partly cortical and partly subcortical, might give rise both to diplegic spasticity and to con- vulsions of confusing tyjie. Single tumors situated in the motor cortex or subcortex may in children as in adults be the cause of spastic hemiplegia and Jacksoniau epilepsy. Peripheral Ohstefrical Panili/sis. Certain forms of peripheral paralysis of the face or extremities which were termed by Duchenne "obstetrical paralyses'' may originate from the direct application of force by traction by the forcejis. Either the face or one of the arms is usually affected. Investigation of such cases will soon reveal that they are peripheral ; and the diagnosis will be assisted by the absence of such symptoms as coma, convulsions, rigidity, and spastic paralysis iuvohing more than one part of the body. The paralysis is usually of a flaccid character and limited to one member or to one side of tlic face. CEREBRAL PARALYSES OF CHILDREN. 623 Differentiation of Prenatcd, Natal, and Postnatal Cases. As regards the differential diagnosis of congenital or fetal cases of diplegia or hemiplegia from those originating during lal)or or after birtli, most of the points of value in their separation have already been given when discussing the different clinical and etiological varieties. A case apparently postnatal may have begun during intra-uterine life, a point to which attention was called when speaking of congenital and acquired porencephaly. Pronounced idiocy is in favor of an intra-uterine etiology, although lower grades of idiocy, imbecility, and feeble-mindedness may be present both in the birth palsies and in those which originate during the first years of life. Asymmetries and special deformities of the cranium, unless they are such as have evidently been produced by instruments during delivery, point to an intra-uterine rather than to a birth paralysis. The shape of the head, like that of the brain, is in these cases determined by congenital causes. A study of facial expression may be an important aid to diagnosis in young infants, in whom it is often difficult to determine the existence of diplegia and imbecility by an investigation for paralysis and rigidity or by general efforts at gauging the child's intelligence. A peculiarly morbid and suggestive appearance is sometimes given to the face, as when the mouth is kept open by the overaction of the radiating on the circular muscles. The child may have the appearance of weeping when it would laugh, or the reverse. The fact that a child is born asphyxiated does not prove that the case is of obstetrical origin. A child may also be born prematurely because it is defective, and the case be supposed to be one due to birth before term. While convulsions are frequently present in natal and postnatal hemiplegias, considering only the diplegias, the presence of epilepsy is, on the whole, in favor of congenital origin. Between diplegias occurring at the time of birth and those which originate later the difficulties of differentiation are sometimes great. Generalized rigidity and paraplegic rigidity are most frequently due to birth lesions. The fact that a child has apparently been born healthy, and that the paralytic or diplegic affection has come on at a definite time and in association with a special attack, is of course of value in separating the cases occurring after birth from natal and prenatal cases. Certain signs or symptoms may remain latent for days, weeks, or months after birth. Epilepsy may thus remain latent, and even the paralysis may not show itself positively for some time. Adenoid Vegetations in Infantile Hemiplegics and Diplegics. It has several times come to my notice that the presence of adenoid vegeta- tions in cases of idiocy and imbecility, with or without paralysis, has led to an error of diagnosis or of prognosis. These vegetations are somewhat commonly present in such cases, and the throat specialist is led to believe that by their removal he can remedy the defects of 624 NERVOUS DISEASES. speech and get rid of what he regards simply as apathy or stupidity due to local lesions. The habit which many diplegics have of hold- ing open the mouth favors the occurrence of such vegetations, which should be properly treated. Some of the special disorders of respi- ration and digestion from which such patients suffer may be relieved by proper treatment of the adenoids, and choreic and athetoid move- ments have also been reported as thus relieved. Prognosis. — It is best to separate the consideration of the prog- nosis of the diplegias from that of the hemiplegias, and particularly from the hemiplegias of postnatal origin. The prognosis of by far the largest number of diplegias is unqualifiedly bad. The paralytic, spastic, and other j^hysical conditions are grave, and the patients usually present a greater or less degree of imbecility or idiocy. In cases of infantile cerebral paralysis acquired after birth it may be difficult to give a prognosis as to the amount of improvement or recovery that will take place until one or two years have elapsed. A very few cases make almost complete recovery ; others, also few in number, remain partially paralyzed, but with fair or even good mental power ; a large number develop epilepsy and various grades of mental retardation. Convulsions may be present at first, may dis- appear for weeks, and may return after months or even years. In other cases they may appear for the first time several months or even years after the onset of a hemii^legia. The presence of con-^iilsions always adds to the gravity of the prognosis. Cases with choreoid and athetoid movements are also of especially unfavorable prognosis. In rare cases patients are met with who present only moderate or even slight degrees of generalized or paraplegic rigidity and are so nearly normal that they are scarcely recognized as diplegics. Cases of paraplegic rigidity or of spastic paraplegia are relatively of more favorable ijrognosis than those in which the upper as well as the lower extremities are involved. IMentally as well as phj^sically these cases are usually less ominous. The double spastic hemiplegias sometimes make slight imi>rovement, and in some instances even considerable improvement, over the conditions first observed in in- fancj^ The bilateral choreas either remain stationary or get pro- gressively but very slowly worse. It may be difficult or impossible to answer with positiveness the question put to the physician as to whether a diplegic child from two to five years old will be able to walk. Such children do sometimes become able to stand or even to walk after they are fix e or six years old, although their gait is spastic or may be of the cross-legged type. In postnatal cases the younger the child the more probable is it that serious mental deterioration will 1k^ left. In the hemiplegies tlie leg and the face nearly always improx'e much more than the arm, so that frequently the patient will regain the power of walking and may be left with little or no asym- metry of the face. JMost cases of diplegia die in childhood or before CEREBRAL PARALYSES OF CHILDREN. 625 the age of adolescence. The hemiplegies have a longer average lease on life, and occasionally reach middle age. In all cases of convul- sions in children care should be taken to note tlic subsequent con- dition of the child, and in some instanci's parents should be warned that a paralytic or mental disorder may l)e left. Treatment. — Treatment of the InitUd Period aixl of Special Symp- toms. In prolonged and difficult labor the skilful use of the forceps may prevent the occurrence of a disastrous meningeal hemorrhage ; but if such hemorrhage should occur and be recognized as present, the question of immediate surgical interference may arise. Opening the skull to remove the clot in a case of meningeal hemorrhage at the time of birth has not, so far as I know, been practised, but, as such a case usually either terminates fatally or leaves serious perma- nent paralysis, the procedure would in some cases be justifiable. Great care, of course, should be taken to avoid injuring the deli- cate brain of the child. When an infant has had a serious fall or has received a blow on the head and a hemiplegia or monoplegia follows, at the present day the tendency is to have recourse promptly to trephining. This in some instances is the correct thing to do, especially as antisepsis has rendered such operations comparatively safe, but oftener it is better to wait. Osier refers to two cases of speedy recovery without operation, one in his own practice and one in that of Murray Cheston. In the former a child twenty-three months old had fallen from a balcony and had a large hematoma of the scalp, with left hemiplegia and coma. The symptoms gradually disappeared, and complete recovery followed. Murray Cheston' s case was that of a child who was tripped up by his brother and fell on his head. There was no external wound or fracture, but hemiplegia developed, which comj^letely disappeared in a few days, leaving the boy entirely well. Such cases may be due to bruising of the brain with little or no hemorrhage. In a case of traumatism, if, in addition to the paralysis, convulsions and other signs of irritation are present and persist, trei^hining for removal of the clot should be resorted to after three or four days ; but if spasm is absent or soon ceases, and if the paralysis begins to disappear after two or three days, operation should be postponed. "When convulsions are present at or soon after birth the child should be kept absolutely quiet, cold applied to the head and heat to the extremities, and small doses of calomel adminis- tered. Either the bromides or chloral in small doses should be given, and repeated if necessary. One grain of chloral by the rectum, or a less amount by the mouth, will be sufficient ; and any of the bromides can be used in doses of from one to three or four grains. The care- ful inhalation of chloroform may be resorted to to check the convul- sions when one follows another in a threatening series. A few drops of the anesthetic can be sprinkled on a soft cloth and cautiously ad- ministered. If the convulsions cease, careful watch should be kept, 40 626 NERVOUS DISEASES. and the inhalations repeated at the first threatenings of a return. After the immediate elfects of the attacit have passed off, small doses of iodide and bromide should be given for several weeks, care- ful attention being paid to the digestive organs of the child. In infants the amount of iodide should not exceed firom one half to two grains. A good method of administration is to give sodium iodide in milk. The bromides can also be given in doses of from two to eight grains. Minute doses of Fowler's solution of arsenic maj' be combined with them. The bromides are particularly called for when the convulsions show a tendency to recur. When heredi- tary syphilis is suspected, small doses of mercurials or of the iodides may be carefully used. If the child shows evidences of rachitis, cod liver oil should be given, either internally or externally, and with it, or alone, XDreparations containing iodine, such as Lugol's solution, syrup of iodide of iron, and syrup of hydriodic acid, may be employed, — of course in minute doses. The emulsions of cod liver oil containing lime are particularly efficient. Antirachitic treatment is especially desirable in some cases because, as shown under diagnosis, a rachitic pseudoparaplegia or a pseudoparaplegic rigidity associated with rickets sometimes may be mistaken for a true diplegia. The treatment in such cases, therefore, may assist in clearing up the diagnosis, and can do no harm, even if it does not do good. The greatest care should be exercised as to warmth and exposure with infants born prematurely. Treatment of the Residual Conditions and Symptoms. — Faradism or galvanism, massage, Swedish movements, or systema- tized exercises, may do good in a few instances. Electric mechanical and other peripheral stimuli may serve to call out some latent power, but care should be taken not to overtreat. The general health should always be maintained at as high a point as possible. For the athe- tosis or athetoid movements often present little can be done. Nerve stretching may stop the movements for a time, but the relief is seldom sufficient to warrant the operation. In one case of severe athetosis referred to l)y Peterson the arm was removed, with great relief to the patient. The persistent athetoid and choreic movements have in some instances been temporarily relieved by mechanical and surgical measuies, and especially by the application of splints and plaster bandages. Congenit:d diplegics will usually not have much capacity for improvement by mental training. Relatively the cases which occur at birth and the i^ostnatal cases, especially the latter, yield better results. A child with a normal brain may be the victim of a meningeal hemorrhage during lalxu' or at any period after birth as the result of A traumatism. The auiouut of damage done by such active lesions will largely determine the degree of improvement that can be accomplished liy subsequent training. Possibilities may in some of these cases l)e neglected if training is not attempted. In the cases CEREBRAL PARALYSIS OF CHILDREN. 627 acquired one or more years after birth, a process of reeducation of the brain may be needed. For defective spcecli as well as for general mental deficiency systematic and persistent efforts at training should be tried. Surgical Pleasures. Eiforts have been made, chiefly surgical, to treat the porencephaly, but from the very nature of the lesion such treatment is usually futile, and may be harmful. An absence of cerebral substance — a htile in the brain — is not to be cured or even relieved by making an opening into that hole and draining its con- tents. If the fluid is removed from the caA-ity it will fill up again ; and if efforts are made to prevent this by drainage, death in all probability will soon result. In addition, the i^atient will be sub- jected to the danger of infection from without. The emptying of brain cysts is in all cases a doubtful procedure, and it is more than doubtful in porencephaly. Operations in such cases are not only most unsuccessful, but are often fatal. If the walls of an old hemor- rhagic or other cyst are a source of irritation, it is conceivable that their removal may diminish this irritation and lead to improvement. Even in old cases of fracture, tumor, and localized meningitis or hemorrhage, trephining does not offer much hope, but operation here has a more reasonable basis and may sometimes be of benefit. In carefully selected cases something can be done to improve the station and gait of diplegics and hemiplegics, most frequently the former, by operations for the relief of the contractures. In cases of extreme rigidity and paralysis with imbecility or idiocy nothing can be accomplished by such procedures, which are sometimes resorted to without due consideration. The child's mental condition is such as to prevent advantage being taken of the results of operation ; and the corticospinal and peripheral motor apparatus is so arrested or degenerated that the limbs tend to return to their former positions. When the patient has sufficient intelligence to submit to advice and training, and when he already has some control over the movements of his limbs, some benefit can be obtained by cutting carefully se- lected tendons. The tenotomies may enable him to get his feet to the floor better, or to assume less constrained positions in standing or walking, or to make somewhat better use of certain groups of muscles over which he has some voluntary control, but too much must not be expected. Photographs of such patients before and after operation, which seem to show that great improvement has l)een attained, are often simply striking as pictures of still life. I would not altogether discourage operations in such cases. In extreme contracture much constitutional disturbance may be produced as the effect of opera- tion, and death may result. The most generally useful of tenotomies is the simplest, namely, that of cutting the tendo Achillis in order to get a plantigrade walk. Neurectomy has been performed with reported success in some cases of contracture. 628 NERVOUS DISEASES. APHASIA AND OTHER DEFECTS OP SPEECH DUE TO DIS- EASE OP THE CEREBRUM. Cerebral Centres and Tracts concerned in Speech. — The cortical centres concerned in speech are (1) the primary and secondary cortical visual centres; (2) the primary and secondary cortical auditory centres; (3) the naming or concept centre ; (4) the motor speech centre; and (5) the motor graphic centre. The cortical centres are united with each other by associating tracts, those on the sensory side are con- nected with the basal receptive centres, and those on the motor side with the basal emissive centres. Higher inhibitory centres are situ- ated in the prefrontal region. For the discussion of the situation and special functions of these centres the reader is referred to the section on cerebral localization in Chapter V. In Pig. 331 are shown the Fig. 331. A, auditory centre (centre for word hearing) ; V, visual centre (centre for word seeing) ; N, naming centre (centre where percepts are given a name) ; B, motor speech centre (in Broca's con- volution) -, G, graphic centre ; U, utterance centre. locations of the various centres enumerated in accordance with the views of the writer. A diagram of the speech centres and tracts is given in Pig. 332. These are, in the first place, the tracts which pass from the basal auditory and ^'isual centres to the primary cortical centres for hearing and vision. In the second place, they are the tracts which pass from the primary cortical centres for hearing and vision to the secondary or higher cortical centres for word hearing and word vision, — it being probable that these tracts converge from the primary cortical centres of both hemispheres to the secondary or higher cortical centres of the left hemisphere. In the third place, they are the tracts which pass from the higher auditory and visual centres to the naming or concept centre : in the diagram only the tract from the auditory centre to the naming centre is represented. Other tracts are that between the concept centre and Broca's centre APHASIA AND OTHER DEFECTS OF SPEECH. 629 iu the left third frontal convolution ; the direct tract, sometimes used, between the auditory centre and Broca's centre ; the direct tract, sometimes used, between the higher visual centres and Broca's centre ; the direct tract, sometimes used, between the higher visual centre and the motor graphic centre ; and the tract or tracts con- necting the motor cortical centres concerned in speech and writing with the centres in the bulb and spinal cord. Tracts also associate the visual and auditory centres, and the motor speech and motor writing centres. These tracts are shown in the diagram and are Fig. 332. LP.O.C. R.P.O.C. R.PA.C. .L.PAC. A, auditory centre (centre for word hearing) ; V, visual centre (centre for word seeing) ; N, naming centre (centre where percepts are given names) ; B, motor speech centre in Broca's convo- lution ; (an utterance centre, U in Fig. 331, is also required to complete the motor side of the speech process;) G, graphic centre ; E. Oc, primary cortical visual centre in the right occipital lobe ; L. Oc, primary cortical visual centre in the left occipital lobe ; R. P. O. C, optic centres at the base of the brain, right side ; L. P. O. C, optic centres at the base of the brain, left side ; E. T., primary cortical auditory centre in the right temporal lobe; L. T., primary cortical auditory centre in the left temporal lobe ; R. P. A. C, auditory centres at the base of the brain, right side ; L. P. A. C, auditory centres at the base of the brain, left side. explained in the legend, the direction in which impulses are con- veyed being indicated by the arrows. Much more than a mere knowledge of the positions and functions of these cortical centres is necessary in order to understand the cerebral mechanism of speech. The student should have a thorough knowledge of the types and subtypes of aphasia, and of the terms descriptive of them. He should know how to diagnosticate one cortical disorder from another, and cortical from subcortical affections. He should be able to fore- cast partial or complete recovery, should comprehend the bearing and significance of pantomime, and should be familiar with the 630 NERVOUS DISEASES. methods of studying aphasic subjects and with the best methods of medical, surgical, and educational treatment. The important rela- tions of cerebral disturbances of speech to mental phenomena require his attention both for medical and medico-legal reasons. Definitions and Synonyms.— Aphasia is the loss or impairment of the power of comprehending or expressing ideas by language or signs ; and, as now commonly employed, the word is a general desig- nation applied to any or all of the defects of speech dependent upon disease of the cerebral hemispheres. The word aphasia was intro- duced by Trousseau, and, strictly construed, means loss of speech. No synonyms have succeeded in displacing it. McLane Hamilton suggested asemasia, which means the inability to communicate by signs or language, and etymologically this is an excellent term. Aphemia was used by Broca and others, and is still sometimes em- ployed in the description of cerebral speech disturbances in general, but is used mostly to describe the commonest forms of motor aphasia. Bastian has suggested that aphemia be restricted in its definition to defects of speech from lesions of those fibres which connect the so- called motor centres of the cerebrum with the bulbar nuclei, — that is, to subcortical motor aphasias. Alalia, employed by Lordat in the general sense afterwards accorded to aphasia, is now commonly re- stricted to the meaning given to it by Kussmaul, who defines it as an entire inability to utter articulate sounds, placing it under defects of enunciation. The proper usage of amnesia is to express loss of memory. With certain qualifying adjectives it correctly describes special varieties of aphasia, as verbal amnesia and literal amnesia. Amnesic aphasia as a general term has been applied to disorders of speech from lesions on the receptive or sensorj" side of the brain ; and ataxic aphasia is another old term, still often used to describe the motor aphasia of common type. Anatomicopathological Varieties of Aphasia. — From the ana- tomical standpoint aphasias can be subdivided into cortical, sub- cortical, and transcortical. A cortical aphasia (pictorial aphasia of Wyllie) is one due to a lesion of the cortex ; a subcortical aphasia is one dependent upon a lesion of the subcortical projection fibres, sensory or motor ; and a transcortical aphasia is the result of dis- ruption of the tracts which associate together the various sensory, motor, and conceptual cortical centres. Two varieties of subcorti- cal aphasia are recognized by A\"ernicke, "Wyllie, and others. The first is subcortical sensor;/ aphasia, in Avhich the affection is due to a lesion of the con\'('rging incoming tracts to the higher sensory cen- tres. These tracts are those which lead to the auditory, visual, tactile, and other cortical receptive centres, but, as a rule, only the incoming auditory and visual paths are considered in discussing the subject. Subcortical auditory aphasia is a variety of subcortical sensory aphasia, and is due to a lesion of the tract which passes APHASIA AND OTHER DEFECTS OP SPEECH. 631 from the centres for general audition to the higher cortical audi- tory centre in the left hemisphere, — the centre for word hearing. Subcortical visual aphasia is due to a lesion of the tract which j)asses from the centres for general vision, or primary cortical visual centres, to the secondary or higher cortical centre of the left hemicere- brum, — the centre for word vision. The second form of subcor- tical aphasia is subcortical motor aphasia, a disorder which is due to a lesion of the tracts connecting the cortical centres for motor speech with the bulbar nuclei. Subcortical sensory and motor apha- sias are sometimes spoken of as infrupictorial sensory aphasias and infrapictorial motor aphasias, because they are the results of lesions of parts of the brain below or beneath the centres where the sen- sory and motor images of words are revived. A subcortical motor agraphia is possible, — an agraphia due to lesion of the tract which passes from the graphic motor centres to the nuclei in the cervical cord which are related to the neuromuscular apparatus concerned in writing. Transcortical aphasias are of as many kinds as there are associating tracts. They are sometimes spoken of as suprapictorial sensory aphasias and suprapictori4:d motor aphasias. The transcortical sensory aphasias are those resulting from severance of the paths between the sensory and concept areas ; the transcortical motor apha- sias are those resulting from the cutting across of the path or tract between the concept and motor speech areas. Transcortical sensory aphasias may be either of an auditory or a visual type, the former being due to lesion of the tract between the auditory and concept centres, and the latter to lesion between the visual and concept cen- tres. Transcortical sensory agraphia is an affection due to lesion between the visual and graphic centres ; while a transcortical motor agraphia is one dependent upon a lesion of the tract between the concept and graphic centres. In some cases sensory centres and associating fibres, or motor centres and associating fibres, or both sensory and motor centres and associating fibres, may be involved in the same lesion, giving rise to different forms of combined or mixed aphasias. An extensive lesion may cause a total sensorimotor aphasia. The term pure is sometimes applied to some of the varieties of apha- sia above described, as to subcortical auditory aphasia, subcortical visual aphasia, and subcortical motor aphasia. The affection of speech in these cases is due to a lesion of the tracts leading to the cerebral percept centres or passing from the cerebral motor centres concerned in speech. The mechanism of interior language is not impaired in the pure aphasias, which are due to a blockage or an interruption of the way in or the way out. Clinical Varieties of Aphasia. — Three main clinical varieties of cortical and subcortical aphasia may be recognized, — sensory aphasia, conceptual aphasia, and motor aphasia. By some authors both sensory and conceptual aphasia are included under sensory aphasia. We 632 NERVOUS DISEASES. may have various forms of sensory or motor aphasia, according to the location of the lesions. Among the forms of sensory aphasia, for instance, are verbal blindness and verbal deafness and their sub- types, and psychic blindness. Concept and motor aphasias are also of several forms, and we may have mixed sensory and concept or mixed concept and motor aphasias, according to the parts implicated in the lesions. These different clinical varieties of aphasia will now be separately considered. Verbal Deafness. — Definition, Varieties, and Symptoms. Word deafness, or verbal deafness, is the inability to understand spoken words. In word deaf patients the external and internal apparatus for hearing may be intact, as may also be the centres and tracts con- cerned with hearing below the cerebrum. The term auditory aphasia is preferred by some authors, as by Wyllie, who thinks that verbal deafness is too narrow a designation, but he evidently includes under his auditory aphasia some affections which should be considered sepa- rately from word deafness. Verbal deafness may be complete or in- complete. It is not infrequently complete at first and gradually recovered from in large part. Sometimes several categories of verbal deafness are made, as (1) that form of deafness in which the patient recognizes the voice as a noise, but as nothing more ; (2) that form in which he recognizes language as such, but does not understand what is said ; and (3) that form in which language is heard and can be repeated, but in which the patient does not understand what he repeats. (Brissaud.) These different varieties may merge into one another, giving irregular types of word deafness, which call for the most critical study. A patient suffering from word deafness does not understand spoken language, unless in occasional instances he is able to recognize his own surname, more rarely his given name, and per- haps a few other words. If he is not otherwise deaf, he recognizes ordinary sounds. He is like one who hears a language of the mean- ing of which he has not the slightest idea. (Dejerine.) He is also unable to read aloud correctly, and, if the verbal deafness is complete, he cannot echo the words of others. If the case is one unassociated with verbal blindness, the patient may be able to read, and perhaps he can even read aloud, but his reading will show paralexia, words and syllables being confused and jumbled in their articulation. He is not able to verify what he reads by his sense of hearing. The position of the centre for word hearing, lesion of which causes the cortical variety of verbal deafness, has already been sufficiently con- sidered (see iwges .">44 and .345 and Fig. 232). The centre is situated in the caudal portions of the first and second temporal convolutions, the chief part in the process probably being played by the first temporal convolution. Pure Word Dea/iiess. A few cases of total verbal deafness not due to lesion of the auditory centre have been recorded. These are illus- APHASIA AND OTHER DEFECTS OF SPEECH. 633 trations of tlie subcortical auditory aphasia which has already been defined. Lichtheim, for instance, has recorded a case of pure word deafness in which the patient preser\'ed the power of volitional speaking, of writing, and of reading aloud. He had neither pnr- aphasia nor paragraphia. S6rieux has reported a case similar to that of Lichtheim. Such a case is probably due to a lesion of the tract or tracts from the primary cortical auditory centre or centres to the secondary cortical auditory centre (the centre for word hear- ing). A lesion of this tract causes word deafness, as does also one of the centre for woid hearing, but in the latter case paraphasia and paralexia are present, because the patient is unable to verify through his centre for word hearing what he says or means, whereas in the former case he can do this. In this form of word deaf- ness the patient does not understand the questions asked him, and is not able to write from dictation. These are the only symp- toms which he presents. He understands writing, — which is the only means of entering into communication with him, — and replies correctly in a loud voice to the questions which are asked him on paper. Spontaneous writing and copying are normal, and intel- ligence is intact. The patient is not the subject of verbal amnesia nor of other forms of - speech distru-bance. The intact centre for word images is cut off from the lower centres and the outside world. The patient may hear the words as sounds although not understand- ing what is said. Mixed Sensory and Concept Aphasia. — In some cases of word deafness verbal amnesia is also present, but this may be due to involvement of the tracts leading from the centres of hearing to the centres for concepts or to the motor centres, or in some in- stances to lesion of the naming or concept centre itself. A lesion of the tract leading from the centre for word hearing to the con- cept centre, as already stated, gives what is anatomically termed transcortical or suprapictorial auditory aphasia. In this trans- cortical auditory aphasia, incoming audible speech is not under- stood, nor, according to Lichtheim and Wernicke, is incoming visual speech, as the path between the auditory centre and the naming or concept centre is cut across, so that the auditory word pictures revived in the auditory centre do not call up the ideas or meanings in this higher centre. What is heard or read is not understood, and yet the word images in the auditory centre are intact and can be re- vived from without. Whatever is heard can be repeated, and the patient can easily read aloud, but he understands neither what he hears nor what he reads. He can write to dictation, and he can copy from print or from writing. Echo speech is a characteristic symp- tom. Amnesia for nouns, paraphasia, and, in consequence of the latter, paragraphia, are also shown. Lichtheim has suggested the name inner commissural word deafness for this variety. 634 NERVOUS DISEASES. Verbal Blindness. — Varieties. Verbal blindness is the inability to understand by sight written or printed words. It may be sub- divided into verbal blindness proper and literal blindness or blindness for letters. Verbal blindness is occasionally uncomplicated, but more frequently it is associated with other clinical phenomena, such as hemianopsia, hemianesthesia, and verbal deafness. It has been as- serted that word blindness and hemianopsia always occur together, but cases have been reported which disprove this, as, for instance, the one reported by Serieux which is referred to under motor agra- phia. We may have verbal blindness without hemianopsia, and hemianopsia without verbal blindness, although the observations to substantiate this position are few. My views as to cortical visual localization have already been given on pages 342-344. The cortical field of the macula is doubtless also the area wherein are stored the visual images of words or letters. This area is the angulo-occipital region on the lateral surface of the hemisphere, nearly where it was first located by Ferrier. One of the forms of word blindness is that which is due to lesion of this cortical visual area. Alexia, or the inability to write, and visual agraphia, as well as verbal and literal blindness, are produced by lesions limited to this region : although the patients can sometimes write their own names or a few simple words or, in rare cases, a number of words, they apparently do this through touch and the muscular sense. Pure Word Blindness. Another form of word blindness, some- times called pure word blindness, has been clearly demonstrated by Dejerine and Serieux. This is the subcortical visual aphasia which has already been defined when speaking of the anatomicopathological varieties of aphasia. It is caused by a lesion which destroys the fibres which pass from both occipital lobes to the left angulo-occipital region. In pure word blindness of this subcortical type, agraphia for spontaneous writing may not be present. The memory pictures can still be revived by the visual centre, and can be made use of by the motor centres for writing. Commonly the lesion producing blind- ness of this kind also causes hemianopsia, because the adjacent optic radiations of Gratiolet are usually involved. In such a case of pure word blindness, while the patient is able to write spontaneously and from dictation, he is not able to read what he himself has written. He may, however, be able to copy mechanically what he has written, like other sensory aphasics. The patient can understand writing by tracing the letters with his finger. Spontaneous speech is present, as is also the ability to repeat the speech of others, and uttered speech is comprehended. Literal Bliiulness. In literal blindness the patient may recog- nize letters as objects having certain forms ; if they are reversed or badly made, he may be aware that something is wrong with them, but he does not know their meaning : he does not know that A is APHASIA AND OTHER DEFECTS OP SPEECH. 635 A, that B is B, or that C is C, etc. Written letters can sometimes be recognized when printed letters cannot. It is proljable that this recognition takes place in the graphic motor centre through the muscular sense rather than through the visual sense. The i>atient has graphic motor memories, which enable him to recall letters even when those which are printed are to him a blank or at least unrecog- nizable. A patient may suffer from literal blindness and not from verbal blindness proper, or he may be blind to words and not to letters. While this is true, literal blindness is, as a rule, accom- panied by verbal blindness. Those who read words by putting the letters of the word together are necessarily blind to words when they lose the memory for letters. That literal blindness may exist without verbal blindness is illustrated by a case reported by Broca. This patient was attacked by partial literal blindness ; that is to say, he had lost the visual memories of some letters. He could even read words in which were letters he did not know, and he changed or sup- pressed letters in words without perceiving what he had done. Such a patient recognizes words as one does a landscape or a face of which he has not analyzed the details. Words are often compre- hended by their general form alone. Reading ceases to be phonetic ; whatever it was originally, it becomes ideographic. (Brissaud.) In cases both of literal blindness and of verbal blindness the ability to recognize numbers sometimes remains, the numbers being symbols of ideas of a special kind. Psychic Blindness. — I^ot infrequently associated with word blindness is another disorder which has been called soul blindness and object blindness. The word apraxia is also used by Kussmaul in practically the same sense, for the loss of the memory of the uses of things, and the understanding of the signs by which things are expressed. In testing for this condition, the physician observes whether the individual examined shows evidences of recognition of objects of various kinds which are j)resented to him. He may not comprehend the use of the simplest things ; and he may also not recognize persons with whom he is intimate. He may recognize an- other by his voice or by touching him, even when he cannot by sight. A comparable form of mind deafness, or psychic deafness, is observed, in which the patient cannot recognize another by the word used nor by the sound of his voice which should be familiar. The centre for the visual images of things probably includes or is adja- cent to that for visual images of words ; but both hemicerebrums doubtless take part in the storage of object images, and in nearly equal degree ; while for the recognition of words, as for many of the other higher faculties, man is mainly left-brained. A few cases of partial mind blindness are on record in which unilateral lesions were present. Even a form of psychic blindness for tvords has been described. The patient can read the letters and the words, and even 636 NERVOUS DISEASES. copy them, without getting their sense. Brissaud has compared this psychic bliiidaess for words to the mental condition of a compositor who does not understand Greek and yet is able to set it up correctly and even to make necessary changes and corrections in his work. Concept Aphasia. — A naming or concept centre has been intro- duced into tlie scheme of the cortical mechanism of speech, its prob- able location lieing in the third or meditemporal convolution. Some of those who seem to recognize the necessity of a separate centre for names or concepts do not discuss special forms of aphasia dependent upon its lesions. Others differ as to its location and extent. Bris- saud places it in the prefrontal region. Broadbent conjectured that it was situated at the under surface of the temporal lobe near its junc- tion with the occipital lobe, and the case recorded by me (page 345) has confirmed this suggestion. In a case of Rosenthal's of verbal amnesia without verbal deafness, an old focus of softening was found in the second and third temporal convolutions, the first temporal having been entirely free from disease. Wyllie holds with many others that it is not necessary to have special "ideational" centres and "naming" centres, but that the interaction of the entire cortex, or of certain of its layers, is concerned with ideation, and that names arise in consciousness through the action of the centres for percepts and the motor centres. Those who do not believe in sepa- rate concept or naming centres do not restrict this organization of the cortex to an area absolutely set apart. It seems to me alto- gether probable, however, that such a region may be located con- veniently intermediate between all the receptive and emissive centres concerned in the mechanism of speech. The chief affections of speech and of thought due to lesion of this naming or concept centre are varieties of verbal amnesia or the aphasia of recollection, with usually additional symptoms, such as paraphasia or some variety of sensory or of motor aphasia, because of the frequent and almost necessary involvement of associating tracts. Destruction of this area will cause loss of the memory of names or nouns. A form of A^erbal amnesia of incomplete type, incomplete articulative amiiesia, may be due to partial destruction of this region, or of the channels connecting it with its correlated centres on either the receptive or the emissive side of the brain. Tlie amnesia literarum to which Wyllie refers may be due to lesion of this concept region. The term is used to indicate "a failure (on the productive side) to call up the images of letters and words in the mind when the effort to write is 1)eing made." Instead of regarding concept aphasia as distinct from both sensory and motor aphasia, it is sometimes con- sidered as a variety of sensory aphasia, although the mental process of symlxiliziug concepts liy name is higher than that of perception. Mixed Concept and Motor Aphasia. — Transcortical motor aphasia is that form of speech disturbance which results from sev- APHASIA AND OTHER DEFECTS OF SPEECH. 637 Fig. Y erance of the path between the naming or concept centre and the centre for motor memories of speech in Broca's convolution. In this form of aphasia the symp- toms are similar to those in true cortical motor aphasia, but with some points of difference. According to Lichtheim, the aphasic of this type cannot express his thoughts any better in writing than in volitional speech, although every- thing else is normal. "What he reads and what is said to him are both understood, and he can repeat with cor- rect articulation words that are spoken to him, under- standing them. He can also write to dictation and copy writing with ease and correctness, understanding in both cases what he writes. For this mixed va- riety of speech disturbance Lichtheim has suggested the term outer commissural aphasia. Motor Aphasias. — Motor Aphasia of Cortical Origin. Motor aphasia, whether cortical or subcor- tical, may be complete or incomplete. "When com- plete, the patient is totally unable to speak, or at most retains only a few simple words. He is unable to repeat words spoken by another, or to read aloud. This loss of power of speak- ing may exist without any paralysis of the tongue, face, or limbs, although it is commonly associated with hemiplegia or monoplegia. As a rule, it is accompanied by inability to write, this defect con- stituting motor agraphia. "When any spoken speech is retained it is of simple much used words, as "yes" or "no," oaths or emotional Licbtheim's diagram showing tlie position of lesions of different tracts and centres producing some of tlie most important forms of aphasia : A, higher auditory centre (centre for word images) ; B, Broca's centre (motor ar- ticulatory centre) ; N, concept or naming centre ; 1, site of lesion causing word deafness (cortical auditory apha- sia, i-)ictorial auditory aphasia) ; 2, lesion causing motor cortical aphasia (pictorial motor aphasia) ; 3, lesion causing the conduction aphasia of ^^■emicke (interpic- torial aphasia) ; 4, lesion causing subcortical auditory aphasia (infrapictorial auditory aphasia, pure word deafness) ; 5, lesion causing transcortical auditory apha- sia (suprapictorial auditory aphasia, inner commisstiral word deafness, mixed sensory and concept aphasia) ; 6, lesion causing transcortical motor aphasia (suprapic- torial motor aphasia, inner commissural motor aphasia, mixed concept and motor aphasia) ; 7, lesion causing subcortical motor aphasia (infrapictorial motor aphasia). In order not to complicate the matter too much, several of the important centres and tracts have been omitted in this diagram. By .substituting the visual for the au- ditory centre a series similar to the above would be produced on a background of visual aphasia. The in- troduction of a graphic centre would give motor cortical agraphia and various forms of conduction, transcortical, and subcortical agraphia. 638 NEKVOUS DISEASES. ejaculations, or recurring utterances, such as "tan, tan," "la, la,'' "Oh-no," and "Come-on-to-nong." The motor aphasic under- stands the meaning of words spoken, and, if sufficiently educated, of words printed and written. He also comprehends the uses and meanings of objects, and can call up their names in consciousness. Close examination, however, shows that his power of calling up auditory images is affected and his ability to read mentally is impaired. He may be al)le to copy words, or in j'are cases, when the power of writing is letained, to translate printed into written words. Compared with other forms of aphasia, pantomime is usu- ally well preserved. The patient may protrude his tongue instinc- tively or involuntarily, but he is often unable to do this when asked. In many cases of hemij)legia, with motor aphasia total at first, the power of speech is in time largely regained ; in others aphasia remains complete until the death of the patient. When recovery, gradual or partial, takes place, simple words and expres- sions return first. Under the designation "articulative ataxia'^ "VVylhe describes what is pi'actically an iiicoinjjlete motor aphasia from partial destruction of Broca's centre. It is simply the old ataxic aphasia, the asynergia verhalis of Lordat. Such a patient gradually imj)roves in speech through recovery of the injured centre, or through the edu- cation of the previously uneducated centre of the right side, and as he does so he shows articulative disturbances of various kinds. In some cases of cortical motor disease, utterance is paralyzed, although the patient does not in reality suffer from an ataxic or asyuergic aphasia. The true motor speech centre is not the seat of lesion in these cases, but that area which is marked U in the diagram (Fig. 331) and is sometimes designated as the utterance centre. This is the cortical area in which are represented the movements of the throat, larynx, lips, and lower face, those movements which are concerned in phonation, vocalization, and the formation of sounds into words and phrases. For a discussion of the differences in the effects of lesions in this area and in the hinder portion of the left subfrontal convolution, the section on cerebral localization should be consulted at pages 348 and 349. Cases are recorded in which limited destruc- tion of this cortical region has caused impairment or loss of articu- late speech, or of the jtower of utterance, without destroying the patient's ability to recall the psychomotor images which are con- cerned in speech, while, on the other hand, destruction of the left third frontal makes all speech impossible. In a case recorded by me, one of orolingual monoparesis with distinct paralysis of the lower face, no interference with propositionizing being present, softening involved this utterance centre, the left subfrontal almost entirely escaping. Subcortical Motor Aphasia. In subcortical or infrapictorial motor aphasia the lesion cuts across only those fibres which connect the APHASIA AND OTHER DEFECTS OF SPEECH. 639 centre for the motor memories of speech in Broca's convolution with the centres for the nerves of speech in the oblongata. Spoken speech, both volitional and on attempted repetition of the words heard, is disabled ; there is no amnesia verbalis, no difficulty in volitional writing, writing to dictation, or copying, and no word deafness. If paralysis prevents writing with the right hand, it can still be done with the left. Motor Agraphia. — Motor agraphia is usually associated with aphasia, hemixjlegia, or other clinical phenomena. It may be com- plete or partial, but most of the cases associated with aphasia are complete. The motor agraphic retains his full intelligence. He understands what he hears and what he sees of sj)oken, printed, or written language ; he may be able to hold the pencil or pen in proper position in his fingers, and yet be unable to write. He may even be able to copy letters or words in their printed or written forms, or geometrical figures, such as a circle or a triangle. Isolated agraphia is, however, very rare. Some hemiplegics with aphasia and agraphia learn after a time to write with the left hand, and sometimes show a tendency to copy from right to left, and with the letters reversed, this constituting the so-called mirror writing. Motor agraphia is a disorder of coordination rather than a disorder of vision or a true paralysis. The agraphic is not able to coordinate or energize those movements by which ideas are expressed in written signs. In order that a patient shall suffer from true motor agraphia, his writing must be of a specialized character, not merely a translation of his spoken language. It is not rare, as shown by Luys, to observe the dissociation of the faculties of speaking and writing in certain insane persons who are not delirious when they speak, but who are de- lirious when they write. The reverse may also be witnessed. This proves that the faculty of writing does not consist merely in the power of assembling letters, but in the psychical elaboration of words, phrases, and sentences, of which writing is but the expres- sion. According to some authorities, agraphia is invariably present when cortical motor aphasia is complete ; but a few cases opposing this conclusion have been recorded. Brissaud has reported a case of hemiplegia and complete motor aphasia in which the patient was able to write with his partially paralyzed right hand by carefully placing the pencil between the fingers of this hand with the left, with which he also assisted the right hand. A few cases of total motor aphasia have been reported in which the patient could write with the left or unparalyzed hand both spontaneously and from copy. In a case of this kind reported by Kostenitsch, autopsy showed de- struction of Broca's convolution. Most cases of motor aphasia are associated with right hemiplegia, and some of these may not be able to write because of the paralysis of the right upper extremity. It was at one time thought that the paralysis was the chief cause of the 640 NERVOUS DISEASES. agraphia ; but cases of pure aphasia without hemiplegia, and others in which the paralysis in the upper extremity is not sufficient to pre- vent writing, and in which the patient is also agraphic, show that this theory is not correct. It is probable, as stated under cortical localization (pages 3-49 and 350), that a separate graphic centre ex- ists, and that it is located in the caudal extremity of the medifrontal convolution, in close relation with the mesal boundary of the true speech centres (Fig. 331). This area must not be confounded with that for movements of the fingers, hands, and other parts concerned in writing. The true graphic centre is in advance of this region, just as the true motor speech centre is a little cephalad of the utterance centre ; and just as the utterance centre is a region con- taining motor executive cells through which speech begins to be exteriorized, so that j)ortion of the cortex which is related to the movements concerned in writing may be regarded as the executive cortical region for the graphic centre. Opinion is by no means set- tled with regard to the existence of this graphic centre. Wyllie con- cludes that it is probable that the power of writing with the right hand may be lost from a lesion of this centre, but that the left hand would be able to draw the visual images of the letters revived at the visual centre. Dejerine holds that no case of pure and uncom- plicated agraphia due to lesion of this centre has been put on record. While recognizing the fact that cases of isolated agraphia are some- times met with, he believes that in these cases the agraphia is the clinical remnant of an aphasia which has been present and has been caused by lesions either of the sensory or motor centres for speech. Transcortical Agraphia. — The ability to write is probably lost not only when the higher visual centre is destroyed, but also, at least in part, when the connection of this centre either with Broca's centre or with the graphic centre is interrupted. In one case reported by Pitres, the patient had paresis and rigidity of the right leg, slight paresis of the right arm, and right homonymous hemianopsia. He could copy letters and figures with his right hand, but otherwise was agraphic. He was flist seen two years after the apoplectic attack which had caused his symptoms, and in the mean time he had trained himself to write with his left hand. After writing numbers with his left hand he could copy them with his right hand ; he had no word blindness, no word deafness, and no difficulty with spoken speech. The existence of the hemianopsia as well as the paralysis showed that this case was not due to an isolated lesion of the graphic centre. The lesion was probably in the centrum ovale involving the motoi- projection fibres, the optic radiations, and the paths between the visual and the graphic centre or between the concept and the grai^hic centre. Conduction Aphasia. — In 1874, Wernicke, under the name of conduction aphasia {Lei1u)igsaph(me), described a form of speech APHASIA AND OTHER DEFECTS OF SPEECH. 641 disturbance in which the patient was neither word deaf nor troubled with any form of asynergetic or ataxic speech disturbance, but in which he had marked paraphumi ; that is, his speech was confused or jargon-like, words or syllables being substituted, transposed, or jumbled together. This form of speech disorder was attributed by Wernicke to lesion of the tracts associating the centre for word hear- ing and the motor speech centre in the left subfrontal convolution. It is in reality a form of transcortical aphasia, being due to disrup tioa of the tracts associating cortical speech centres. In these cases the lesions have usually been found in the insula and the floor of the Sylvian fossa. As the transcortical aphasias of the mixed sensory and concept types and of the mixed motor and concept types have already been described, it will only be necessary to speak of these cases as distinct when they sever the direct pathway between the auditory and motor speech legions. Some of those who recognize the conduction aphasia of Wernicke as a distinctive type do not acknowledge the existence of separate concept and naming centres as taught in this article. Beside the paraphasia or jargon speech, analogous conditions for writing, reading, or pantomime may be present as the result of lesions producing paraphasia. Thus, the patient may suffer from 2>(i>'(iff''('I}hia, his writing being incoherent or disconnected, or from paralexia, the words being misused, trans- posed, or substituted in reading ; or he may misuse signs and there- fore be a sufferer from paramimia. Dysphasia, dysgraphia, dyslexia, and dysmimia indicate difSculty or fatigue in articulation, writing, reading, or pantomime, the result of exhaustion or partial lesion of conducting tracts, although these affections may also sometimes be due, in part at least, to exhaustion or partial destruction of centres as well as of tracts. Amusia and the Aphasia of Intonation. — Theoretically as many varieties of cerebral deafness may exist as there are varieties of auditory symbols. A patient may be musically deaf, for instance, and the deafness may be either a receptive or an emissive amusia. Iv such cases the adaptation of the conventional sound to the idea it ex- presses has become impossible. Language does not consist of articu- late sounds alone, it is also sung. The faculty of intonation may be preserved even when the motor images of words cannot be revived in the cortex. One of Brissaud's patients, already referred to under motor agraphia, was a woman who was neither word deaf nor word blind. She was able to copy accurately printed or written words, but she was absolutely aphasic so far as the articulation of words was concerned. In attempting to communicate her ideas she not only made use of the facial muscles of expression, but used certain clucking, chattering, gurgling, or shrill sounds, varying the intona- tions in an infinitely delicate manner. These intonations were modu- lated like a sort of song, sometimes soft, sometimes loud, sometimes 41 642 NERVOUS DISEASES. accelerated and sometimes slackened in rhythm, according to the idea she intended to express. The cortical centres for motor images were probably intact. Such a case would seem to prove that the conducting fil)ies for articulation are not the same as for intonation. Intonation x)recedes articulation in the development of the language of races as in that of individuals. Articulation is the complement of intonation, not intonation of articulation. Accent, according to Eousseau, is the soul of discourse. Intonation may be used and has been used with great advantage in the training of deaf mutes and imbeciles. It was used by Itard in his attempts to train his famous wild boy. Articulation and intonation are often lost together, but articulation may be lost and intonation remain, as shown by the above case. (Brissaud.) Edren has reported a case of transient paraphasia and verbal deafness, and also permanent deafness for musical notes, in which, at the autopsy, lesions were found in the anterior two-thirds of the first temporal and anterior half of the second temporal lobe of the left hemicerebrum. Fifty-one other cases bearing on the subject were collected by this writer, and of these eleven were with postmortem examination records. He arrives at the following conclusions : (1) Any pathological process within the skull may destroy the musical faculties of the patient in the same way as the speech faculties, thus leading to different clinical forms of amusia ; (2) the different forms of amusia have some clinical independence in relation to each other, as well as to the different corresponding forms of aphasia ; (3) the clinical forms of amusia show a great analogy with the clinical forms of aphasia, the former being often, not always, accompanied by the corresponding forms of the latter ; (4) amusia may occur iu the clinical picture without aphasia, and vice verm ; (5) some of the forms of amusia have very probably an anatomical independence, and are always localized in the neighborhood of the areas of the corresponding forms of aphasia ; (6) musical deafness, that is, the perception of notes, accords, and melodies without comprehending their musical meaning, is probably located in the first or the first and second left temporal convolutions, anterior to the area of verbal deafness. The Nature of Aphasic Phenomena. — Differing Views. The statements above made regarding the varieties of aphasia and their symptomatology are, I belio\e, based upon conclusions which can be justly drawn from clinicoputhological observations and a general study of the entire subject. The views taken differ considerably from those of some high authorities, but are largely in accord with those held by others equally high, although differing perhaps in sf)rae respects from all. It will serve a good purpose to discuss briefly some of the theoretical points which from time to time have claimed attention, and wliich are yet the source of controversy not always amiable. If the differing opinions are carefully sifted, they APHASIA AND OTHER DEFECTS OF SPEEfH. 643 will be found to be more in agreement than at first sight appears. Much of the seeming difference is due to the manner in which the same phenomena are interpreted by different observers. In not a few cases the differences are matters of words rather than real antag- onisms. The Zone of Langmge. Special prominence is given by Freud and Dejerine to the idea of a "cerebral zone of language." The extent of this zone is given somewhat differently by different authorities. According to Dejerine, it embraces those portions of the cortex of the left hemicerebrum which are shown in the shaded area in the diagram (Fig. 334:). As there indicated, beginning at the ascending branch of the Sylvian fissure, it includes on the motor side the hinder part of the third frontal convolution and the lower extremity of the precentral convolution, extending to but not taking in the second frontal. On the sensory side it is made to include almost the entire Fig. .S34. The zone of language according to Dejerine (shown by the shaded area). first temporal and the posterior extremity of the second temporal convolution, and also those portions of the parietal and occipital lobes which are usually spoken of as the supramarginal and the angular convolution. Its sensory and motor subdivisions are united l)y way of the Sylvian fossa by means of the associating fibres which pass beneath the insula and the retroinsular con^'olutions. This zone of language includes three centres, — namely, that for the motor images of articulation, that for auditory images, and that for visual images. Each of these centres is situated in the part of the zone of lan- guage which approaches most nearly to its corresponding general zone, motor or sensory. The motor centre of articulation is in proximity to the psychomotor region ; the centre of visual images approaches most nearly the general visual zone ; and the centre of auditory images is in close relation with the general auditory sphere. In this zone of language the centre for auditory images is that first 644 NERVOUS DISEASES. evolved and most deeply organized. As a rule, the child's first ideas of language come through hearing ; articulate speech is next evolved ; the child hears, and it speaks ; it learns to repeat the names of persons and objects with which it comes into relation ; later, in those who be- come educated, a centre for the visual images of letters and words is organized, and still later, at least according to some authorities, a centre for graphic motor images. The auditory and motor speech centres continue to be for the vast majority of people most imijortant constituents of the zone of language. According to Dejerine, altera- tion of any one of his three centres for sensory or motor images causes a change in language which implicates the functions of all iiarts of the zone of language ; alterations in the tracts which associate these centres lead also to some change in all the forms or modes of language. Certain symptoms predominate, however, according to the particular centre or tract directly and most profoundly affected. If Dejerine's visual centre is destroyed, the fiinctions of Wernicke's auditory centre and even, to a less degree, those of Broca's motor centre are im- paired. If Broca's centre is destroyed, the functions of the visual and auditory sensory centres are affected. If "Wernicke's centre is de- stroyed, those of the visual and articulatory centres and all parts of the zone of language are perverted. Motor aphasia dominates when the lesion is situated in the centre of Broca, verbal deafness when in Wernicke's centre, and verbal blindness when in the angular con- volution, but in each and every case, according to the view of Deje- rine, all other modes of language are altered. Verbal blindness, either manifest or latent, is always present in cortical motor aphasia ; and while verbal deafness, as a rule, is not present, or at least does not continue, the power of spontaneously evoking auditory images is impaired. It is held by the advocates of this view that the facts which prove the involvement of all parts of the zone of language are frequently overlooked owing to the carelessness, or at least to the want of precision and fulness, in the methods of examining patients. While for many years the study of motor aphasia has been a favorite one and has not infrequently been conducted along somewhat elaborate lines, it is only recently that its investigation has been made sufficiently methodical and complete to give results of much value regarding disputed questions. It will be seen that the conception of aphasia and of a zone of language just given is not entirely in accord with the views indicated in the diagrams Figs. 331 and 332 and A\ith the teachings of the preceding portions of this section. I would enlarge the zone of language, as given by Dejerine, so as to make it include a centre for concepts in the third temporal convolution and pr)ssil)ly extending over more of the midtemporal region, and in addition a graphic motor centre in the caudal por- tion of the second frontal convolution (Fig. 335). This zone of language unquestionably has its deepest organization and highest APHASIA AND OTHER DEFECTS OF SPEECH. 645 development in the region encircling the Sylvian fossa, for here are situated the auditory centre out of which the others may be said to have been evolved, and the motor articulatory and visual centres which are next in importance as they ha^'e been next in develop- ment ; but it must also include those portions of the brain in which concepts originate, and, if the views of those who believe in separate graphic motor centres are correct, also those i^arts in which graphic motor images are represented. Moreover, language on its produc- tive side may result from impressions received through any of the sensory gateways ; written and spoken language is evoked not only by auditory and visual images, but also through olfactory, tactile, gustatory, and spatial percepts ; so that in a lesser degree the centres for touch, taste, smell, and other senses than those of audition and Fig. 335. The zone of language according to the author. This is made to include the midtemporal region as the probable location of the area for concepts, and also the caudal portion of the second frontal convolution as the graphic motor centre. The motor articulatory centre is made to extend a slight distance in front of the ascending branch of the Sylvian fissure, which is in accordance with the author's general diagram of the cortical centres and areas. (See Fig. 22».) vision, and the tracts which associate these centres with the motor side of the brain, may be regarded as properly constituting, at least at times, a part of the zone of language. The Separate Existence of Concept Centres. — Let us again brieiiy direct our attention especially to the question of concept centres or areas, and to the part which they play in the mechanism of speech. Even Lichtheim, who finds it necessary to make use of concept centres in his schemes, does not regard such centres as having a local or at least a restricted habitation. In his diagrams he has represented a centre for concepts, but this he says he has done for simplicity's sake, believing with others that the function of form- ing concepts is not localized in any one spot of the brain, but results rather from the combined action of the whole sensorial sphere. According to him, the concept centre should be distributed over 646 NERVOUS DISEASES. many spots, radiations from which converge to the sensory and motor speech centres. He holds that in order to haAC all the com- missural connections broken between the concept centre or centres and either the sensory or the motor centres for speech, the lesion should be close to the percept centres on the one hand or to the motor centres on the other. The matter does not present itself to me in exactly this way. Stjuctural and functional lines pass from all the centres on the sensory side, to reach eventually by direct or indirect paths the centre of Broca. The locations of the separate centres are such that the structural connections are most probably made by way of the midbasal portions of the temporal lobe. The recognized sensory percept centres surround this region, and within it fibres from them to the motor areas probably converge and cross. As stated when discussing the naming centre, Broadbent long ago con- jectured that this would naturally be the location of such a centre. This "centre" need not be as strictly limited anatomically as the separate centres for percepts, but it would occupy a region more or less localized, although it might be diffused over a considerable area. That differences of opinion about aphasic phenomena are sometimes apparent rather than real is illustrated by this discussion of the question of the existence of a separate concept centre. Freud con- tends that aphasia is always caused by disruption of associating tracts or paths, and that different forms of aphasia occur with certain symptoms predominating according to the position in his zone of language in which such disruption takes place. If a destructive lesion attacks the centre of his zone, the disorder of language will be such as to involve all the forms and phases of language. The centre of such a system of associations would be, anatomically speak- ing, where the structural lines which pass from the different sensory to the motor centres of speech cross, commingle, or most nearly approach one another. The symptoms presented when the mid- temporal region is destroyed, as illustrated by my naming centre case, indicate interference with all the modalities or elements of language. The ^-erbal amnesia, or the aphasia of recollection, caused by lesion of this region, includes within it some disturbance of all the elements of speeeli. In a typical case the patient cannot recall names through sight, touch, hearing, smell, or any other sense, and as they cannot be recalled they cannot be written or spoken, at least not spontaneously. The patient may repeat after another, may copy or may write to dictation, but he does this by using the direct pathways between the sensory and the motor centres. He under- stands the meanings and the uses of the objects for which the names stand because his percept centres are intact. Eoss held that in pass- ing from thinking by ])ercepts to tliinking by concepts, and from that to thinking by al)stracts, no new centres are introduced, but only complication ujion ((iiiiplication of the percept centre or centres. APHASIA AND OTHEB DEFECTS OF SPEECH. 647 The evolution of such a complex mechanism, however, necessitates the enlargement of the sensory percept areas, and this would have as its particular result the development of a new structural area intercalated between the recepti\'e and the emissive portions of the brain, but more closely related to the former than to the latter. When lesions occur near, but not in, the sensory inlets, a disorder of language, conceptual in character, results. The portions of the cortex the activity of which is related to thinking by concepts and abstracts can be reached in the word blind through the eye, in the word deaf through the ear, and in those who cerebrally are both deaf and blind through the nerves of the other special senses. If this be so, in some region of the brain the structural lines must converge or at least commingle and cross on their way from the sensory centres to the motor centres, and this area, however re- stricted or extended, constitutes the concept region of the zone of language. The symptomatology which results from a lesion of this concept area is that which was present in the case reported by the writer as localizing this naming or concept centre. Somewhat similar cases are sometimes spoken of as cases of optic aphasia, but our case was more than this ; the patient was unable to recall through either the sense of sight or that of touch the names of objects the uses of which she evidently recognized. A typically perfect case w^ould be one in which the patient should be unable to call uj) through any of the senses the name of an object the use and meaning of which are comprehended. The Question of a Motor Graphic Centre. — In the paragraph on motor agraphia I have indicated my belief in the existence of a motor graphic centre and the possibility of having a pure motor agraphia from lesion of this centre. To some extent I have dis- cussed the subject ; but so much that relates to the whole subject of aphasia, and especially to that of interior language, is involved in the question of agraphia that it may be well to consider further the views held by opposing authorities. In the days of Trousseau, and later, motor agraj^hia was generally regarded as dependent upon motor aphasia. The doctrine of a distinct graphic centre, however, soon received considerable support, and for years was largely ac- cepted ; but recently the tendency has been to return to the view of Trousseau. D6jerine in particular strongly upholds this view, which has been presented by him in special articles, and is ably discussed by his disciple Miralli6 in his valuable monograph on sensorial aphasia. Wernicke, Lichtheim, Serieux, and many others in recent years have acceded to this view. On the whole, however, the facts are in favor of the existence of a separate graphic motor centre. Arguments psycho- logical, physiological, clinical, and pathological have been marshalled for both sides of the discussion. The psychological arguments in favor of the existence of such a centre were best stated by Charcot and have 648 NEKVOUS DISEASES. been best defended by Ballet. According to them, a word is the result of the association of four distinct images, — auditory, visual, articula- tory, and graphic. During silent reflection we hear, see, or speak men- tally, and in special instances we think by means of graphic images. When we think about a word or words, the first images revived are those which constitute the primary couj^le in language, — namely, the auditory and motor articulatory ; when we read, the visual images are revived, and along with them also the auditory and motor articulatory images ; in writing, the visual images are revived in those who can see, and in addition the graphic motor images. When writing is a medium for the expression of thought, all four images are revived, in different degrees in different individuals according to their mental aptness and special training. In some, auditory and motor images, in others the visual, and in others, probably few in number, the graphic images, play the most important part. The recorded clin- icopathological observations in support of and in opposition to this view seem to me to be of almost equal weight. On the one hand it is held that nearly all cases of so-called motor aphasia have agraphia associated with them ; that in visual and even in auditory aphasias some degree of agraphia is usually present ; that cases of agraphia unassociated with visual, auditory, or motor articulatory defect are almost unknown ; and that when agraphia is present without aphasia it is usually the relic or remnant of a previous aphasia. On the other hand, it is contended that a few clinical cases with autopsies support the conception of the existence of a separate motor graphic centre ; that in rare cases agraphia has been absent when motor aphasia has been almost total ; that agraphia is sometimes observed when neither auditory nor visual defect is present, and that in exceedingly rare cases agraphia has been noted as the result of an isolated lesion. Cer- tainly the well-known cases recorded by Charcot, Bar, Kostenitsch, Ogle, and others lend considerable support to the view that favors the existence of a separate centre. In Bar's case a lesion was found limited strictly to the second frontal convolution, the patient being a total agraphic and also an aphasic ; here the third frontal convolution escaped, and the agraphia was due to a lesion of the second frontal. It is probable that tlie aphasia was dependent upon the pressure exerted upon the neighboring third frontal or upon the destruction of some of its subcortical or association fibres. In Kostenitsch' s case the third frontal cortex as well as subcortex was certainly destroyed in very large part, and yet the patient was not agraphic. Against the doctrine of a separate graphic centre has been arrayed the fact that certain individuals learn to write with their toes, elbow, knee, or mouth ; but this argument does not seem to me to have as much weight as is usually given to it. If a graphic centre exists, it is dis- tinct from the centre for movements of the finger and hand, just as the true motor speech centre is distinct from the centres for the move- APHASIA AND OTHER DEFECTS OF SPEECH. 649 merits of the lips, tongue, and face. When writing is performed by unusual methods, the graphic motor images are revived in the graphic motor centre, but they are exteriorized by different portions of the so-called motor zone, associations being formed between the grax)hio motor centre and the different regions for motor exteriorization. The same thought is applicable to the explanation of writing with the left hand instead of with the right. It has been found that aphasic patients are awkward in forming letters or words with alphabetical cubes or blocks just in proportion to the degree of aphasia and agraphia from which they suffer, and hence it is argued that a graphic motor centre does not exist, and that the defects shown are due not to loss of graphic images, but to the loss of the notion of the word or words. With equal force it might be argued that it is not the loss of articulatory images but the loss of the notion of the word which causes the aphasia, the notion of the word not being dependent, entirely at least, upon either graphic or motor articulatory images, but upon the associated action of the entire zone of language. The fact that the congeni- tally blind, who have no visual images, can be trained to write or print their names in ordinary characters is in favor of the existence of a separate motor graphic centre. Having no visual images, they must depend exclusively upon the motor memories of writing, what some authorities term the kinesthetic memories of writing. (Wyllie.) The argument would seem to be still stronger in the case of those who are both blind and deaf and who have been taught to write and to give expression to thought in writing. Eecently in the nervous wards of the Philadelphia Hospital, in the service of Dr. James Hendrie Lloyd, I have had the opportunity of studying with him and with Dr. . W. G. Spiller a patient whose symptoms seem to bear out the idea of the existence of a separate graphic centre. This patient has disturbances of language which have been of gradual de- velopment. He is not word deaf, he is not a true motor aphasic, but he is a total agraphic. He is only able to copy mechanically printed letters or words. At times he seems to have great difficulty in recog- nizing words or special letters ; so that it is difficult to decide whether he is suffering from literal or word blindness. The ophthal- moscope shows considerable optic atrophy, and this may be partly responsible for his visual defects in reading. He is not paralyzed in either the upper or the lower extremities, but has slight paresis of the right face. His condition varies ; on some occasions he can talk with comparative iiuency, but never perfectly ; at other times he has moderate or great difficulty either in remembering or in articulating words, it is difficult to say which. He has an area of extreme tender- ness which corresponds externally to the first and second left frontal convolutions, and in this area frequent tests seem to indicate the presence of percussion dulness. The case is somewhat perplexing, but it is probable that a tumor or other lesion involves the first two 650 NERVOUS DISEASES. frontal convolutions. It is not improbable that the patient is also suffering from chronic arterial sclerosis with softening and recurring edemas. Albumen and casts are present in his urine. Relative Importance of Centres and Association Tracts. — Usually most importance is given to "centres" in the explanation of the phenomena and affecti(jiis of speech ; but Freud lays greatest stress upon the part played by association fibres, and, according to him, lesions of the centres are to be relegated to the second place. Wernicke, Lichtheim, and others have paid especial attention to the aphasias of conduction, — affections due to disruptions of association tracts. It has been shown that their lesions give rise to special morbid phenomena, but their importance is not greater than that which is assigned to lesions of the centres for images. These so- called conduction aphasias have not been regarded as playing even an equal role with the disorders due to lesions of the various centres. The forms of subcortical and transcortical aphasia described are, from the standpoint of most observers, restricted to lesions of associa- tion tracts. The usual conception is that all forms of aphasia are due to isolated lesions either of centres or tracts or of both in the same case ; but with Freud, lesions of the association fibres, which cause disruption of the functions which take part in the mechanism of speech, are of dominating importance in the production of apha- sias. For him the aphasic sj-m^^tom or syndrome is above all a sign of dissociation, speech being altered because the patient is not able mentally to pass from one image to another. According to the ex- tent and degree of the destruction of associations is the impairment of speech. The so-called centres, placed in the periphery of the zone of language, are only points farthest removed from other centres, where therefore the fibres of association are least abundant and where a localized lesion is more likely to include only a single ele- ment of language. A destructive lesion at the place where the fibres of association cross among themselves will give for the clinical picture alterations in all the jnodes in which language is manifested. Considerable credit is due to Freud for directing the attention of neurologists to the importance of association tracts in the pathology of aphasia ; but mistakes are likely to be made as regards both centres and association systems. As stated elsewhere, the use of the term centre in neurology. A\-hile important, is largely a matter of convenience. A centre is simply a collection of gray and white matter which repj-esents physiologically some action, function, or faculty. Its destruction causes loss or impairment of function, and its irritation leads to excess of functional activity. Centres, like cells, are too often considered as points where force originates. They are best regarded simply as points in reflex arcs or in systems of association, interference with which causes definite phenomena. Impulses, we now know, are transmitted from nerve cell to nerve APHASIA AND OTHER DEFECTS OF SPEECH. 651 cell by contact, and not by continuous fibres over distances indefi- nitely prolonged. It is an error to make too great a distinction between the effects of lesions of association tracts and of centres. Centre and tract each plays its own important role, and it is for us simply to learn, through clinical and pathological observation, the results caused by their lesions when these are of definite size and in deiiuite locations. Importance of the Distinction between Pure Aphasias and Aphasias due to Impairment of the Mechanism of Interior Language. — The distinction between the so-called pure aphasias, which include pure motor aphasia (subcortical motor aphasia), pure verbal deafness (subcortical auditory aphasia), and pure verbal blindness (subcortical visual aphasia), and the aphasias due to dis- turbances of interior language as the result of lesions of the so- called zone of language, is a general one which must prove help- ful to the physician in the differential diagnosis of the cerebral af- fections of speech. Word deafness or word blindness as the result of isolated lesion of the tracts which pass from the iDrimary cortical centres for vision and audition to the higher secondary centres for word vision and word hearing is not associated with other disturbances of language, such as verbal amnesia, motor aphasia, agraphia, or para- phasia. The patient's interior language remains intact. Similarly the patient who is suffering from the pure form of motor aphasia, from defect of speech due to destruction of the subcortical projec- tion fibres, has a pure disorder of motor speech. Articulation, and it may be enunciation, are greatly impaired, but he does not in any degree, if the affection is complete, suffer from word blindness, word deafness, dyslexia, alexia, paraphasia, or even agraphia, although he may have an apparent agraphia because of the paralysis of the upper extremity which usually accompanies the aphasia. It is rare, however, to meet with an entirely pure case of either of the forms of sensory or motor aphasia, as the destruction produced by disease does not commonly confine itself strictly to special centres and tracts. Disorders of Pantomime among Aphasics. — Definition of Pan- tomime, and Varieties of Fantomiinic Disorder. Pantomime is the rep- resentation of thoughts or ideas by action or movements, and, like the higher forms of speech, is a method of intellectual intercourse. The individual by pantomime may show that he hears, sees, or other- wise receives impressions, or that he is conscious of what is meant by the words or actions of another. He may indicate that certain thoughts have arisen spontaneously in his mind, or he may make use of this method of expression to convey the ideas to others. Panto- mime, like speech, may therefore have its sensory or receptive aspect, its concept sphere, and its motor or emissive side. Disorders of pantomime and of speech may go hand in hand, or may be more or 652 NERVOUS DISEASES. less dissociated ; in some cases they may be entirely independent of one another. The rule is that cerebral disturbances of speech have accompanying pantomimic disorders. These are forms of aseniia, which is the inability to understand, form, or express any symbol of thought or of feeling. In a study of cases a distinction must be made between pantomime and gesticulation ; the former is a higher process than the latter. According to Hughlings Jackson, panto- mime differs from gesticulation as a proposition differs from an oath. The former is a method of presenting ideas, the latter of giving vent to feelings. The same action, however, may be pantomime in one and in another gesticulation, as when movements of the head or limbs are used in one case to make clear a meaning and in another to exhibit emotion or mere emphasis. The chief varieties of panto- mimic disorder observed among aphasics are amimia and paramimia. Amimia, which is a loss of the power of expressing thoughts by signs or movements, may be sensory, conceptual, motor, or mixed. It may also have special varieties, as musical amimia, in which the patient has lost the power of receiving or interpreting music by means of signs or movements. He may be unable to play upon instruments, although he has been a thorough musician and is still capable of appreciating the music. Paramimia, a somewhat common disorder among aphasics, is an affection in which the patient misuses, trans- poses, or confuses signs intended to convey his meaning. It is a disorder which, as regards signs, is comparable to paraphasia for speech, paralexia for reading, and paragraphia for writing. It may be due to lesions of either centres or tracts, or of both in the same case. It is most frequently dependent upon the destruction of the tracts which associate the sensory, concept, and motor centres. Relation of Pantomime to the Varieties of Aphasia. Attention will be directed to a few points in connection with the relation of panto- mime to the different varieties of aphasia and to its diagnostic im- portance. I have made a study of pantomime in a large number of cases of different varieties of aphasia. In cases of word deafness or word blindness pantomime is most disturbed on the sensory or re- ceptive side. If these disorders are associated with verbal amnesia and any of the forms of apraxia, marked disturbances of pantomime will be present. In true motor aphasia, even when this is complete or nearly complete, the patient sometimes shows marked preser- vation of pantomime. Such aphasia is, of course, usually accom- panied by right hemiplegia, but the patients have the full use of the left upper extremity, as well as of the head and other parts of the body, and with these are often able to communicate by pantomime. In some cases, however, of even ordinary motor aphasia, pantomime is more or less impaired, the difference being probably dependent in part at least upon the ability of different individuals to use both sides of their body in signs and pantomime. In mixed sensorimotor aphasia APHASIA AND OTHER DEFECTS OP SPEECH. 653 pantomime may be of very uncertain character. One marked case of this kind was examined by me, with the result of showing that her pantomime, which was usually correct, had in it an element of un- certainty, slowness, and awkwardness. (Fig. 3.36.) She pointed, beckoned, and motioned away, but awkwardly. On being told to close her eyes, she did so promptly ; on being told to lift her right hand, she tried to raise this which was her pai-alyzed hand, and, finding she could not do it, said, '' Can't tell.'' When asked whether Fig. 336. Right hemiplegia with raarl^erl contractures; almost complete aphasia, with unreliable and confusing pantomime ; patient flfty-four years old ; she had had two attacks of apoplexy twenty- three years before observation ; lesion probably subcortical and capsular. she was married, she said, "Yes," with the proper forward nod of ' assent, but immediately after said, "No,'' shaking her head prop- erly for dissent. On being asked if she had headache, she said. Yes," with an assenting nod. When asked if she had any houses, she nodded, "Yes," and assented when she was asked if she had but one house ; she responded similarly to various tests. She could assent and dissent by pantomime understandingly : she did not, however, always do this correctly, but usually she corrected herself when she was wrong. 654 NERVOUS DISEASES. Fig. Cases with Limited Speech and Limited Pantomime. — Cases which retain only a single recurring utterance are usually almost equally limited in pantomime. Just as such cases have only one or a few utterances, so they may have only one or a few recur- ring signs, as an energetic movement of one arm, or a movement of the head accompanied by a certain facial expression, as shown in Fig. 337. This patient's only utterance is, "La, la," and the case is one of almost complete amimia. When she makes use of this recurring utterance, it is almost invariably accompanied by the facial expi-ession which has been caught in the photograph. Sub- cortical motor aphasics j)re- serve the power of pantomime. Pantomime is also largely pre- served in subcortical sensory ajihasia. although in subcor- tical visual aphasia the patient may in some instances be blind to signs as he is to letters. The '■yes" and "no" of an aphasio are ^nell known to have very diverse degrees of value. One of these two words may be used to express both assent and dissent ; or ^with its proper meaning ; or to express assent when dissent is meant ; or sim- ply as an emotional or an ac- cidental expression. In like manner the usual pantomimic methods of expressing assent by the forward nod or bowing of the head, and of dissent by shakes or half rotations of the head, will be found in aphasics to have as many in- terpretations as the articulated "yes" and "no." Diagnostic Points regarding Pantomime. Great care should be taken not to misinterpret the emotional manifestations of an aphasic. The gestures and appearance of the face indicative of displeasure, anger, ol)stinacy, or irritability are often strongly suggestive of dissent ; while, on the other hand, those which merely indicate pleasure, anuisenient, or ]-)layfulness may sometimes be mistaken for assent or accord. Wlien the lesion is entirely in the straits between the ganglia, tlie corona radiata escaping, pantomime is either not lost or is soon regained. The speech defect in such a case is of the nature of an rt«(i)#r/ff,— that is, a defect or disturbance of articulation. It is a pseudobulbar affection. A diagnostic point is the aliility of the patient to throw even into the paralyzed mem- Kiglit hemiplegia with marked contractures : complete aphasia of the mixed type ; a single re- curring utterance and rectirring facial expres- sion ; almost complete amimia. APHASIA AND OTHER DEFECTS OF SPEECH. 655 bers some volition. In numerous instances hemiplegic patients who at first suffer from marked paralysis of the leg, arm, and face, and complete or nearly complete aphasia, recover largely control over the face, and ability to speak as well as to use pantomime, while loss of power in the leg and arm remains. This form of hemix^legia is familiar to all neurologists. In patients of this class the lesion is usually situated in the posterior half of the internal capsule, in- volving often the lenticular body. Speech Disturbances and Mental Disease. — From lesion of the prefrontal lobes or from general deterioration of the brain a patient may suffer from alogia, or inability to speak owing to defect of his higher psychical faculties, and this may be dependent upon a diffuse destructive cerebral lesion. In various forms of idiocy and imbecility, absence of si^eech may not be in a strict sense of an aphasic character, but rather dependent upon the general lack of intelligence, being one of numerous evidences of arrested mental development. In some forms of delusional insanity the patients are prevented from speaking by their delusions. Aphasia dissociated from marked mental impairmenu is of more frequent occurrence than aphasia in association with such impairment ; so that in a case of suspected insanity the burden of proof rests on those who maintain that mental disease is present. "The varieties of in- sanity which are most apt to be complicated by the occurrence of functional aphasia are those in which there is obvious depression of the nervous energies of the brain. The depression of energy may be lasting, as in senile dementia and acute melancholia, or it may be temporary, as after one or other of the numerous forms of nervous seizure which the insane are peculiarly apt to experience from time to time." (Wyllie.) Amnesic aphasia is often one of the most striking phenomena of senile dementia, and it may or may not be associated with disorders of articulation. In melancholia, as Seglas has shown, not only is mutism sometimes present, but the patient may exhibit what may be regarded as word deafness due to functional exhaustion or disablement. He hears sounds, but he does not recognize them as words. Occasionally an aphasic is supposed to be demented or deranged when he is simply disturbed in mind, he being apparently incapacitated mentally because he is deprived of his ability to communicate with others by language or signs or both. Cases of this kind have evident medico-legal importance. Hallu- cinations of hearing, of sight, of speech, and the various forms of mixed hallucinatory disorders from which the insane suffer, are doubtless frequently due to functional or organic irritation of the various cortical centres and tracts concerned in speech phenomena. In a disease like general paralysis of the insane, with a well known meningeal and cortical pathology, the speech defects have a real organic basis. It is unusual to observe a case of complete sensory, 656 NERVOUS DISEASES. motor, or mixed aphasia in paretics or pseudoparetics, but occa- sionally they are seen as the result of intercurrent apoplexy or of the invasion of a syphilitic organic lesion. In paralytic dementia a combination of active pathological conditions and secondary degen- erative changes has sapped the integrity of some or, it may be, of all parts of the cortex required in the mechanism of normal speech, so that we may have any variety, usually incomplete, of paralytic or ataxic speech, or of speech defects conditioned by changes which have taken place in recepti\'e or conceptive cortical areas. In senile dementia the cerebral cortex is more or less deteriorated and disinte- grated, and hence, among other phenomena, we have the uncertain, tremulous, mumbling, and piping speech of the aged dement. Pick has recorded a case of senile atrophy presenting the symptoms of transcortical sensory aphasia. The patient had lost the understand- ing of vocal and written speech, was paraphasic, and had partial loss of ability to repeat spoken words. W. Bevan Lewis has reported a similar case, cited by Pick, in which the patient presented amnesic and ataxic aphasia (mixed sensory and motor aphasia), and in which the brain showed marked atrophy of the left fi-ontal and parietal lobes and less pronounced general atrophy. A few other similar cases have been reported. Seglas, Eobertson, and Wyllie have paid special attention to the forms of speech disorder among the insane. The activity of the various centres or tracts concerned in speech, or at least of some of them, is suppressed or inhibited in melancholia, is increased in mania, and may be perverted in various ways in both of these mental affections. The hallucinations and delusions in pro- gressive systematized insanity are dependent upon, or are concomi- tants of, localized cortical perturbation. Mirror 'Writing. — Definition and General Remarks. Mirror writing is so called because it can be easily read in a mirror, in which the reflection appears as ordinary writing. Erlenmeyer, in a monograph published in 1879, called particular attention to this curious defect, and it has received attention from a few investigators, particularly those interested in the study of brain physiology in its relations to disorders of speech and of writing, and those who have discussed the dual action of the brain. According to Savage, mirror writing is met with in some forms of mental weakness and in conditions of mental disorder allied to hysteria ; occurring also in cases of moral perversion, where it may be only temporary. It is observed more commonly among women than among men, and is most easily ac(iuired in highly nervous jieople. In writing or copying a word from right to left, one would ordinarily trace first the last letter, and then the next, and so on backward to the beginning of the word. In mirror writing the image of the word is reversed, the first letter in it appearing on the right, so that the word will appear in the ordinary position when reflected from the mirror or when seen from APHASIA AND OTHER DEFECTS OF SPEECH. 657 behind through transparent or translucent paper. Mirror -writing can, of course, be done as a triclv, or for amusement, and with the right or the left hand, but those who try it will usually at first find it difficult to make particular letters, and especially to connect them consecutively. Dr. Wilbur sent to Dr. Ireland specimens of the writing of a man who could write the same words with both hands at once, the writing done with the left being mirror writing ; but, as he could do the same with both hands moving from left to right in ordinary text, the performance was probably sleight of hand. Illustrative Gases. Ireland gives the details of several interesting cases. One was a paralytic, imbecile girl, between eleven and twelve years old ; another was a genetous imbecile girl of fourteen ; another, a congenital imbecile of twelve ; another, a boy of thirteen of mod- erate intelligence : all of these defective children wrote with their left hands. He also mentions two left-handed idiot boys who formed pot-hooks from right to left. Buchwald, cited by Ireland, has re- ported the case of a right hemiplegic and apliasic, forty-five years old, who soon learned to write in a skilful manner, but in mirror writing, his name, as well as the numerals from one to ten, except the figure eight, which he had forgotten. Although the reverse direction of his writing was pointed out to him, he could not be induced to try writing from left to right ; and although by persist- ence he learned to copy some things correctly but awkwardly, he would again fall into the mirror writing. Mirror Writing and Left-handedness. The left-handed show a physiological tendency to mirror writing. Of a class of sixty boys and girls who tried to write their names with their left hands, two boys and three girls wrote in mirror writing, and all of these were found to be left-handed. Out of another set of one hundred and thirty-four children, six were left-handed, and three of these were mirror writers. Imbecile children who are often left-handed also frequently show a tendency to reversions in spelling and in pro- nouncing words. One of Leonardo da Vinci's manuscripts is an example of mirror writing, and it has been supposed that this singular style was adopted to preserve the work from superficial readers ; but another reason is suggested. A priest who visited Leonardo during the last years of his life has recorded the fact that he had paralysis of the right hand, and, as he was unable to use his right hand, it may be that he learned to write with his left and became a mirror writer. A telegraph operator has informed me that at times when an operator is occupied in sending a message with the right hand, and wishes without stopping to make a mem- orandum with the left, often the letters are reversed, B, for instance, being written a. Two explanations of this are suggested : one, that the operator can with more readiness write in the centrifugal direc- tion from the trunk, and will therefore incline to reverse the letters ; 42 658 NERVOUS DISEASES. the other, that the left hemisphere being intensely occupied with both the mental and the manual effort required in sending a message, the right takes separate charge of the left hand in making the memorandum. Mechanifim and Pathology of Mirror Writing. Ireland comments as follows on the probable mechanism of mirror writing : "It may be asked, is the image or impression, or change in the brain tissue from which the image is formed in the mind of the mirror writer, reversed like the negative of a photograph ; or if a double vision be formed in the visual centre, one in the right hemisphere of the brain and the other in the left, do the images lie to each other in the opposite directions, e.g., C on the right side and on the left side? We can thus conceive that the image on the left side of the brain being effaced through disease, the inverse image would remain in the right hemi- sphere, which would render the patient apt to trace letters from right to left, the execution of which would be rendered all the more natural from the greater facility of the left hand to work iu a centrifugal direction. Moreover, when one used the left hand to write, there would be probably a tendency to copj the inverse impression or image on the right side of the brain." Special convolutions in the right liemisphere have in a quiescent and undeveloped state the same functions that are active in the corresponding convolutions of the left hemisphere, as many observations on aphasic patients have demonstrated. The right side of the brain is not functionless, but its functions are in part, and sometimes largely, in abeyance. When the individual has the perfect use of the left half of his brain, — is right-handed, has the usual expertness with his right hand, has speech and vision in accordance with his inheritance and his train- ing, — impressions which come to him through his eyes are received by both the lower and the higher visual centres, so as to jiresent to his consciousness a normal or a usual image, which, as a rule, has been registered only by the visual centre of the left hemisphere. In this centre the images are recognized as in correct position ; the image formed on the right side, if one exists, is probably usually suppressed. When now tlie left side of the brain is destroyed, or when its development has been arrested, the individual is guided in writing by images formed in the right side of the brain. In Fig. 338 is given the mirror writing of the patient shown in Fig. 330 on page 614. Pathological Etiology and Etiological Diagnosis of Aphasia. — The pathological cause of aphasia may be hemorrhage, softening, meningitis, encephalitis, tumor, or almost any organic cerebral affec- tion which may also gi\e rise to loss, impairment, or disturbances of speech which strictly art' not aphasias. The distinction between aphasia and the Aarious hysterical affections of speech, such as aphonia, hysterical mutism, hysterical stammering, etc.. is an in- APHASIA AND OTHER DEFECTS OP SPEECH. 659 teresting practical matter, but is best considered in connection with hysteria. One or two diagnostic points may here be noted. A case of hysterical mutism or aphonia usually retains the power of writing, while the true aphasic, as a rule, is also agraphic ; but it must be re- membered that good authorities, as Ladauie, believe that an affection which is properly designated aphasia and may be associated with agraphia is sometimes found among the hysterical. In catalepsy, astasia abasia, and chorea, marked disorders of speech are often present. The diagnosis of their real nature is to be made by a close scrutiny of the affection in which they occur, and by a comparison of the speech phenomena with those of true aphasia. The disturb- ances of speech observed in catalepsy and astasia abasia are hysteri- cal in character, like the other phenomena of these affections. In chorea they are usually dependent upon incoordination of the muscles FiQ. 338. niustration of mirror writing. concerned in articulation, phonation, and respiration ; although a true amnesic aphasia may sometimes be exhibited. Occasionally aphasia and other disturbances of speech are due to reflex irrita- tion ; among cases of this kind which have been put on record are those due to worms or to accumulations of scybala or other irritating matter in the intestines. The occurrence of aphasia and other troubles of speech as the result of toxemia needs to be borne in mind. Any toxic or infectious substance which acts powerfully upon the brain may cause aphasia. Among the substances intro- duced from without which are known to have acted in this way are tobacco, belladonna, opium, cannabis indica, alcohol, the poison of snakes, and lead. Among the toxic agents formed within the body are those which are present in the uremia of nephritis and the aceto- nemia of diabetes ; also those which occur in typhoid and typhus 660 NERVOUS DISEASES. fever, \'aiiola, measles, and malarial fevers ; in faet, any of the in- fectious dist'ases may cause aphasia, and, as has already been shown when considering the cerebral palsies of children, may lead to pa- ralysis. A distinction must be made between cases of temporary ajihasia, in which the speech disorder is simply a nervous symptom due perhaps to anemia and exhaustion of the brain, and those cases in which licmorrhage or cmbdlisui occurs during the course of an infectious fever and gi\'es rise to hemiplegia, monoplegia, or aphasia, or to a combination of aphasia with one of the forms of paralysis. A form of dijaioiliriu or diiliculty of articulation which occurs during fevers has bci-n particularly studied by AVestphal, who describes a slow staccato utterance like that of multiple sclerosis as not infre- quent in the course of smallpox. Slurring of speech when extreme is a grave symptom of fevers. (Wyllie.) Systematic Examination of Patients for Aphasia. — In order to determine that aphasia is present, and its variety, the examination of a patient should be thorough and systematic. It is best in a gen- eral way to follow methods which are suggested liy the order in which the different forms of aphasia have been considered, although for special reasons this order may be departed fi'om and the patient tested for whatever seems the most important at the time. The patient should be examined critically for word deafness, and in doing this it may be necessary to determine first that he is not deaf for ordinary sounds, and that his deafness is not due to peripheral dis- ease. It should also be determined whether or not he can read ; and if he can read aloud, whether he does so correctly or whether his reading is of a stumbling kind, — that is, whether he suffers from paralexia. He should be studied for word blindness. If he suffers from verbal or literal blindness or from both, further examination should be made to determine whether he can write spontaneously and from copy or from dictation. The manner in which he writes or copies should be particularly observed. It should be ascertained whether he understands what he writes, and also whether he can read what he himself has written. It must, of course, be determined whether his defects in writing are due to ignorance, want of edu- cation, or perij)heral detects in vision, or to inability to coordinate and synergize the movements necessary in writing, instead of being dependent upon word or letter blindness. Wyllie suggests to ask the patiiuit first to write his name, and, if he succeeds, to put simple questions to him and ask him to answer them in writing ; if he writes with comiiarat i\-e eas(>. to ask him to write at his leisure the history of his illness, and to note in his performance evidence of— (1) l)aragraphia (which is usually only the written translation of par- aphasia) ; (2) intoxication of the mind with a letter or a word ; and (3) faults of spelling or of syntax. If the right hand is paralyzed, he suggests to let the patient try to write with the left ; if the right APHASIA AND OTHER DEFECTS OF SPEECH. 661 hand is not paraljzed, to let him furnish examples of his per- formance in writing with both the right hand and the left. He should be tested not only as to whether he understands printed or written letters, but also as to his comprehension of such graphic symbols as numbers, algebraic signs, and musical notes. Of course an examination in these directions would be necessary or not aceoid- ing to the previous education of the patient. He should be studied as to his powers of comprehending verbs and nouns, as well as to his methods of using these parts of speech. In examining for verbal amnesia, the patient should be shown common objects and asked to name them. If he is completely speechless, it should be learned whether or not he is able to write the name of the object which is shown him. If he can neither speak nor write, he may be tested as to his abilitj' to exjjress his meaning through pantomime. Following the method of Lichtheim, for instance, he can be asked to indicate with his fingers the uuml>er of syllables in the name of the object shown to him. He can be tested also as to psychical deafness by observing whether or not he recognizes the use of objects about which he is told. In studying motor aphasia, if a patient can speak only a few words or expressions, what these are should be noted, and whether his utterances are of a recurring character ; also whether he uses words with their proper meaning, as "yes" for "yes" and "no" for "no." If he is able to talk, the character of his utterance should be observed, and the manner in which he uses his organs of articu- lation ; it should also be observed whether he has any paresis of the face or tongue or of the facial muscles. He should be tested not only as to whether he understands speech, but also as to whether he understands music and musical tones. It should be observed whether the patient repeats or echoes the words spoken to him, and also, if he does this, whether he seems to understand the words which he repeats or echoes. He should be thoroughly examined for pantomime, after the methods indicated in the brief discussion of this subject. The investigator should constantly keep before his mind that he is to de- termine not only what the patient has lost, but also what he retains, of language or of thought. His general mental condition should be carefully considered. The physician should satisfy himself that the patient is not suffering from stuporous melancholia, nor from de- mentia, nor from hysterical mutism, nor from any of the forms of nervous or mental diseases which may impair his language or render Mm mute. Diagnosis. — Differentiation of the Clinical Varieties of Aphasia. Much that has been said in describing the different forms of apha- sia will be of value in separating the varieties of speech defects from one another, — the sensory from the motor, both of these from the conceptual forms, and the different varieties of sensory and motor aphasia from one another. Word deafness is readily separated from 662 NERVOUS DISEASES. motor aphasia, but the one may be complicated with the other when large lesions are present. If it is clear that noises or sounds are heard, but that the words cannot be perceived as such, it is evident that verljal deafness is present. The patient does not respond to verbal stimulation. Comph'te cerebral deafness may result from double or successive lesions in the superior portions of the temporal lobes, and it might be difficult to tell whether the patient was or had been word deaf. The history of the case would be of most value. The existence of i^eripheral deafness is, of course, determined by the ordinary methods of aural examination. Verbal deafness may be complicated with both motor aphasia and verbal blindness, when it may be difficult to determine whether the patient is suffering from true verbal deafness, or is deaf, mute, or demented. Such a compli- cation is rare, and would most likely be due to multiple lesions. The confusion and irritability of the patient would add to the difS- culty, and the problem could be solved only by a close analysis of the symptoms and the method of their appearance. The history of apoplectic attacks, the association of paralj'sis with speech disturb- ances, and the existence of previous mental health would be against the case being one of melancholia or dementia with deafness and mutism. Differentiation of Cortical from Subcortical and Suhcerebral Aphasia. A study of the patient's power of pantomime will sometimes assist in the diagnosis of cortical from subcortical aphasia. When, for instance, a patient totally aphasic so far as articulate words are con- cerned is asked how old he is, or how many syllables are in a word, if his cortical centres for motor images are intact he may be able to answer in pantomime, by opening and closing his hand a certain number of times, or by lifting the hand and letting it fall, or by a certain number of nods of the head. Speech disturbances are some- times present and marked in lesions of the pons, and especially when these lesions are bilateral. These disturbances are similar to those which have been described as present in cases of subcortical motor aphasia. They are of the nature of anarthrias. The diagnosis from subcortical aphasia due to cerebral lesion would be made by a con- sideration of the other symptoms and signs of pontile lesion. Differentiation of Different Forms of Agraphia. It is hardly neces- sary to say tliat in the diagnosis of agraphia the patient's education and previous aV>ility to write must not be overlooked. It may, of course, be difficult to tell in hemiplegic aphasics whether or not the agraphia is (lejicndrnt upon the paralysis and contracture. The true agraphic will not at first be able to write either with the unparalyzed or with the paralyzed hand, and if he tries with the unaffected member he may write in mirror fashion. If he is a true motor agraphic, even though he retain sonic power in his partially paralyzed hand and fingers, he cannot write, <->r even in most cases make an effort to APHASIA AND OTHER DEFECTS OF SPEECH. 663 write, with the paralyzed hand. A cortical motor aphasic if he pre- serves the power of copying with either hand usually copies the words very exactly, but turns the printed letters into script; the sensory aphasic copies mechanically with great dif&culty letter by letter, as one would reproduce any figure or picture before him. Motor agraphia can be differentiated from the agraphia which is due to lesion of the visual centres by the presence of other symptoms which indicate involvement of the sensory or receptive side of the brain, such as word blindness and letter blindness. S6rieux has re- ported a case of word blindness with agraphia in which the left in- ferior parietal lobule and angular gyre were softened ; the patient had no paralysis, no hemianopsia, and her general vision was good ; she could scarcely make out a single letter. Although the move- ments of the right hand were perfect, she could not write a word legibly. Writing from dictation and from copy, as well as sponta- neous writing, was very difficult. Prognosis. — The prognosis of a case of aphasia varies according to the severity of the attack, the pathological nature of the lesion causing it, and, to some extent, the variety of the aphasia. Attacks due to large and destructive lesions of the cerebral substance are, of course, always of comparatively unfavorable omen. Aphasia, which may be complete and is often of the motor or mixed form, sometimes persists for years or until death, the patient either recovering no speech or at at best recovering only a few stock or recurring expres- sions. Such cases are usually associated with a large amount of paralysis. It is not wise, however, to decide too early that a case of complete hemiplegia with nearly complete aphasia will have an entirely unfavorable prognosis. The aphasia in these cases is some- times due to compression or the effects of cerebral shock, and when this passes away speech is rapidly recovered. The existence of a large destructive lesion permanently affecting the speech centres and tracts can be determined with some approach to accui-acy after the acute and subacute symptoms of the apoplectic attack have subsided. In cases which are due to localized s^-philitic lesions, as to a gumma, to localized meningitis, or to encephalitis, the prognosis is compara- tively good unless the specific lesion has persisted sufficiently long and its invasions have been such as to cause considerable destruction of brain substance. On the whole, the prognosis of a case of aphasia due to hemorrhage is somewhat better than when it is due to acute softening from embolism or thrombosis. As to the variety of aphasia, much that has already been said indicates that some of the forms have a more hopeful outlook than others. The receptive and inter- ceptive or conceptual aphasias are, on the whole, more likely to im- prove, at least to make partial and in some cases considerable im- provement, than are those of a motor or a productive character. Word blindness, often at first complete or nearly complete, may in a 664 NERVOUS DISEASES. large degree pass away, while the paraphasia and the motor aphasia, if the case be of mixed type, largely jjersist. Complete word blind- ness, unless transient and partial, is not often recovered from entirely. Much, of course, will depend on the extent of the loss of language and on the previous intelligence of the patient. Thomas and Eoux, after a study of seventeen cases of cortical motor aphasia, concluded that the patient in the course of improvement first recognizes the appearance of the word, then associates the syllables which form the word, next the letters which form each syllable of each word, and at last the meaning of the whole word. In other words, such an aphasic patient reeo\ers the ability to read in exactly the inverse order in which a child learns tg read. Aphasia of the most complete type and of almost any variety is sometimes due to organic but evanescent disease of the brain or its membranes, as to meningitis, encephalitis, or meningoencephalitis ; or it may be dependent upon concussion, compression, or contusion of the brain. In compression and concussion, extravasations of blood are sometimes present either in the interior of the brain or aljove or below the dura. Inflamma- tion subsides, or absorption of the extravasation takes place, and the patient recovers in whole or in large part from his speech as from other disturbances. Whether aphasia is due to hyi:)eremia of the brain is regarded as doubtful by some. Many cases of evanescent aphasia were formerly attributed to congestion of the brain ; but often the cases so explained were due to other causes. Treatment. — Medical Treatment. The patient may be treated either medically or surgically for the affection which has caused the aphasia. If he has a syphilitic history, the jjossibility of a tumor should be considered, and mercury and the iodides should be used as in other cases of cerebral syphilis. Even when the disease attacks chiefly the vessels, such treatment may be of some avail in prevent- ing its rapid inroads. The nutrition of aphasic patients shorild re- ceive careful attention, as the weakened and injured brain needs to be nourished and supported. Occasionally aphasia may be due to gouty inflammation of the membranes, or, as has been shown in a previous paragraph, to localized or diffuse hyperemia. In such cases the medicinal treatment should be in accordance with the condition supposed to be present. Lithium and colcbicum preparations can be gi\'en in the gouty cases, and local and general depletion used with the Ijromides, hydrobomic at'id, ergot, and drugs of a similar kind, to }'elicve the congestive attacks. Siini'iCid Treatment. Some of the most interesting and successful cases in the history of cerebral surgery have been those in which aphasia has been relieved as the result of trephining. Surgeons should be able to recognize the types and subtypes of aphasia. The centres and tracts f( >r speech are so far apart that the trephine needs to be placed in distinctly different regions, separated in some cases APHASIA AND OTHER DEFECTS OF SPEECH. 665 by several inches. In some head injuries with aphasia, in whicii the nature of the aphasia, and therefore the site of the lesion causing it, can with a fair degree of certainty be fixed, it may nevertheless be best to wait a few days before operating. Such a case may be due to contusion, hemorrhage, or fracture, and in a short time the aphasia may pass away. In a case seen by me in consultation with Dr. Deaver at the German Hospital, the patient had marked motor aphasia, paraphasia, paralexia, and paragraphia, associated with paresis of the lower portion of the right side of the face, and evidences of injury in other parts of the body. Operation was postponed, al- though the lesion was regarded as probably a meningeal or cortical hemorrhage implicating Broca's convolution and the face centre. In about a week the aphasia began to disappear, and soon the patient entirely recovered. Other re- corded cases, however, have F^"- 339. shown the importance of not postponing operation. (Fig. 339.) Macewen, for instance, reports a case of hemiplegia, aphasia, and convulsions in which trephining was pro- The left hemisphere of the brain, showing situa- tion of clots causing motor aphasia and right hemi- plegia in a case successfully operated upon. (Starr.) posed, but, after a consulta- tion, was negatived. The pa- tient died, and after his death trephining was performed in the same position as had been suggested during life, namely, over the left subfrontal con- volution, and an abscess was revealed which occuj)ied chiefly the white matter of the posterior extremities of both the second and third frontal convolutions. Aphasia and forms of cerebral paralysis occasionally occur after operations. The records show, for instance, the occurrence of such cases after amputations, after the removal of hemorrhoids, and after operations about the face. Allied to these cases are those of paraly- sis and aphasia which now and then are observed after labor or during the lying-in period. Treatment by Training. The most important matter in the treat- ment of aphasia is that of training, which must differ according to the variety. Many cases improve greatly without training, but the importance of persistent efforts in this direction has been strongly impressed upon me by the results of my observations in several cases. A few years ago I carefully studied a case of transcortical and motor aphasia of very complete type. The patient was a determined man of considerable intelligence, and made persevering and successful efforts to reeducate himself in both speaking and writing, being 666 NERVOUS DISEASES. spurred on by his own ambition and the interest manifested by others. He improved so that he could talk, read, and write legibly and intelligently, although with some awkwardness at times in his mode of expression. A few special words need to be said about the methods of training in the different varieties of aphasia, a subject to which Wyllie has given considerable attention. In the treatment of auditory aphasia words should be slowly and clearly pronounced in the hearing of the patient, who should be asked to repeat them, and he should also be asked to read printed words. It is probable that in this way the word images are sufficiently imprinted in the uneducated auditory centres and at the same time connections of the requisite intimacy are established between these images and those of the other speech centres. (Wyllie. ) Often verbal blindness is susceptible of improvement, although when due to destructive lesion it is probably never entirely cured. In a few cases the preservation of the auditory and motor memories enables the visual memory to be partly re-edu- cated. In the attempts to treat patients suffering from literal or verbal blindness, printed and written letters and words should be shown to them, and they should be told what they are and asked to repeat them. The same letters or words should be shown at other times and in other relations, until the patient learns to recognize them through the formation of the visual images. When patients suffer from verbal amnesia and from apraxia, objects should be shown and named, the patient being asked to repeat the names. In some of these cases of verbal or psychic amnesia without verbal blindness or deafness or motor aphasia, considerable and sometimes rapid im- provement is made ; in other cases the improvement is slight. Efforts at training a motor aphasic, if conducted with great patience, often give favorable results. At first the patient should be made to repeat letters and simple words. Step by step more difficult words and simple phrases and sentences should be tried. Certain principles can be followed with advantage in this process of training. Wyllie suggests that if the patient can be made to master the letter sounds it will be easier for him afterwards to produce their combinations in the form of words. In one of his cases he adopted the "mother's method.'- Beginning with the labials, the aphasic was first taught to say papa, y the loss of taste, and may become depressed and hysterical. The api)etite frequently fails. Hemiageusia, or loss of taste confined to one side of the tongue, palate, and other surfaces AFFECTIONS OF TASTE. 699 concerned with taste, is more frc(inent than the total abolition of this sense, but even heniiageusia of a complete type is not common. Most frequently the loss of taste is obser^'ed at the tip and lateral portion of the tongue on one side in the region of the gustatory fibres of the chorda tympani nerve. The cases in which the sense of taste has been abolished in this region are more numerous than those in which it has been impaired or abolished in the posterior half and in the pala- tine region. Occasionally taste is lost in islets of the mucous surfaces concerned with this function. When the loss of taste is local, and even in some cases when it extends over a large unilateral area, the patient may not at first complain of the defect, articles of food and drink being so rapidly distributed over all portions of the tongue and mouth that their taste is quickly appreciated l>y the unimpaired portion of the peripheral gustatory apparatus. Occasionally the patient and the physician first become aware of partial ageusia as the result of examination in cases where other symptoms attract the chief attention, as in paralysis of the seventh or facial nerve or of the motor and sensory subdi\'isions of the fifth nerve, or when paralysis affects any one or more of the cranial nerves from the fifth to the ninth. In some instances the ability to appreciate certain special qualities of taste is most affected ; thus, the power to discriminate between sweetness and bitterness may be lost, while the patient may be able to distinguish sourness or saltiness. The normal taste be- comes, of course, in a great degree developed and intensified in those whose occupations or inclinations lead them to the careful and skil- ful employment of this sense, as in wine tasters, tea tasters, and epi- cures. These unusual powers of discrimination l»y taste or by both taste and smell may be lost when the ability to distinguish between the standard qualities of taste is retained. In hypergeusia sapid substances are intensely and almost painfully appreciated, just as in some cases the organs of hearing are hypersensitive to sound and those of sight to light. The standards for taste vary somewhat, not only with education and training, but also with nationality and race. The insane frequently have hallucinations and illusions which take the form of gustatory sensations of an intense or acute type. Para- geusia is sometimes an isolated symptom, but more frequentlj^ it occurs in connection with partial ageusia or hypergeusia. It shows itself as an alteration of the sense of taste amounting sometimes to an almost complete inversion, as when things which are sweet appear bitter or metallic. Substances which under normal conditions are agreeable may become disagreeable or loathsome, or the reverse of this may be observed. The patient maj' complain of all sorts of un- pleasant gustatory sensations, which may be blended with perversion of common sensibilitj', as when the complaint is of an unpleasant taste with burning or tingling sensations in the tongue. One of the rather uncommon forms of epileptic aura is that in which the patient 700 NERVOUS DISEASES. complains of a peculiar taste which may or may not be associated with an odor. The taste may be offensive or i^leasant, but it is more frequently tlie former. It may be regarded as either a hypergeusia or a parageusia, and is probably a sign either of local cerebral irri- tation or of disease of the olfactory or gustatory cerebral tracts or centres. iSecondanj Sensations of Taste, or Taste Photisms. Secondary sensa- tions of taste, or taste photisms, are rare as compared with light and sound photisms. In certain individuals agreeable and delicate tastes and smells call up agreeable and delicate shades of color, and dis- agreeable gustatory and olfactory sensations evoke correspondingly disagreeable colors. A taste photism is usually referred to that part of the mouth which receives the sensation. (Bleuler.) Symptomatology of Focal Lesions of the Peripheral Gustatory Appara- tus. Lesions in the gustatory apparatus anywhere from the taste buds to the cortical centres for taste may give rise to disorders of taste. In diseases affecting the mucous membrane of the tongue, the soft palate, and other peripheral gustatory regions, the taste buds may become involved, as in glossitis, or in catarrhal and in ulcerative affections of the mouth, just as anosmia may result from disease of the Schneiderian mucous membrane. The taste buds and the terminals of the glosso- pharyngeal and chorda tympani nerves are at times affected by toxic agents, or in rarer instances by injuries. Occasionally a unique peripheral gustatory affection is met with that is difficult of solution. Several years since, I saw a case in which an affection of both taste and common sensibility appeared to be due to the action of a vulcan- ite dental plate. This patient, whom I saw with Dr. O. B. Gross, of Camden, Kew Jersey, was a woman sixty- one years old, of nervous temperament. A short time after the vulcanite plate was put in her mouth she began to have an unpleasant taste, and soon she had also almost constant burning and tingling sensations of the tongue and lips. After about four months she ceased to wear the plate, but the burning sensation, which was conlined to about one inch of the ante- rior extremity of the tongue on both sides, continued. Nothing seemed to taste to her as it should, and she complained of always having a coppery taste. Her mouth was dry, especially at night. Her lips and tongue were extremely sensitive to hot liquids and hard substances. The most reasonable explanation of such a case as this, if it was not hysterical, is that the influence of the plate or some of its ingredients upon the end organs of taste and of common sensi- bility in the tongire and lips caused a form of terminal neuritis with parageusia. When the loss of taste is due to lesions localized in the chorda tympani or pars intermedia of Wrisberg, it is, as before indi- cated, confined to the anterior and lateral portions of the tongue, and, as a rule, the ageusia is associated with other symptoms which indicate the position of the lesion. The affection is common, for AFFECTIONS OF TASTE. 701 instance, in peripheral facial paralysis ; and many cases have been reported in which it has been present when the lesion has been located anywhere in the course of the ner^e from the entrance of the internal auditory meatus to the stylomastoid foramen. Very few intracranial peripheral cases of Bell's palsy with loss of taste have been recorded, but in such cases testing for taste is generally neglected. In one case recently studied bj^ me of old facial and audi- tory paralysis evidently due to a syphilitic lesion at or near the so- called superficial origin of the facial and cochlear (auditory) nerves, taste in the peripheral distribution of the chorda tympani nerve was abolished. When the glossopharyngeal is affected anywhere in its course the loss of taste will be present on the posterior asi^ect of the tongue and in the palatal and other regions supplied by this nerve. (See Figs. 346 and 348. ) In the rare case of a lesion invading the foramen or its immediate vicinity either just inside or just outside of the skull the symptoms show implication of the pneumogastric and spinal accessory nerves, the cervical sympathetic, the jugular vein, and the petrosal sinuses. While a considerable number of cases of aneurism, tumor, and other gross lesions involving the pneu- mogastric and spinal accessory in the necl: have been recorded, the glossopharyngeal either has not been involved or observations de- monstrating its implication have been overlooked. In such cases, besides the loss of taste in the posterior portion of the tongue and in the palatal regions, the symptoms to be expected would be such as more or less difficulty in swallowing, slow or irregular respiration and cardiac action, spasm or paresis of the muscles supplied by the spinal accessory nerve, laryngeal disorder, and symptoms of venous obstruction. When the lesion is in the intracranial course or at the superficial origin of the glossopharyngeal the symptoms will show in- volvement of the neighboring nerves and tracts according to the size and extensions of the lesion. In Pope's case (page 688), for instance, the patient, in addition to loss of taste, had diminution of power in the limbs, difficulty in swallowing, and other symptoms which showed involvement of the i^neumogastric nerve and of some of the fibre tracts in the postoblongata. Symptoms in G-ustatory Affections of Nuclear Origin. In cranial bulbar paralysis of the nuclear tyiie loss of taste is exceedingly rare. The nuclei usually involved are those for motor nerves, as that of the hypoglossal, the motor subdivision of the pneumogastric, the spinal accessory, the motor nucleus of the glossopharyngeal and of the facial. In acute apoplectiform bulbar paralysis the nucleus of the gustatory portion of the glossopharyngeal, including that for the pars intermedia of Wrisberg, may be involved ; but reports of cases of this kind with loss of taste are rare. Tumor, softening, hemor- rhage, or other gross focal lesion may involve the solitary fasciculus and cause disorders of taste. 702 NERVOUS DISEASES. Synvptomfi associated toiih Loss of Taste in Ohlongatal and Pontile Lesions. When a lesion causing a disorder of taste is situated in the substance of the oblongata or the pons, at a point removed from the glossophaiyugeal nucleus, the associated symptoms will vary ac- cording to the other nuclei and root fibres and tracts implicated in the lesion. In a ease reported by Gowers, to which reference has been made on iiage 698, a tumor was supposed to be present in the pons near the knel of the origin of the fifth. The patient had paralysis of conjugate lateral movements to the right, paralysis of the masticatory muscles of the same side, and entire loss of taste over the half of the tongue and the palate of the same side, but without any anesthesia. In a recent ease of cerebrospinal syphilis studied by the author the patient had distinct loss of taste in the anterior portion of the tongue on one side, and some impairment of taste in other portions of the tongue. In this case, as in Gowers' s, sensation was not im- paired. Complete paralysis of the right external rectus muscles, paresis of the right side of the face, deafness on the left side, and some loss of hearing on the right, were present. Smell was also markedly affected, anosmia being complete on the left and almost complete on the right side. Sight was considerably impaired, the disks being pallid, but not atrophic, and the patient had polyuria. The lesion in this case was probably situated in the pons in such a position as to involve the root fibres of the abducent, and to a less degree those of the facial, auditory, and pars intermedia, or the bulbocerebral auditory and gustatory tracts in the pons may have been involved. In another case observed by the author, presumably of a syphilitic lesion at the base, taste was lost on both the anterior and posterior portions of the tongue ; the other symptoms i^resent being complete paralj^sis and anesthesia of all the muscles of the right side of the face, marked diminution of hearing on the same side, and a ringing sensation in the right ear. In this case a large gumnla probably occupied the lateral aspect of the pons and oblon- gata. In a case which occurred in the Polyclinic service of the author, and which has been put on record by Drs. Bundy and McConnell, paralysis of the right external rectus, slight drooping of the right side of the face, abolition of pain sense on the right side of the head and fixce (tactile and temperature sense being unimpaired or but slightly affected), almost complete deafness in the right ear, complete loss of taste on the right side both anteriorly and posteriorly, and paralysis of the left arm and leg, were present. The authors in reporting this ease are inclined to attribute the complete loss of the sense of taste on the right side to a lesion affecting taste by way of the trigeminal nerve, believing that the absence of paralysis of any of the muscles supplied by the glossopharyngeal nerve gives a valid objection to the idea that this ner^'e or its root fibres were damaged. Instead of this explanation it seems, however, more reasonable to AFFECTIONS OP TASTE. 703 believe that the gustatory pathway from the glossopharyngeal nuclei through the pons to the midbrain and higher regions was implicated in the lesion. Although the course of this tract, as has been stated, has not yet been clearly determined, it is probable that it is in the lateral or superior mesal fillet. Symptoms in Lesions of the Cortical Gustatory Area. As stated on page 348, the cortical area for the sense of taste has not yet been positively determined, but it is probably in the inferior aspect of the temporal lobe, and in part at least in the fourth temporal convolution. Anderson has recorded a case of cerebral tumor affecting the left tem- poral lobe at the base. It arose from the pituitary body, occupied the space of the intrapeduncular ganglion, and grew chiefly to the left and backward, so that the first part of the cortex involved by it had been the anterior part of the inner border of the left temporal lobe. The patient had epileptiform attacks preceded by a rough, bitter sensation in his mouth, which remained during the attack. Smell was normal in the right nostril, but defective or absent in the left. Taste was ajiparently defective on both sides. Other phe- nomena were present to which reference need not here be made. In cortical tumors in the gustatorj- areas we should therefore expect to have auras of a gustatory type, and later more or less complete loss of taste. Loss of Taste from Encephalic Lesions variously situated. In several cases of cerebral tumor loss of taste has been among the symptoms present. Thus, in a case reported by Howe, the different symptoms were loss of sight, increasing to total blindness, and gradually in- creasing loss of hearing, of smell, and of taste, in the order named, no anesthesia nor paralysis being mentioned. The autopsy showed a fibrosarcoma involving the inferior portion of the right anterior (prefrontal) lobe. The first and second pairs of nerves were in- volved, but no others. In another case, recorded by Broadbent, the symptoms were mental depression, right-sided temporal and orbital neuralgia, anesthesia of the left arm, slight attacks of spasm with unconsciousness in the left face, left arm, and left hand, paresis of the left arm, blindness, optic neuritis, dilated and immovable pupils, and loss of smell and taste. The autopsy showed gummata in the right supramarginal lobule, two tumors the size of a pea lying super- ficially. Eskridge has reported a case of tumor of the right lateral lobe of the cerebellum, with loss of taste on the side of the tumor, associated with other typical symptoms, local and general, of an en- cephalic neoplasm ; and Formad has reported another case, a tumor of the left lateral lobe of the cerebellum and the vermis, in which during the last days of life the patient suffered from loss of power of deglutition and also from loss of taste, of smell, and of hearing. Gustatory Affections in Tabetic Cases. In rare cases of posterior sclerosis and of other chronic degenerative neuraxial diseases I have 704 NERVOUS DISEASES. observed loss of taste in the region supplied by the gustatory subdi- vision of the glossopharyngeal. In some of these cases it is probable that the ]ietrous and jugular ganglia become affected with degenera- tive disease similar to that which attacks the spinal ganglia. Alt- haus has recorded a case of tal^es in which the patient had lost the power of distinguishiug flavors, smell and taste both l^eing apparently affected. Both hyperosmia and hypergeusia, at least hypersensitive- ness of taste, are sometimes observed in tabes, and in these cases the odors are usually offensive and everything that is eaten has an un- pleasant flavor. The gustatory impressions are never of an agree- able character. They are not infrequently premonitions of mental derangement such as occurs in the tabetic. Affections of Taste of Hysterical Origin. Affections of taste are rarely of hysterical origin, although cases are occasionally seen which will hardly bear any other explanation. Although I have tested for taste in a number of cases of hysterical hemianesthesia and hemi- paresis with other stigmata, I ha^'e not yet observed a case in which taste was impaired or absent. Eeceutly I examined a case of almost universal anesthesia, only islets of retained sensation being here and there i^resent, but taste was fully preserved. Hysterical, or at least neurotic, individuals often seem to have an unusual acuteness of taste, detecting ingredients in food or medicine which may not be appreciable to others. In consultation with Dr. Samuel Ayres, of Pittsburg, I saw an interesting case of Inlateral loss of taste, insali- vation, partial analgesia over the anterior two thirds of the tongue and inner surfeces of the mouth, and diminished tactile and pain sense in the region supplied liy the great auricular and small occipital nerves. The patient was a woman of ner\ous temperament, and had undergone much strain and worriment. Her appetite failed, and she became indifferent as to what she ate or whether she ate at all. She first noticed that sweet substances, such as sugar, did not taste so sweet as thej' should, and she soon observed that all vegetables were insipid. Everything had a sort of metallic taste, and eventually all food became repugnant. Sleep liecame irregular and unrefreshing, and she frequently felt despondent, with a sense of impending trouble. The patient was undoubtedly neurasthenic. She eAentually recovered. The disorder of taste was probably, but not certainly, of hysterical origin. Etiology and Pathological Anatomy. — The etiology of disorders of taste \aries according to the nature of the lesion causing them. The majority of cases is due to focal lesions. A large number of cases is found in association Avith peripheral facial paralysis (see article on facial paralysis). Other recorded focal causes, which have been more fully referred to in discussing the gustatory path and centres an'stem, have been variously named. The best dcsi^'uations are those suggested by Eetzius, namely, anterior, posterior, and erleniol. The anterior is also known as the superior, the superior vertical, and the sagittal ; the posterior as the frontal and the posterior vertical ; the external as the infericir or horizontal. While the terms suggested by Retzius are most correct anatomically, the expressions vertical and horizontal are useful particu- larly in ilescriljing the results of physiological experiment and of lesions of these canals. AFFECTIONS OF EQUILIBRATION. 729 experiments since the time of Flourens, and on the whole the results of clinicopathological observation, have tended to confirm the theory that the semicircular canals in some way act as balancing organs for the body. Some authorities, however, do not accord with this view, and a few experiments seem to contradict it. Steiner experimented on sharks caught in the Bay of Naples. The semicircular canals in these animals are readily exposed, and their excision, according to this experimenter, did not induce any disturbance of equilibrium when the shark was again placed in the water, although traction on the auditory nerves caused compulsory circular and rotatory move- ments. Similar experiments on frogs and lizards gave similar results. It is held by those who do not believe that the semicircular canals are organs of equilibration that the disturbances of equilibrium pro- duced by the above mentioned experiments and lesions are due to injury of neighboring parts, as the cerebellum or its peduncles. This explanation, however, will not hold for the majority of the observa- tions. The weight of evidence is in favor of the view commonly held, that the semicircular canals and their contents are structures con- cerned with the spatial sense or sense of equilibrium, although they have some subsidiary or associative auditory functions. As to the mechanism of the movements caused by operations or by lesions of the semicircular canals, some believe that they are due to irritation of the peripheral nerve apparatus ; others, that they are dependent upon a withdrawal of the normal stimulus communicated by the mobile contents of the semicircular canals to the nervous structures and thence transmitted to the cerebellum and the cerebrum. Both explanations may be applicable in different cases. The membranous canals are furnished with nerves only at their ampullte. The canals are filled with fluid. When the head is at rest the fluid in the labyrinth is also at rest, and any sudden movement of the head or body, by causing variations of pressure in the ampuUse, will call forth, through the impressions made upon the ampullary sense organs, adaptive movements of coordination. The experiments of Crum Brown have been mentioned (see page 158, Chapter II.). Peripheral Vestibular End Organs. — The peripheral end organs of the vestibular nerve, like those of the cochlear nerve, are modified epithelial structures, to and among which pass the exceed- ingly fine terminal processes which are derived from the cells of the ganglion of Scarpa. The hair cells of these end organs, like those of the organ of Corti, are modified epithelial tissues. The term crista acmtica (acoustic crest) is applied to the slight elevations which are caused by the presence of the nerve terminals and end organs in the floor of the ampullae, and the term macula acustica to the termina- tions of the vestibular nerve in the utricle and of Schwalbe's branch in the saccule. The macula acustica differs from the crista acustica, however, in that the free surface of the neuroepithelium of the former 730 NERVOUS DISEASES. is covered with what is known as the otolith membrane. The otoliths (minute crystals of calcium carbonate) play some part in the recep- tion and adaptation of the impressions received by the utricle and saccule. The ganglion of Scarpa (intumescentia ganglioformis Scarpce) is situated at about the point of junction of the facial with the ves- tibular nerve, in or near the external auditory meatus. The cells com- posing this ganglion are situated along the course of both the true vestibular nerve and the sacculo-ampullary nerve of Schwalbe. Like those of the spiral ganglion, they are bipolar, the peripheral processes going to the end organs, while the central ones pass in the trunks of the nerves to the oblongata. The subdivision of the branch of Schwalbe which goes to the ampulla of the posterior semicircular canal has along its course two small ganglia of its own {ganglia of Corti). Other small ganglia are present on the A^estibular branches to the other semicircular canals. The course of the vestibular nerve from the ganglion of Scarpa to the postoblongata has been sufficiently described when speaking of the course of the cochlear nerve (see page 710). The courses of both nerves from their termini to their end nuclei are indicated in the diagram Fig. 349. Terminal Nuclei of the Vestibular Nerve and their Con- nections. — Lying ventrally to the cochlear nerve, the vestibular nerve continues as the internal root of the eighth nerve, between the restis and the descending or spinal root of the trigeminus, and ter- minates in three separate cell nests, usually spoken of as the mesal or chief nucleus, the nucleus of Deiters, and the nucleus of Bech- terew. In contrast to the ventrolateral nucleus (or combined coch- lear nuclei) the combined vestibular nuclei might be designated the dorsomesal nucleus.* Although nothing definite is known as to the distinct functions of the different nuclei which compose the entire terminal nuclei of the vestibular and of the cochlear nerve, it is not improbable that the different branches of both nerves have separate nuclear terminations in the bulb. It is of interest in this connection to note the fact that the dorsomesal or vestibular nucleus has three constituent nuclei, and that the vestibular nerve has at least three separate branches which go to different portions of the labyrinth. Eventually the separate end nuclei for each separate subdivision of * T\yo of the constituent parts of this dorsomesal nucleus, like the sub- divisions of the ventrolateral nucleus, have a variety of names. The dorsal or chief nucleus (called "chief" because formerly supposed to be the chief auditory nucleus) is also spoken of as centntl nucleus, inner nucleus, posterior nucleus, nucleus of the jio.iterlor root, and medal or mesal portion of the superior nucleus. The nucleus of Deiters is also known as the exlernal acoustic nucleus, superior nucleus or lateral part of the superior nucleus, mesial (or mesal) nucleus of the anterior root, large celled nucleus, and inner segment of the restiform body. The dorsal nucleus and the large celled nucleus taken together are sometimes spoken of as the superior nucleus. Bechterew's nucleus, an extension of the nucleus of Deiters, is fortunate thus far in not having been christened with more than one name. AFFECTIONS OF EQUILIBRATION. 731 the nerve will probably be determined. The bifurcation of the ves- tibular nerve into a descending and an ascending root after its en- trance into the oblongata has been clearly demonstrated. The latter passes to the nucleus of Bechterew, and from this enters the acoustic cerebellar bundle, giving collaterals which pass not only to the dorsal or chief nucleus but to the nucleus of Deiters, also distributing other finer fibres which pass to the cells lying between the fibres of the bundle of the descending root. The process of the peripheral '' neu- ron" or nerve cell arises in the ganglion of Scarpa and splits up about the cells of the dorsal nucleus and other nuclei as just de- scribed. One of the bifurcating portions passes into the descending and the other into the ascending cerebellar root. The next neuron, beginning in the dorsal nucleus, passes in the trapezoid body, crosses in the raphe to the niesal fillet, and thus continues towards the cortex. Bruce found that in transverse dorsoventral sections made at tbe extreme cephalic limit of the postoblongata through this structure and the flocculus, some of the fibres of the flocculus appear to bend upward towards the cells at the lateral angle of the oblongata, in a position whicb corresponds to that given by Bechterew as that of one of the nuclei of the vestibular roots of the auditory nerve (Bech- terew' s nucleus). The fibres at this situation, according to Bruce, break up into a fine network, from which a comparatively small number passes backward along the lateral wall of the fourth ven- tricle towards the vermiform lobe. Their manner of termination he was not able to establish. The flocculus and some portions of the vermis would therefore seem to be important central (cerebellar) connections of the nuclei of the vestibular root of the eighth nerve. The same investigator, as already stated, has shown it to be also a central (cerebellar) connection of the accessory nucleus of the coch- lear nerve, and almost certainly of the sixth nucleus. As sum- marized by Eamon y Cajal, by means of the ascending branch the vestibular nerve is spread out over the upper portion of the nucleus of Deiters, over the entire nucleus of Bechterew, over the multipolar cells of the acoustic cerebellar bundle, and finally over the tegmental nucleus and dentatum of the cerebellum. The cells of the chief or dorsal nucleus are connected with the lateral vestibular tract, in which they unite with fibres coming from the nucleus of Deiters. A large portion of the axis cylinders of the nucleus, however, cross the raphe and enter the lateral vestibular tract of the opposite side. As stated on page 82, the acoustic connections of Deiters' s nucleus have been regarded by many as doubtful. The most recent re- searches, and especially those of Eamon y Cajal (1896), show the important relations of this nucleus to the vestibular nerve. Cerebral Terminus of the Vestibular Nerve. — It is proba- ble that the cerebral representation of the vestibular nerve is dis- tinct from that of the cochlear, and Dana has suggested that this 732 NERVOUS DISEASES. representation is in the temporal lobe, and especially on the right side, basing this view upon two personal cases of focal lesion of the right temporal lobe, and also upon a study of the meagre literature of the subject. Bechterew believes that the evidence afforded by the cases compiled by him justifies the hypothesis that the pre- peduncles are connected with the upper portion of the parietal lobe, but Dana holds that, while the muscular sense may be impaired through destruction of this lobe, the true spatial sense is not affected. Schafer has shown that irritation of the temporal lobe causes conju- gate deviation of the head and eyes. The well known fact that a large proportion of deaf mutes cannot be made vertiginous has some bearing upon this subject. Bechterew and others believe that they have shown that the temporo-occipital region is connected with the cerebellum of the opposite side by a band of afferent fibres which pass by way of the medipeduncle, the pontile nuclei, and an external bundle in the crus. That this is not connected with the first and the upper and anterior part of the second temporal convolution was shown by Spiller and the author. In a case of cerebral abscess situated at the posterior part of the external capsule, and involving the medullary substance of the first temporal and part of the second temporal convolution and also the posterior part of the lenticula, this band of fibres was not degenerated. Dejerine has shown that the external bundle of the crus is formed by projection fibres which come from the temporal lobe, and especially from the second and third temporal convolutions, and he also believes that this fasciculus remains intact after lesion of the occipital lobe, differing in this respect from Bechterew. In the ' ' naming centre' ' case (page 345), in which a tumor involved the midtemporal region and chiefiy the left third and fourth convolutions and subjacent medullary substance, one of the first symptoms complained of by the patient, five years before her death, was vertigo ; and this was a recurring phenomenon. She did not, however, suffer from ataxia or forced movements. In Dana's two cases destructive lesions were present in the middle portion of the right temporal lobe, and in both vertigo and forced movements were important symptoms. It must not be overlooked that in one of these cases, at least, the dura was markedlj- involved, and that vertigo is a well known symptom of irritative dural disease. The membranes were not, however, involved to any extent in the other cases, and special forced movements are not characteristic of pachy- meningeal vertigo. Clinical History. — Symptoms of Pure Yestihidar Disease. The special symptoms of disease of the vestibular nerve and of its cen- tral connections are, speaking in general terms, disorders of equi- libration : these symptoms are usually more or less severe vertigo and a sensation of unbalanced movements, which the patient may refer to himself. Often the chief complaint is of dizziness, giddi- AFFECTIONS OF EQUILIBRATION. 733 ness, or vertigo ; sometimes, but less frequently, it is of pitching, reeling, swaying, or staggering. One or several of these terms may be chosen by the patient to describe what to him seems to be his most important symptom. The terms vertigo, giddiness, and dizziness are commonly used interchangeably, or without any special distinction, by doctors and patients. Vertigo comes from vertere, "to turn," and the word is best used to define a sense of disturbed equilibrium which may or may not be associated with actual movement of the patient or of objects external to him. It is not merely a sensation, but a sensation which indicates that a motor process has been dis- turbed. Occasionally cases of pure vestibular nerve disease are ob- served. Such cases have fallen under my own observation. In them vertigo, with a marked tendency to fall or turn in a certain direc- tion, has been present, without any disturbance of hearing, and the cases could not be explained on the theory of disease of the cerebel- lum or of any portion of the brain. The following cases belong to this category. A woman, thirty-four years of age, had at intervals since her fourteenth year been subject about the menstrual period to slight attacks of vertigo. Several weeks before coming under my ob- servation this "vertigo" had returned, and had persisted. Headache was absent, and careful examination revealed no loss of hearing and no aural disease. She showed an almost constant tendency to go to the left, complained of her head swimming and of objects seeming to move. The feeling recurred whenever she turned to the left. It was necessary for her to take great care in getting off street cars, for if she got off towards the left she was liable to fall. She was tested a number of times, and always tended to fall to the left on turning in that direction, while when she turned to the right there was no tendency to fall to that side. She had no condition of refraction suf&cient to account for the trouble. A middle-aged physician con- sulted me with reference to a ftersistent vertigo. Six months pre- vious to coming under observation he had his first attack, one week later the second, and two months before my examination he had a third attack, and afterwards was almost constantly vertiginous, the intensity of his symptoms varying. He had a tendency sometimes to go to the right, at other times to the left ; on looking up to the left he inclined to the right, and the reverse. Sometimes he almost fell. He had no tinnitus and no auditory symptoms of any sort. Careful examination of his eyes showed some astigmatism. He presented no paralytic symptoms. In the purer forms of vestibular vertigo the patient, without any auditory symptoms, may show a tendency to turn or fall in some particular direction, or objects may seem to be falling or moving, or a tendency to deviate to one side in standing or walking may be shown. While vertiginous paroxysms are nearly always most marked when the patient is in a standing or a sitting position, this is not always the case. Both in vestibular vertigoes 734 NERVOUS DISEASES. and vertigoes of the purer forms and in those due to cochleovestibu- lar disease (Meniere's disease; the paroxysms of dizziness come on occasionally when the patient is in the recumbent position. They may occur at night after he has retired. It is not impossible in such cases, as has been suggested by Gowers, that the tendency of the attack to occur only when the patient is in the horizontal posi- tion is related to the fact that the focus of disease is in some one particular portion of the semicircular canals. Special Symptoms of Focal Lesions in the Vestibular Pathway. A lesion limited to either the vestibule or the semicircular canals causes vertigo, and this in most instances is extreme. It varies in character and severity according to the extent and the exact location of the disease. The directions taken in the sensations of falling and in the tendency to fall differ according to the side of the body and the par- ticular canal most markedly affected, in accordance with physiologi- cal observations already discussed. If a gross lesion is situated in the internal auditory meatus or on the lateral border of the oblongata, the symptoms may show implication not only of the cochlear nerve but also of the facial and of the pars intermedia of Wrisberg. The remarks made when focal lesions of the cochlear nerve were discussed are applicable here. Bruce has suggested that tumors of the dura situated near the internal auditory meatus probably give rise to vertigo through their influence on the flocculus and the vestibular fibres which run in its peduncle. A lesion affecting the nerve after it has passed into the oblongata produces symptoms which vary according to its exact position and its ramifications. Auditory, sen- sory, motor, vasomotor, and other symptoms may be present accord- ing to the degree of involvement of the cochlear nuclei, the fillet, the pyramidal tract, and other structures. Focal lesions in several situa- tions may cause conjointly disturbances of equilibrium and of vision. The abducent, optic, oculomotor, and eighth nerves, including both the cochlear and the vestibular nerve, have important connections with one another, and with various centres and tracts, many of which have been described. Tabetic Atrophy of the Vestibular Nerve. — According to Althaus, the vestibular portion of the eighth nerve suffers more fre- quently than the cochlear nerve in tabes. I have made a number of observations on the occurrence of vertigo in tabes. The patients in these cases experience a sensation of fulness and swimming in the head ; they may feel as if everything is spinning around, and may stagger and lose their balance unless supported. A tendency may be shown to fall in some special direction, — ^backward or for- ward, or to the right or the left. In these cases it is not improbable that the nuclei of origin or the bulbar nuclei of the vestibular nerve are attacked by an irritative and degenerative process similar to that which occurs in the spinal ganglia. AFFECTIONS OF EQUILIBRATION. 735 Vertigoes not directly the Result of Disease of the Appara- tus of Equilibration. — Clmsification of Vertigoes of Indirect Origin. Thus far in the present section, in our consideration of disorders of equilibration, the symptoms discussed have presumably been due to lesions or disturbances directly affecting that portion of the labyrinth from which the vestibular nerve originates, or the trunk, root fibres, terminal nuclei, bulbocerebellar or bulbocerebral tracts, or cortical termini of this nerve. The equilibratory apparatus may, however, be pathologically influenced by causes not acting primarily on any of these parts, and in this indirect way some of the best known forms of vertigo are produced. These vertigoes are considered under various heads and from different points of view by different authors, but their discussion properly belongs here, as in their production the apparatus of equilibration must take part. The most important of these varieties of vertigo are (1) reflex vertigo ; (2) vertigo depend- ent upon irritative intracranial disease situated outside of the equi- Ubratory apparatus ; (3) vertigo due to disease of the heart and bloodvessels ; (4) vertigo which has its source in the state of the blood, this probably including (5) Gerlier's vertigo ; and (6) vertigoes or pseudo-vertigoes of functional or mixed origin. Beflex Vertigo. Irritation may be reflected to the apparatus of equilibration from almost any portion of the body, near or far. It is for this reason that special designations are sometimes given to par- ticular varieties of reflex vertigo, as when they are termed ocular, aural, nasal, pharyngeal, gastric, gastrointestinal, hepatic, uterine, or ovarian, according to the organ which seems to be the fountain head, but if they are truly reflex disorders the mechanism of their production is practically the same in all cases, namely, a disturbance of equilibrium produced by the reflection of an abnormal stimulus upon a more or less nonresisting equilibratory apparatus. The reflex origin of vertigo is sometimes more apparent than real, and too great a tendency is shown to attribute this, as well as to refer other nervous symptoms, to reflex action. Kot a few of the cases regarded as reflex are probably due either to a toxic state of the blood or to some unde- termined condition directly acting upon the vestibular nerve appa- ratus. It remains true, however, that a certain percentage of cases can be properly classed as reflex vertigoes and are to be treated by attacking the primary focus of irritation wherever it may be situated. The occurrence of vertigo, usually in the form of a transient giddi- ness or dizziness, as the result of disease or disturbance of the exter- nal or middle ear may or may not be regarded as of reflex character, according to the peculiar method of its development. It is only necessary to remember that a true aural vertigo may occur even when the labyrinthine portion of the neural apparatus for hearing and equilibration is intact. Every one is familiar with transient vertigo from irritation or compression of the tympanic membrane 736 NERVOUS DISEASES. and from Eustacliiaii or other forms of middle ear disease. In these cases the labyrinthine structures, cochlear and vestibular, may be affected, either through the transmission of pressure, by continuity of inflammation, or by reflected irritation. The vertigo is to be re- lieved by measures directed to the parts primarily affected. Tran- sient vertigoes of external origin often demand earnest attention, and in most cases are probably conjointly toxic and reflex. These are the vertiginous seizures which arise from the ingestion of articles of food or drink which are indigestible or with regard to which the individual has special idiosyncrasies. The vertigoes which are to be traced to nasal polypi, to irritation of the gums, to tapeworm, and to various other special forms of irritation need only this brief refer- ence. One form of laryngeal vertigo is sometimes described as an "epilepsy," and is, because of its serious appearance, of especial clinical importance. It is usually a disease of middle age, although it may occur at any period of life. The sufferer from the attacks frequently has some form of chronic laryngitis or bronchitis. The paroxysms begin with unpleasant sensations, often those of burning or tingling in the larynx or trachea, with dyspnea and an uncon- trollable spasmodic cough. The patient may fall and remain for a brief time unconscious, and often twitchings or light convulsive movements have been observed. Interrelationships of Vertigo and Ocular Disturbances. Affections of ocular centres and tracts, organic or functional, may excite auditory and vestibular symptoms ; and when the vestibular nerve, its centres, or its associating systems are affected, important ocular symptoms, as well as disorders of equilibration, may be present. Vertigo, on the one hand, may be accompanied by ocular manifestations like nystagmus and vacillating strabismus, and, on the other hand, re- fractive, accommodative, and other visual defects and disturbances may reflexly cause vertiginous manifestations ; and, further, a vertigo which is primarily dependent upon a lesion of either the peripheral end organs, the trunk, or the central pathway of the vestibular nerve may be intensified by errors of refraction. Such refractive errors may remain unnoticed until the development of some disease of the apparatus for equilibration. While vertigo may be caused solely by ocular defects, such cases are rare. Weir Mitchell and Thomp- son were among the first to call attention to the subject of ver- tigo due to eyestrain. Cases have been recorded by Bonnier, Osier, and others, showing the special relationship between labyrinthine vertigo and ocular defects. The facts necessary to the understand- ing of this subject have been given in previous paragraphs in the discussion of the nuclei and tracts of the vestibular and cochlear nerves and their associated structures. In one of Bonnier' s cases disturbance of accommodation followed auditory irritation, the latter having been caused by aural irrigation which drove a plug of wax AFFECTIONS OF EQUILIBRATION. 737 against the tympanic membrane. A patient of Osier's for eighteen months before coming under observation had had a number of attacks of vertigo, with iiatulence, a few of them severe. The ver- tigo appeared to be both objective and subjective, objects seeming to go to the right, and the patient feeling as if he also turned. The man was a little deaf, particularly in the right ear, in which he had almost constant tinnitus. Examination showed that the deafness was probably due to labyrinthine disease. Decided hyperopic astig- matism was also present. Properly adjusted glasses improved the patient's vision, and relieved his vertigo for more than two months, when he began to suffer with vomiting, which continued for two weeks until his death. It seems probable that the primary lesion in this case was somewhere in the cochleovestibular apparatus. The case is of particular interest as showing the intimate and reciprocal relationship between the ocular, the equilibratory, and the digestive apparatus. Double vision may occur during or after an attack of aural vertigo, and in addition objects sometimes appear to undergo a jerking movement. The patient may be unable to calculate distances properly, and so cannot readily touch an object, or in walking may miscalculate and step beyond an intended point. Vertigo due to Irritative Intracranial Disease, and especially to Brain Tumor. Vertigo may be dependent upon irritative intracranial dis- ease, and especially upon tumor and pachymeningitis, not referring in this connection to the disturbances of equilibration arising from disease of the cerebellum or the quadrigeminum. The three most frequent general symptoms of intracranial tumor are headache, nausea or vomiting, and vertigo, and these are commonly dependent upon the same mechanism. Most cases of brain tumor originate in the encephalic membranes. The trigeminal nerve has a wide dis- tribution in the dura, and intense localized irritation of its branches gives rise directly to pain, and indirectly to vertigo, nausea, or vomiting. The reiiection or irradiation of powerful impressions from the bulbar nuclei of the fifth to the vestibular and pneumo- gastric nerves is the best explanation of the mechanism of the pro- duction of these symptoms. The fact that a vertigo is due to a neoplasm, and not directly to disease of the vestibular nerve, can be best determined by a study of the general and focal symptoms of tumor of the brain. The remarks just made regarding the vertigo of brain tumor are equally applicable to that observed in localized meningitis. Vertigo due to Disease of the Heart and Bloodvessels. Vertigo is sometimes dependent upon imperfect action of the heart, and this itself may be due either to degenerative disease of the cardiac walls or to faulty innervation. The brain in such instances is irregularly and imperfectly supplied with blood. Vertigo may also be due to disease of the bloodvessels, as to arteriosclerosis (see pages 445 and 47 738 NERVOUS DISEASES. 446). The diagnosis of these cases as there indicated is to be made chiefly by a careful examination for arterial or arteriocapillary fibro- sis, and the usual accompanying conditions of the heart, kidneys, liver, and other organs. Vertigo due to States of the Blood. Vertigo may have its source in the state of the blood, as when it arises from anemia or hyperemia, lithemia, and a number of toxemias, including those occurring in connection with infectious diseases and from the direct action of drugs and poisons. Lithemic vertigo is of great practical impor- tance, as it is of comparatively frequent occurrence, usually ex- cites great alarm, and is more or less rapidly relieved by treatment directed to the lithemic state. Occasionally a pronounced vertigo is one of the early symptoms of an acute infectious disease, and it may be accompanied by a severe headache, or even by marked mental symptoms. The vertigoes due to the ingestion of alcohol or of special drugs are much influenced by individual idiosyncrasy. The dizziness due to opium and some other narcotics and drugs is usually made much worse by the erect position, and often disappears entirely when the patient is lying down. Gciiier^s Disease, or Paralyzing Vertigo. lender the name oi para- lyzing vertigo, Gerlier of Perney has described an affection, probably of toxemic origin, of which little has been observed in other parts of the world than southern France and Switzerland. The affection comes on abruptly, and its phenomena recur in paroxysms. The patient becomes very dizzy, has severe pain in the neck, double ptosis, a weakness of the muscles of a paretic or a paralytic char- acter, general lassitude, and in some cases loss of speech. Conscious- ness is not lost, and the attack commonly passes off in a few minutes. The first attack is followed by others which occur at intervals of a few months, weeks, days, or hours ; most frequently they are weeks or months apart, and the general health of the patient in the inter- vals is usually good. This curious disease has been noted especially in the canton of Geneva, where it is sometimes epidemic. It occurs more frequently during the hot weather, and chiefly among laborers, herdsmen, or others working on farms. It is believed by Gerlier and others that the affection is due to germs from the marshes and stables, but, as suggested by Hirt, this does not explain the immunity of the female sex. Thus far nothing has been learned of the pathology and morbid anatomy of this disease. Vertigoes of FuncVtonal or Mixed Origin. Certain forms of vertigo or pseudoveitigo ha\'e been described as mental or psychical, but should in the majority of cases be considered rather as obsessions. The vertigo attributed to hysteria and neurasthenia can usually be explained better by ocular defects, changes in the blood, reflex irri- tation, jisychical influence, or labyrinthine complications. In like manner the so-called essential vertigo which has been described by AFFECTIONS OF EQUILIBRATION. 739 Eamskill, "Weir Mitchell, and others recedes more and more as knowledge increases. The vertigoes with nausea and vomiting which so frequently arise during journeys by sea or rail are to be arranged under one or several forms already described ; probably they are commonly dependent upon direct or indirect distui-bances of the contents of the labyrinth. They are sometimes spoken of as me- chanical vertigoes, and to the same class are to be referred those forms which result from sudden or unusual movements, as from swinging and turning rapidly, or from the motion of elevators. Cochleovestibular Disease. — The effort has been made in the preceding pages to consider separately affections of the cochlear nerve and of the vestibular nerve. It has been shown that these nerves originate in separate portions of the labyrinth, that they pass separately although for a part of their course in the same bundle to the oblongata, that they separate on entering the oblongata into dif- ferent roots, that they terminate in different bulbar nuclei, that their bulbar connections and bulbocerebral pathways are different, and that they probably have different cerebellar and cerebral termini. It has also been shown that a different and separable symptoma- tology can be recognized for each of these nerves and their related structures. "While this is true, it is a well known clinical fact that the apparatus for hearing and that for equilibration are frequently affected together, perhaps almost as frequently together as sepa- rately. The clinician is confronted with many instances of cochleo- vestibular disease, — disease which may affect all or various parts of the labyrinth, the conjoint cochlear and vestibular nerve trunks or nerve roots, or the centres and pathways of both nerves within the brain stem and the brain. These points have been already sufd- ciently emphasized in the consideration of each of these nerves, with the exception that it is necessary to discuss one or two well known affections in which conjoint disease of the labyrinthine portions of both nerves is present. One of these is the labyrinthine otitis of Voltolini ; but the most important is that which has long been known as Meniere's disease. Voltolini 's Labyrinthitis. — Various forms of otitis labyrinth! ca are known to otologists, and for their full discussion works on aural disease should be consulted. As, however, both cochlear and ves- tibular nerves are necessarily involved in these affections, and as the neural and encephalic symptoms sometimes dominate the clinical picture, it is important that some at least of these affections should receive consideration from the neurological standpoint. Voltolini, against much opposition, advocated the theory that a primary laby- rinthitis was of comparatively frequent occurrence, and his views are now generally accepted, although, doubtless, some of the cases at- tributed by him to primary inflammation of the labyrinthine struc- tures were secondary to disease elsewhere. The disease is of most fre- 740 NERVOUS DISEASES. quent occurrence among children, but cases in adults with autopsies ha\'e been recorded. In some of its features the disease closely sim- ulates meningitis. Meningitis may indeed occur secondary to primary labyrinthine inflammation, and the reverse is well known to occur. Most frequently the labyrinthitis begins in children abruptly, coming on with fever and excitement, and sometimes with vomiting ; uncon- sciousness, partial or complete, may ensue early. In a common type of the affection in from two to four days the unconsciousness dis- appears and the children recover their senses rapidly, but when they first attempt to walk are found to stagger. This gait gradually disappears, but incurable deafness is left. Considerable differences are observed in different cases ; occasionally fever is absent entii'ely or almost entirely throughout the attack. The diagnosis of labyrin- thitis is often difficult, and is to be made by a close study of the evidences of aural and vestibular disease. Its recognition is impor- tant, because while the prognosis as to hearing is bad it may for life and subsequent general health be comparatively good. Meniere's Disease. — Meniere's Syndrome and its Pathological Cause. The manner in which Meniere summarized his subject showed the probability of the existence of nerves with distinct functions taking part in the production of the syndrome which bears his name. He endeavored to establish that a previously normal auditory apparatus may suddenly become the seat of func- tional disturbance, consisting of noises of a Aariable nature, which were accompanied sooner or later by diminution of hearing ; func- tional troubles which might give rise to vertigo, unsteadiness of gait, turnings to right or left, and falling, these being sometimes attended by nausea, vomiting, and syncope. These manifestations, often in- termittent, culminate in deafness, which gradually grows worse and becomes total. Meniere held that the lesion which was the cause of these disturbances was situated in the semicircular canals, not making any clear distinction between the nerve distribution in the cochlea and in the semicircular canals. Meniere' s syndrome in its most com- plete and independent form is without doubt most frequently of laby- rinthine origin ; but, while aural vertigo usually means labyrinthine vertigo, the labyrinth is not always the seat of the primary lesion, and in some cases no lesion of the latter is present, irritation being reflected to it, or inflammation extending to it, from other parts. It is best, therefore, to consider aural vertigo under the three forms of external eai' vertigo, middle ear vertigo, and internal ear vertigo, according as the irritation which produces the symptom is in either of these portions of the ear ; and following this classification the term Meniere's disease, if retained at all, should be used to indicate vertigo and its accompaniments due to disease or injury of the laby- rinth. It is a disease in which both hearing and equilibration are affected as the result of lesions implicating the peripheral expansion AFFECTIONS OF EQUILIBRATION. 741 of both the cochlear and the vestibular nerve. Gruber has suggested either to apply the term Meniere's disease solely to those cases in which a hemorrhage has occurred in the labyrinth, or else to drop it altogether ; and most authorities are inclined to restrict it to an acute or rapidly developed disease of the labyrinth. In Meniere's original case the lesion was a reddish plastic exudation in the mucous mem- brane of the labyrinth, no other evidence of disease being present. Any sudden effusion or exudation upon or into the membranous labyrinth will interfere with and probably annihilate its functions. A disorder which may be properly classed as Meniere's disease usually presents itself in two forms : (1) a transient but severe apo- plectic affection ; and (2) a chronic affection of varying severity with marked paroxysms or exacerbations. Transient Apoplectic Form of Meniere's Disease. In the abrupt apoplectiform variety of Meniere's disease the patient, in previously good health, is suddenly seized with symptoms which sometimes so closely simulate a true cerebral apoplexy as at first to deceive the expert diagnostician. Such acute apoplectiform cases are usually of bad omen so far as hearing is concerned, although in rare instances the patient may entirely recover, probably because of the rapid absorption of a hemorrhage or other effusion. Kenefick has reported such a case. The patient, a man aged forty-five, with no history of previous disease, was attacked suddenly in the night with violent vomiting and persistent and alarming dizziness. He showed no motor nor sensory disturbance. ISToises in the right ear and marked deafness were present. The vomiting and dizziness continued for several hours, then ceased, but began whenever he raised his head. The vomiting yielded to ipecac in small doses, but the dizziness and deafness continued. Visual hallucinations were present, but disappeared in a few hours. The slightest attempt to rise gave the patient the sensation that the bed and himself were being rapidly revolved. Vomiting ceased, but the deafness remained two weeks, when this and the giddiness gradually disappeared. At the end of six weeks he was able, with tottering gait and with assistance, to reach his office daily, and finally he completely recovered. Paroxysmal Form of Meniere's Disease. In the majority of cases Meniere's disease is a subacute or chronic affection, which appears first about middle life or a little later. The disease, even when it assumes the chronic form, sometimes begins with an abrupt attack. The paroxysms or exacerbations of the disease may recur at very irregular intervals ; sometimes several succeed one another in quick succession, giving a form of vertiginous status. In others a consid- erable interval may intervene between the different attacks ; in still others the patient is liable to be attacked at almost any time, especially if he is not careful to avoid haste and excitement. In the paroxysms the tinnitus and the vertiginous sensations may be 742 NERVOUS DISEASES. extreme, nausea or vomiting may or may not be present, and the deafness, if not already complete, is increased. Occasionally forced movements and ocular manifestations, such as diplopia, nystagmus, and visual hallucinations, are present. In rare instances uncon- sciousness results, but this is momentary. A sense of terror usually accompanies the attack, and the patient is left pale, and perhaps covered with profuse perspiration. In the intervals between the attacks, which may vary considerably in severity, the patient usually suffers from a train of symptoms — more or less deafness, tinnitus, and slight vertiginous sensations — which indicate implication of the cochleovestibular neural apparatus. Not infrequentljr the symp- toms, as regards both the paroxysms and the intervals between them, progressively advance, but when deafness becomes complete the vertigo may disappear. Etiology and Pathology of Vestibular and Cochleovestibular Disease. — In many particulars the etiology of disease of the vestib- ular nerve is the same as that of cochlear disease, and for numerous points of causation it is only necessary to refer to what has been said under etiology in the pre Anions section (see page 721). Disorders of ■ the vestibular nerve or of the peripheral cochleovestibular appara- tus may, for example, be congenital, or may be due to exfoliation of the bony labyrinth, to labyrinthine inflammation of various types, to local syphilitic disease, to anemia, hj^peremia, or toxemia, to extravasations into the labyrinth, and to blows, falls, and other traumatisms. Exposure to high temperature sometimes plays a special part in the production of forms of labyrinthine inflammation. One of my patients was overcome with heat while working in his office on a hot summer day, the attack coming on with faiutness and dizziness ; he was so weak and giddy that for two weeks he was con- fined to the house, and ever since, now more than a year, he has been much troubled with a sense of vertigo, which is not excessive, but seldom leaves him. He usually feels as if going to the right. Hearing is defective in both ears, but more markedly so in the right than in the left, and careful examination shows that the defect is due to labyrinthine disease. Any form of intracranial focal lesion affect- ing the vestibular nerve or its central terminations and continuations will give rise to disorders of equilibrium, a subject to which sufficient reference has been made when discussing focal lesions. The etiology of the transient, apoplectic form either of pure vestibular vertigo or of Meniere's disease is comparatively simple. It is commonly due either to intense hyijeremia or to a hemorrhage or other effusion into some portion of the labyrinth. The subacute or chronic paroxysmal form of Meniere's disease may in different cases certainly have a diflferent pathogenesis. It cannot be doubted that in not a few in- stances the paroxysmal and continuous symptoms of Meniere's dis- ease are due to some form of chronic labyrinthine disease, most AFFECTIONS OF EQUILIBRATION. 743 commonly a labyrinthitis, and this may be due to syphilis, tubercu- losis, or other infection, or may have originated from some special cause, as from a traumatism. In these cases the patients suffer more or less constantly from symptoms which indicate cochleovestibular disease, and the acute, irregularly occurring paroxysms are probably dependent upon temporary changes in the circulation. An interest- ing vasomotor theory has been advanced by Brunner to account for some of the cases of Meniere's disease. A toxic condition of the blood, an irritative focal lesion, or some other initial cause acting upon the vasomotor nerves of the labyrinth leads to paroxysmal disturbances of the circulation, and to variations of labyrinthine pressure, during which the patient suffers from the symptoms which make up the picture of Meniere's disease. The underlying cause of the disease as understood by the author is situated somewhere in the labyrinth. In making this statement he is fully aware that in not a few cases the Meniere's syndrome may in whole or in part result. from extralabyrinthine encephalic disease, but these cases should not be regarded as true instances of Meniere's disease. In a case re- corded by Wolfe in which Meniere's sjai drome was present, autopsy showed a tumor of the amygdala and another of the cerebral cortex. Nothing more regarding the morbid anatomy of the affections under consideration need be said than has been given under various pre- ceding heads. Diagnosis. — The manner in which disease of the cochlear and the vestibular nerves and their correlated central structures has been discussed in the preceding pages renders it unnecessary t» discuss at any length the subject of diagnosis. The differential features of cochlear, vestibular, and cochleovestibular disease have been largely given in discussing their symptoms ; and the differentiation of the etiological varieties of vertigo has been sufficiently indicated. One of the most important diagnostic matters is to distinguish between an acute encephalic apoplexj^ and the transient but severe apo- plectic form of Meniere's disease. This distinction is sometimes difficult, and a mistake is more likely to be made because of the fact that the apoplectic form of Meniere's disease is rare, while apoplexy of the ordinary type is comparatively common. Dizziness and vomiting are of somewhat frequent occurrence preceding apo- plectic attacks, but in some cases tinnitus and other disorders of hearing may also be prodromes, as for instance when the affection occurs in the auditory sphere of the cerebrum. When a sudden attack of partial or complete deafness occurs in an individual whose hearing has been previously normal, associated with the phenomena of an apoplectic attack, and when later the gait becomes uncertain or staggering but without paralysis in the areas of other cranial nerves than the eighth, and when an examination made soon after the attack shows a normal tympanic membrane and permeable 744 NERVOUS DISEASES. Eustachian tube, the conclusion that an affection of the labyrinth is present can be reached with great probability. The reader is referred to the section on cerebral hemorrhage (pages 465-469) for further diagnostic points. The diagnosis of Yoltolini's labyrinthitis can be made only by a close study of the symptomatology of the cases. It occurs most frequently in children, and it is sometimes endemic or epidemic, facts that are of diagnostic value. The diagnosis of Ger- lier's vertigo is to be made from M6niere's disease and other forms of vertigo, and from syphilitic, alcoholic, and other varieties of apo- plectic attacts. The symptoms and course of the disease as detailed are so absolutely distinctive that a mistake is not likely to be made, particularly if the affection occurs among farm hands and is endemic. Seguin has called attention to the close similarity of the symptoms to those produced by poisoning by conium maculatum. Prognosis. — The prognosis of disease of the vestibular nerve and of the cochleovestibular apparatus must of course depend upon the cause or special variety of the disease. When due to hyperemia or to acute inflammation, the prognosis is relatively good. When dependent upon chronic inflammatory disease, it is usually bad, although something can be done in such cases by persistent treat- ment. The prognosis of the different forms of vertigo of indirect causation is dependent upon the practicability of relieving or re- moving the source of the irritation. In rare instances, as in Kene- fick's case to which reference has been made (page 741), almost com- plete recovery takes place from acute apoplectic Meniere's disease. In the vast majority of cases, however, the damage which has been done can be remedied to only a slight degree, if at all. The prognosis of Voltolini's labyrinthitis, or of labyrinthitis secondary to extra- labyrinthine disease, is usually bad so far as the affection of hearing is concerned. Considerable improvement is sometimes made in the disorder of equilibration, — which indeed is more likely to persist if the deafness is incomplete. The prognosis of the paroxysmal form of Meniere's disease is variable. It is bad so far as complete re- covery is concerned, but marked improvement may take place, and in rare instances the paroxysms ce:ise. On the contrary, however, the disease may become so severe and the paroxysms recur with such frequency and suddenness that the patient is compelled to take permanently to bed. The prognosis as to final recovery in G-erlier's disease is good, but the patient may have a succession of attacks. Great alarm is usually felt by the sufferers and their friends. Treatment. — Whatever measures of treatment are decided upon for labyrinthine dise;ise, whether it takes the form of cochlear, ves- tibular, or cochleovestibular manifestations (Meniere's disease), the indications for treatment are various, and differ in different cases, l^early all that has been said regarding the treatment of cochlear disease is applicable here, and need not be repeated (see page 726). AFFECTIONS OF EQUILIBRATION. 745 The local conditions present must in all cases be thoroughly con- sidered. As syphilis is a somewhat frequent cause of Meniere's syndrome, and as even when it is not a part of the history the disease may be hemorrhagic or inflammatory, remedies like the iodides and mercury are often distinctly indicated, and sometimes their administration is followed by great benefit. When the rheu- matic or the gouty diathesis is present, cathartics, alkalies, the sali- cylic compounds, colchicum, and lithia salts, should be given a thorough trial. Charcot strongly advocated the use of quinine, as stated when discussing the treatment of cochlear nerve disease. In connection with the use of large doses of quinine it is worth while to remember that we have a well known but not very common form of vertigo which is distinctly malarial in origin, the toxic agent probably acting upon the nervous apparatus of the labyrinth or upon the encephalic centres of equilibration. Little is known as to the best methods of treatment of Gerlier's disease. In a case recorded by Ackerman the attacks disappeared during the employ- ment of warm baths and two grammes of potassium iodide daily, Although Meniere's disease is either primarily or secondarily labyrin- thine, when the indications for treatment are being considered by the physician the importance of the central condition — of the state of induced instability of the cerebellar or other centres of equilibration — should not be overlooked. Eemedies like the bromides which are efficient in the reduction of cortical or ganglionic excitability should be used. Arsenic may be combined with the bromides, both to pre- vent bromism and for its roborant effects on the nervous sj^stem ; and belladonna, aconite, antifebrin, antipyrin, and phenacetin may also be tried for their effects on the centres and the circulation. The use of strychnine or nux vomica has many supporters. A method of treatment made use of by Hamilton in one case is suggestive. The patient was in the habit of asking his wife to turn him the other way when the attacks of vertigo occurred, and as a portion of his treatment the doctor had him practise at intervals turning in a direc- tion opposite to that caused by the disease. This procedure and other methods of balancing gymnastics may prove of service in a few cases. Local counterirritant or derivative treatment has some- times a basis for its use, and great benefit has followed such measures as counterirritation or leeching behind or below the ears, and the application of the cautery over the mastoid. The treatment of the miscellaneous forms of vertigo of indirect origin — those due to reflex causes, ocular disturbances, intracranial affections, diseases of the heart and bloodvessels, states of the blood, hysteria, and neuras- thenia — are to be treated by measures directed to the relief of the causes, the most important of which measures have been referred to when considering the vertigoes themselves in preceding paragraphs of this section. 746 NERVOUS DISEASES. AFFECTIONS OF SIGHT DUE TO DISEASE OF THE OPTIC NERVE AND OF THE ENCEPHALIC VISUAL APPA- RATUS. The Optic Nerve a Part of the Central Nervous System. — It has alieiidy been stated that the olfactory nerve and bulb are now generally regarded as integral parts of the forebrain. It is also held by many that the optie nerves and tracts should be recognized as a part of the central nervous system, as much as the cerebellum or the posterior columns of the spinal cord, to which they present a close similarity. Like the posterior columns, the optic nerves grow out of cells in the direction in which they convey impulses. They do not have the sheath of Schwann, as do true peripheral nerves. The optic tracts, the parts internal to the chiasm, in structure and in the arrange- ment of their constituents resemble the white matter of the brain. Their myelin fibres are intermingled with neurogliar cells. The functions of the optic nerve, like those of the posterior columns, are afferent ; both optic nerves and posterior columns are liable to de- generative diseiises of the same character ; they are often affected to- gether, or successively after a comparatively short time ; they may in rare instances be independently attacked, as in some cases of so- called tabetic atrophy ; and, finally, the visual apparatus can be made to substitute functionally the apparatus for general seusibilitj'. One anatomical difference must, however, not be overlooked. The spinal process of the ganglion cell comes from the same cell as the peripheral process, and is not part of an independent nerve cell ; it corresponds to the axis cylinder, and the peripheral process to the dendritic process. The connection of the retina with the central nervous system is never lost, as is also the case with the olfactory bulb ; but the optic nerve differs from the olfactory nerve in that it is never associated by nervous elements with modified epithelial cells at the surface ectoderm. It is, therefore, the only portion of the cen- tral nervous system upon which external infiuences act directly, un- less we assume that the lens and the surface epithelium of the cornea play a part in relation to the retinal elements comparable to tliat per- formed by the terminal nerve elements of the skin. The retina has bi'cu compared to a modified basal ganglion, and the optic nerves to assDciation bundles bringing it into relationship with other parts of the brain. ( ]Monro, Eobinson, and Van Gehuchteu.) End Sheathing of the Optic Nerve. — Externally the optic nerve is supplied with a strong dural sheath, which becomes the sclerotic coat of the eyeball. It is closely invested with a pial sheath. Between t hi 'two is a delicate arachnoidean layer, which peripherally unites with the dural sheath, and hence the subdural and subarach- noid spaces b(>(ome continuous as the eye is approached. The ojitic nerve is narrower at the lamina cribrosa, which is the scleral layer AFFECTIONS OF SIGHT. 747 transformed into a very open network to allow the passage of the nerve fibres. The separate fibres of the optic nerve are estimated as numbering four hundred and filly thousand. Structure of the Retina.—The retina is a delicate and highly evolved structure, and has been variously subdivided into layers. The researches of Eamon y Cajal, Van Gehuchten, Edinger, and others seem to show that it is best from the histological point of view to recognize three principal layers, namely, (1) the luiier of visual cells; (2) the hu/er of bipolar cells ; and (3) the lai/ci- of ganglionic cells. These three layers can be divided into other k'ss well defined layers or strata. The layer of \isual cells is the outermost of the retinal layers. Fig. 353. Cross-section of health;- optic nerve about five millimetres behind the eyeball (magnified eighteen diameters) : dti, dural sheath ; p, plal sheath ; s, subdural space ; between the dural and pial sheaths are seen fibres of the arachnoid ; vr, central vessels. (Wilder.) The most distal portion of the peripheral prolongations (protoplasmic or dendritic processes) of its cells constitutes tlie rods and cones of the retina. The central prolongations of these cells pass into the deeper portions of the retina, where they end free. Beneath the layer of visual cells is the layer of bipolar cells. Its peripheral (protoplasmic or den- dritic processes) terminate in arborizations which interlace and are in contact with the similar terminations of the central processes of the cells of the visual layer (forming the extciiud molecular lai/er), while the axis cylinders or central prolongations of the bipolar cells end in their turn in an elaborate arborization in the depths of the retinti. The deepest of the three great layers of the retina, the layer of gan- glionic cells, is composed of cells of very large size, whose peripheral 748 NERVOUS DISEASES. (protoplasmic or dendritic) processes, terminating in a complex arbor- ization, intermingle with the cential arborizations of the cells of the bipolar layer (forming the internal molecular layer). Centrally each ganglionic cell has a single axis cylinder which becomes one of the fibres or elements of the optic nerve trunk. These fibres taken to- gether at their origin are sometimes spoken of as the layer of nerve fibres. It wiU be seen that the sub- ordinate layers or strata are the results in some instances simply of subdivision of the three layers, and in others of combinations of portions of two of these layers. Three of these subordinate layers not yet de- scribed are the external granular layer, the intenud granular layer, and the layer of ganglionic cells. In the illustration (Fig. 354) are shown the main elements of the retina and its arrangement into three principal lay- ers and other subordinate layers or strata. According to this descrip- tion, three superimposed systems of nerve cells or neurons are found in the retina. The visual cells first receiving the luminous impressions, these are conveyed centrally to the bipolar cells, and from the latter by way of the axis cylinder processes of these ganglionic cells into the optic nerve trunk. The optic nerve fibres conduct these impressions to the pri- mary basal centres in the inter- brain and midbrain, and from these they are conveyed to the cerebral cortex. Besides the nervous ele- ments just described, among these elements are found cells of an epithelial nature, which are usually regarded as sustentacular. In the retina also are certain cell bodies and their processes, which take a more or less horizontal direction, some of which seem to connect visual and bipolar cells which are sepaiated by a considerable distance. Throughout tlie thickness of the external molecular layer are found cells of large size, called ^pongioNa^ta, with apparently no axis cylin- ders, but with numerous dendritic processes which are directed inter- nally. Their functions haxc not yet been determined. Because of the absence, or apparent absence, of axis cylinders, Eamon y Cajal has suggested the name aniacrinc cells for the spongioblasts. The arrangement of tlu^ rods and cones varies according to the region of Layers of the retina : A, layer of visual cells ; B, layer of bipolar cells ; c, layer of ganglion cells ; a, rods and cones ; 5, exter- nal granular layer ; c, external molecular layer ; d, internal granular layer ; e, inter- nal molecular layer ; /, ganglion layer ; g, layer of nerve fibres. (After Van Ge- huchten.) AFFECTIONS OF SIGHT. 749 the retina in which they are found. In the macula the cones are closely packed together, being separated only by a single layer of rods, while in other regions they may be separated by three or four such layers. The cones are probably necessary for higher acuity of vision. According to Salzer, the cones of the human retina number about three million three hundred and sixty thousand, and Krause has estimated the rods at one hundred and thiity millions more. Fur- ther researches may render necessary some change in these estimates. General Course and Connections of the Optic Nerves and Tracts. — Arising in the deepest of the retinal layers, the optic nerves traverse the choroid and sclerotic coats, the orbital cavities, and the opti'c foramina, reaching the base of the brain just cephalad of the Fig. 355. Section of the retina of a do^ : a, a, a, cone fibres ; &, b, rod granules and fibres ; c. c, c, c, bipolar nerve cells whose erect distal arborizations pass to the central prolongations of the rods ; c, e, bi- polar nerve cells with horizontal arborizations which pass to the central prolongations of the cones ; /, giant bipolar cell with horizontal ramifications ; g, g, special elements with uncertain relations ; h, diffuse amacrine cell (spongioblast) ; i, i, ascending axis cylinder processes ; j^ j, cen- trifugal nerve fibres ; m, m, nerve fibres penetrating the internal molecular or inner plexiform layer; n, one of the ganglion cells receiving ramifications from the rod bipolar cells ; A, external molecular layer ; B, internal molecular layer. (RamOn y Cajal.) infundibulum. They here undergo partial decussation, forming the chiasm, which rests in the transverse furrow, called the optic groove, on the superior face of the sphenoid bone. Caudad of the chiasm the optic nerves become the oj^tic tracts or strice. Each optic tract as it passes backward winds around the cerebral crus on its way to the interbrain and midbrain. In most descriptive anatomies the fibres of the optic tract are spoken of as dividing into an extermd or lat- eral and an internal or mesal root. What is designated as the ex- ternal root is in reality, however, the true continuation of the optic nerve and tract. The fibres of the so-called internal root are in the main derived from Gudden's and Meynert's commissures, and they do not in a proper sense form a part of the optic nerve and optic tract, although for a part of their course they are in imme- 750 NEEVOUS DISEASES. diate juxtaposition with the latter. All authorities are not in accord as to the exact basal termini of the optic tracts. Usually it is held that the vast majority of the optic fibres terminate by free ramifi- cations in the pregeniculum, the pregeminum, or the pulvinar. The visual centres in the interbrain and midbrain are connected with the calcariue cortex by a special band of cerebral fibres, the optic radi- ations of Gratiolet. The angular and the external occipital cortex are also connected with these basal centres indirectly through the calcarine cortex, and, not improbably, also by some direct bundles, although the passage of projection fibres directly to this region is generally denied. According to some authorities, a few of the fibres of the optic tract do not terminate in either the interbrain or the midbrain, but pass into the white substance of the cerebrum, event- ually tf) reach the gray matter of the visual cortex of the same side. The evidence in favor of the existence of this tract is not, however, of a positive character, or at least is not conclusive. The optic tract is firmly attached by brain substance to the precribrum and the crus. The basal ganglia overlie the tracts. It is probable that the optic nerve has direct connection with the lenticula. Through the external capsule it is probably connected also with the first and second temporal convolutions. Separate Fasciculi of the Optic Nerves and Tracts. — The fibres constituting the optic nerves and tracts are arranged into sev- eral separate bundles or fasciculi, each of which has a particular function. The main bundles, three great afferent visual fasciculi, are (1) a bundle of direct fibres which comes from the external or tem- poral third or fourth of each retina and passes into the optic tract of the same side ; (2) a bundle of fibres which comes from the internal or nasal two-thirds or three-fourths of the retina and passes at the chiasm into the oi)tic tract of the opposite side ; and (3) a bundle of fibres which proceeds from the region of the macula and also decus- sates, passing partly to the optic tract of the same side and partly to the optic tract of the opposite side. The crossed fibres of this macular bundle prf)bably come from the nasal side of the macula, and the un- crossed fibres from its temporal side. A scheme of the course and connection of tlie visual tracts from the retina to the cortex, and of the separate fasciculi of the optic tracts, is shown in Fig. 356. The first two fasciculi of the optic tract convey luminous impressions from all portions of the retina except the macula, but they do this, as just indicated, in unequal proportion. By means of their fibres those lumi- nous impressions whicli are concerned with the general recognition of form and color are transmitted. The fasciculus of uncrossed fibres <)ccu])ies the outer or lateial part of the chiasm, while that of crossed fibres makes up the more central larger part which is left. The miicular bundle is that which brings the retinal area of clear vision into relation with special encephalic centres, basal and cortical. It AFFECTIONS OF SIGHT. 751 occupies about one fourth of the extent of the nerve, and is tri- angular. At first it is situated in the inferotemporal portion ol the nerve, but as the nerve passes backward through the orbit this fasciculus gets near the centre, and just in front of the chiasm it occupies the dorsomesal portion of the nerve. In the optic tract it again passes into the central portion of the nerve, where it remains Uncrossed tract - -- Macular fascicle j ""^E?!!!? '-i " )aaed ( Ant Quadrigemina'l (Post Parieto-occipital fissure Cuneua Calcarioe fissure External geniculate body. Internal geniculate body. Optic radiations. - Posterior horn of lateral ventricle. Scheme of the general course and relations and separate fasciculi of the optic nerves and tracts, showing also the fields of monocular and binocular vision, (Hill.) almost completely encased in the other bundles until the brain is reached. In the diagram Fig. 357 are shown the relative positions of the macular and other bundles at different points of the optic nerve and optic tract. Fibres of the Optic Nerve of Central Origin. — It is now wc41 known that the optic nerve and its tract are not composed entirely of fibres which arise in the retina ; some have been shown to originate in the basal centres, their cells of origin being in the pulvinar, the pregeniculum, or the pregeminum. The functions of these periph- erally directed optic fibres have not yet been satisfactorily estab- lished, but Eamon y Cajal supposes that the purpose of some of them is to act upon the protoplasmic processes of the amacrine cells or spongioblasts found in the internal molecular layer. The layers of 752 NERVOUS DISEASES. the retina to which they are distributed are rich in bloodvessels. A number of investigators have demonstrated the influence of the sympathetic nerve in the neck on the vessels of the retina, and the researches of M. Elinson have shown that a large number of cen- FiG. 357. Diagram of the optic nerve and tract, showing the relative positions of the macular and other bundles in transections at different points. The position of the macular bundle, indicated in black, is in accordance with the views of Samelsohn, and that of the uncrossed bundles, shown by oblique shading, is according to Wernicke and Schmidt-Rimpler. The decussation of the macular bundle at the chiasm is shown, and the position of the commissural fasciculi posterior to the chiasm is indicated by the dotted line. trifugal fibres of the optic nerve which he has traced into the retina have their origin in the sympathetic. It is ijrobable, therefore, that a large portion of the fibres described by Eamon y Cajal as being in relation with the amacrine cells of the retina are especially destined for the innervation of its bloodvessels and do not play any direct role in the act of vision. Partial and Total Decussation of the Optic Tracts. — Partial decussation of the optic nerves and tracts is the rule in man. In fish and birds this decussation is total. As an anomaly total decussation may sometimes be present in the human being. As the theory of total decussation seems to have recently received some support from high authority, it may be well to summarize briefly a few important facts bearing upon this subject. Jacobsohn extirpated one eye in rab- bits, guinea pigs, cats, and monkeys, and, studying recent degenera- tion after the method of Marchi, found that in rabbits and guinea AFFECTIONS OF SIGHT. 763 pigs not a single degenerated nerve libre eonld be traced tlirough the chiasm to the optic tract of the same side, but that all sucli fibres passed to the tract of the opposite side. In the cat and in the monkey a large nnniber of degenerated fibres passed to the optic tract of the opposite side, and also very many to the tract of the same side, show- ing that the decussation is partial in these animals. Studies in de- generation have also shown that in man the decussation is partial. Bernheimer reported in 1896 a case of old complete atrophy of the right optic nerve with a perfectly normal condition of the left nerve. The left optic tract contained a certain number of atrophic fibres, although not so many as the right tract. As the left oi^tic nerve was perfectly normal, these degenerated fibres in the left tract must have come from the right optic nerve. This case is in accord with a pre- vious observation of Bernheimer, and proves the presence of un- crossed fibres in man. Eecent histological observations are not, how- ever, in accord. Michel, for instance, asserts that he found a total decussation in the rabbit, dog, cat, and man. Eamon y Oajal found in the rabbit and mouse a direct optic bundle. According to Munk, the decussation is not complete even in birds. Koelliker found in man, and in the dog, cat, and rabbit, total decussation in every instance. Pick has confirmed the observations of Koelliker with regard to total decussation in the rabbit. We must, however, agree with the stand taken by Obersteiner, who, in reviewing Koelliker' s work, asserts that total decussation of the optic fibres in man can hardly ever again be accepted by clinicians, in spite of the fact that so important an authority as Koelliker is in favor of this view. As suggested by Van Gehuchten, if total decussation at the chiasm is accepted, the well known cases of homonymous lateral hemianopsia from unilateral lesion of the occipital cortex can be explained only on the supposi- tion of the partial decussation of the optic fibres which connect the basal centres for vision with the cerebral cortex. Commissural Fasciculi (Gudden's commissure and Mey- nert's commissure). — In both Gudden's commissure and Meynert's commissure are probably situated the fasciculi which take part in the accommodation and the light reflexes. Gudden's commissure is the more important of the two bundles. It is situated in the caudodorsal portion of the chiasm, and constitutes about one third of its entire mass. It is sometimes difficult to separate the fibres of this com- missure from those of the adjacent visual fibres proper. Meynert's bundle is situated in the dorsal portion of the chiasm, and is of much smaller size than Gudden's commissure. The fibres of this commis- sure, arising from the gray matter of the tuber cinereum, cross the middle line together, enter the crusta of the opposite side, and thence probably pass into the subthalamic body. The Basal Centres for Vision and the Optic Reflexes. — The shrinkage of the pregeniculum after extirpation of the eye has been 48 754 NEEVOUS DISEASES. clearly demonstrated. It has also been shown to undergo processes of atrophy or involution after removal of the occipital lobe or after a large lesion in this region of the cerebrum. According to Von Mona- kow, while the ground substance of the pregeniculum tends to dis- appear after removal of the eyeball, its cells remain. The end brushes of certain retinal cells terminate in the pregeniculum, and other large cells connected with vision here originate, the latter representing neurons which pass to the cortex. I do not know of any facts which prove that the macular fibres alotie terminate in the pregeniculum, as Knies suggests. The sheet of white fibres which covers the thala- mus and is known as the stratum sonale is composed, at least in part, of fibres of the optic tracts which pass over the pregeniculum, but just what course these fibres finally take is uncertain. The pulvinar, like the pregeniculum, is said to atrophy after destruction of the eyeball and the optic nerve. Histological research tends to show that, as in the case of the pregeniculum, fibres from retinal cells terminate in this portion of the thalamus, while cell bodies are found whose pro- cesses pass to the occipital cortex. It is not necessary to conclude, however, that these are true visual fibres, or that the nerve cells from the pulvinar to the cortex are visual in the sense that they convey impressions of light and color. The exact i^art played by the pul- vinar in the mechanism of vision seems to be less well established than the functions of the pregeniculum and pregeminum, although the pulvinar is certainly an important organ intercalated in the visual pathway. Henschen believes that the fibres of the optic nerve which pass into the pulvinar are not visual, and this is the view that the author has taken in preceding pages (pp. 355 and 358). Degenera- tion of the pulvinar does not produce hemianopsia when the pre- geniculum and optic radiations are intact, and we may have a lesion involving a large portion of the pulvinar without hemianopsia. When hemianopsia has been observed in cases of lesion of the pul- vinar, the disease may not have been strictly confined to this gan- glion. Both pulvinar and pregeminum are probably great reflex optic centres, but the problem of the functions of the former cannot be regarded as settled. Certain alfereut fasciculi of the optic nerve pass to the pregeminum, in the nuclei of which are cells of large size. Axis cylinder fibres pass from these cell bodies, and in front of the nuclei of the third ner\'e decussate in the raphe. They become con- stituent fibres of the dorsal longitudinal bundle, and give off collat- erals which ramify among the root fibres of the third, fourth, and sixth nerves, and thus is established a communication between the optic nerve fibres and the cell nests of all the motor nerves of the muscles of the eye. Lesions of the pregeniculum undoubtedly cause motor troubles of the eye and disorders of pupillary innervation. Pathological observations of recent date show that the pregeminum may degenerate without any essential change in vision. The atfec- AFFECTIONS OF SIGHT. 755 tions of vision referred to as occurring in connection with lesions of the pregeininum are of. a reflex character, rather than true dis- orders of vision. The luminous impressions which invoke ocular and pupillary movements may be interfered with, but not those which awaken the cerebral sensations of light and color. The Optic Radiations.— In the white substance of the occipital lobe are found large numbers of projection fibres which connect the basal centres for vision and for ocular and pupillary raovements with the cortical visual region. These taken together are usually spoken of as the optic radiations of Gratiolet ; but Gratiolet described only a portion of these fibres, those which he believed were directly trace- able into the optic tracts. Certain projection fibres are also found here, which unite the cerebral cortex to the cortex of the cerebellum ; still other fibres unite the occipital cortex with the most caudal por- tion of the internal capsule. Besides these j)rojection fibres the sub- cortex of the occipital lobe contains a large number of association tracts which are in some way connected with visualization. Among these are tracts connecting the occipital with the temporal lobe, one convolution of the occipital lobe with other convolutions of the same lobe, and the occipital lobe of one side with the occipital lobe of the other by way of the splenium of the callosum. Cortical Termini of the Visual Tracts. — Under visual local- ization (pp. 342-344) the subject of the cortical centres for vision has already been somewhat fully considered. It will be necessary here to recall that the primary cortical centres for vision are situated in the region of the calcarine cortex of both hemispheres, and the secondary or higher visual centres, including the centre for word seeing, in the angular and external occipital convolutions. As indicated under visual localization and in the discussion of aphasia (see diagram and legend, p. 629, Fig. 332), tracts proceed from the primary visual cen- tres of the calcarine cortex on both sides to the higher visual centre of each side. The pure word blindness of Dejerine is caused by a lesion destroying the connection between both occipital lobes and the higher angulo-occipital region of the left side (see p. 634). Henschen re- gards the macula lutea as represented in the front of the floor of the calcarine fissure. Others hold that the macular region of the field of vision, if not represented in the calcarine fissure, has its representa- tion in its immediate neighborhood. According to Ferrier, each an- gular gyre is in relation with the macula of the opposite side, partly by fibres which are supposed to decussate in the chiasm, and partly by fibres which decussate in the basal centres. The views of Ferrier as to macular representation are indicated in Fig. 358. The accept- ance of the view that the macula has its representation in the angular and adjoining occipital region does not make it necessary to accept also the hypothesis as to a second decussation of the optic pathway in or behind the basal centres, although it is difficult to explain some of 756 NERVOUS DISEASES. Fig. 358. the phenomena of central amblyopia except on this supposition. The macula, like all other portions of the retina, probably primarily has relations with tlie region of tlje calcarine cor-tex and secondarily with the angular and external occipital region. The macular bundle with its cortical continuation may preserve its separate place not only to the pregeniculum, but also through the optic radiations of Gratiolet to the primary cortical cfiitre.s, and from these centres to the angulo-occipital region. The higher visual centre has its ciiicf development in the left hemi- sphere. It is difficult to explain the cases of hemianopsia, single and double, in which a small area of clear vision remains, except on the supposition that the area of macular representation is in part at least in a portion of tlie cortex somewhat removed from the cal- carine fissure. According to Von ^Monakow, the fxnd cortical area employed in seeing, and the exact relations of the primary optic cen- tres to the visual cortex, have not yet been de-teimined. He belie\'es that the cortical area certainly in- res..nt.s the retinal relations of O' , the inter- cludftS morC than the CUnCaS, Un- rupted line indicates the retinal relations of A , , , , , , ,. - -^ i gual lobe, and descending occipital gyru>. He found that fibres con- 0' KfhtTfii- of the optic tracts and vi.'-iml itn- tres : A, the right and A', the left angular g>Tus ; C, optic chiasm ; E, the right and E', tlie left eye ; n, the right and //', the left optic nerve ; 0, the right and ()', the left occipital lobe ; T, the right and T', the left optic tract ; the thin continuous line represents the retinal relations of O ; the thick continuous line rep- and the dotted line the retinal relations of A' ; the relations of A and A' with the eye on the same side are indicated by finer interrupted and dotted lines respectively. (Fcrricr.^ believes tliat it is probable that neet the posterior part of the tliala- mas with the parietal lobe, and lie a close eonnection exi.'^ts between the angular gyms and the superior pai ietal ecjnvolution on the one hand and the posterior pint of the thalamus on the other, .i small portion of the posterior part of the thalamus not Vjeing included in this eonijeetion. Yon Monakow beliexes that the first, second, and third oeeijjital con\olntion>, are ceitainly inclnded in the cortical visnal ai-ea. and most ])]oiialily also the superior and inferior parietal loljiiles. He holds that e\ery portion of the cxteinal geniculate bodj- ri-eeivr-s filiies fioiii the iiinMila, and that tJiese fibres are so projeet<-i| enrtieidly tliat tliey extend to the farthest limits of the vi.sual e(>rtex : so tJiat when a lesion U-a\-es only a small portion of the visual eoitex inlaet. the fibics of this intact portion are suffi- eieiit for vision thiongh the macula. Dejeiine i.s, in jjart at least, in ac'cord with those who hold that tlie iuigular convolution is a AFFECTIONS OF SIGHT. 767 higher visual centre. He believes that letters, like objects, are seen with the help of the visual centres of the calcarine cortex, but they are seen here simply like other objects, or like letters of an unknown tongue. In order that an assemblage of letters may awaken the idea of words, he holds that it is necessary that this cortical centre of common vision should enter into connection witli the zone of speech, which is fully represented only in the left hemisphere, pa- thology showing that the centre of the visual memories of letters re- sides in the position of the angular gyre. Certain facts regarding the spectra and other visual sensations which occur in epilepsy and mi- graine seem, as suggested by Gowers, to postulate the existence of separate and higher centres. Gowers adopts the view of Perrier, which has been subscribed to by the writer. Some of the most carefally recorded observations regarding the spectra of migraine show that these, whatever form they take, tend to occupy only the peripheral portion of the retinal field. The central field is nearly always free from these spectra, and the zigzag or other lines diminish in length as they approach it ; but this central field is subject, on the other hand, to inhibition, becoming obscured or absolutely darkened. Focal Lesions of the Visual Pathway. — Definitions and Special Visual Symptoms. Many of the terms used in the description of dis- orders of the visual apparatus have already been defined in whole or in part, and the methods of investigating disorders of this apparatus which especially interest the neurologist have been briefly described in Chapter II. Although the forins of hemianopsia are not described in detail, their general characteristics are there indicated by descrip- tive terms, and the exact significance of the special forms will appear when the lesions causing them are described. Hemianopsia of what- ever type may be partial or complete — a part of the half field or the entire half field may be obscured. Hemianopsia may be absolute — the perception of light, form, and color may be wanting ; or it may be relative — one or two of the special functions of sight being lost, while the others may be retained. Double hemianopsia is a very un- usual form of visual disorder, in which, as the result of successive or simultaneous attacks of homonymous lateral hemianopsia, the entire field of vision, with the exception of the central or macular area, is obscured (see pp. 343, 344). Great irregularities in the method of obscuration of the visual field and in its degree may be met with, particularly in connection with disseminated lesions. It is rare to find hemianopsia present as an absolutely isolated symptom. For total loss of vision blindness is the simplest and best term. Formerly the word amaurosis was much used in the description of loss or im- pairment of vision, but it is being displaced by terms more exact and special. Amblyopia is most commonly used to designate partial loss of vision from various causes. Color Blindness. The color sense is the faculty by which colors 758 NERVOUS DISEASES. are distinguished. Achromatopsia is color blindness. It is total only in extremely rare cases, and even when total the individual may dis- tinguish differences in brightness or luminosity in what are to others different colors. When the loss for color is in one half field the affection of sight is designated hemiachromatopsia. Dyschromatopsia is difficulty in distinguishing colors, and t\\& tevvn parachromatism \% sometimes applied to a false or incorrect perception of color. Hemi- achromatopsia from a focal lesion is rare, but in one case observed by de Sch^einitz the patient at first was absolutely hemianopsic, although later the form sense and the light sense returned, the hemi- achromatopsia remaining. The case was one of homonymous lateral hemiachromatopsia. A few other cases have been recorded. Par- tial color blindness is usually subdivided into red-blindness, green- blmdness, and violet-blindness. Dalton suffered from red-blindness : hence color blindness is often called Daltonism. It is doubtless true that in different cases different portions of the visual apparatus may be afi'ected. The normal retina appreciates the colors in different degrees in its different parts. In the extreme peripheral portion of the field of vision colors are not recognized, everything appearing gray ; as the periphery of the field is left, the difference between blue and yellow becomes appreciable ; and still nearer to the middle, red and green are differentiated. The congenital hereditarj- forms of color blindness are, as a rule, due to an arrest of cerebral devel- opment, the defect not being in the perceptive but in the appercep- tive portion of the visual apparatus. According to some authorities, the portions of the cortex which respond to different color impres- sions are distinct, although they may be near to each other ; accord- ing to others, the different powers of color apperception reside in different layers of the cortex ; but the exact truth remains to be discovered. Certain disturbances or lesions of the conducting fibres of the optic tracts give rise to optic disturbances in color ^'ision. In some of these cases the visible spectrum gradually narrows from both sides, red, orange, and yellow on the one side, and violet and blue on the other, becoming less and less distinct, and thus, step by step, the entire middle portion of the spectrum becomes colorless. (Knies.) According to one largely accepted view, the defect in some cases of color blindness is in the retina, and the mechanism of its occurrence is variously explained. The three main colors which include all color sensations are supposed to be dependent upon the stimulation of three sets of retinal fibres, and this or that form of color blindness is present according to the particular retinal fibres which are affected. Another theory is that color blindness is due to the absence of some substance in the retina, red-green blindness being due to the absence of the red-green substance, and other forms to the absence of other substances. Oases of uniocular color blindness would certainly seem to show that, in some instances at least, the dis- AFFECTIONS OF SIGHT. 759 ease or defect producing tlie color blindness must lie in front of the chiasm, and, as in these cases visual acuity has not been reduced, the disturbance has most probably been in the retina. The same nerve may be the conducting apparatus for different colors, the brain being the differentiating organ, the nerve fibres simply undergoing differ- ent changes according to the colors that strike the nerve termini ; or the retina is the differentiating or sifting organ, and the nerve tract conveys the color stimuli, already differentiated, to the special centres in the brain. The discussion of the entire subject of color blindness is foreign to a work of this kind. The chief interest of the neurologist is centred on those cases of this defect which are due to cerebral disease. For7ns of Central Amblyopia. A lesion involving any portion of the visual apparatus from the tips of the rods and cones to and in- cluding the cortex of the higher visual centres gives rise to affections of sight. Macular or central amblyopia may be produced by destruc- tion of the macula itself, but lesions of intraocular origin come almost exclusively under the attention of the ophthalmologist. Central am- blyopia will result from a small infiltrating lesion, a nodule of sclero- sis or a focus of hemorrhage which may, by rare chance, be so situ- ated as to destroy the macular bundle alone in any part of its course. Clinical experience has also shown that this bundle is especially liable to be affected by certain toxic agents (see Toxic Amblyopias). As the fibres of the macular bundle are undoubtedly distributed to the pregeniculum, a lesion of this body or of a special portion of it might lead to central amblyopia. While it is probable, it cannot, however, be regarded as fully settled that the i^regeniculum is the basal centre for all portions of the retina. Knies, who believes that the pregeniculum is the special basal terminus of the macular bundle, has suggested that lesion of this body on one side should cause a par- tial amblyopia in both opposite halves of the fields of vision, and if both pregeniculi are destroyed, central vision should completely dis- appear. A lesion of any of the fasciculi of the occipital lobe which constitute the continuation of the macular pathway from the pre- geniculum to the cortex will probably cause central amblyopia, par- tial or complete. A lesion of either the primary or the secondary cortical centre for the macula should also cause central amblyopia, although some facts would seem to show that this results from corti- cal lesions only when they are situated in or near the angular con- volution. Lesions of the left cerebral hemisphere produce more posi- tive effects ui5on central vision than those of the right. It is probable that partial central amblyopia, including pure word blindness, is caused by a lesion in the tract or tracts which pass from the primary cortical optic centres of the calcarine cortex of both sides to the angular region of the left side. The term crossed amblyopia has been used by Charcot, Perrier, and Gowers to describe an affection in 760 NERVOUS DISEASES. which the patient suffers from obscuration of vision in the eye oppo- site to the side of the cerebral lesion. A few clinical cases are on record in which a lesion of the angular convolution and its immediate neighborhood has apparently caused this symptom. Pathological observations and some experimental facts seem to show that the field of the same side, as well as that of the opposite side, is affected as the result of such lesions, some amblyopia usually being present on the side of the lesion, but less in degree than on the opposite side. Occasionally a very remarkable condition results from limited visual disturbances, of which I have seen two illustrations. The patients have what might be termed macular or central hemianopsia, or hemi- anopsic amblyopia. One half of the central field is obscured or lost, the peripheral field being maintained or, it may be, partially ob- scured. The patient is half blind for words. A word of more than four or five letters will only be half seen, or at least will be partially cut off unless the patient turns his eyes so that the unimpaired half of the central field shall take in different parts of the word in suc- cession. Such a visual defect may be due to destruction of a part of the convolutional area for word vision. Symptoms of Focal Lesions in front of the Chiasm. As the optic nerve has a length of about five centimetres (1.97 inches) from the retina to the chiasm, it may be affected by a gross but small focal lesion in this position. It may, for instance, be compressed by a gliomatous growth, an orbital exostosis, a thickening of the dura, or a hemorrhage. A lesion affecting the nerve in this part of its course is most likely to be situated in the orbit, as about three fifths of its length is here located. The symptoms will depend upon the extent and destructiveness of the lesion. Total destruction of the nerve will of course give total blindness in the corresponding eye. In some cases, as when the nerve is gradually compressed, sight disappears step by step, concentric contraction of the field gradually taking place. An infiltrating or an irregular lesion may destroy only por- tions of the nerve, and give corresponding limitations in the field. In addition to the loss of vision, the pupillary and other reflexes which are completed through the nerve are abolished. Symptoms of Lesions inrolvinfji the Chiasm, including Forms of Hete- ronymous Hemianopsia. A destructive lesion involving the entire chiasm causes complete blindness. ^A^hen a lesion involves the optic nerve in front of the chiasm, and also in part the chiasm itself, in addition to blindness in one eye the fields of vision in the other eye will be affected according to the degree of the chiasmal im- plication. Nasal hriniauopsias result from lesions affecting the un- crossed fasciculi which are usually regarded as passing in the lat- eral portion of the nerve, chiasm, and tract from the external or temporal portion of the retina. A unilateral lesion sometimes com- X^resses one side of the chiasm and gives rise to a unilateral nwial AFFECTIONS OF SIGHT. 761 hemianopsia. Binasal hemianopsia is rare, but cases have been re- ported in which it has been produced by calcified and enlarged carotid arteries pressing upon both sides of the chiasm. Irregular nasal hemianopsia has been reported as occurring at certain stages of toxic or tabetic cases, the explanation e\'idently being that in these cases the lateral fasciculi of the nerves and tracts are first attacked. When a lesion occurs so as to destroy the caudal or posterior portion of the chiasm, bitemporal hemianopsia results, to produce which the lesion must be so placed as to destroy only the crossed fibres. Bitem- FiG. 359. Visual fields in binasal hemianopsia. (Bramwell. j poral hemianopsia has been recorded in acromegalia, and this may have been due to hypertrophy of the hypophysis, a lesion which has been observed in several instances of this disease. Other cases of bitemporal hemianopsia have been reported in connection with frac- tures, and in intracranial gummata and sarcomata. In a case re- ported by Weir Mitchell an aneurism of an anomalous artery con- necting the two carotids was present, and had destroyed the chiasm in the median line, causing bitemporal hemianopsia. When a lesion at the chiasm is so placed as to destroy not only both sets of crossing fibres but also one set of lateral fibres, hemianopsia with complete loss of vision, on one side, will be present. Infiltrating or other forms of irregular lesion of the chiasm may give rise to combinations of dif- ferent forms of partial hemianopsia with partial or complete central amblyopia. Lateral hemianopsia of one eye has been noted in asso- ciation with obscuration of three quadrants of the other eye. A form of transient bitemporal hemianopsia, hemianopsia bitemporalis fugax, is sometimes observed in syphilitic subjects, and this may yield rapidly to the iodides or mercurial inunction. Oppenheim has re- corded several such cases due either to a syphilitic new growth or to a gummatous meningitis, ^ot all such cases yield fully to specific treatment, necrotic processes sometimes having taken place. In Pig. 762 NERVOUS DISEASES. 362 is shown a frontal section of a gumma overlying the chiasm. Under the general designation of heteronymous hemianopsia several of the irregular varieties of hemianopsia just described are usually classified, the term being used as contradistinctive to homonymous. Thus the different forms of nasal and temporal hemianopsia are some- times spoken of as heteronymous. In the homonymous forms of this disorder the visual obscuration affects corresponding portions of the visual field, that is, portions of the visual field of each eye which or- . dinarily act together ; while in the heteronymous hemianopsias por- FiG. 360. Fig. 361. FOC POC Fig. 360.— Chiasm hemianopsia ; loss of vision in left eye, temporal hemianopsia in right eye ; complete atrophy of the left optic nerve, partial atrophy of the right ; no other symptoms of cere- bral lesion ; heraiopic pupillary inaction. Fig. 361.— Chiasm hemianopsia : partial blindness, with marked atrophy of both optic nerves ; bitemporal hemianopsia plus obscuration of upper nasal quadrant of left field ; no other symptoms of cerebral disease ; hemiopic pupillary inaction in right eye. LF, left visual field ; EF, right visual field ; O.s', left eye ; OD, right eye ; A' and T, nasal and temporal halves of each retina ; XOS, left optic nerve ; NOD, right optic nerve ; FCS, left crossed bundle ; FLD, right uncrossed bundle ; C, chiasm ; CIC, commissural fasciculi (non-visual fibres of chiasm) ; TOD. right optic truct ; CGL, pregeniculum, and LO, pregeminum, which together make up POC, the basal primary optic centres. (Seguin.) tions of the visual field Avhich do not ordinarily act in conjunction are obscured. In what has just been said about the forms of hete- ronymous hemianopsia fi'om lesions involving the chiasm, the usually accc])t('(l \ iews witli regard to the position of the decussating and nondccussating tracts of the chia.sm have been followed. These views are not, however, unixcrsally held, and observations of Wernicke and Schmidt-Rimpler would seem to show that the uncrossed fibres at the chiasm coalesce into a .single bundle, which lies to the inside and a little interiorly, instead of laterally as usually held. Schmidt- AFFECTIONS OF SIGHT. 763 Eimpler traced bands of degeneration which indicated this course in a case of hemianopsia. In the diagram Pig. 357, showing the position of the macular bundle, the course of the uncrossed fibres according to Schmidt-Eimpler is also shown by means of shading. As remarked by Knies, if we assume that the course of the fibres in the optic nerve and chiasm is like that described by ^Vernicke and Schmidt-Eimpler, Frontal section of gumma overlying chiasm, four times magniiied : a, a, optic nerves ; b, h, brain substance : c, c, main mass of gumma ', d,d, new growth extending into chiasm, between and around optic nerves ; e, vessel with thickened and infiltrated walls ; /, necrotic spots within gumma. (Oppenheim.) tlien a single lesion of the anterior angle of the chiasm between the two optic nerves might give rise to a condition similar to binasal hemianopsia. The probabilities are, however, that the course of the crossed and uncrossed bundles as described by Schmidt-Eimpler is exceptional. Symptoms most frequently associated with Heteronymous Hemmnopsia. Heteronymous hemianopsia, which, as just shown, usually points to a chiasmal lesion, is commonly associated with other symptoms of disease at the base of the brain, a knowledge of which will facilitate exact diagnosis. Binasal hemianopsia may be associated with paraly- sis of all or nearly all the motor and sens(jry nerves of both ej^es, and this indicates a chiasmal lesion spread out so as to affect the orbital nerves, leaving the central decussating fibres of the chiasm intact. Bitemporal hemianopsia may be associated with unilateral or bilat- eral anosmia, indicating disease of the mediofrontal edges of the chiasm and extending forward. When bitemporal hemianopsia is 764 NERVOUS DISEASES. Fig. 363. present with blindness of one eye (later) and paralysis of some or all of the nerves which enter the orbit of the blind eye, the lesion is probably laterad of the chiasm, involving the orbital nerves and the optic nerves as well as a large part of the chiasm. (Seguin.) The pupillary reflexes will be abolished in part in these cases. The hght reaction cannot be (obtained from the blind portion of the field. The accommodation reaction and the reaction to cutaneous irritation will be present. It cannot be emphasized too much that in cases of chi- asmal lesion Die visual defects may be of a very irregular character. Homonymous Lateral Semianopsia. In homonymous lateral hemi- anopsia, the most common form of hemiopic defect, the temporal field of one eye and the nasal field of the other are darkened to the right of the fixation point, or the corresponding fields to the left, causing the left or right form of homon- ymous lateral hemianopsia. This form of hemianopsia may be caused by lesions situated in the optic tract back of the chiasm, in the pregeniculum, in the optic radiations, or in the calcarine cortex. According to some, it may also be caused by lesions of the pulvinar. Forms of incomplete lateral hemianopsia are most fre- quently due to lesions of the occipital cortex or subcortex. In a considerable percentage of the cases of homonymous lateral hemianopsia, a small, central, semicircular area rep- resenting a portion of the mac- ular field is not darkened, while in other cases the hemi- anopsia is complete. The ex- act position and extent of the lesions giving each of these two forms of hemianopsia have not yet been clearly demonstrated. T/ie Afisoi'iiilion of Hemianopsia icith Hemiplegia. Hemiplegia, pai'- tial or complete, transient or permanent, is a frequent association of hemiano])sia. In many cases of hemianopsia with hemianesthesia partial hemiplegia is also present. In these cases the lesion prob- E V Right homonymous lateral hemianopsia, from lesion of the left visual centre of the cortex or left optic tract : A, dark left nasal half field from blind temporal half of retina ; A', dark right temporal half field from blind nasal half of retina : B, left eye : E', right eye ; C, C, left and right optic nerves, com- posed of the crossed bundles of fibres ; D, D', left and right crossed bundles ; E, E', left and right occipital lobes ; F, F', left and right posterior horns ; G, G', optic radiations ; H, H', optic chiasm ; I. I', angular gyrus ; K, region of optic th.alamus, geniculate Invly, and quailrigemlnal bo'lics, collectively termed the pri- mary optic centres ; M, M', cunetis. The left cuneus and optic tract arc shaded, to show lesion of these parts and the influence of the lesion upon the retina. AFFECTIONS OF SIGHT. 765 ably involves directly or indirectly the internal capsule, and when the hemiplegia is prominent and persistent the capsule may be in- volved almost the entire distance from its knee to its extreme caudal portion. Transient hemianopsia may be present in the early stages Fig. 364. Visual fields in a case of left homonymous lateral hemianopsia. (Starr.) of an apoplectic attack with hemiplegia and other unilateral mani- festations, disappearing in a few hours or days. In these cases the hemianopsia is probably due to the effects of pressure or inhibition, or of both, upon the parts of the visual pathway which are not in- cluded in the destructive lesion. It is not well, therefore, in the early stages of some apoplectic cases to draw conclusions as to the Fig. 365. Visual fields in a case of left lateral hemianopsia. exact extensions of a lesion based upon the presence of hemianopsia. In nearly all cases the loss of sensation and of power, and the other disorders of motion which accompany hemianopsia, are on the same side of the body as the blind half fields. Potts has reported a case 766 NERVOUS DISEASES. of hemiplegia of the right side with hemianopsia of the left, caused by a penetrating wound of the brain ; but in this case evidently the optic nerve on one side and the motor region of the brain on the other were injured. Partial and Special Forms of Hemianopsia. Various partial and special forms of hemianopsia are sometimes observed. The defect may be limited to a portion of the half field. Some interesting cases of special forms of quadrant or sector defect from cortical lesions ha^'e been reported. In a well-known case reported by Hun, for example, in which the lower lateral half of the visual field of one side was obscured, the lesion involved only the lower portion of the cuneus. The obscuration may extend only over a quadrant, a sector, or some irregular segment of the retina, and this may or may not be entirely confined to one side of the vertical line. The term hemi- anopsia, which etymologically refers to an impairment or loss of vision in a half field, is not strictly api^licable to these defects, but it is sometimes used as a matter of convenience, generally with a quali- fying expression indicating the limitation of the obscuration : thus, quadrant hemianopsia, sector hemianopsia, or segmental hemianopsia may be spoken of in discussing the visual disorder. Properly speak- Fro. 366. Visual fields in a case of right lateral quadrant anopsia. ing, these visual defects are anopsias. "When the darkening of the field of vision in these forms of partial hemianopsia is largely or alto- gether confined to one side of a -sertical line passing through the fixa- tion point, the lesion causing the visual defect is usually a limited one in some of the positions already spoken of, as in the optic tract, prcgeniculum, optic radiations, or calcarine coitex. In a large major- ity of these partial cases, bowe^'er, the lesions are situated in the occipi- tal cortex or subcortex, and ])articularly in the former. When a quad- rant or sectorial defect is due to limited lesion of the cortical visual zone, the sj'mptom usually stands almost alone ; but sometimes alexia, sensorial agraphia, or the so-called psychic blindness may be present. AFFECTIONS OF Sl(iHT. 767 When sectorial defects originate from lesion of the occipital snbcor- tex, the defective portions of the fields are not likely to be so well defined in boundaries as when the lesions are cortical. The loss of Ught sense will probably be less complete than in cortical cases, and irregular spaces where light is recognized may be mingled with the blind spaces. Sectorial, quadrant, or other jiartial defects may arise from lesions of the optic tracts, but when this is the case they will be accompanied by other significant symptoms of basal disease, and, as in all cases of lesion of the optic tract, the senses of light, form, and color will be lost together. (N"oyes.) The appearance of the fields in a case of double hemianopsia, caused by successive attacks of lateral hemianopsia, is shown in Figure 367. Fig. 367. Visual fields in a case of double hemiple^a with double hemianopsia and loss of orientation, the result of two successive apoplectic attacks : the small central white area represents the limits of the preserved field (macular vision). (Dunn.) Horizontal Hemianopsias. Instead of the hemianopsia being lat- eral or vertical, it may be Iwrizontal or altitudinaJ. In horizontal hemianopsia the line which divides the fields of obscured and pre- served vision is horizontal. The obscuration may be either superior or inferior, in the former the upper half fields being darkened, and in the latter the lower half fields. The superior and inferior forms of horizontal hemianopsia, like vertical hemianopsia, may be partial ; in other words, the obscuration may be limited to a smaller or a larger portion of the upper or lower fields. Forms of horizontal hemianopsia may be due to a lesion of the chiasm or optic tracts so situated as to destroy or compress either the dorsal or the ventral fibres of the tracts in these positions. They might also be due to a lesion in the eye, as, for instance, to embolism of the central artery of the retina, or to circumscribed retinitis ; and it is also possible that symmetrical, bilateral, cortical lesions may involve such por- tions of the cortex on both sides as to cause a superior or an inferior form of hemianopsia. In Hun's case of lesion of the cuneus a part of the inferior fields was obscured. 768 NERVOUS DISEASES. Symptoms associated tvith Hemianopsia when the Lesions present involve the Basal Centres for Vision and the Optic Reflexes. While it is rare to have a lesion isolated to either of the so-called basal primary centres for vision, gross lesions involving one or more of these bodies and the regions lying adjacent to them are comparatively common, and hemi- anopsia has been noted in a number of the cases in which such lesions ha\^e been recorded. As indicated in the discussion of the I'elations of the pregeniculum to the visual pathway, it is probable that a lesion of this ganglion will cause hemianopsia of complete or in- complete type, and it is also probable that lesions of this ganglion or of a portion of it will cause central amblyopia. The hemianopsia in such cases can therefore properly be referred to the lesion of the pre- geniculum itself, or it may be conjointly due to invoh'ement of this basal centre and of the tracts which enter or leave it. Other symp- toms likely to be present will be those of disease of the thalamus and possibly also of the quadrigeminum, as these ganglia lie so close to- gether that they may be easily involved in a gross lesion. Oculo- motor paralysis from lesion of the third nerve, and hemiplegia or hemiparesis, might result, if the lesion were of considerable size and extended into the crus. The hemianopsia in these cases is of the homonymous lateral type, and hemiopic pupillary inaction is present. Hemianopsia has certainly been observed in a considerable percent- age of cases of disease of the thalamus, and this fact is used as an argument in favor of the view that the pulvinar is to be regarded as a true basal visual centre. Amblyopia is also sometimes present, but in other cases visual symptoms have been absent. Whatever view is taken, the clinician should be familiar with the symptoms which are commonly associated with hemianopsia in cases of thalamic disease. These are largely the same as those which accompany hemianopsia when the external geniculate body is implicated. The symptoms will, of course, vary according to the extent of the destruction of the thalamus. In several places in preceding pages the effects of lesions of different portions of the thalamus have been considered rpp. SSS-.'JSS). Besides the visual symptoms, sensory, motor, audi- tory, olfactory, thermic, vasomotor, and psychic symptoms have been recorded. The symptoms most commonly associated with hemi- anopsia in thalamic lesions are hemianesthesia, hemiataxia, hemi- choiea, and hemiparesis or hemiplegia. Tlie hemianopsia may in these cases be due to lesion of the pregeniculum or of the adjoin- ing oi)tic radiations. Wlien the lesion is limited to the pregeminum, visual symptoms, stviclly speaking, are not caused, but the proper coordination of \isnal impressions and pupillary and other ocular movements will be pi-evented. So far as conjoint movements of the eye are deiieiideiit upon visual impressions received by the eye oppo- site to the lesion, these will be abolished in lesions of one pregeminum. Disorders of station and locomotion, clonicotonic spa.stic phenomena, AFFECTIONS OF SIGHT. 769 and other symptoms which have been considered under lesions of the quadrigeminal body may be present. (See pp. 370 and .'571.) When gross lesions in\'olve all the primary oi)tic centres, as in some cases of tumor, the resulting symptoms will be of a most complex charac- ter ; but a careful consideration of the phenomena to be expected from implication of each of these ganglia may enable the clinician to unravel the confused tangle which is presented to him for diagnosis. The hemiopic pupillary inaction will be present when any of these basal centres are the sites of the lesions. Knies has called attention to a peculiar and highly interesting symptom which might result from isolated lesion of the pregeminum. As the fibres which go to the pupillary sphincter pass close to or through the pregeminum, if these are destroyed on one side at the same time as the pregeminum, the hemiopic pupillary reaction (inaction) without hemianopsia would result, but the symptomatology might readily escape observa- tion. "When quadrigeminal disease is suspected, the patient should therefore be tested for Wernicke's hemiopic pupillary inaction. AssociaUo7i of Hemianopsia with Disorders of Ocular Movements. When homonymous lateral hemianopsia is associated with some of the forms of alternate hemiplegia the lesion is most probably situated at the base of the brain in such a position as to injure the optic tj'acts and crus and adjoining structures. A combination sometimes pre- sented is that of paralysis of the third and fourth, and more rarely of the fifth and sixth, cranial nerves, on the side of the lesion, with homonymous lateral hemianopsia, and hemiplegia or hemiparesis on the opposite side. In such a case the hemiopic pupillary inaction will be present, as in all cases in which the lesion is situated so as to involve the optic tracts or the basal primary optic centres. Association of Hemianopsia with Disturbances of Speech. Various forms of disturbance of speech are somewhat frequently associated with hemianopsia. The position of the lesion in these cases is in large part to be determined by a study of the exact nature of the speech defect, which is sometimes a motor aphasia, at other times a sensorimotor aphasia ; or it may be word blindness, dyslexia, verbal amnesia, or word deafness. According to Seguin, lateral hemianop- sia with typical hemiplegia, spastic after a time, aphasia if the right side be paralyzed, and with little or no anesthesia, is certainly due to an extensive superficial lesion in the area supplied by the middle cerebral artery. Cases with lesions so extensive as this are rare, but when a true motor or sensorimotor aphasia occurs with hemi- anopsia, destruction of a considerable portion of the region supplied by the Sylvian artery should be expected, with also lesion of the occipital lobe. In the majority of cases of hemianopsia the asso- ciated speech disturbance is of the sensory or concept variety. Cor- tical word blindness or the pure word blindness of Dejerine may be present, the lesion in these cases in all probability involving the 49 770 NERVOUS DISEASES. parieto-oocipital cortex or subcortex, especially on tlie left side. When in these cases, besides the lateral hemianopsia and the word blindness or dyslexia, there is also hemianesthesia, the lesion in- volves both the caudal portion of the internal capsule and the white matter of the parietal and occipital lobes. When hemianopsia is associated with verbal amnesia and partial word blindness, the lesion is probably situated in the inferior temporo-occipital region, as in one of my cases, in which the patient suffered from verbal amnesia, partial word blindness, and later from partial hemiplegia, with par- tial homonymous lateral hemianopsia, as shown in the diagram Fig. 368. The lesion in this case was found to be a tumor involving the midtemporal and temporo-occipital region. Word deafness may be associated with homonymous lateral hemianopsia, as in a case re- ported by Dr. Spiller and the writer, in which an abscess was situ- FiG. 368. Visual fields in a case of verbal amnesia with lesion of the midtemporal and inferior temporo- occipital cortex and subcortex. ated at the posterior part of the external capsule, involving the medullary substance of the first temporal convolution and also the posterior part of the lenticular nucleus. A microscopical section through the lesion in this case is shown in Pig. 369. This patient had had several epileptiform convulsions, was partially paralyzed on the right side, and could not talk properly, although the exact nature of his aphasia was not determined. The loss of function in the motor and visual tracts was probably due to pressure exerted by the pus in the abscess cavity, but the hemianopsia persisted during the time that the patient was under observation. The peculiar site of this lesion should be remembered in cases in which hemianopsia is asso- ciated with verbal deafness. Association of Ecmianopsia with Loss of the Color Sense. Hemiachro- matopsia is a comparatively rare accompaniment of hemianopsia. When the perception of light is wanting, necessarily that of form AFFECTIONS OF SIGHT. 771 and that of color are also wanting ; but if the light sense is preserved either the color sense or the form sense or both may be deficient or absent. When the color sense (and the same is true of the form sense) is lacking or lost, the light sense being preserved, meagre clinical and pathological data show that the defects are most com- monly, if not invariably, due to lesion, direct or indirect, of the visual cortex. This subject has been studied by Swanzy, Noyes, and others. At least one case has been recorded with an autopsy, by Fig. 369. A H-- - -E 1 I ^ H G F Lesion in a case of homonymous lateral hemianopsia with word deafness ; microscopic section (unmagnified) from the left hemisphere at the level of the parallel fissure ; the first temporal gyrus extends to ahout three-eighths of an inch below the level of this section ; the abscess cavity termi- nates a short distance below this level : A, posterior limb of internal capsule ; B, thalamus ; C, sep- arated terminations of the abscess cavity ; D, optic radiations ; E, second temporal gyrus ; F, chief portion of abscess cavity ; G, parallel (supertemporal) fissure ; H, degenerated first temporal gyms ; I, Sylvian Assure ; M, anterior limb of internal capsule ; N, putamen. (Mills and Spiller.) Verrey. A lady sixty years old, after an apoplectic attack, had abso- lute color blindness in the right half of each field, with reduced but not complete loss of light sense and form sense in the same region, but without dyslexia and mental blindness. The lesion which had caused this defect was an old hemorrhagic cyst in the lower part of the left occipital lobe, extending into the temporal lobe on the mesal side. The cyst was situated between the floor of the posterior horn of the left lateral ventricle and the basal surface of the left occipital lobe. 772 NERVOUS DISEASES. It had occupied the white substance of the inferior occipital convolu- tion, and had almost completely destroyed the white substance of the posterior extremity of the occipitotemporal convolutions, as well as that of the posteroinferior part of the cuneus. The cyst had de- sti'oyed the deeper layers of the cortex and of the cuneus and other convolutions mentioned. (Swanzy and Noyes. ) Several other cases of hemiachromatopsia without autopsies have been recorded. In one of these mental blindness, agraphia, and amnesic aphasia coexisted with right hemianopsia, the achromatopsia being of the left lateral variety. In this case all the symptoms except the right hemianopsia improved, and eventually disappeared. (Siemerling and Wilbrand.) Other cases of irregular combinations of loss of the color sense with hemianopsia, speech disturbances, and other symptoms have been re- corded, all appearing to point to lesion of some part of the visual cortex as the origin of the achromatopsic disturbances. Diagnosis, Prognosis, and Treatment of Hemianopsia. — The etiology, pathology, and diagnosis of hemianopsia have been largely considered in the ijreceding discussion of this visual symptom. A close study of the paragraphs relating to the site of the lesion in each of the forms of hemianopsia, and to the special associations of symp- toms in the different forms, will make the focal diagnosis compara- tively easy. Probably the most important single point in the differ- ential diagnosis of the position of a focal lesion in hemianopsia is the presence or absence of Wernicke's symj)tom, the hemiopic pupillary inaction. If its presence is determined the hemianopsia may be cer- tainly regarded as due to a lesion in the primary optic centres or in the tracts or nerves in front of these centres ; its absence throws the lesion backward into the optic radiations or cortical visual centres. It is important to separate the hemianopsias due to focal lesions from the toxic, infectious, hysterical, or fugacious forms of this affection. When the subject of toxic amblyopias is considered, it will be seen that by far the most frequent visual defect resulting from poisoning by alcohol and other toxic agents is a central amblyopia ; but in rare cases toxic or infectious agents produce hemianopsia. Hemianopsia, for example, has been observed in cases of uremia and malaria. The progress of such cases and the absence of the symptoms usually asso- ciated with hemianopsia assist iu showing that a focal lesion was probably not present. Peunoff, when suffering fi'om malaria, had an attack of complete blindness, aphasia, left hemiplegia, and hemianes- thesia. Eeich had right homonymous lateral hemianopsia while suf- fering from malarial fever. Leidy in 1889 reported to the Philadel- phia Neurological Societj" a case in which bitemporal hemianopsia was present in a patient suffering from j)ronounced malaria. Harlan later made a more elaborate report on this case. The corpuscles of Laveran \\ere present, and the patient was cured by quinine. It was at one time supposed that hysterical hemianopsia did not occurj AFFECTIONS OF SIGHT. 773 but a few cases have now been put on record. Landolt recorded one case, presumably of hysterical hemianopsia, but the ophthalmoscope showed abnormal findings. Glorieux reported another case of tem- porary right hemianopsia with right hemianesthesia in a boy sixteen years old. Eosenstein has also reported a case of right hemianopsia in a case of hysteria. (Knies.) Hemianopsia is certainly so rare in hysteria that its occurrence should lead to a careful sifting of the symptoms for the possible presence of organic disease as a factor or as a complication. Fugacious and rapidly changing forms of hemi- anopsia are probably due most frequently to temporary disturbances of circulation in the cell layers of the calcarine cortex, and usually are of the homonymous lateral type, but the obscuration maj^ be of only a portion of the half field, or it may be partial at first and become complete later in the attack. Sometimes it takes the form of a hemiachromatopsia, which may be partial. Peculiar scintilla- tions of a zigzag or bizarre character in the obscured field and phos- phenes of varying intensity and of differing forms may be present. These forms of fugacious hemianopsia with phosphenes and other visual phenomena are sometimes a portion of the symptom picture in migraine. The visual symptoms may precede the migrainous attack, or may be present in its early stages. Among other evidences of disturbances of the visual cortex occasionally observed in these cases of fugacious hemianopsia are transient alexia, verbal blindness, or other disturbances of vision-speech. Oppenheira has suggested a method of examination in cases of incomplete hemianopsia — when the sensibility of the affected portion of the retina is greatly dimin- ished but is not wholly lost. It is especially applicable in cases of bitemporal or binasal hemianopsia. Two objects of the same kind are presented to the patient simultaneously in such a way that one lies in the outer and the other in the inner half of the field of vision. When the patient is asked what he sees, he points to the object in the clear field, while the other escapes his notice. As Oppenheim sug- gests, the image produced by the normal retina is so vivid in com- parison with the other that it blinds the mind and renders it unaware of the shadowy impression conveyed from the blunted part. The prognosis of hemianopsia will, in the first place, vary with the nature of the affection. If hysterical, if associated with migraine, or if of toxic or infectious origin, the prognosis is comi^aratively good. When due to a focal lesion the prognosis is that of the affection causing it, and varies according to the site of the lesion and its nature. A growth or an abscess involving some portion of the occipital lobe gives a more favorable prognosis than when the lesion causing the hemianopsia is situated at the base of the brain, as in the former case the lesion may be amenable to surgical treatment. When hemianop- sia is one of the active manifestations of syphilis the prognosis is more favorable than when due to other causes. The treatment of hemi- 774 NERVOUS DISEASES. anopsia is that of its causative affections. Malarial hemianopsia, as in the case recorded by Leidy, may disappear under the administra- tion of large doses of quinine, and hysterical hemianopsia may pass away under the influence of suggestive therapeutics and tonic medi- cation. The surgical and medical measures intended for the relief of tumor, abscess, hemorrhage, and other focal lesions which cause hemi- anopsia are of course the same as those discussed when these focal affections were considered. Diffuse Diseases of the Visual Apparatus. — Varieties. The preceding pages of the present section have been devoted mainly to focal lesions of the visual apparatus which most frequently claim the attention of the neurologist. The retina, optic nerves, tracts, and visual centres may also be the seats of a variety of diffuse diseases, which may be inflammatory, degenerative, or functional. The ma- jority of these come especially under the care of the ophthalmologist, but some of them are of importance both to the general practitioner and to the neurologist. Of these affections the following will be briefly considered : hyperemia and anemia of the retina and optic nerve, papillitis or optic neuritis, toxic amlihjopias, atrophy of the optic nerve, and a few miscellaneous affections, — visual anesthesia, visual hyperestliesia, visual neurasthenia, day blindness, night hlindness, and visual hallucina- tions. The Normal Eye Ground (Fundus Oculi). — Before discussing affections of the optic nerve, such as hyperemia, anemia, papillitis, toxic amblyopias, and atrophy, the diagnosis of which is largely to be made by the ophthalmoscope, the appearances of the normal fundus or ej^e ground should be described. The ophthalmoscope should be used in most cases of suspected disease of the cerebrospinal axis, and especially when intracranial disease is supposed to be present. By the fundus, or eye ground, as these words are commonly used, is meant the posterior interior portion of the eye as seen by the oph- thalmoscope. In the first place, it is well to remember that the ap- pearance of the fundus differs somewhat according to the complexion of the patient, and Jaeger and others have furnished colored plates showing these appearances in the brunette and other persons. In the normal fundus of the brunette the general tinge of the retina is slightly darker than in persons of lighter complexion. The main fea- tures of the landscape of the fundus are the optic disk or papilla and its immediate surroundings, and the bloodvessels, both arteries and veins. The optic disk is a- yellowish white spot with a pinkish fringe, and is made up of fibres coming from all portions of the retina, which converge and pass through the lamina cribrosa to form the optic nerve. This convergence of the retinal fibres at the optic disk is shown in Fig. 370. The whitish appearance of the disk is due to the fact that the lamina cribrosa and the myelinated fibres of the optic nerve posterior to the lamina can be seen through the comparatively AFFECTIONS OF SIGHT. 775 transparent unmyelinated axis cylinders of the nerve proper. The actual average measurement of the optic disk is usually given as from one and four tenths to about two millimetres. It appears much larger because of the magnification produced by seeing it through the cornea and crystalline lens. It seems almost circular in outline, but in real- ity is slightly oval, the greater length of the ellipse being vertical. The surface of the disk, even in the normal state, is somewhat de- pressed, causing what is called the physiological cup or excavation. Eadiation of the optic nerve fibres upon the retina : A, optic disk ; B, macula lutea. The image is reversed. (Michel.) Baker objects to the use of the name papilla because the nerve head presents a depression rather than an elevation, the apparent eleva- tion being an optical illusion caused by the whitish nerve fibres show- ing through the transparent surroundings. The physiological excava- tion or depression is not situated exactly in the centre of the disk, but a little towards its nasal side. It varies considerably in depth, and also in shape, sometimes being almost round and at other times funnel-shaped. The depression is caused by the convergence of the fibres coming from various portions of the retina to enter the optic nerve (Fig. 370). The disk is surrounded by an inner or scleral ring, which is of a whitish color and represents the edge of the sclerotic coat. It is also surrounded by an outer or choroidal ring, which is a 776 NEEVOUS DISEASES. dark pigmented circle. Tkese rings are sometimes seen obscurely on the nasal side of the disk. They become strikingly changed in out- line in some forms of ocular disease, as in high grades of myopia. The main ai'tery of the optic nerve and retina is the central artery of the retina, which is a branch of the ophthalmic artery. It enters the retina from the optic nerve at the position of the physiological ex- cavation. It commonly divides into a superior and an inferior branch, called the superior and inferior papillary arteries, and each of these two branches soon divides into a temporal and a nasal branch. The branches continue to divide dichotomotisly (Fig. 371). The methods of branching and termination of the retinal arteries are similar to Fig. 371. Normal eye ground of an individual mth light brown hair. (Jaeger.) those of the "S'essels of the cerebral cortex. Their terminals do not anastomose with one another, so that each portion of the retina is supplied by its own particular vessels. The arteries are everywhere accompanied by veins, which are a little larger than the arteries. Under normal conditions the arteries do not pulsate, but the veins may pulsate spontaneously even when the eye ground is normal. As a rule, the blood appears of a yellowish red tint in the arteries, and of a dark red or purplish color in the veins. Numerous variations and anomalies in the size of the arteries and veins of the fundus may be met with, and it is only by a considerable practical experience with the ophthalmoscope that the physician will be able always to see when the vascular ajjpearances are absolutely normal. Those por- AFFECTIONS OF SIGHT. 777 tions of the eye ground which are removed from the optic disk usu- ally present a yellowish or brownish red color. The macula lutea, the seat of most acute vision, is an oval spot, somewhat darker than other portions of the retina, owing to an excessive amount of pigment granules diffused throughout its tissues. The fovea centralis, the cen- tral portion of the macula, is situated almost exactly in the axis of the ocular globe, at an average distance of about 3.915 millimetres outward from the centre of the disk. The normal appearances of the fundus are different at different ages, these differences being especially marked between the period of childhood or youth aud that of old age. For a fuller description of the appearances of the normal fundus, works on ophthalmology should be consulted. Hyperemia of the Retina and Optic Nerve. — Etiological Varie- ties. Hyperemia of the optic nerve and retina is comparatively rare as a clearly recognizable and isolated affection, although its presence is frequently diagnosticated without due consideration. A true hy- peremia is present in the early stages of papillitis or optic neuritis, but the progress of such a case soon shows its true nature, the optic disk in a short time visibly swelling, while changes take place which make its structure less transparent and obscure its borders. The hyperemia which results from intraocular disease such as iritis, and that which is due to such causes as exposure to heat or glare, fall exclusively under the care of the ophthalmologist, and will not be here discussed. The forms of hyperemia of the retina and optic nerve which most concern us are associated with various diseases of the cerebrospinal axis, and especially with irritative diseases, like intracranial tumor, abscess, and meningitis. These affections are, as a rule, associated with a true papillitis, but in some instances give rise only to a retinal and neural hyperemia. Occasionally in oases of brain tumor decided venous engorgement without swelling of the disk or blurring of its edges is present. In epilepsy congestion of the retina and optic disk has been noted, and a low grade of con- gestion is sometimes chronic. An acute hyperemia may be the immediate result of a convulsive attack, or it may be produced by disease of the heart, or by any other cause which leads to engorge- ment of the vessels of the head, as, for instance, obstruction of the vessels of the neck. Violent coughing or sneezing may cause tran- sient but comparatively severe forms of hyperemia. The condition of the vessels of the optic nerve and retina in various forms of in- sanity has been carefully studied by different observers. Wigles- worth and Bickerton hold that, in the first place, it is necessary to draw a clear distinction between general paralysis of the insane and other forms of insanity, in arriving at conclusions as to the ophthal- moscopic appearances in the insane. They conclude that in insanity proper, including general paralysis of the insane, no connection can be traced between the condition of the fundus and the patient's 778 NEEVOUS DISEASES. mental state. In a minority of cases of general paralysis of the insane, clear and precise ophthalmoscopic lesions were found, these cases falling into two classes : cases which tend to develop isolated neuritis, and cases tending to pass into optic atrophy. In the former of these chisses the affection declares itself as a hyperemia of the disk. The hyperemia and neuritis tend, if the patient lives long enough, to be replaced by atrophy. Allbutt observed hyperemia in mania, de- mentia, and general paralysis of the insane. Various observers have remarked a similar condition in the early stages of general paralysis of the insane, and it has even been recorded as present in melan- cholia. Lautenbach found retinal hyperemia in forty per cent, of the acute cases examined by him, his entire investigation including over seven hundred cases of insanity of different forms. Some infectious diseases and certain toxic agents, such as alcohol, tobacco, lead, and arsenic, give rise sometimes both to hyperemia and to inilammation of the optic nerve, a subject which will be more fully considered under toxic amblyopias. A true hyperemia which may pass into a low grade of inflammation is an accompaniment of some disorders of refraction which cause almost constant eyestrain. As all efforts at convergence and accommodation are followed by increased flow of blood to the eye, abnormal and prolonged efforts must tend to pro- duce congestion and even inflammatory states. Symptomatology, Diagnosis, Prognosis, and Treatment. Only a thor- oughly competent ophthalmologist can determine the presence of a true congestion of the fundus unassociated with inflammation. Even the existence of a degree of redness in excess of that which is nor- mally found in the nerve is not a proof of the presence of true hyper- emia ; but when, instead of the yellowish white appearance of the nerve, with its pinkish border, the disk assumes a dull red or brick- dust color, and when the edge of the disk is so obscured that it can only with difficulty be distinguished from the general eye ground, the condition may be regarded as one of true hyperemia. (Gowers.) In some cases the hyperemia is monocular, when a comparison of the two eye grounds will make the diagnosis much more easy. If the condition is one of hyperemia and not a true inflammation, the papilla will not project into the eye, and hemorrhages will not be present. A skilful observer can make out the borders of the disk, although these may be somewhat obscured. Unusual tortuosity of the veins is present in hyperemia, as in neuritis ; but too much stress must not be laid upon mere tortuosity of the veins. The diagnosis of hyperemia of the retina and ojitic nerve is therefore to be reached by making a critical distinction lietween the appearances presented by the normal fundus, those of inflammation in different stages, and those which have been just described as characteristic of genuine hyperemia. The ]n'ognosis of hyperemia will depend largely upon the disease with which it is associated ; when present as an inde- AFFECTIONS OF SIGHT. 779 pendent affection the prognosis is usually comparatively good, the hyperemia disappearing with the removal of the causes which have led to its presence or continuance. The treatment will usually be that for abscess, brain tumor, meningitis, encephalitis, general paral- ysis of the insane, and the other affections with which it is ordinarily associated. In simple hyperemia of unknown origin the eye should be kept at rest as much as possible, and remedies like local blood- letting, bromides, and ergot may be used. Tinted glasses are some- times required to protect the eyes from unusual glare. Anemia of the Retina and Optic Disk.— Anemia of the retina and optic disk accompanies general anemia, and also at times certain forms of insanity and certain focal diseases of the brain, such as em- bolism. Simple anemia was one of the four abnormal conditions of the optic disk found by Wiglesworth and Bickerton in their exami- nations of the eye grounds of the insane. Anemia of the retina has been noted in melancholia and chronic mania. It is necessarj^ to distinguish simple anemia of the optic disk from the pallor of the early stages of atrophy, but when the atrophy has made some ad- vance this difficulty disappears. Sudden retinal anemia is some- times caused by occlusion of the centi-al artery of the retina, or the same result may be brought about by compression of this vessel. Anemia from spasm of the retinal vessels is also said to occur in cases of acute poisoning from quinine, and in these cases more or less contraction of the visual fields may remain. The ophthalmoscope shows pallor of the disk and attenuation of the vessels of the fundus. Optic Neuritis or Papillitis. — Symptomatology. Optic neuritis or papillitis is a subject of great importance both to the neurologist and to the ophthalmologist, but has already been largely considered in this work when discussing meningitis, tumor, and abscess. It has been especially discussed under encephalic tumors. (See pages 510, 511, also 521. 522.) The presence of papillitis or optic neuritis is to be determined by the use of the ophthalmoscope and by a com- parison of the known appearances of the nerve when normal and when hyperemic, anemic, or atrophic. The appearances presented by the nerve in a well marked case of papillitis are shown on page 511, Pig. 294. As the papillitis develops, the nerve head becomes red and swollen and soon loses its normal contour. Its edges become indistinct and are gradually entirely obscured. The tissues are infiltrated and present hemorrhagic spots ; the veins are increased in size, while the arteries become shrunken. The nerve head is sometimes so enormously swollen as visibly to project into the eye. It may reach the size of three millimetres, although it is commonly much less than this. Vision is affected very irregularly. Some- times it is rapidly lost, more frequently it slowly diminishes. Occa- sionally it is preserved in a remarkable manner even with extreme swelling of the disk, and in rare instances it may for a time be 780 NERVOUS DISEASES. more acute than normal. The field for form is usually concentrically contracted, color changes commonly taking place early. As a rule, the perception of red and green is lost first. In what is usually termed choked disk the inflammation is more intense, the papilla is more swollen, and hemorrhages are more frequent. Edema both of the disk itself and of the surrounding retina is present, while the Fig. .S72. Longitudinal section through the head of the optic nerve, showing choked disk : the optic disk is swollen and the vessels are engorged : a, the retina ; 6, the choroid ; c, the sclera ; d, the dural sheath ; p, the pial sheath ; ar, the arachnoid space. (Wilder. ) vessels are greatly engorged. In Pig. 372 is shown a longitudinal section through the head of an optic nerve presenting the condition known as choked disk. Theories as to the Nature of Optic Neuritis. Eeference has been made to the Leber-Deutschmann theory of the pathology or method of causation of optic neuritis, which the writer regards as most prob- ably correct. Several other theories concerning the mechanism of optic neuritis, however, have been advanced, and for a full discus- sion of these, works on ophthalmology should be consulted. Ee- cently Parinaud has revived the old theory that papillitis is due to an edema of the trunk of the optic nerve, similar to the edema which occurs in brain tissue, the later inflammation of the retina, so com- mon in optic neuritis, being caused by the presence in the nerve of extraneous material. He believes that excessi^'e intracranial tension is incapable of producing edema of the papilla, and that edema of the nerve does not require any considerable excess of this tension nor mechanical damming up of fluids in the nerve. He suggests calling the neuritis of intracranial origin edematous neuritis. Etiology. Papillitis is most freciuently associated with such focal intracranial diseases as tumor, meningitis, or abscess. Its special features, and the frequency of its occurrence in these affections, have already been sufiiciently considered. It is occasionally present in myelitis. It occurs also in poisoning from lead, arsenic, alcohol, and other drugs, and in the course of some of the infectious diseases, as scarlet fever, measles, diphtheria, typhoid fever, and influenza. It AFFECTIONS OF SIGHT. 781 is sometimes observed in the course of disorders which greatly im- pair nutrition, as in pernicious anemia, leucocythemia, diabetes, and Bright's disease. In the last affection the ophthalmoscopic appear- ances are often of a special character (see page 522). It is somewhat frequently present in syphilitic disease, even when intracranial gum- mata cannot be diagnosticated. Syphilis may undoubtedly attack the optic nerve directly, leading either to neuritis or to noninflam- matory degenerations. Acute monocular optic neuritis has been ob- served as the result of gonorrheal infection. (Highet and Eeiss.) Acute rheumatic optic neuritis is occasionally seen, and is important from prognostic and therapeutic points of view. It is often monocu- lar, follows exposure, and is characterized by sudden onset. In these cases papillitis is sometimes typical, and, unless the neuritis be eifi- ciently attacked, white atrophy may result. (Zimmerman.) In rare instances optic neuritis seems to be an inherited or family form of disease ; and in reported cases of this kind it has usually attacked male members of the family at about the age of twenty years. Neu- ritis may occur as a purely local disease from inflammations, tumors, or other lesions in the orbit. Most of the causes above mentioned may give rise to an acute, subacute, or chronic optic neuritis. Acute retrobulbar neuritis most frequently results from lesions in the orbit, or from infectious and constitutional or diathetic processes. Toxic agents, like alcohol, occasionally give rise to severe forms of acute retrobulbar neuritis, but more frequently they produce the chronic forms of this affection, — the toxic amblyopias. W. H. Wilder re- ports a case in which he believes excessive weeping produced dis- turbances of circulation and excited the neuritis. When an optic neuritis arises apparently without cause it is probable that some un- known infection or toxemia is the source of the disease. Overwork, physical or mental, is an assigned cause. Diagnosis, Prognosis, and Treatment. The diagnosis is chiefly to be made with the aid of the ophthalmoscope, although photophobia and disturbances of vision may cause the neuritis to be suspected. Low grades of inflammation which scarcely deserve the name of neuritis are observed in a comparatively large number of cases of abnormal refraction. According to N^orris, if the swelling of the papilla is two diopters or over, intracranial or intraorbital disease is the probable cause. This is an important diagnostic point in diifer- entiating papillitis due to intracranial or constitutional causes from the inflammation which accompanies disorders of refraction. In the latter a swelling of from one to one and a half diopters can sometimes be determined. The prognosis in the vast majority of cases of optic neuritis associated with intracranial disease is unfavorable, although the inflammation may improve after trephinings and even when growths are not removed. In those cases in which the papillitis is due to infectious or toxic agents the prognosis is relatively more favor- 782 NERVOUS DISEASES. able, depending somewhat upon the activity of the treatment, but even in these cases the inflammation frequently goes on to atrophy. In a considerable percentage of the cases of acute retrobulbar neuritis a partial or complete cure is effected. In the neuritis associated with disorders of refraction the prognosis is relatively good. The treat- ment of optic neuritis is chiefly that of the disease or condition with which the affection is associated, as tumor, meningitis, abscess, rheu- matism, diabetes, syphilis, and the other affections which have been mentioned in the discussion of etiology. General rest, absolute rest of the eyes, and protection from glare are of great importance. The local abstraction of blood, the use of derivatives to the head and the temples, and other local measures, may be required. Eepeated mer- curialization and the iodides in syphilitic and sometimes in non- syphilitic cases ; the salicylates when a rheumatic cause is suspected ; and iron, arsenic, peptomangan, and other blood tonics in anemic and diabetic cases, are among the remedies naturally suggested. Toxic Amblyopias. — Definition and Varieties. Toxic amblyopias are affections in which vision is obscured or lost as the result of the action of toxic agents taken into the system.* The lesions produced by these agents are sometimes distinctly limited to portions of the optic nerves, but in other cases they may involve the retina and other more central portions of the visual apparatus. Toxic agents may affect any portion of the optic-ocular mechanism ; thus, they may produce either mydriasis or myosis, through their influence upon the pupillary mechanism. Our only concern in the present connection is with those poisons which directly affect the optic nerve and retina, and especially with those which produce certain peculiar disturb- ances of central vision. The toxic amblyopias may be either acute or chronic ; but the latter have received the most attention. Toxic Agents which most frequently cause Amblyopia. The two drugs which hold the first place in the production of toxic ambly- opias are alcohol and tobacco. Amblyopias are also of comparatively frequent occurrence as the result of the use of quinine and lead. Cinchonidia salicylate, sodium salicylate, and salicylic preparations in general, when given in large doses or when taken by persons with idiosyncrasies, may produce toxic effects upon the visual appa- ratus similar to those caused by quinine. ^Yhen the optic nerve is toxically affected by lead, the entire bulk of the nerve is likely to be involved. Alcohol has been known as a cause of amblyopia since the time of Boerhaave (1751), but special attention has been directed * The most important reci'iit work on Toric Amblyopias is by Professor (ieorge E. de .Sehweinitz, ]\I.D., of Philadelphia. This work, which has been used in the preparation of the present section, discusses the subject in all its aspects, reviewing the literature and giving the ex])erience of the author. The fields shown in Figs. 373, 374, and 375 were kindly furnished by Professor de Sehweinitz. AFFECTIONS OF SIGHT. 783 to the subject only in recent years. Alcohol and tobacco sometimes act conjointly in causing amblyopia, and some have even d»- y»«- "V^~- \ ^- \ % ■^ / Xf \ X^^6 Longitudinal vertical section through the human brain, shomng (diagrammatically) the position of the nerve nuclei of the ocular muscles, according to Hensen and Volckers ; A, post- geminum ; B, pregeminum ; C, cerebellum ; D, conarium ; E, gray commissure in the middle of the third ventricle, which, with the iter and fourth ventricle, is represented in black ; F, pons ; G, postoblongata ; 1 to 6, different centres of the third nerve nucleus, viz. , 1, for accommodation ; 2, for the sphincter of the pupil ; 3, for the rectus internus ; 4, for the rectus superior ; 5, for the levator palpebr^e superioris ; 6, for the rectus inferior ; 7, nucleus of the fourth nerve (trochlearis) for the superior oblique ; S, nucleus of the sixth nerve for the rectus extemus. (Bramwell.) the centres physiologically associated close together. Westphal (1888) sharply demarcated a subnucleus of the oculomotor nerve, cephalad of the main nucleus, this according to him and Edinger (1885) being connected with the innervation of the interior muscles of the eye (with the ciliary or the iris muscle or with both). Spitzka (1888) found in reptiles but little differentiation of the cell nests of the third pair ; in birds he found that the nucleus of the third pair is very large ; that in the dog, cat, sea-lion, and lion, the nuclei were disposed in a peculiar manner much as in man ; that in crepuscular bats the cell nests were very small ; while in the mole they were al- most absent, and only in anthropoid apes was the anatomy of the cell ANATOMY AND PHYSIOLOGY OF THE OCULAR NERVES. 801 nests and their intranidal tracts approximately as complex as in man. Knies (1894) suggests that the Edinger-Westphal centre is for accom- modation only, and the Darkschewitsch centre for the regulation of pupillary movements. Mendel (1887) located the centre for the oculofacial movements at the posterior extremity of the oculomotor nucleus, although this localization is not usually accepted. The centre for the levator palpebrse has been placed by me just posterior to the centre for convergence, as shown in the scheme Fig. 383. Darkschewitsch (1889) located a cell nest in the upper part of the aqueduct above the third nucleus and extending into the walls of the third ventricle, the cells having no connection with the main oculomotor nucleus, but being connected with the postcommissure and the posterior longitudinal fasciculus. Siemerling (1891) in a study of a case of unilateral congenital ptosis observed degenerative changes in the chief oculomotor nucleus, these being bilateral and in the proximal portion. The ventral and dorsal nuclei were equally affected. In the paper in which he contributed this observation he argued in favor of an anterior position for the nidus of the levator palpebrse superioris. Obersteiner speaks of a lateral nucleus which sometimes may be divided into two parts, a medioventral and a dorsolateral nucleus, some of the cells of which are found in the posterior longitudinal fasciculus, or even ventrad to this. Petiia's Central Nucleus. Commonly the muscles of accommoda- tion and convergence (ciliary and internal straight muscles) act to- gether, as in accommodation for near vision, but this conjoint action is not invariable. A separate convergence centre therefore doubtless exists, and this, it will be readily understood, should be situated in the median line. Such a centre has been described by Perlia (1889), and is sometimes designated as Perlia^ s central nucleus. It is composed of ganglion cells from both sides, meeting in the mesal line beneath the iter. This convergence centre is distinct from, although closely related both anatomically and physiologically to, the centres for the internal straight muscles, which are situated on each side of the mesal line. It is a centre for the associated internal movement of both eyes. Bruce' s Investigations. Bruce (1893) found a series of separate nuclei the whole or a portion of which can be related to the separate oculomotor centres. He found a comparatively long anterior or ventral group of cells close to and a little removed from the median line. In this long anterior or ventral group of cells are probably included several of the centres as given by Perlia and Knies, those, for instance, for the inferior oblique, rectus internus, and rectus infe- rior. He describes also a posteroexternal group of cells, probably corresponding to the centres for the inferior oblique (dorsal nucleus of Edinger and Siemerling), and in his description is included an additional posteromesal or pale nucleus, which probably corresponds 51 802 NERVOUS DISEASES. to the Edinger-Westphal nucleus. Bruce' s superior nucleus corre- sponds to the anterolateral or small- celled nucleus of Darkschewitsch, the centre for the sphincter pupillse. A small external nucleus de- scribed by Bruce has not been, so far as I know, correlated with any special nerve distribution. Bi'.searchcfi and Views of Koelliker, Starr, Bernheimer, and others. According to Koelliker, the third nerve arises in a nucleus about five millimetres long ; according to Perlia, it is about ten millimetres, but he includes Darkschewitsch's nucleus, which Koelliker does not. Koelliker thinks that a sharp separation of the nuclei of the third nerve in man is scarcely possible. He found that the third nerve has essentially only one nucleus in embryos, at the cerebral end of which a round nucleus branches off. He holds to only one chief nucleus with two subdivisions, the dorsolateral with large cells and the dorso- mesal with smaller cells, although he admits a central nucleus, with large cells in the proximal portion of the third nucleus, and many neste of cells within the dorsal longitudinal fasciculus. A connection of the third nucleus with the pyramidal tracts has not been positively shown, although it probably exists. The connection of the dorsal longitudinal fasciculus with the third, fourth, and sixth nerves is quite certain. Koelliker was the first who showed that the fibres of the posterior longitudinal fasciculus give off numerous collaterals, and this finding has been confirmed. These collaterals end in the nucleus of the twelfth and in the nuclei of the three eye nerves. It is imiDOSsible in the scope of a chapter like the present to refer even briefly to all the numerous workers who have contributed to our knowledge of nuclear anatomy and physiology and to our means of applying this knowledge. Starr was one of the first to construct a table locating the relative positions of the groups of cells governing the ocular muscles, his conclusions being based upon a careful, crit- ical analysis of a large number of cases compiled from the literature of the siilyect. Edsall and Diller have contributed a paper based upon the report of an interesting case exhibiting bilateral palsy of the sui>erior rectus muscle, the iris, and the ciliary muscle, with loss of power of convergence, and have constructed a tabular arrangement of the groups of cells in the anterior portion of the general nucleus for the different constituents of the third nerve, as follows : Ciliary muscle. Convergence. Sphincter iridis. Kectns snjierior. Levator palpebrte, rectus internus. Eectus inferior, obliquus inferior. Obliquus superior, fourth nerve. One of the most recent and authoritative in\estigations is that of Bernheimer (1897), who extirpated certain ocular muscles and then ANATOMY AND PHYSIOLOGY OF THE OCULAR NERVES. 803 examined the nuclei of the third nerve by the method of ISTissl. He operated on rabbits and monkeys. In the latter the third nerve centres seem to be arranged in the same order as in man. He de- stroyed all the external ocular muscles except the levator palpebne. According to him, the centres for the external ocular muscles inner- vated by the third nerve are in the distal and middle thirds of the lateral chief nucleus and in the "lateral cells" (groups of cells be- tween and on the outer side of the dorsal longitudinal bundles). In the more distal portion of the centres the nuclei are chiefly on the side opposite to the nerve ; in the middle third they are nearly equally distributed on both sides of the raphe. According to him, the most anterior part of the lateral chief nucleus, the double small-celled Edinger-Westphal nucleus, and the large-celled median nucleus are respectively the centres for the levator palpebrae, the iris, and the ciliary muscle. The Edinger-Westphal nucleus of the right side supplies the right eye ; the large- celled median nu- cleus supplies both eyes. Prom a com- parison of the different facts and views thus outlined, and in accordance with our own present experience, we have arrived at conclusions with regard to the arrangement of the nuclei of the nerves of ocular movements and of their central and peripheral tracts as exhib- ited in the scheme Pig. 383, page 808. General Course of the Third or Common Oculomotor Nerve. — Al- though the third pair of cranial nerves is commonly designated as the oculo- motor (motor oculi), this name is not a good one, as the fourth and sixth nerves are also concerned with ocular move- ments, and all three sets of nerves can be more properly spoken of as "oculo- motor." It must, however, always be remembered that in common usage the term oculomotor or motor oculi is ap- plied only to the third nerve. Emerging from the inner side of the crus, close to the upper border of the pons, the numerous root fibres of this nerve combine into one bundle. The nerve trunk thus formed passes between the supercerebellar and postcerebral arteries, forward and A partly diagrammatic view of the floor of the aqueduct, looking upward (dorsally) : nuclei of the third and fourth nerves and the decussating fibres of the latter all shown ; the third nerve nuclei are subdivided into an anterior nucleus, the Edinger-Westphal nucleus (o and b), and a posterior nucleus ; the posterior nucleus has a dorsal, a ventral, and a mesal portion ; the decussation of the fibres from the dorsal portion of the posterior nucleus of the third nerve is shown. (Edinger.) 804 NERVOUS DISEASES. slightly outward, soon to pierce the dura between the anterior and posterior clinoid processes. It then runs forward in the outer wall of the cavernous sinus to the sphenoidal fissure, where it is above and internal to the fourth nerve. It here subdivides and sends branches to the various extraocular and intraocular muscles, which it supplies. While in the outer wall of the cavernous sinus it re- ceives slender branches from the cavernous plexus, and also a minute branch from the ophthalmic division of the fifth. It has superior and inferior subdivisions, branches passing from the former to the rectus superior and the levator palpebrse, and from the latter to the rectus internus, rectus inferior, and obliquus inferior. The par- ticular branch which goes to the last sends an offshoot to the ciliary ganglion. This branch, as already stated, contains fibres which eventually supply the ciliary muscle and the sphincter of the pupil. Structures adjoining and closely connected with the Third Nerve. — The third nerve in its course after its emergence from the crus, ''superficial origin," on its way to the orbit, lies adjacent to a number of important structures. These, and the symptoms resulting from lesions affecting them, have been referred to when considering cavernous sinus thrombosis (page 307). At the position of the cav- ernous sinus the third and fourth nerves and the ophthalmic branch of the fifth lie close to each other, in the order given from above downward and from within outward. The sixth is separate, being close to the carotid artery in the cavernous sinus, and lying internal to the ophthalmic nerve. The somewhat separated position of this nerve accounts for its escape in some cases of basal lesion in which the third, fourth, and ophthalmic di'^'ision of the fifth are implicated. Near the sphenoidal fissure the sixth nerve is close to the others. In the fissure the fourth and the frontal and lachrymal branches of the fifth lie on the same level, the fourth being the nearest to the inner side. They enter the orbit in the following order from above downward : the uj)per division of the third, the nasal branch of the fifth, the lower division of the third, and, lowest of all, the sixth. (Quain's Anatomy.) The Nucleus and the Root Fibres of the Fourth Nerve. — The position of the nucleus of the fourth nerve is shown in several illustrations (Figs. 6, 88, 381, and 388). It appears practically as a caudal continuation of the series of nuclei of the third nerve, fi"om which it is not clearly separated. It is dorsal to the dorsal lon- gitudinal bundle and occupies a concavity in this fasciculus, and is revealed by a transection through the cephalic extremity of the postgeminum. Its root fibres have a considerable course within the brain stem, emerging just caudad of the postgeminum. As Obersteiner observes, nothing is more certain in brain anatomy than the crossing in the vnlvula of the vast majority of root fibres which constitute the fourth or trochlear nerve. Some of the root fibres ANATOMY AND PHYSIOLOGY OP THE OCrLAE NERVES. 805 of this nerve, however, probably emerge on the side of origin, in this respect following the same rule as the other motor cranial nerves. It has connections with the cerebrum, the pregeminum, and the dorsal longitudinal bundle, similar to those of the third and sixth nerves. According to some authorities, it has crossed relations with the nucleus of the abducens. Axis cylinders pass from the nerve cells of the cortex to the nucleus of origin of the fourth nerve constituting the first neuron of this nerve series. A group of small cells caudad to the fourth nucleus was supposed by Westphal to belong to this nucleus. This is probably incorrect. Fro. 382. B H A B Microscopical section througli the decussation of tlie fourtii nerve : A, decussation of tlie fourtli nerve ; B, B, doisal longitudinal bundles ; C, 0, prepeduncles ; D, D, lateral (lower) lemnisei ; E, E, mesal (upper) lemnisei ; F, decussation of prepeduncles ; G, deep transverse fibres of the pons ; H, iter. Between the iter and the most lateral portion of the dorsal longitudinal bundles the large cells of the locus cemleus are seen. Peripheral Course of the Fourth Nerve. — -The fourth (pathetic or trochlear) nerve trunk emerges from the valve of Vieussens near the frenulum (cephalic border of the valvula), just below the post- geminum, and, crossing the prepeduncle, winds around the crus between the supercerebellar and postcerebral arteries, reaching the ventral aspect of the pons at its cephalic margin. It pierces the dura near the posterior clinoid process, and passes cephalad in the wall of the cavernous sinus, lying between the third nerve, which is above and internal to it, and the ophthalmic branch of the fifth nerve, below and external to it. When it reaches the sphenoidal fissure it bends upward, crosses the third nerve, and, passing into 806 NERVOUS DISEASKS. the orbit, above the external straight muscle, and also over the levator palpebrae and superior straight, ends in the superior oblique muscle. This nerve is the smallest in diameter of the cranial nerves, and it is distributed to a single muscle. In the cavernous sinus it is connected by small filaments both with the sympathetic and with the ophthalmic branch of the fifth. It has been estimated to contain about twelve hundred fibres. Gaskell believes that he discovered near its superficial origin vestiges of a degenerated ganglion. The Nucleus and the Root Fibres of the Abducens Nerve. — The position of the abducens nucleus, which is almost globular in general shape, is shown in several illustrations (Figs. 6, 84, 383, and 396). According to Obersteiner, the separate bundles of the abducens nerve, traced dorsad in gently curving arches, apply them- selves to the mesal side of the nucleus, curve around it dorsally, extending in some cases as far as its lateral aspect, and sink succes- sively into its substance, to their cells of origin. A very small and easily overlooked portion of the abducens turns mesad beneath the nucleus, extends to the raphe, traverses it apparently as far as its dorsal edge, and then, passing beneath the ascending crus of the facial nerve, enters the abducens nucleus of the opposite side. Koelliker has not been able to see the obscure fibr&s described by Obersteiner as crossing the raphe to the opposite sixth nucleus. Duval has de- scribed in the monkey fibres which arise in the sixth nucleus and enter the dorsal longitudinal fasciculus and then pass to the fourth and third nuclei of the opposite side. According to this, the right sixth nucleus would innervate the right rectus ext«rnus and the left superior oblique and certain muscles supplied by the third, as, for example, the internal rectus (Duval and Laborde). The central neuron of the abducens passes from the cortex to the abducens nucleus of the opposite side, and the peripheral neuron beginning in this nucleus takes its course, as described when tracing the root fibres and peripheral course of the nerve, to the external rectus muscle. It is customary to consider the fibres connecting the sixth nucleus with the superior olive as part of the central tract of the eighth nerve, which is united by the trapezoid body to the superior olive, and thus to exxjlain reflex movements of the eyelialls due to sound impulses, but the accuracy of this view must be determined by further inves- tigations. It seems to Koelliker just as probable that this connec- tion of the superior olive with the sixth nucleus is a sensory tract of the second order, which by means of the lateral fillet connects the sixth nucleus with the proximal quadrigeminal body and in this way with the optic apparatus. Gudden and Gowers have con- clusi\'ely shown that the seventh nerAe receives no fibres from the sixth nucleus, though at one time the opposite view was held by many. Tlie cerebral connection with the sixth nucleus is probably througli the pyramidal tract. ANATOMY AND PHYSIOLOGY OP THE OCULAR NERVES. 807 Peripheral Course of the Abducens Nerve. — The root fibres which eventually constitute the trunk of the abducens nerve emerge in the furrow between the pons and the postoblongata, immediately external to the pyramids ("superficial origin"). Occasionally one or two of the fibres are distinct from the others at their place of emergence. The rounded nerve trunk passes forward along the ven- tral surface of the pons, and pierces the dura to the inside of and below the fifth nerve. It crosses the apex of the petrous bone, enters the wall of the cavernous sinus, and, proceeding forward internally along the outer wall of the carotid artery, passes through the sphe- noidal fissure into the orbit, to be distributed to the rectus exter- nus muscle. It is below the other nerves as it enters the orbit. It receives small filaments from the cavernous plexus and from the ophthalmic division of the fifth nerve. It has been estimated to have as many as three thousand fibres in its trunk. Scheme of the Nuclei for Ocular Movements.— The scheme shown in the diagram Pig. 383 seems to us most in accord with the most recent facts relating to the oculomotor mechanism ; but it must be remembered that the relative positions of some of the centres illustrated in this diagram have not been conclusively fixed. This remark is especially applicable to the location assigned to the centres of the levator palpebrae, which according to some authorities are the most anterior of the centres for the ocular nerves. According to this diagram, the most cephalic or anterior centres are those for the ciliary muscle and for convergence, the centres for the levator palpebrte being placed close to the mesal line caudad of the convergence centre. These centres are situated in the central cinerea, close to the caudal extremity of the third ventricle, and therefore close also to the ante- rior extremity of the iter. The centres for the other ocular muscles are given in what we believe to be the order which corresponds with the facts as generally accepted, as follows : rectus superior, rectus internus, obliquus inferior, rectus inferior, obliquus superior, and rectus internus. The decussations of the root fibres of certain of these centres, their connections with the pregeminum and the optic tract, and their relations to the cortex are also shown in the diagram. The Ciliospinal Centre. — Numerous observations, physiological and clinicopathological, have corroborated the existence and position of a ciliospinal centre extending from the sixth or seventh segment of the cervical portion of the spinal cord downward to the region from the first to the third thoracic segment. Unilateral extirpation of the cord in this region causes myosis and irritation mydriasis or dilatation of the pupil on the same side. Fibres pass from this area through the ventral roots of the two lowermost cervical and two uppermost thoracic nerves into the cervical gangliated (sympathetic) system of nerves. In goats and cats this centre, even after separa- tion from the oblongata, can be excited directly by dyspneic blood. 808 NERVOUS DISEASES. and also reflexly by the stimulation of sensory nerves, especially when the reflex excitability of the cord is increased by the action of strychnine or atropine. Certain radiating smooth fibres in the eye- FiG. 383. Sphincter iridis. Musculus ciliaris. Convergence centre. Eectus superior. Rectus internns. Levator palpebrse superioris. Obliquus inferior. Rectus inferior, Obliquus superior. Rectus externuB. Scheme of the nuclei of the nerves of ocular movement and of their central and peripheral tracts : M, right eye ; L. left eye ; C, chiasm ; On, optic nerve ; Ot, optic tract ; Q, pregeminum (anterior quadrigeminal body); P, cortical centre for the movement of elevation of the upper eyelid; M, cortical centre for ocular movements; Tn, course of all the ocular nerves in the cavernous sinus. The names of the different nuclei are printed on the diagram, and the nerve tracts going from these nuclei can be readily traced to where they converge in their course in the cavernous sinus and where they diver^'-c to pass to the various muscles of the eye. The dotted lines represent associating and commissural tracts. lidSj the dilator fibres of the iris, and the so-called Mueller^s muscle in the orbit, it is believed, are supplied from the ciliospinal centre. The fact that elevation of the upper eyelid, dilatation of the pupil, and protrusion forward of the eyeball are ocular phenomena which occur together^ affords a clinical illustration that all these movements DISTURBANCES OP OCULAE MOVEMENTS. 809 are probably controlled from a single central region. Since the investigations of Madame Dejeriae-Klumpke we have a form of paralysis known by her name, due to a lesion of the lower roots of the brachial plexus, i.e., of the eighth cervical and first thoracic root fibres. In this form of paralysis the small muscles of the hand, and some of the muscles of the forearm, especially the flexors, are in- volved. Sensation may be altered in the distribution of the ulnar and median ner^-es and on the inner side of the forearm. If these roots of the brachial plexus are affected in the portions which con- tain the fibres of the rami communicantes, oculopupillary symptoms are usually present. Madame Dejerine-Klumpke demonstrated that the oculo-pupillary fibres in the dog leave the spinal cord by means of the first thoracic roots, and since the publication of her experi- ments numerous cases have shown that these fibres in man have the same course, but it is not positively known whether the eighth cervical and second thoracic roots also contain some of these fibres. Physiological Action of the Ocular Muscles. — The lateral movements of the eye are regulated by the rectus internus and rectus externus ; the upward movements, by the rectus superior and ob- liquus inferior ; the downward movements, by the rectus inferior and obliquus sujperior ; the movements upward and inward, by the superior and internal straight acting with the inferior oblique ; the downward and inward, by the inferior and internal straight acting with the superior oblique ; upward and outward movements, by the superior and external straight acting with the inferior oblique ; and downward and outward movements, by the inferior and external straight acting with the superior oblique. The clinician is chiefly concerned with the lateral and vertical movements, although move- ments in special directions may have a particular interest in rare cases. The excursion of the eyes in the vertical and horizontal directions amounts to about ninety degrees. (De Schweinitz.) DISTURBANCES OP OCULAR MOVEMENTS. Terminology and Symptomatology. —MisceJlaneovs Terms. Cer- tain terms relating to the oculomotor apparatus have already been defined, as nystagmus and exophthalmus (page 159), iridoplegia, hippus, and other pupillary phenomena (pages 162 and 163), and conjugate deviation (page 166). Some of the terms are so well known as hardly to need explanation. Monocular vision is vision with one eye, and binocular vision is the vision which results from using both eyes together without the production of diplopia. Stere- oscopic vision is a form of binocular vision. Diplopia, or double vision, is usually binocular, and then depends upon the unequal or unbalanced action of both eyes ; but it may be monocular, resulting from the action of only one eye, in which case it is commonly de- pendent upon some imperfection of the iris or of the ocular media. 810 NERVOUS DISEASES. False projection is a symptom produced when the position of an object cannot be accurately estimated by vision. ISTormally objects are so projected with regard to vision that the observer can accu- rately estimate the position in the visual field, but some forms of paralysis and of paresis of the ocular muscles cause false projection. Mydriasis, the term applied to dilatation of the pupil, is divided into a paralytic and an irritation variety. The former is dependent upon destruction of the centre for pupillary contraction, or of the fibres which go to or from this centre, or is due to lack of light stimu- lation from the retina. The latter results from irritative lesions. Contraction of the pupil known as myosis may also be of the paralytic or of the irritation variety, the former being due to a destructive lesion causing paralysis of the centres or fibres which control the dilatation of the pupil, and the latter to irritation of the same centres or fibres. Special forms of mydriasis or myosis according to the locality of the lesion are sometimes described : thus we may have a spinal myosis or a cerebral mydriasis. Paralyses and Insufficiencies of Ocular Muscles. Prom some affec- tions of the oculomotor apparatus result various forms of strabismus, that abnormality of the eyes and vision in which the visual axes do not meet at the point at which they would normally come together if the actions of the external ocular muscles were properly coordinated. In recent years various convenient terms expressive of the position of the visual axes in partial or complete strabismus have been intro- duced into ophthalmological and neurological nomenclatiu'e. The general term heterotropia is used as descriptive of deviation of any kind ; hypertropia, when one visual line is placed above another ; esotropia, for deviation inward ; and exotropia, for deviation outward. In like manner heterophoria is used to indicate the tendency of visual lines to take some other direction than that of parallelism, and according as the direction is upward, inward, or outward the effect is described as hyperphoria, esophoria, or exophoria. Syper esophoria expresses the tendency of the visual lines to be directed both upward and inward, while hyper exophoria indicates a tendency both upward and outward. These affections, which result from in- sufficient or incoordinate action of the ocular muscles, are in some instances dependent upon conditions which properly claim the atten- tion of the neurologist. They are often classed under the general head of miiscii.lar asthenopia. Forms of Ocular Deviation. As the result of paralysis of certain of the ocular muscles, various forms of deviation may occur. The tevm primary deviation is applied to those cases in which the direction taken is away from the muscle affected. The limitation is in the direction of what would be the action of the affected muscle. In seeiiiidary deviation the affected eye fixes while the normal eye de- viates. The amount of stimulus required for the affected eye is such DISTURBANCES OF OCULAR MOVEMENTS. 811 as abnormally to stimulate the normal eye and thus bring about this deviation. Ophthalmoplegias. The term ophthalmoplegia is frequently and somewhat loosely used in describing various forms of ocular paresis or paralyses. It means simply paralysis of the muscles concerned in ocular movements, and is sometimes employed in this broad sense, but it has been more generally applied to particular forms of pro- gressive and more or less symmetrical paralysis of the muscles of the eyeballs. It is true, as has been said by Jeffries, that to make a diagnosis of "ophthalmoplegia" is about as significant as to make that of stomachache, but nevertheless it will be found convenient to define and consider separately some forms of ophthalmoplegia. External ophthalmoplegia, rare as an isolated affection, is paralysis of the extraocular muscles. The term internal ophthalmoplegia is applied to paralysis both of the ciliary muscle (cycloplegia) and of the sphincter of the iris {irkloplegia). In cycloplegia the pupil does not respond to efforts at accommodation. Iridoplegia shows itself by dilatation of the pupil, and may be of several varieties. In reflex iridoplegia, commonly called the Argyll- Eobertson pupil, usually the pupil is small, or it may be of normal size, or even dilated, the es- sential factor being the nonresponse of the iris to the stimulus of light. Accommodation may be affected in iridoplegia, but usually it is not. It may be either unilateral or bilateral, and occasionally curious combinations or dissociations of iridoplegia and cycloplegia are observed. Schwarz, for instance, has reported a case of right incomplete reflex iridoplegia and left incomplete accommodation palsy. In rare cases the converse of the Argyll-Eobertson pupil is observed, the pupil or pupils responding to light, but not contracting during efforts at accommodation and convergence. No special term has, so far as I know, been applied to this particular form of inter- nal ophthalmoplegia. Ophthalmoplegias are sometimes subdivided and named according to the locality of the lesion producing them ; thus they may be cortical, subcortical, pedunctdar, nuclear, radicular, commissural, trim'kal, orbital, and endocular. The general term basal is sometimes applied to different forms of ophthalmoplegia due to lesions variously situated at the base of the brain. Ophthalmo- plegias have been designated by some authorities as fascicular, this term simply referring to the fact that nerve bundles and not nerve centres are affected by the lesions. Each of the above anatomical or topographical forms of ophthalmoplegia will receive attention in its proper place. Ophthalmospasms . ISTot a few of the affections of the intraocular muscles are spasmodic rather than paralytic, hyperkineses and not akineses. To these the term ophthalmospasm may be conveniently applied. Such spasms may be clo7iic or tonic. They may also be either functional or organic, and functional cases may be further 812 NERVOUS DISEASES. subdivided into hysterical and neurasthenic forms. Special varieties of ocular spasm are also spoken of, according to the muscles affected, as blepharospasm, or spasmodic closure of the lids, due chiefly to spasm of the orbicularis palpebrarum ; ciliary spasm, when the ciliary muscle is affected ; .^ijatiniodic ptosis, when the spasm is of the levator jjalpebrae, or of this muscle together with the frontalis or corrugator supercilii ; and spasmodic strabismus, which may be of different forms according to the muscles affected. Some of the forms of conjugate deviation of the eyes are spasmodic. Nystagmus. N"ystagmus has already been defined (page 159), and reference has been made to its occurrence and cause in several places (pages 380 and 736). The different varieties of nystagmus are enumerated by Fuchs as nystagmus oscillatorius, oscillating or vibrating nystagmus, nystagmus rotatorius, or rolling nystagmus, and nystagmus mixtus, in which the oscillatory and rotatory movements are combined in the same case. Nystagmus is usually bilateral, but may be more marked in one eye than in the other, and even in rare cases may be present in only one eye. It may be caused by ambly- opia, blennorrhoea, corneal opacities, and absence of choroidal pig- ment. As has been indicated in several cases, it is a not infrequent accompaniment of degenerative diseases, and especially of dissemi- nated sclerosis. The fact in which we are most interested in this connection is, however, that nystagmus may accompany various forms of paralytic and spasmodic disorder of ocular movement, and may be due to lesions either of the nuclei of the ocular nerves or of the associated or commissural tracts which relate these nuclei to each other and to various portions of the brain. In connection with the known facts regarding the association of the cochlear centres with the abducens nucleus it is interesting to note the occasional occur- rence of nystagmus in those who have affections of hearing of either peripheral or central origin . I^ystagmus has, for instance, been ob- served in connection with otitis media, in Meniere's disease, and in disease of the auditory centres and tracts. The interrelationships of vertigo and ocular disturbances, including nystagmus, ha-^e been discussed under vestibular disease (page 736). Some interesting forms of nystagmus associated with disorders of ocular movement have fallen under my observation. Methods of Examination. — For minute details regarding the examination of patients suffering from affections of ocular move- ments, works on ophthalmology should be consulted.* The patient is seated several metres from the testing object, usually a candle flame. It is necessary to have a pair of spectacle frames in which to * For some of the details given, as well as for other important facts and views, use has been made of the paper on " Eye Paralyses" by DV. John Amory Jeflfries, edited since his death l>y Dr. Philip Coombs Knapji. DISTURBANCES OF OCULAR MOVEMENTS. 813 place one colorless and one plain glass. The existence of monocular diplopia is excluded by testing first with one eye and then with the other. The testing flame is moved to the right and left, upward and downward, and in various other directions, the relative positions and the distance between the double images being noted. The fact that one image is colored and the other not makes the procedure easy. When vision is impaired, care must be taken not to mistake mon- ocular vision due to lack of sight in the peripheral portion of one retina for parallel vision. The absence of double vision does not prove the existence of paralysis, as one of the images may be dis- regarded or lost, or only one image may be present, as in some cases of conjugate paralysis. After testing with the double images the motions of the eyes should be observed when following some object. The range of motion— the excursion of the eyeball — should be noted, as should also the position of the upper lids, and whether they follow the pupils in looking downward. Any differences in the motion of the eye when its mate is covered should be noted, as a paresis or paralysis of one eye may disappear if the other be covered, and in other cases the paralysis is apparent only when the unaffected eye is closed. Secondary deviation of the sound eye is determined by placing a screen between the eye to be tested and the object looked at. When now the screen is removed, if the deviation exists the eye will turn back a few degrees as the object comes into view. The screen should be held sufficiently near to prevent fixation of the eye, and yet so that it can be seen by the observer. In studying false projection, if a small object is fixed with the paretic eye and the patient makes an effort to pick it up quickly the hand will miss the object and go too far in the direction towards which the eye movement is weak. In making this test the other eye should be closed, the motion should be made rapidly, and the object — as a pin stuck into a table — should be so placed as to involve the use of the affected muscles. Besides these tests, which are chiefly for phenom- ena due to affections of extraocular muscles, the patient should be tested for reaction of the pupil to light (pages 160, 163) ; he should also be examined for near vision, and sensations of the skin should be noted, as well as the actions of the ciliary muscles. Ocular Paralysis as studied by the Diplopia Tests. — Forms of Diplopia. That form of diplopia showing two horizontal images is called lateral diplopia. In vertical diplopia the images show a ver- tical displacement : one is seen above the other. In simple, direct, or homonymous diplopia each image is seen by the eye of the side on which it appears ; that on the right side belongs to the right eye, that on the left to the left eye. In crossed or heteronymous diplopia each image is seen by the eye of the side opposite to that on which it appears, — that on the right by the left eye, that on the left by the right eye. Diplopia may be either homonymous or heteronymous 814 NERVOUS DISEASES. Fig. 384. in forms of both lateral and vertical diplopia. In the latter, while one image is above the other, it is always displaced a little to the right or to the left. Homony- mous diplopia is always asso- ciated with convergence, and crossed diplopia with diver- gence, as shown in the diagram Pig. 384. Lateral diplopia indi- cates paralysis of the rectus inter- nus or rectus externus. When the images are homonymous the paralysis is of the exteruus, images separating to the right indicating paralysis of the right externus, and images separating to the left paralysis of the left externus. Crossed or heterony- mous images indicate paralysis of the rectus internus. Images separating to the right indicate paralysis of the left internus, and images separating to the left paralysis of the right internus. Diagram fallowing the diflerence between ho- monymous and heteronymous images : o, obiect fixed by the right eye, R; L, left eye ; mcd, visual line of the left eye ; a, point on the nasal side of the retina of the left eye where the image of the object is received and from which it is projected in such a way that it appears at 02 at the left side < if the true object. As shown in this diagram, the left image, 02, belongs to the left eye, and the right image, u, to tlie right eye ; the diplopia is therefore homonymous. If the left eye diverges, the right image belongs to the left eye, and the left to the right, the diplopia being heteronymous. (Hotz.) Tcrticcd diplopia in the upper field indicates paralysis of either the rectus superior or the obliquus inferior. Like lateral diplopia, it presents itself in two forms, one homonymous and the other heteronymous. Homonymous images indicate paralysis of the obliquus inferior, and when the image of the right eye is higher than that of the left it means paralysis of the inferior oblique of the right eye, while if the image of the right eye is lower than that of the left it means paralysis of the inferior oblique of the left eye. Crossed images in vertical diplopia in the upper field indicate pa- ralysis of the superior rectus. "When the image of the right eye is higher than that of the left the paralysis is of the rectus superior of the right eye, while when the image of the right eye is lower than that of the left the paralysis is of the i-ectus superior of the left eye. Vertical dipli)pia in the lower field indicates paralysis of the rectus inferior or obliquus superior. Homonymous images indicate paralysis of the superior oblique. If the image of the right eye is lower than that of the left the paralysis is of the superior oblique of the right eye, and if the image of tlie right eye is higher than that of the left the paralysis is of the superior olilique of the left eye. Crossed images indicate paralysis of the rectus inferior, the image of the right eye being lower than that of the left in paralysis of the rectus inferior of the right eye, and the image of the right eye being higher than that of the left in i)a.ralysis of the rectus inferior of the left eye. (Hotz.) DISTURBANCES OP OCULAR MOVEMENTS. 815 Infrequency of Affections of Single Ocular Nerves.— Affec- tions of single ocular ner\'es are neitiier coinnion nor very rare. The sixth and third nerves are more fretiuently affected than the fourth by diseases limited to their trunks or nuclei. When isolated afflic- tions of the third, fourth, or sixth nerve are periphei'al (trunkal) they are probably in most cases due to forms of neuritis or perineu- ritis, as gross lesions at the base are not likely to single out a separate nerve trunk ; but it is possible that a small lesion, as, for instance, a nodosity in one form of periarteritis, an aneurism, or a small exu- date, may so affect the trunk of a. single nerve, or even one of the branches of such trunk at its beginning, as to produce an isolated paralysis. When not due to neuritis they are most frequently nuclear in origin. When paralysis of the third, fourth, or sixth nerve is due to a gross lesion at the base of the brain, a more or less extensive syndrome is present. Commonly several cranial nerves Fig. 385. are conjointly affected, and, ac- cording to the location of the lesion, motor, sensory, and other tracts may also be involved, giving associated symptoms which are not referable solely to the cranial nerves. Cases show- ing this association of peripheral disease of the third nerve with disease of other cranial nerves are discussed in several places in succeeding jiages (see pages 816, 817, and Fig. 388 ; also page 883 and Pig. 411). Symptomatology of Paral- yses of the Third Nerve.— Total Third Nerve Paralysis. The appearances presented in com- plete paralysis of one third nerve are shown in the illustrations Pigs. 385 and 386. The upper lid hangs loosely down, covering or almost covering the eye, and in order to obtain a view of the eyeball it is necessary to separate the lids by means of the fingers, as shown in Pig. 386. The upper lid can sometimes be partially raised by the overaction of the occipitofrontalis muscle. On opening the eyelids with the fingers the eye is seen to be turned outward and somewhat downward, because of the unopposed action of the two muscles which are not paralyzed, namely, the external straight and the superior oblique. The jjupil is dilated and immovable, I'esponding neither to light nor to efforts at accommodation. Usually the eye projects Oculomotor paralysis, showing ptosis. The case proved to be one of fjummatous meningitis, endarteritis, and thrombosis of the internal caro- tid ; the right third nerve was bound down by exudate. 816 NERVOUS DISEASES. slightly, because of the paralysis of three of the muscles which ordi- narily hold it firmly in place. If the paralysis is confined to the third nerve, the movements of the muscles supplied by the fourth and sixth are not affected, and examination will show no loss of sensation. Oculomotor paralysis : the eye heM open. Same patient shown in Fig. 386. Paralysis of the Third Nerve in Cases of Multiple Syphilitic Lesions. In syphilitic, as well as in tubercular, cases, paralysis of the third nerve is not infrequently one of a series oi' one of a collection of more or less unrelated symptoms. The illustration Fig. 387 shows some of the gross and microscopic appearances found in a case in which the lesions were in several portions of the encephalon. Im- portant vessels were closed by thrombi ; an old gummatous mass was found in the Sylvian fossa ; both optic and oculomotor nerves were compressed and atrophied ; and the heads of the lenticula and cau- datum on each side were softened. The symptoms were complete right oculomotor paralysis, with paresis of the left leg, and mental disturbance. The ]iatient, who first came under observation several months befoie her death, was about twenty-nine years old, and had a pi'evious history of syphilis and general dissipation. The ophthal- moplegia was both external and internal. The specimens from this case were afterwards submitted to microscopical examination, and a report, with illustrations, was made upon them by Dr. Mary Alice Schively, of the Neurological Laboratory of the Philadelphia Poly- DISTURBANCES OF OCULAR MOVEMENTS. 817 clinic. In the case of which an illustration is given in FUr. .388 the patient showed not only right oculomotor paralysis, but also facial paresis and evidences of nieningocortical disease. Dramng shDninij the ledums jiresent iii the ( u^e ilhisti.ited in Firs _,s i and Iso : a, right third nerve adherent to libroid mass , b, right internal carotid plugged by a thrombus , c, fibroid mass filling the Sylvian fossa and extending backward to the cms ; d, chiasm ; e, left internal carotid containing recently organized thrombus ; /, left third nerve ; g, left postcommunicant at junction with postcerebral ; A, basilar giving off postcerebral. Peripheral Paralysis of all the Extraocular Muscles supplied by the Third Nerve and limited to them. Cases have been recorded which show that it is possible to have paralysis of all the extraocular muscles without paralysis of either the iris or the ciliary muscle. These cases can probably be best explained by lesions situated at the beginning of the peripheral course of the third nerve, just before all its fibres have converged into one trunk, or by a lesion attacking the fibres of the trunk after they have diverged to go to their various 52 818 NERVOUS DISEASES. Right oculorarttnr paralysis, facial paresis, and meniiigocortical disease. destinations in the orbit. Where the nerves make their exit from the brain stem the ciliary and pupillary fibres are nearer the middle line than are the others, and there- fore they may remain intact when all the other fibres of the third nerve are destroyed. In these cases the symptoms are ptosis and divergent strabismus, the eye turning outward and downward, as in cases of total third nerve paralysis, but the pupils respond both to light and to accommoda- tion. Paralysis of Single Extraocular Muscles supplied by the Third Feme. Any one of the extraocular mus- cles supplied by the third nerve— the rectus internus, the rectus su- perior, the rectus inferior, the oh- liquus inferior, or the levator pal- pebrse — may be paralyzed alone. Paralysis of the obliquus inferior and of the levator palpebrse is uncommon, and when present the former is usually due to nuclear disease and the latter to an affection of the cortex or subcortex. Paralysis of the internal straight muscle is one of the most frequent of the single ocular palsies. When marked, the facial axes clearly diverge. Pronounced secondary deviation of the sound eye occurs when the paralyzed eye is made to fix. In paralysis of the rectus in- ternus the head is usually turned towards the unaffected side. When the superior straight muscle is paralyzed the patient complains of double vision in looking upward, and the tendency is to throw the head backward. Single vision is present in the lower part of the field. The double images are crossed. On covering the sound eye and attempting fixation with the affected eye on an object slightly above the horizontal, secondary deviation upward of the sound eye results. Paralysis of one inferior straight muscle causes the patient to hold his head downward and somewhat inclined towards the par- alyzed side. The double images are found everywhere in the lower fields, and are crossed. Paralysis of the inferior oblique is exceed- ingly rare, and indeed its existence as a separate affection is doubted by some of the best ophthalmological authorities, but Mauthner has reported a case which followed an injury to the muscle during an orbital operation. Theoretically homonymous double images should b(> caused in the upper field. The reader is I'eferred to the para- graph on forms of ocular paralysis as studied by the diplopia tests DISTURBANCES OF OCULAR MOVEMENTS. 819 (page 813) for a clearer understanding of the positions of the double images in each of the different forms of paralysis of single muscles supplied by branches of the third nerve. Fig. 389. Nearly isolated paralysis of left internal rectus (left external .'itrabismus without ptosis) ; both pupils responsive to light ; ocular paralysis came on after scarlet fever, when the patient was one year old, (Photograph taken at the age of sixty-.seven.) Paralysis of the Levator PaJpehrm Siqyejioris. Isolated paralj^sis of the levator palpebrse superioris, with its symptom, ptosis, is exceed- ingly rare as a peripheral trunkal affection, although more common as the result of a nuclear or of a cortical or subcortical lesion. "While rare as a persistent symptom of peripheral third nerve disease, isolated ptosis is often the earliest symptom of a later more complete oculomotor paralysis ; it is not infrequently the first sign of such paralysis. The patient has first a slight drooping of one lid, and in the course of hours, days, or weeks the other muscles supplied by the third nerve are successively involved. The explanation of such a case as this would probably be found in the fact of the greater expo- sure of the peripheral distribution of the levator branch of the third nerve, or perhaps, as suggested by Jeffries, owing to its constant use its defects are more i^romptly recognized. It should be borne in mind that the lid is in part raised by unstriped fibres supplied from 820 NERVOUS DISEASES. Fif!. ;;9n. the gangliated system, and that slight drooping of the lid occurs sometimes because of involvement of these fibres. Bilateral Paralysis of the Third Nerve. Bilateral paralysis of the third nerve in the adult is usually of syphilitic origin. Such a case, of incomplete bilateral type, is shown in Pig. 390. This patient had com- plete ptosis of the left eye and partial ptosis of the right eye ; movements of the eye internally, ujiward, and down- ward were completely lost, both eyes being drawn at first into the external canthi and being immovable in any di- rection. The i)upils did not respond •■^ ^. to light or to accommodation. The Bilateral oculomotor paralysis. patient complained of a sensation of weakness in his lower extremities, and had an imperfect girdle sensation around the waist, but otherwise no paralytic symptoms except those of the oculomotor muscles. The third nerve paralysis in this case was most probablj' due to syphilitic neuritis, as a basilar meningitis or gumma would be likely to involve other structures than the third nerve. "WTien a lesion causing bilateral third nerve paralysis is focal and superficial it is of course situated at about the point of junction of the crura, whence both third nerves proceed in their course to the cavernous sinus. In other cases, however, the lesions are deeply situated, and these are usually either focal encephalitis or plugging or rupture of small vessels. Such cases are of course rarely pnre in type, as even comparatively minute lesions must involve other structures with definite functions, but the third nerve symptoms so predominate as to overshadow the others. Occasionally in sj^ringomyelia or in progressive muscular atrophy paralysis of both third nerves is present. A few cases of congenital bilateral paralysis of the third nerves, as of other forms of unilateral and bilateral ocular paralysis, have been recorded. These are doubtless due to arrested or imperfect development of the ocular nidi. The illustrations (Pigs. .391 and 392) are of a case of bilateral nerve paralysis in a child recorded by Davidson. The patient was twelve years old, and when she first came under observation had ptosis on both sides, but most marked on the right, the occipito- frontalis, as shown in Fig. 391, contracting in order to counteract the lack of power in the elevators of the eyelids. Divergent strabis- mus wiis present in both eyes, most marked on the right. All the external muscles of the eyeball supplied by the third nerves of both eyes were more or less paralyzed. The pupils were active and re- DISTURBANCES OP OCULAR MOVEMENTS. 821 sponded normally, and accommodation was unaffected. Vision and ophthalmoscopic appearances were also normal. Later in the history of the case the pnpils became moderately dilated and did not react to light ; still later the response to light returned in both eyes, but Fig. 391. FiQ. 392. Bilateral paralysis of the extraocular muscles supplied by the third nerve. (Davidson.) Photograph of case shown in P'ig. 391, taken five months after recovery from bi- lateral paralysis of the extraocular muscles supplied by the third nerve. (Davidson.) both failed to react to accommodation. Under the use of potassium iodide, after one relapse, she was discharged cured. In Fig. 392 this child is shown as she appeared five months after she was finally discharged. Affections of the Intraocular Muscles supplied by the Third Nerve. — Effects of Focal Lesions variously situated in the Optic Pupillary Pathivay. The special effects of lesions of the optic pupillary pathway vary according as these lesions are destructive or irritative, unilateral or bilateral, and according as they are situated in the centripetal, central, or centrifugal portion of the reflex arc. They can be best understood by a careful study of ' ' the scheme of the nuclei of the nerves of ocular movements, and of their central and peripheral parts" (Fig. 383, page 808). When the nuclei of both the sphincter iridis and the ciliary muscle are the seats of destructive lesions, paralysis of all the intraocular muscles results. When one nucleus alone is affected, the muscle supplied by the nerve which originates in this nucleus is paralyzed, causing either dilatation and rigidity of the pupil or loss of accommodation. Spasmodic affections of the intraocular muscles result from irritative lesions of the nuclei of the nerves to these muscles, but they are rare. When the intraocular 822 NERVOUS DISEASES. portion of the optic oculomotor tract is diseased in the pregeminum or in the tracts which connect the pregeminum with the nucleus of the sphincter of the iris, the pupils do not react to light, but the reactions to accommodation and conveigence remain. True disturb- ances of vision are absent. When the connections of the pregemi- nums with the sphincter nuclei are diseased, the reflex rigidity of the pupil (loss of reaction to light) with normal reaction to accommo- dation and convergence is ijreseut. Some interesting cases illus- trating varieties of consensual iritic reaction have been observed, and Fig. .393. Right irifjnplegia (riilatation of right pupil) ; paresis of convergence : accommodation normal: interference with consentaneous action of pupils— direct light stimulation of the right eye pro- duces no pupillary reaction in this eye, but reflex response in the left eye ; light thrown Into the left eye produces pupillary reaction in tliis eye, but no response in the right eye. In the diagram Fig. 394 the probable position of the lesion causing the iridoiilegia is shown at A. some results of general clinical application have been obtained espe- cially by Redlich in the course of his studies of paralytic dementia. He found that in all cases M'hen each iris responded to direct light stimulation the consensual reaction was intact in each eye. If, for instance, the riglit and left pupil each responded to direct light stimulation, light thrown into the left- eye caused response in the right, and light thrown into the right eye caused response in the left. If neither iris responded to the stimulation of light, consensual re- DISTURBANCES OF OCULAR MOVEMENTS. 823 Fig. 394. action was absent in both irides. In all cases in which the one iris failed to respond to direct illumination the consensual reaction in the other eye could be elicited ; but in these cases when the sound eye was exposed to light no pupillary response was induced in the irido- plegic eye. Eedlich's conclusion from his observations on these cases was that a partial decussation of the optic iritic fibres takes place, so that from each optic nerve fibres proceed both to the right and to the left oculomotor nuclei. In the eases cited by him the lesions must have been situated centrad of the decussation, which probably takes place in the chiasm or postcommissure. These pecu- liarities of consensual iritic reaction are seen in other diseases than paretic dementia, and may indeed occur as the results of any disease giving a lesion of the optic iritic tract or its centres. An interest- ing case of this kind was a patient at the Philadelphia Hospital, a photograph of whom is shown in Pig. 393. Examination of this case showed no hemianopsia, but general contraction of the visual field. The Position of Lesions in. the Optic Pupilkiri/ Puthway with Reference to the Production of the Hemiopic Pupillary Reaction. — Wernicke's hemi- opic pupillary reaction (or inaction) has been described and the method of determining it explained on pages 160 and 161, and references to this pupillary phenomenon have been made in other places. It will only he necessary to refer here to the po- sitions in the pupillary arc of lesions which would or would not cause this interesting diagnostic sign. The fol- lowing is a summary of Henschen's conclusions regarding this matter. The reaction is caused (1) by mere pressure on the optic tract ; (2) usu- ally by lesions of the optic tract, even when they are very minute ; (3) by lesions of the chiasm, although occa- sionally for some unknown reason it is not present with such lesions ; (1) by injury to the optic nerve with monocular hemianopsia ; and (5) by lesions of the posterior segment of the thalamus and pulvinar, it being here probably the result of pressure on the optic tract or of destruc- tion of the brachium anterius (prebrachium). The sign is not pro- duced (1) with destructive lesions, like softening of the occipital, parietal, or temporal lobe, even when these are extensive ; and it is absent even in tumors of these regions which destroy the optic Diagram showing the probable position of a lesion (at ^1) in the coui«e of the optic iritic tracts in a case of right iridoplegia, in which the iris on the paralyzed side failed to respond to direct light stimulation, the left pupil responding both to direct and to indirect stimulation. The larger circles represent the quadrigeminal bodies, and the smaller the centres for the iritic sphinc- ters : the arrows indicate the directions of the afferent and efferent impulses. 824 NERVOUS DISEASES. radiations and cause considerable pressure ; (2) by lesions of the postgeniculum ; (3) by destruction of the pulvinar ; (4) by destruc- tion of the postgeminuin. The effect of lesion of the pregeniculum is, according to Henschen, uncertain. The Cutaneous Papillary Reflex. Strong sensory stimuli applied to the skin almost anywhere may produce dilatation of the pupil, but this effect is particularly brought about when the skin of the neck is stimulated, as, for instance, by an electrical current. The path for the completion of this reflex is supposed to be by way of the cervical gangliated system, the ciliospinal centre in the cord, and the pathway through the oblongata which connects this region with the centre for the sphincter iridis. Lesions of any portion of this arc may of course produce either dilatation or contraction of the pupil according to their character. PupilUiry Phenomena resulting from Lesions involving the Fifth Nerve. Both dilatation and contraction of the pupil have been noted in con- nection with lesions of the fifth nerve trunk and also of its roots, especially of its great spinal root. It has been suggested that in some cases at least these pupillary disturbances are of a reflex character, that is, are the result of irritation reflected to the pupillary centres and fibres. Whether this explanation is or is not correct for some of the cases, it is probable that in other instances the pupillary change is produced by lesions which, while involving the trigeminal roots, implicate the tract in the oblongata associating the spinal and the encephalic pupillary regions. When trigeminal anesthesia is asso- ciated with reflex pupillary immobility. Turner holds that it is due to a lesion of the spinal (formerly called the ascending) root of the fifth. RaaVs Cortical Pupillary Peflcx. It was found by Haab that con- traction of both pupils took place when attention was suddenly di- rected to a bright object in a somewhat darkened room. The amount of contraction is proportionate to the brightness of the object. The pupillary contraction is independent of any distinct change due to convergence or accommodation. Owing to the fact that the contrac- tion follows a purely psychical process, Haab believed that it was in all probability of cortical origin. The occurrence of this reflex pre- sujiposes that the network of the motor corona radiata to the motor oculi nucleus, and the ganglion cells of the nucleus of the sphincter, are intact. ' ' The cells or fibres of the accommodation nucleus may be incapable of function, and Ha;)l> reports two cases in which the reflex was retained despite jjaralysis of accojnmodation. The reflex will be lost if tlie intorunclear fibres between the nuclei of the ciliary muscle and pupillary si)hincter are destroyed, even though both nuclei are intact. In such a case accommodation and the involun- tary light reflex of the pupil may be normal, and this has also been observed by Haab." (Knies. ) DISTURBANCES OF OCULAR MOVEMENTS. 825 Ciliary 8pasm. Ciliary spasm is of frequent occurrence in con- nection with disorders of refraction, especially with hypermetropia or hypermetropic astigmatism. Efforts to accommodate for near vision in these instances sometimes produce a strong and persisting cramp, which may be so great as to mask the real degree of optical defect which is present. Under mydriatics this spasm disappears, and the latent disorder of refraction comes to the surface. Ciliary spasm is also sometimes due to the instillation of drugs like eserine or pilo- carpine, and occiisionally this form of spasm may be of severe type. Usually it passes off promptly after discontinuance of the instillation. Valk has reported true tonic spasm of accommodation occurring in a case of marked myopic astigmatism. The eyes were sensitive to light. The use of atropine four grains to the ounce almost continuously for five months gave marked relief During the treatment the patient was given strychnine in small doses for a month, and twice the temples were leeched. Patients suffering from ciliary spasm have a feeling of discomfort in the eyes, not often of the nature of real pain, but sometimes described as one of drawing or contraction. The light, freqaently complained of, probal)ly acts as an irritant and an aug- menting factor in the induction of the spasm. In rare cases acute cihary spasm is unconnected with disorders of refraction or witli the use of drugs, and such cases may be due to irritative lesions of the accommodation centre. In some forms of disease of the spinal cord, as myelitis, sclerosis, or tumor, a severe ciliary spasm with myosis is present, and is probably due to irritation reflected to the accommo- dation centre. Spasm of accommodation may be due to cortical irri- tation. The centre of representation of macular or acute \ision, while situated in the general visual sphere, is separated from that for the representation of associated halves of the retina. Obregia noted that irritation of the macular region of the visual sphere excited scarcely any movement, but that the conjugate movements of the eyes towards the opposite side became more extensive the nearer the periphery of the visual sphere was approached. If the image of an object falls upon the fovea centralis of the retina and is conducted thence to the macular portion of the visual sphere, no con- jugate movement will result, because the eye is already adjusted ; convergence and accommodation are alone necessary, and for these two movements the macular portion of the visual sphere must be regarded as the cortical centre. If a separate cortical centre for macular representation exists, and if this centre is also the centre or contains the centre or centres concerned with convergence and ac- commodation, it follows that a focal irritative lesion of this region might produce ciliary spasm with contraction of the pupil, narrowing of the eyelids, and reduction of acuity of vision. While, so far as I know, such cases have not been recorded, it is easy to see that they might have been overlooked. If a focal cortical lesion results in 826 NERVOUS DISEASES. ciliary spasm, it follows that a lesion of the fibres associating the macular and the oculomotor cortex, or of the projection fibres from the cortex to the ciliary or accommodation nucleus, might also cause ciliary spasm. Parah/ais of the Associated Motion of the Eyes in Convergence. It has already been stated that a centre of convergence (Perlia's central nucleus) is located far forward in the oculomotor nucleus, between the centres for the internal straight muscle and for accommodation. Paralysis of near vision, or conjugate convergence paralysis, is, as suggested by Jeffries, the obverse of lateral conjugate paralysis. Neither eye will turn in when both eyes are opened, but if one is covered the other turns in at once, while the other turns out to a parallel position. Benzler records the case of a bandman who while playing on the horn suddenly lost sight of his music. Careful ex- amination showed that distant vision was good, but near vision was poor and unaccompanied by crossed diplopia. "When one eye was covered, the other turned in well for near vision, the covered eye turning out at the same time. The right pupil reacted to light, but not to accommodation. (Jeffries.) Spasm in Convergence. Millingen has reported a case (cited by Spitzka) in which a focus of disease situated to the right of the aque- duct pressed close ou the median line of the central tubular cinerea. During life the patient had suffered from spastic (irritative) con- tracture of both internal straight muscles. To account for this case it is necessary to assume an irritative lesion of the cell nests re- lated to both internal straight muscles, or, what is more probable, of Perlia' s central nucleus (the convei-gent centre). Affections of Ocular Movements due to Disease limited to the Fourth Nerve or its Nucleus. — Symptoms of Fourth Nerve Paralysis. Disease limited to the trunk of the fourth nerve or its nucleus is comparatively rare. When the disease is unilateral a form of strabismus is produced in which the eye is rotated slightly upward and inward. Double images appear when the eyes are turned downward. The diplopia is homonymous, and the images are placed one above the other. The image on the paralyzed side is lower than that on the other, and is inclined towards the unaffected side. The images become more widely separated both vertically and laterally, and the test object is carried farther downward and out- ward. Often scjuint is so slight that it will be overlooked on mere inspection, but it will be clearly shown by careful testing for double images. When the paralyzed eye is fixed by covering the sound eye, secondary deviation of the sound eye downward and inward occurs. The patient inclines to turn the head forward and towards the healthy side to cor reel the fiilse projection, which is downward and a little outward. This form of paralysis frequently produces marked vertigo, and causes great confusion to the patient, owing to DISTUKBANCES OF OCULAR MOVEMENTS. 827 the curiously placed double images in tlie lower field. The third and fourth uerves are not infrequently paralyzed together. Double Fourth Nerve Faralysis. As has been shown, the fouj-th nerve makes a complete, or nearly complete, decussation ^\hich is readily traced just above the posterior extremity of the aqueduct. Should a lesion happen to affect this place of crossing, the chiasm of the fourth nerve, the result would bo a doul)le paralysis of the superior oblique. I have not been able to discover any cases of this kind in the liteiature to which I have had access. Double fomth nerve paralysis may also be caused by lesions inA'olving both nuclei or both trunks of the fourth nerve, and may be anticipated especially in some cases of multiple syphilitic lesions. Affections of Ocular Movements due to Disease limited to the Sixth Nerve or its Nucleus. — Unilateral Paralysis of the Sixth Nerve. Isolated paralysis in the domain of the sixth cranial nerve vies in frequency -with cases of third nerve paralysis. When the paralysis is unilateral it gives rise to convergent strabismus on one side; when bilateral, to double convergent stra- '''■ '^' ' hismus. In the unilateral cases double images are likewise seen when the eyes are turned in the horizontal plane towards the paralyzed side. If the paragraph which de- scribes the diplopia tests he consulted, the position of the different images in cases of this form of paralysis will be clearly seen. The distance be- tween these images in- creases according as the object is moved towards the paralyzed side. Like isolated paralysis of the third and fourth nerves, it is most frequently due either to a periph- eral neuritis or to nuclear lesion. It is a comparatively common accompaniment of the other symptoms of the early stages of tabes, and transient forms of atadu- cens paralysis of unknown origin are observed especially after sixty years of age. Occasionally it results from traumatisms directly affect- ing the muscle or nerve. In marked cases of abducens paralysis Paralysis of the left exlernal rectus aad paresis of the right external rectus ; accommodation good ; vision reduced to about one half in the right eye, to about one third in the left ; abducens root fibres implicated in the lesions as found on autopsy and microscopical examination. 828 NERVOUS DISEASES. the patient cannot turn the eye beyond the median line, and vertigo, with or without nausea and vomiting, is often severe. Bilateral Paralij.sis of the Sixth Nerve. Bilateral paralysis of the muscles supplied by the sixth nerve is rare in any form, and is es- pecially infre(£uent as an acquired disease in the adult. It may, however, ficcur as the result of a nuclear ophthalmoplegia limited to both nidi of the sixth pair, or to multiple lesions which by unusual chance affect only the tracts for the peripheral distribution of both sixth nerves. As a congenital disorder it has been observed in a number of recorded instances. Leszynsky, in recording a case, has also given a summary of the literature of this suljject. His patient was four years of age when first studied. To\\ards the end of his first year he began to draw his head backward, and his mother then noticed that his eyes both turned inward. Examination showed that the convergent strabismus present in both eyes was more pronounced in the left. He was unable to move either eye outward beyond the middle line. About a dozen cases corresponding more or less closely to that of Leszynsky have been recorded. One case associated with bilateral facial paralysis, reported by Harlan, was also seen and studied by the writer. General Remarks on the Focal Diagnosis of Disturbances of Ocular Movements. — As the subject of cerebral localization has already been considered at length, our concern here will be more with the peripheral and nuclear affections, and yet it will not be possible to understand clearly diseases of the oculomotor apparatus unless they are all glanced at in the same connection. Certain principles of comparatively easy application can be used in differentiating af- fections at different le\'els in the oculomotor system, which includes the whole apparatus related to ocular movements from the surface of the brain to the motorial end plates in the intraocular and extraocular muscles. With one exception— ptosis from paralysis of the levator palpebrse — lesions of the cerebral cortex and subcortex never cause paralytic or spasmodic affections of single ocular muscles. When these are present, therefore, lesions of the nuclei, root fibres, or nerve trunks at the base should be expected. As the coordinations of ocu- lar movements are in a certain degree determined by the action of tracts which associate cortical centres together or bind these centres with basal regions, lesifins of the subcortex or internal capsule, crus, or pons may give rise to disturbances of these coordinations, and these maybe either of a paralytic or of a spasmodic type. Other points of particular diagnostic ^alue will appear as focal lesions at different sites are considered. Consulting the scheme Fig. 383, page 808, it will be seen that the ptosis in the cortical cases, to which reference has just l>een madt', will be caused by lesion of P, the cor- tical centre iov the le\ator palpebra' superioris. As to what would be the effect of the destruction of the cortical oculomotor centre of DISTURBANCES OF OCULAE MOVEMENTS. 829 one hemisphere, few clinical facts are at command. Destruction of one oculomotor centre should cause total paralyfiis of all muscles supplied by the nerves whose nuclei are in connection with the destroyed cortical area. These nuclei include all those which are situated on the diseased side, with the exception of the nucleus of the levator palpebrse and the nuclei of the fourth and sixth nerves. The cerebrobulbar ocular tracts decussate before passing to the fourth and sixth nuclei. So also does probably the nerve branch to the nucleus of the inferior oblique muscle. If, therefore, the right oculomotor centre is destroyed, all the ocular movements of the right side, with the exception of those performed by the inferior oblique and the levator palpebrge, are paralyzed, but the movements produced by the right abducens and the right trochlearis are not paralyzed. On the left side the movements performed by the abdu- cens or trochlearis and the inferior oblique are affected, while the others are performed normally. The clinical result will be that con- jugate movement of the eyes towards the left will be impossible, while convergence of both eyes can be performed. This conver- gence is possible because the convergent nucleus (Perlia's central nucleus) is innervated from both oculomotor cortical centres. The transient conjugate deviation in cerebral apoplexies is probably due to destruction of the cortical oculomotor centres or of the subcor- tical oculomotor tracts. Irritation of one oculomotor centre or tract causes deviation of both eyes towards the opposite side. In some cases of diplopia the effects of both irritation and destruction are commingled and cause a confusing picture. * Disorders of Ocular Movements due to Cortical Lesions. — Herter has reported a case in which unilateral ptosis was apparently due to a limited cortical lesion of the opposite hemisphere. The right arm and right leg were flaccid, the facial muscles not being affected. The limbs of the left side showed no weakness, but ptosis, not quite complete, was present on this side, and the left pupil was slightly dilated, reacting poorly to light as compared with the right. The autopsy showed extensive pulmonary tuberculosis and suppu- rative nephritis. In the right hemisphere, just below the intrapari- etal fissure was a circular patch of softening, one inch in diameter, occupying the angular convolution. The softening involved the cortex, and to a slight extent the substance beneatli it. Herter be- lieved that it was safe to refer the left-sided ptosis to this lesion in the right angular convolution, and that the right-sided hemiparesis may have been due to uraemia associated with the kidney disease. * Some of the diagnostic points given here, and also when the lesions of the optic pupillary pathway were considered, have been taken from Magnus (Anleitung zur Diagnostik der centralen Storungen des optischen Apparates, Breslau, 1892). 830 NERVOUS DISEASES. Cases of one-sided ptosis due to cortical lesion have been reported by other observers. About thirty cases of ptosis, either congenital or acquired, probably due to corticular arrest or lesion, have been placed on record (Swauzy). The left lid is most frequently affected. In most of the cases referred to by Swanzy the ptosis has been com- bined with associated movements of the affected eyelid. At least three conditions have been observed, namely, elevation of the droop- ing lid when the eye is abducted, when the eye is adducted, and when the mouth is open. In some cases a synchronous contraction of the pupil has been noticed, while in others a lateral motion of the jaw and movements of deglutition are accompanied by elevation of the lid. According to Swanzy, ptosis has no value as indicating the locality of a lesion in the cortex, but when monolateral and the only focal symx>tom it occurs with cortical lesions alone. In not a few cases it is probably a distant symptom. Disorders of Ocular Movements due to Limited Subcortical (Cerebral) Lesions. — Very few cases have been put on record in which limited lesions of the corona radiata or of the internal cap- sule have caused disorders of ocular movements. The sym^jtoms of destruction of the oculomotor tracts, as stated in the last paragraph, are probably similar to those of one of the oculomotor centres. It is probable, however, that these symptoms will be of a more persistent character than when the lesions are purely cortical or nearly so. If, for example, the oculomotor tract for the right side is destroyed, conjugate movement of the eyes towards the left will become impos- sible, although the power of convergence may remain. If the lesion of these tracts is more irritative than destructive, the conjugate deviation of the eyes will take place towards the opposite side, and I believe that this will be the case even when the lesion is above the pons. It will be necessary to discuss briefly some of the points con- nected with cerebral coordination of ocular movements, and to give in detail some of the facts regarding affections of consentaneous ocular movements. Ptosis from Lesions of the Striatum. — According to Noth- nagel, ptosis or pseudoptosis with a peculiar train of accompanying symptoms has been found in lesions of the striatum. In these cases the symptoms are (1 ) apparent ptosis of the paralyzed side, due to contraction of the palpebral aperture ; (2) contraction of the pupil of the same side ; (3) an apparent shrinkage back of the eyeball into the orbit ; (4) an abnormal secretion of mucus from the corresponding nostril, of tears from the eye, and of saliva from the corresponding side of the mouth. (Swanzy.) Cerebral Coordinations of Ocular Movements. — The chief cerebral coordinations of ocular movements are four in number : (1) movements of both eyes to the right; (2) movements of both eyes to the left ; (3) movements of both eyes downward and inward, DISTURBANCES OF OCULAR MOVEMENTS. 831 narrowing of the pupils, and contraction of the ciliary muscles, pro- ducing increased convergence and accommodation ; (4) movements of both eyes upward and outward, producing diminished comer- gence, and accompanied by, though not actively producing, a widen- ing of the pupils and relaxation of accommodation. These sevei al forms of compound movements are produced by the action of dis- tinct brain centres (Priestley Smith). Theoretically, any one of these forms of coordinating movements may be affected by either paralysis or spasm. Afiections of lateral movements are by far the most frequent. As a rule, eyes and head are moved together, but the former may alone be affected. Some of the Varieties of Conjugate Deviation and their Mechanism.— Conjugate Deviation due to Cortical and Huheortical Lesions. Numerous physiological observations have shown that con- jugate deviation (sometimes called Pievost's symptom) may result from irritation of almost all parts of the cerebral cortex ; but exact experiments have determined that such de\'iation can be obtained with most certainty from irritation of the occipital lobe, — in other words, from iiritation of the visual sphere. In a few cases this deviation remains constant after a cei'ebral hemo]'rhage, or is a per- sistent symptom the result of some other form of focal lesion. Wer- nicke held that such deviation coming on with shock and without loss of consciousness pointed to disease of the lower temporal region of the opposite side, but Jeffries regarded Wernicke's cases as un- satisfactory. In a very small number of cases lesions of the frontal convolutions have been accompanied by disorders of ocular move- ments of such a kind as to suggest some connection with the lesion. The supposed positions in the internal capsule of the tracts con- taining the motor fibres for these movements are seen in Fig. 236, page 360, where they are placed as if located just in front of the knee of the capsule, and are designated by the expressions -'eyes opened" and "eyes turned." The fasciculus conveying fibres con- cerned with the movements of the turning of the head is represented as just at the knee of the capsule. Conjugate Deviation due to Pontile Lesions. Bleuler, in 1885, col- lected a series of cases of conjugate deviation due to pontile disease. Jeffries, in 1892, nearly doubled the number of such cases. He summarized as follows the different ocular states found as the result of such lesions : (1) complete paralysis of one external rectus and a crossed paralysis of the internal rectus, so that neither muscle is capable of motion, the eyes looking forward or to the other side according to the state of the opposite pair of muscles, in these cases the eyes turning readily to the opposite side, up or down, but stop- ping at the midline as if transtixed ; (2) precisely the same state as in the first class, except that the internal rectus acts perfectly for near or for convergent vision ; (3) when both eyes are open, the eye with 832 NEETOUS DISEASES. Fig. 396. Bleuler's diagram in explanation of tlie mechanism of conjugate paralysis : o, o', optic tracts ; R, R', cortical centres ; a, a', abducens nuclei ; i, i\ internal rectus nuclei ; v'^, S', point where the internal rectus fibres bend ; 1, lesion pro- ducing Prevost's symptom ; 2, 3, lesions producing paralysis of one abducens and the opposite internal rectus for all movements ; 4, lesion producing paralysis of one abducens and weakness of the opposite internal rectus for all move- ments : 5, paralysis of left abducens, absolute defect of right internal rectus for associated lateral movements, weakness of both internal recti for convergence ; 6, paralysis of abdu- cens and inactivity of otijiosite internal rectus for lateral movements only ; 7, total paralysis of opposite internal rectus; «., double abducens paralysis; (3, paralysis of con- vergence ; accoriling to the view of Bleuler, fibres run direct from the cortex to their respective root nuclei, but there are two sets of fibres for the internal rectus, one for conju- gate vision and one for near vision ; the fibres nm down as separate bundles below their nucleus close to the sixth nucleus, and then turn back and cross to their nucleus. (Jeffries.) the paralyzed internal rectus does not turn in for objects on the other side of the nose, but does if the other eye is cov- ered ; (4) the internal rectus does not act in conjugate but does in near vision, the external rectus being normal ; (5) though devoid of any signs of conjugate paral- ysis, simple nuclear sixth nerve paralysis must be considered as an element of conjugate paralysis. Jeffries found it espe- cially difficult to exj)lain those cases in which when both eyes are opened the eye with the paralyzed internal rectus does not tui-n in, but turns in when the other eye is covered. He believed that the only way out of the difficulty was to as- sume that the apparent conjugate movement in monocular vision is not in fact this, but really a substituted convergent movement. Conjugate Deviation due to Tumor (Irritative Le- sion) of the Pons. The most striking illustra- tions of spasmodic conju- gate deviation due to en- cephalic lesion have been afforded by disease of the pons, and especially tumors in this location. In 1882 I reported an interesting case of this kind, in which the chief DISTUBBANCES OP OCULAR MOVEMENTS. 833 symptoms of focal lesion were hemiparesis, partial right ptosis, diminished sensation on the left side of the face and in the right limbs, conjugate deviation of the eyes and rotation of the head to the right, persistent epistaxis, and a tendency to hemorrhage from the mucous membranes. The autopsy revealed a gumma about half an inch in diameter, distinctly limited to the left cephalic quarter of the pons. Other similar cases have been recorded. When the lesion is irritative, the deviation is towards the side of the lesion ; when it is destructive, it is away from the side of the lesion. Affections of Upward and Downward Botation of Both Eyeballs. Cases in which the movements of both eyes upward or downward are affected are comparatiA'ely rare, and they are usually paralytic in type. Jeffries refers to five of these cases, and at least as many more have been reported under various names, such as paralysis of the superior recti muscles, paralysis of upward rotation, paralysis of the inferior recti, and paralysis of downward rotation or downward movement. In nearly all cases with autopsies lesions have been foimd at about the level of the third pair, but Thomson has reported a case in which the conjugate paralysis of movement was apparently due to a gumma at the point of exit of the third nerve between the albicantia and the crura. The nuclei of the third nerve were normal. Bruner, under the title of "paralysis of the superior recti muscles," has reported a case in which intermittency in the relative strengths of the two paretic muscles was shown. Nothing in the case indi- cated spasm of the inferior oblique, and two degrees of esophoria were present. The reporter of this case inclines to the view that the paralysis was congenital, and believes that the condition was due to a central deficiency rather than to malformation or arrested develop- ment of the muscles. Eecently in consultation with Dr. Elwood Patrick, of West Chester, and Dr. H. F. Hansell, of Philadelphia, I saw an interesting case of paralysis of the movements of upward rotation of both eyes. In this case the trouble with vision began about four years before coming under observation, and for nearly half this time the patient had been troubled with diplopia. Accord- ing to the report received from Dr. Hansell, since two years before, when first Seen by him, the patient had had paralysis of upward de- viation of both corneas, it being impossible for him to raise his eyes beyond the horizontal plane. The left eye diverged slightly, but there was no true lateral paralysis. The pupils were equal, reacting to light and accommodation both individually and consensually, but their movements were sluggish. The right field was concentrically limited to a decided degree, and slight concentric limitation was present on the left. The media and fundus were healthy. The cen- tral acuity of vision was 20 / 40 in the right eye and 20 / 30 in the left. Examination showed slight difficulty in speaking. The tongue was protruded slightly and a little to the left, and the patient showed 53 834 NERVOUS DISEASES. some tendency to drooling. He complained of a general feeling of weakness in botli legs. Both knee jerks were exaggerated, and a slight, probably spurious, ankle clonus was present on the left. It is not imj)robable that in this case the lesion present was one of the nuclei or root fibres, and was similar to the lesions recorded in the few cases in which autopsies have been placed on record. Nuclear Ophthalmoplegia. — Varieties. The subject of nuclear ophthalmoplegia is one that has claimed much attention from neu- rologists and neuroophthalmologists. The term is strictly correct If properly applied, but many of the cases which are classed as "nuclear" — and this remark applies to other forms of so-called nuclear paralysis as well as to the ocular palsies — are not solely nuclear, and some of them perhaps are not nuclear at all. In Wernicke's poliomyelitis superior, and in some other forms of focal lesion of the pons which are said to give rise to nuclear ophthalmo- plegia, lesion destroys nerve roots as well as nerve nuclei, and in- deed not infrequently involves structures other than those related tO' the ocular muscles. These cases are examples of nuclear ophthalmo- plegia and something more. Radicular or fascicular ocular palsy, either of which may in its symptomatology very closely simulate ophthalmoplegia due to nidal lesion, is sometimes classed as nuclear. A true nuclear ophthalmoplegia is a paralysis which is due to a de- structive or a degenerative lesion which expends its baneful influence on the cell nests proper and on these alone, and is best represented by chronic slowly progressive degenerative disease which gives simi- larly chronic and slowly progressive degenerative paralysis of the ocular muscles. In the iirst place, nuclear ophthalmoplegia, whether pure or mixed, may be divided into acute and chronic forms. Each of these varieties may be subdivided according to the exact locality and limitation or diffusion of the lesion producing the paralysis. Nucleai' ophthalmoplegia may, for example, be unilatend or bilateral, internal or external, isolated when confined to one nucleus or one set of nuclei, and total when all the oculomotor nuclei are implicated. Objections have been made to this differentiation into special focal varieties, but they are certainly useful for practical diagnostic pur- poses. Acute Nuclear Ophthalmoplegia. Acute nuclear ophthalmoplegia presents itself in se^^eral varieties, according to the nature of the attack and the extent of its ra\ages. In a few cases it is abrupt, and it may be fubninant, rapidly destroying all the ocular centres and the life of the patient by the in\asion of other vital portions of the pons and oblongata ; or it is comparatively slow in onset, and, while serious in its results, recedes after an indefinite amount of permanent damage has been done to the nuclei of the nerves of the ocular muscles, and also in some instances to adjoining parts. In a third class of cases the disease, while more or less acute in its. DISTURBANCES OF OCULAR MOVEMENTS. 835 onset, is comparatively mild in its results, the patients making at least approximate recoveries, slight defect of motion in some of the muscles affected being the only lasting evidence of the attack. In still another class it would seem from recorded instances that the affection is purely functional, probably a form of nuclear neuras- thenia. In the severe type of acute nuclear ophthalmoplegia the patient may have marked fever, and convulsions are of frequent occurrence. The acute form of ophthalmoplegia may be associated with some symptoms of spinal disease, like poliomyelitis, or with evidences of more diffuse bulbar disease, such as facial, glosso- pharyngeal, or hypoglossal paralysis, or indeed paralysis of any of the cranial nerves. Under the name of poUoencephalitis superior, Wernicke long since described a form of paralysis in which the ocular muscles were chiefly but not exclusively involved. The cases included in his description would be classed by us under mixed nuclear paralyses, — that is, nuclear paralyses associated with condi- tions due to destruction of adjoining structures, such as the nerve radicles and pontile tracts. The affection is entirely analogous to the other forms of focal encephalitis attacking the bulbar region, such as those which produce the so-called polioencephalitis inferior and various irregular types of bulbar paralysis. Not infrequently ophthalmoplegia due to a polioencephalitis superior expands into a more complete form of bulbar paralysis, or other forms of bulbar paralysis late in their history include ophthalmoplegia in their syn- drome. Chronic Nuclear Ophthalmoplegia. Chronic nuclear ophthalmo- plegia, like acute nuclear ophthalmoplegia, may be of several varie- ties, according to the mode of onset, the method of progression, and the nuclei simultaneously or successively attacked. Thus we may have (1) a chronic form in which one nucleus after another is slowly invaded until the whole nuclear oculomotor substratum is destroyed or nearly destroyed ; (2) a form in which two or more of the ocular nuclei are attacked slowly but practically at the same time ; and (3) a form in which a chronic condition of partial paralysis is left after an acute nuclear ophthalmoplegia (although perhaps in a strict sense this class should not be included under forms of chronic nuclear ophthalmoplegia). Chronic nuclear ophthalmoplegia may be asso- ciated with such diseases as multiple or combined sclerosis, Fried- reich's ataxia, tabes, paretic dementia, progressive muscular atrophy, syringomyelia, and bulbar paralysis of a general type. One of the distinctions usually made in chronic nuclear ophthalmoplegia is be- tween the stationary and the progressive form. Most of the so-called stationary chronic ophthalmoplegias do not, of course, in a strict sense deserve this name. A certain degree of ophthalmoplegia, usu- ally symmetrical and confined to the extraocular muscles, is reached after a variable but comparatively short period ; then little or no 836 NERVOUS DISEASES. progression is made for another period, also variable, but often quite long^ — it may be months or years. The symptoms have remained stationary for at least ten years. In the genuine progressive variety the disease slowly but surely saps the vitality of the whole nuclear apparatus. A form of what might be termed congenital chronic nuclear ophthalmoplegia is somewhat rarely observed. Most fre- quently it is bilateral and involves only a limited number of the nuclei. Double congenital ptosis is a comparatively common affec- tion, and may be nuclear. When cortical it is much more fre- quently unilateral. Instead of double ptosis the congenital nuclear affection may be a bilateral paralysis of the abducens or of any one of the series of extraocular muscles, although such double congenital paralysis of the fourth nerve is extremely rare. Either the nuclear paralysis of the intraocular muscles is an affection of extreme rarity or the cases have not been observed or recorded. It is often a matter of exceeding difiiculty to decide in congenital cases whether cortex, subcortex, nucleus, nerve trunks, or muscles were the parts pri- marily attacked. A form of chronic nuclear paralysis is occasion- ally seen in young children who have apparently been born with normal ocular apparatus. Such cases may occur in more than one member of the same family, and they probably simply represent another type of the so-called family affections of teratological or de- generative character. Radicular or Fascicular Oculomotor Paralysis. — It is a rare occurrence to find an ocular or any other form of cranial nerve pa- ralysis caused by a lesion strictly limited to the root fibres of the nerve affected. Although the course of these radicles is in some instances long, — as, for example, in the case of the abducens, — the rootlets run in such close connection with other important structures that the paralysis is not likely to be isolated. It is therefore a diag- nostic point of some importance to know that when abducens or fourth nerve paralysis, but especially the former, is associated with facial or trigeminal symptoms of the same side, and anesthesia or paralysis of the opposite side referable to lesion of the lemniscus or pyramidal tract, the lesion producing this combination of phenomena, so far as the ocular affection is concerned, is probably radicular. In other words, some of the forms of alternate hemiplegia — cranial nerve paralysis of one side, with paralysis of the extremities of the other — are produced by lesions which involve the root fibres of the cranial nerves. Alternate Hemiplegias of the Ocular Type. — The best known forms of alternate hemiplegias are those in which the arm and leg of the opposite side and the face of the same side as the lesion are para- lyzed. These alternate hemiplegias have already been considered (page 572). It will only be necessary here to direct renewed atten- tion to the fact that lesions situated on the ventral surface of the DISTURBANCES OF OCULAR MOVEMENTS. 837 crus at about its junction with the pons or in the cei)haloventral segment of the pons may give rise to the oculomotor or third nerve type of alternate hemiplegia or to a paralysis in which both third and fourth nerves may be affected on the same side, and the face, limbs, and body on the opposite side. Alternate hemiplegia in- volving the abducens alone is necessarily very rare, owing to the close relations which this nerve has with the facial and auditory nerves at its nucleus, in its course, and at its superficial origin. In such a case paresis of the rectus externus on the side opposite to the abducens paralysis is usually present, owing to the physio- logical and anatomical association of the nerves supplying the rectus externus of one side and the rectus internus of the other. This form of alternate hemiplegia is accompanied by some conj ngate paralysis, but close examination will show that paralysis of the abducens of one side predominates as a symptom over the loss of the power of conjugate movement. Fig. 397. Complete paralysis of the right third nerve ; partial paralysis (jf left internal rectus {left divergent squint and limitation of movement inward) ; pupils unequal, the right nonresponsive to light, the left reacting to light and shade. Hemiplegia with Irregular Varieties of Oculomotor Paraly- sis.— Instead of alternate hemiplegia of the ocular type, now and then hemiplegias with irregular varieties of oculomotor paralysis are 838 NERVOUS DISEASES. observed, as in the case shown in the illustration Fig. 397, which is an enlarged view of the face of the patient whose full length pho- tograph is given in Fig. 308, page 574. This case was one of right hemiplegia with strong contractures involving the affected limbs, with marked atrophy in the upper extremity, with less complete paralysis of the right third nerve, and with limitation of the move- ments of the left eye. Dr. Charles A. Oliver has furnished me with the following ophthalmic examination of this case: "Vision with the right eye is lowered to one sixth of normal, that with the left eye being reduced to one tenth of normal. Accommodative power is very much lessened, especially in the left eye. The eye grounds are apparently free from any coarse changes. The pupil of the right eye is one third larger than that of the left- eye, which is two milli- metres in size. There is want of response of the right iris to light stimulus, with doubtful reaction of the left. The right superior and right inferior straight muscles are paralyzed. A slight action of the right external rectus muscle is obtainable. The right internal straight muscle almost entirely fails to act. The levator of the right lid is pal- sied, and the palpebral fissure is narrower than that of the fellow eye. The upper fibres of the right orbicularis muscle are less paretic than those of the corresponding lower portion. The lateral and vertical movements of the left eye are somewhat impeded, the excursions of the globe being accomplished by a series of coarse oscillatory motions. The left orbicularis muscle has good action." In this case the lesion was probably syphilitic and irregularly diffused or multiple,— a gummatous meningitis with some infiltration of the substance of the brain, one lesion being at about the superficial origin of the right third nerve, the other in the left half of the pons, so situated as to affect the pyramidal tracts and also some of the root fibres and asso- ciation bundles of the ocular nerves. Pareses or Paralyses of Ocular Muscles associated with Forms of Hemianesthesia. — Paresis or paralysis of one or more of the ocular muscles is sometimes found in association with hemi- anesthesia or even with partial bilateral anesthesia of the trunk and limbs. The anesthesia is usually of the dissociated type, —always in my experience partial or complete loss of the senses of pain and tem- perature. The most common combination probably is that of abdu- cens paresis with loss or partial loss of pain and temperature sense on the same side. I ha\e seen a number of such cases, with a clear syphilitic history, in which the patients had sudden attacks of ver- tigo, without unconsciousness, immediately after which they suffered from lateral diplopia with pathic and thermic hemianesthesia. These cases, under time and antisyithilitic treatment, usually greatly im- prove, but as a rule do not entirely recover. The diplopia sometimes disappears, the impair(Hl sensation remaining, but in lessened degree. The syndrome would seem to be due to some form of focal lesion DISTURBANCES OF OCULAR MOVEMENTS. 839 affecting the substance of the pons, so as to invade the lemniscus and the abducens or third or fourth ner\'e root fibres, or the fibres which associate the ocular nuclei may be affected instead of the true root fibres of the uerves themselves. Ocular Paralyses caused by Gross Lesions at the Base of the Brain. — A small gross lesion implicating any or all of the cranial nerves to the ocular muscles can be located with considerable accu- racy in any one of several ijositions at the base of the brain. In doing this one of the chief dependences will be on the associated symptoms. Sometimes cranial nerves and encephalic tracts on both sides of the mesal line are evidently involved in the disease. Be- sides the nerves to the ocular muscles, the nerves most likely to be included are the ophthalmic division of the fifth, the optic, the olfac- tory, and the branches of the sympathetic which run in and near the cavernous sinus. The symptoms associated with a third, sixth, or fourth nerve palsy in the case of a gross lesion at the base of the brain ■will, therefore, usually be such as anesthesia in some of the subdivi- sions of the fifth, and especially in the distribution of its first branch ; vasomotor and trophic phenomena referable to implication of the fibres of the gangliated system ; partial or complete blindness from involvement of the optic nerve, and anosmia, parosmia, or some affection of smell from lesion of the olfactory nerve. In addition to these cranial nerve symptoms a hemiplegia from pressure upon the descending pyramidal tracts may be present. Both the internal and the external ocular muscles are, as a rule, conjointly attacked in such basilar lesions. Complete unilateral ophthalmoplegia is usually due to a gross lesion at the base. A case of this kind was studied by me in the Philadelphia Hospital. When first examined, the left eyeball was completely immobile and protruding, ptosis being almost complete. The pupil of the same eye was dilated and nonre- sponsive to light and to accommodation. Among the diagnoses sug- gested by different members of the staff were neuritis, gross lesion of the orbit, cavernous thrombosis, basic meningitis, aneurism or tumor at the base, and nuclear ophthalmoplegia. My own final diagnosis was thrombosis of the cavernous sinus with associated hasic meningitis. Hearing and smell were impaired on the left side, and during the progress of the case the patient became totally blind in the left eye. Sensation to touch, pain, and temperature was at first abolished or greatly impaired in both the first and the second division of the fifth nerve. Under treatment with sodium iodide and mercurial inunction the pain and other active symptoms diminished, the area of anesthesia was reduced so as to be confined strictly to the distribution of the first branch of the trigeminus, and her mental condition improved. Ooupland has recorded a similar but bilateral case with autopsy which showed a considerable basic meningitis, the third nerves being embedded in the exudation. The 840 NERVOUS DISEASES. cavernous sinus on each side was completely occluded by a thrombus of old date. Ocular Paralyses due to Orbital Lesions. — Any or all of the muscles of the eye may be involved in an orbital neoplasm, abscess, or inflammatory disease of the orbit. The loss of movement may be dependent either on pressure or on the pain which results from such movement, or in part on both. A paralysis due to lesion of the muscle substance is rare, but edema at the insertion of the muscle or of several muscles may be present and will be accom- panied by pain which may partially or completely inhibit ocular movements. Some poisonous drugs may paralyze ocular as they may other muscles. When the inferior oblique and internal ocular muscles of one side alone are affected, the case is not improbably due to an orbital lesion, for, as has been shown, an offshoot of that por- tion of the third nerve which goes to the inferior oblique passes to the ciliary ganglion, and, as the ciliary muscle and the iris are sup- plied from this ganglion, if the case is one in which the syndrome is paralysis of the inferior oblique with internal ophthalmoplegia and anesthesia, the lesion is probably orbital, — one involving the ciliary ganglion itself, and the nerve branches between it and the inferior oblique and internal ocular muscles. When an ocidar paralysis is due to a tumor or an inflammation in the orbital cavity, exophthal- mus will usually be present, and the optic nerve, as well as the nerves to the ocular muscles, will generally be involved. In time atrophy of the nerve, with partial or complete blindness, may result. In congenital oculomotor palsies the muscles within the orbit may be atrophied or absent, although in these cases the lesion may not be in a strict sense one of the orbit, but rather one of arrested develop- ment, the levator palpebrte and the superior rectus being the muscles the development of which is most fi'equently arrested. The orbital foramens offer opportunity for trouble by the growth of exostoses. Fracture is another cause of orbital paralyses. Etiology. — The Association of Disturbances of Ocular Movements with Degenerative Constitutional and Infectious Diseases. In the con- sideration of the etiology and pathogenesis of the aifections of ocular movements treated in the present chapter it is particularly necessary to keep in mind the frequent association of these disorders with various degenerative, constitutional, and infectious diseases. In a broad sense a discussion of the relations between these diseases and the disturbances of ocular movements constitutes a most important portion of the etiology of oculomuscular disease. Eeference has al- ready been made incidentally to some of these associations. Among these degenerative diseases are paralytic dementia, tabes, multiple sclerosis, Friedreich's ataxia, progressive muscular atrophy, and syringomyelia ; and among important constitutional and diathetic affections are syphilis, tuberculosis, rheumatism, gout, lithemia, dia- DISTURBANCES OF OCULAR MOVEMENTS. 841 betes, and exopMhalmic goitre. Diphtheria, scarlet fever, measles, influenza, and cerebrospinal fever are in this respect the most imf)or- tant infectious diseases. Degenerative Diseases with Disorders of Ocular Movements. It will be remembered that Eedlich investigated the occurrence of special disturbances of the direct and consensual iritic reflexes in paretic dementia (see page 822). The subject has claimed the attention of many other alienists and ophthalmologists. According to Bevan Lewis, the eye symptoms in general paralysis form a highly charac- teristic and significant group. Both the extrinsic and the intrinsic muscles suffer. The extraocular muscles present derangements in exceptional cases only, while the intraocular muscles are affected in some way in all cases at some stage of the affection. He summarizes the most frequent motor derangements as follows : (1) spastic myosis ; (2) paralytic mydriasis ; (3) all degrees of irregularity of pupil ; (4) irregular contour from partial spasm or paralysis ; (5) loss of sympa- thetic reflex ; (6) loss of consensual movements ; (7) reflex iridople- gia (Argyll -Eobertson pupil) ; (8) associative iridoplegia ; (9) cyclo- plegia. According to Oliver, the oculomotor symptoms of the third stage of general paralysis of the insane show paretic and paralytic disturbances connected with the oculomotor apparatus itself, all of greater amount and of more serious consequence than those seen in the same apparatus during the second stage of the disease. In a large percentage of cases of tabes some disorder of the ocular muscles is sooner or later present. The enumeration of these motor derange- ments occurring in paretic dementia would apply almost absolutely to tabes ; probably cycloplegia is of less frequent occurrence in the latter. It is weU known that a more or less transient diplopia is one of the frequent symptoms in the early stages of this disease. Examination may show no definite paralysis of any ocular muscle, while in other cases, even in the early stages, such paralysis, or an insuificiency which borders on a true paresis, may be readily determined. In- stead of loss of power a true ataxia of the ocular muscles is occasion- ally observed. In one case recorded by Althaus the patient had the greatest difficulty in combining the ocular muscles to synergetic ac- tion. He easily saw double, and any sudden purposive movement of the eyes distressed him. It was exceedingly difl&cult for him to look upward, although the muscles concerned in this movement showed no trace of paralysis. Extensive investigations have been made upon the occurrence of affections of both the optic nerves and the ocular muscles in disseminated sclerosis. TJhthoff found from a study of one hundred cases of multiple sclerosis that paralysis of the ocular muscles, nystagmus, and nystagmic tremor may exist in this affection either separately or combined. Paresis of the ocular muscles was found in seventeen cases, and pronounced ophthalmoplegia externa in two instances, but in all the pupils reacted normally to light and 842 NERVOUS DISEASES. accommodation. In two cases upon convergence slight contraction was barely perceptible, and in a third case it was absent in one eye. Nystagmus and nystagmic tremor are of somewhat frequent occur- rence both in tabes and in disseminated sclerosis. In Friedreich's ataxia a peculiar form of nystagmus is often one of the late symp- toms. Friedreich belicAed this nystagmus to be due to disease of the ocular nuclei. It would seem more probable that it is dependent not only upon affection of the nuclei but on disease affecting the tract associating these nuclei together or uniting them with other parts of the brain. In progressive muscular atrophy both dilatation and con- traction of the pupils have been observed. Commonly the contrac- tion is unilateral, and it is probably dependent upon the degenera- tion attacking the ciliospinal centre. Ptosis, single or double, and other forms of extraocular paralysis have been recorded, but some of these cases may have been part of the syndrome of syringomyelia, which was formerly not clearly distinguished from amyotrophic lateral sclerosis and chronic muscular atrophy. A few cases of partial ex- ternal ophthalmoplegia have been recorded as occurring in syringo- mj'elia. The pupils are occasionally unequal. Iridoplegia and cy- cloplegia are not present. I have seen several interesting cases of syringomyelia with ocular and other bulbar symptoms. A man had had two apoplectic attacks, without loss of consciousness, six or seven years before. Lateral rotation of the eyes to the right and left was greatly restricted, and he had partial double ptosis. The arm and leg of the left side were paretic, as was also the right side of the face, particularly in its lower part. Irregularly distributed anes- thesia to pain and temperature was present in both lower extremities. In this case a gliomatous process had probably attacked the lower portion of the spinal cord and the upper central region of the bulb. Nystagmus is a symptom of rare occurrence. Constitutional and Diathetic Diseases witli Disorders of Ocular llove- ments. Fully fifty per cent, of all cases of paralysis and spasm of the ocular neuromuscular apparatus can be attributed to syphUis, and among the forms of syphilitic disease which cause these disorders are gummatous meningitis, encephalitis, neuritis, and disease of the bloodvessels, such as nodose periarteritis. Syphilis exerts its influ- ence upon the muscular apparatus both directly and indirectly, the symptoms sometimes being due to pressure, at other times to de- struction or irritation or to both. The degenerative diseases which attack the oculomotor nuclei and tracts are in some instances para- s>'philitic ; in other words, they are the remote effects of syphilis which has set afoot processes whicli have determined the occurrence of degeneration. Tuberculous processes, and especially the basal form of tubercular meningitis, are often the direct causes of paralytic or spasmodic affections of the ocular muscles. Eheumatism acts chiefly as a peripheral cause, and sometimes attacks special branches DISTURBANCES OF OCULAR MOVEMENTS. 843 of single nerves, or even the muscles themselves, or the nerve endings in the muscles. When the external rectus or any other of the extra- ocular muscles is paralyzed apparently as the result of exxjosure, rheumatic neuritis or myositis may often be presumed. Eheumatic affections of the ocular muscles do not, however, usually present themsehes during the acute rheumatic attacks of the articular ^a- riety. True gout sometimes originates ocular disorder, and menin- gitis or neuritis may involve the ocular as well as other nerves in its progress. Eisley has called attention to the fact that lithemia is both a primary and a modifying factor in many ocular discomforts and disturbances. Paralyses of the extiaocular muscles, and espe- cially of the rectus externus, have been noted in a number of cases of diabetes. Oculomotor paralysis is occasionally seen in association with exophthalmic goitre. Usually both the internal and external recti are affected, or complete ophthalmoplegia may be present. Schlesinger has reported a case with exophthalmus, tachycardia, and enlarged thyreoid, — a typical case of Basedow's disease. When the patient extended her fingers they presented a fine tremor. When the eyes followed an object in an ascending plane the lids remained stationary, but not so in a descending plane. The right superior rectus muscle was paralyzed, an observation never before made. Eecklinghausen has shown that in exophthalmic goitre a fatty de- generation of the muscles of the eye may occur. Other observers hold that the paralysis may be due to disease of the oblongata or of the peripheral nerves. Disorders of Ocular Movements accoynpanying Infectious Diseases. Almost any form of infectious fever may be accompanied or followed by some type of ophthalmoplegia. The ocular muscles are particu- larly likely to suffer after diphtheria, and cycloplegia is the most frequent of the ocular disorders. The disorder of accommodation may be overlooked, especially in myopic patients, but it is of so marked a character in others, if they are old enough to use their eyes for reading or other forms of near vision, that it is readily recognized. Iridoplegia may be present, but is of much less fre- quent occurrence, and forms of external ophthalmoplegia are com- paratively common. Of these the paralysis of the external recti is most frequent, and, as would be expected, this is often associated with paralysis of the ciliary muscle. Ptosis, total paralysis of all the muscles supplied by one third nerve, and almost complete paralysis of almost all the muscles of one side have been observed. (Gowers.) It is probable that not a few of the cases of diphtheritic paralysis of the muscles and ocular paralysis associated with other forms of infectious disease are due to forms of acute nuclear ophthalmoplegia, but if this is the case the inflammation is in most cases benign, as most of them recover. Diplegia and oculomotor paralysis have been observed after measles, cerebrospinal fever, influenza, and malaria. 844 NERVOUS DISEASES. Disorders of Ocular Movements of Toxic Origin. In the production of disturbances of ocular movements, poisonous substances, whether introduced from without or formed within the body, are related in their mode of action to constitutional and diathetic diseases, and especially to the infectious fevers. Their action, like that of these fevers, may be purely toxemic, they not having given rise to inflam- mation of either the nerves or the brain substance. Changes in structure and the symptoms which result may, in other words, be dependent, in many instances at least, upon the direct influence of the poisonous agent, or on a ptomaine or ptomaines generated in the blood. Alcohol, nicotine, lead, arsenic, carbolic acid, chloral, gel- semium, — in fact, almost any of the poisons which have been already discussed under the toxic amblyopias, — may be more or less influen- tial in the production of the disorders of ocular movements. Gutmann reports a case of bilateral acute ophthalmoplegia following the use of spoiled meat, in which the paralysis affected all the external and internal muscles of the eye, and disappeared after two weeks. Other similar cases have been recorded. In the affection known as asthenic bulbar paralysis the ocular muscles are sometimes affected, ptosis with some involvement of the third or the sixth nerve being among the recorded symptoms. Although these cases are sometimes rapidly fatal, in some instances they are curable. The most reasonable ex- planation of the origin of this aifection is the production in the system of poisons of exogenous or endogenous origin, these toxic substances exerting their most baneful influence on the ganglionic cells of the motor system, and especially on those of the bulbar region of the brain. Congenital Ocular Paralyses. When speaking of bulbar paralysis of the sixth nerve, reference was made to the congenital origin of some of the forms of paralysis of the nerves supplying the ocular muscles. The exact pathological nature of these paralyses is not settled, or at least the lesions are probably different in different cases. It may be said in general terms that most of them are due to special forms of arrest of encephalic development : in most cases probably the nuclei are involved. In rare instances some of the ocular muscles have been entirely absent ; in other instances they are inserted abnormally. Affections of the Third ^erre in Mif/raine. It is well known that visual symptoms, and especially forms of spectra, are of frequent occurrence in attacks of migraine. Transient oculomotor paralyses also sometimes constitute a part of the symptomatology of this dis- order. The paralyses are temporary, but often recur in the same patient at irregular intervals. Suckling, for example, reports a case of migraine followed by temporary paralysis of the third nerve, in a young man eighteen years old who had suffered since infancy with severe headaches, which gradually increased in frequency. The DISTURBANCES OF OCULAR MOVEMENTS. 845 patient during his attaclts had to remain in bed two days without sleep or food. The eye affection was first noticed in infancy, and had frequently recurred. The left eyelid began to droop when the pain was wearing off, and in twenty-four hours had completely dropped. On two occasions the eye had turned outward. This case is a type of a number of others that have been reported, although the ocular paralytic phenomena assumed somewhat different appearances. Becwrrent and Relapsing Oculomotor Paralysis. Interesting forms of transient oculomotor paralysis have been observed. One of these, of organic origin, can usually be traced to syphilis. Some or all branches of the third nerve may be involved, and in rare cases the fourth and sixth nerves may be implicated. The affection frequently attacks children ; and in one of the cases reported local meningitis was discovered after death. Headache, nausea, and general malaise accompany the disorder. The cases are sometimes of rapid and at other times of slow development. Sometimes anesthesia and pares- thesia of the face, trunk, or limbs are present. The cases of approx- imate recovery between the attacks are much more frequent than those in which the recovery is complete. Instead of complete re- covery with recurrence it is perhaps better to speak of what usually happens as periodical exacerbations. Some of the organic cases are gliomatous rather than syphilitic ; but, whatever their pathological origin, these cases must be carefully separated from those forms of transient oculomotor paralysis just considered which follow attacks of migraine. A few cases of recurrent paralysis of the third nerve with autopsy have been reported. It is of great interest to note that in all of these, in spite of the various theories advanced, some form of local disease of the nerve, as tubercle, fibroma, or meningitis, was found ; but, as Jeffries remarks, in citing these cases they could not he called instances of true recurrent paralysis, since a certain amount of paresis had remained between the spells, but they were rather paresis of the third nerve with recurrent exacerbations. Gowers gives some interesting details as to the time of onset and methods of recurrence of some of these forms of ocular palsy. The attacks may begin in early childhood, and even in infancy, and may continue to middle life or even later. They may occur at about the same time each year, or at intervals of six months. Ifo fixed limit, however, can be placed to the time of absence or recurrence, as in some in- stances they are exceedingly irregular. The attacks incline to be long when the intervals between them are long, and the reverse. The same authority describes a special form of relapsing ocular palsy which occurs usually in syphilitic subjects and has a particular tendency to relapse and persist. "One third nerve becomes para- lyzed, improves under treatment, and then, perhaps while the treat- ment is being continued, the other third nerve suffers, and after- wards the affection of the first returns." 846 NERVOUS DISEASES. Ocular Paralysis of Hysterical Origin. Forms of ocular paralysis and spasm are sometimes observed in hysteria. Weir Mitchell has described a form of ptosis usually met with in women. He belie^•es it to be of hysterical origin. In a large experience he had never encountered a case among men, and this accords with my own expe- rience. Mitchell describes it as a "simple, quiet closing of the lids, and a resistance on attempting to lift them with the fingers, and also an absolute incapacity for a time to raise them by the will." This affection usually comes on in women who are neurasthenic or hys- terical, and may have an emotional origin. MisceJhuieous Causes. Among causes not enumerated in the above paragraphs are injuries either directly to the nerves and muscles or involving the nuclei or trunks of these nerves at the base of the brain. In some instances fracture of the orbital walls has resulted in special forms of oculai' paralysis. That some of the affections of ocular movement are due to disorder of refraction is now universally recognized, although perhaps too much stress is laid bj' some enthu- siasts upon this etiology. Some cases of ocular paralysis not other- wise explicable are vaguely attributed to reflex disturbances, and it is i)ossible that a focus of extreme irritation like a diseased and painful tooth may cause ocular paralj'sis by reflex inhibition, but such cases are, in my opinion, rare. A purely functional ophthal- moplegia is also very rare, and yet cases have been recorded which Fig. .399. would seem to be capable of no other explanation. Fig. 398. X^- /// ^ mi . W .o Microscopical section of right oculomotor nerve, showinR complete degeiicnition and almost total clLsapjiearanco of the nerve fibres. High magnitiiation. Specimen from case shown in Figs. liS.'i and 3,S(i. Microscopical section of right oculomotor nerve, showing complete degeneration and almost total disappearance of the ner\'e fibres. Low magnitieation. Specimen from case shown in Figs. 385 and 3,H6. Pathological Anatomy. — The pathogenesis and pathological anatomy of the disorders of ocnlai' movements have been more or less fully considered in the discussion of special forms of these disorders in the previous pages. In syphilitic cases the lesions are DISTURBANCES OF OCULAR MOVEMENTS. 847 Fig. 400, those which have been so often described as occurring in the course of encephalic syphilitic disease, no matter where it may be situated,— gummatous meningitis, focal or diffuse encephalitis, isolated or mul- tiple neuritis, inflammatory disease of the large or small bloodvessels, and degenerative processes set up by the remote effects of the syphi- litic virus. In one of my cases of third nerve paralysis almost the en- tire series of syphilitic findings were present. CFig. 387, page 817.) Illustrations, drawn by Dr. Mary Alice Schively, are shown of the microscopi- cal sections of the oculomotor and optic nerves, and of the gummatous formation with diseased vessels which was present in the Sylvian fossa. (Pigs. 398, 399, 400, 401.) Some of the many changes which have been found in nu- clear and peripheral cases may be summarized. Miliary hemorrhages have been present throughout the central gray matter of the third ventricle, the aqueduct, and the preob- longata. In some cases more or less extensive degeneration of the nuclei has been present, and this degeneration may be altogether similar to that which was found in chronic muscular atrophy. Gross lesions of all sorts have been discovered, as myelitis, tumor, and endarteritis. The well-known pathological conditions present in tabes, multiple sclerosis, and general paralysis have of course been noted. (Jeffries. ) Of syphilitic disease of the mem- branes as a cause of eye paralysis Jeffries says that it is usually in reality a more or less diffuse gummatous or round cell growth spring- ing from the dura and skull ; and these growths, though small in size, can produce great mischief by creeping along the base of the skull and crowding the foramina. In the acute form of ijoliomyelitis superior hemorrhagica autopsies have shown in several cases numer- ous punctiform hemorrhages in the central cinerea. In one case, which lasted twenty days, commencing degeneration of the nuclei was found, being most advanced in the abducens and hypoglossus, less in the motor oculi, and least in the trochlear ncr\-e. In the chronic progressive form of nuclear paralysis the changes usually consist in Microscfipical section of right optic nerve, from the cape of third nerve paralysis shown in Figs, :>8.5 and 386, showing new fibrous formation, round cell infiltration, and some degeneration of the nerve fi bres. 848 NERVOUS DISEASES. atrophy and degeneration of the nuclei and roots, although some intact ganglionic cells are found in almost all cases. Ependymitis with secondary degeneration of the cinerea is another cause. Fig. 401. ^^^:s#s^ ; Microscopical section sliowing gummatous formation and caseation, endarteritis, and peri- arteritis, and involvement of the meninges and brain substance, from the case shov^Ti in Figs. 385 and 386. Diagnosis. — While the subject of diagnosis is of great importance in connection with disorders of ocular movements, as elsewhere, little needs to be added to what has already been given under various heads. The methods of focal diagnosis have been detailed when dis- cussing the symptomatology of lesions isolated to the different nerves sujiplying the ocular muscles, and of lesions of various points in the oculomotor pathway from the cortex to the orbit. As it is practi- cally impossible to examine the ocular muscles electrically, we are shut out from this method of differentiating peripheral from central ocular paralysis, and must rely rather on the differences in symptom- atology. The diagnosis of the nature of the lesion causing the ocular affection may be materially assisted by a study of the associated dis- eases and symptoms. When, for instance, oculomotor and oculopu- pillary phenomena are present in cases of tabes, multiple sclerosis, or paralytic dementia, the disease causing them is almost always of a degenerative type ; and when they are due to lesions limited to peripheral ocular nerves or their nuclei, syphilitic lesions are their most frequent cause. The diagnosis of organic from functional or hysterical cases is usually not difiacult, although recurrent forms of transient oculomotor paralysis may be due to syphilis, neurasthenia, or hysteria. When dependent upon the first of these causes, although the paralysis is transient and recurs it rarely disappears entirely ; some evidences of its presence can nearly always be discovered on careful examination. The ocular type of asthenic bulbar paralysis DISTURBANCES OF OCULAR MOVEMENTS. 849 can scarcely be diagnosticated with certainty at an early period. It will be remembered that it comes on usually after feelings of great fatigue and rapid exhaustion in all the parts which are eventually affected, and that no constitutional or other cause can be determined. But this subject will be more fully treated later. Ocular palsies and spasms of hysterical type are to be differentiated chiefly by a search for the stigmata of hysteria. It needs only to be remembered that hysteria and organic disease of the encephalon may be present in the same case. The absence of the pupil reflex is usually, and I believe correctly, regarded as significant of organic disease, although Karplus called attention to its absence in what he believed to be attacks of hysteria, and Fere seems to have noticed this before. Karplus' s observations were made in the clinic of Prof. Krafft-Ebing, who con- firmed the diagnosis and the fact of the absent reflex. The latter was also confirmed by the ophthalmologist Bernheimer. The obser- vations were made by having the lids held apart, the eye being illu- minated by a hand lamp and the cornea protected by a salt solution. Thus the eyes could be observed for several minutes. The pupils were wide open and motionless for twenty seconds. These observa- tions, if confirmed, will make it necessary to use with reserve the absent pupil reflex as a negative pathognomonic sign in suspected hysteria. It is necessary to be on one's guard against accepting too readily the statement that the absence of the pupil reflex in this case was purely an hysterical phenomenon. A nuclear degeneration or a toxine acting upon the nucleus for the sphincter iridis might have been the cause of the phenomenon. "To make the diagnosis of pa- ralyses of the ocular muscles, it is not sufficient to know the signs of the paralysis of each individual muscle and then see to which of them any case that may be before us fits. In this way, to be sure, we would quickly make the diagnosis in the typical and uncomplicated cases, but In the numerous cases of combined paralysis we would be helpless. A much more proper way of going to work is to determine exactly all the symptoms in any given case, and from them find out in what direction the motility of the eye is incomplete." (Puchs.) Prognosis. — The prognosis of disorders of ocular movements varies according to the nature and the site of the lesion. Cases occurring in the course of degenerative diseases are necessarily un- favorable in prognosis, as they are portions of a disease which tends to tissue death. Cases which are due to syphilis vary in prognosis according to the nature, extent, and destructive influences of the lesion. Gummatous meningitis gives a comparatively favorable prognosis, although when the meningitis is associated with infiltra- tion of the brain substance recoveries are usually only partial. When the lesion causing the ocular affection is an embolus or a thrombus the prognosis is unfavorable, at least so far as the per- sistent affection is dependent upon the destructiveness of the lesion ; 54 850 NERVOUS DISEASES. but in some of these cases, as in other affections due to embolism and thrombosis, the early symptoms are more pronounced and extensive than those which persist, a fact which is of course explained by the acute conditions which aie present at first and which disappear in whole or in part as the result of the establishment of collateral cir- culation. The prognosis in diseases like tubercular meningitis is simply that of the general affection. The discussion of recurrent and relapsing cases has sufficiently indicated their prognosis. In infectious aud toxic cases and in those due to neurasthenia, or those which form a part of the syndrome of hysteria, the prognosis is good. Cases due to neuritis, whether syphilitic or rheumatic, afford a comparatively favorable prognosis, as do also those associated with affections like gout and lithemia. Treatment.— Strychnine or nux vomica is the most valuable of stimulating drugs in the treatment of oculoparalytic affections. It should be given in full or augmenting doses, and may be used by the mouth or hypodermatically. In some cases the hypodermatic use of strychnine nitrate appears to be of great service, as it is in optic nerve atrophy. In rheumatic cases, in the acute stage the sali- cylates and such remedies as the potassium and sodium carbonates may prove of great service, and pilocarpine and other diaphoretic drugs may also be of value. Hysterical eases are to be treated by methods applicable to hysteria of any form, — by tonics and nutrients, by static electricity, and by various forms of suggestion. Even hyp- notic suggestion may here be useful. Syphilis attacks the neuromus- cular apparatus in a variety of ways, — through disease of the blood- vessels which supply its centres and peripheral portions, through tumors, through gummatous meningitis, and by arousing into activity processes which eventually lead to degeneration. A consideration of these different methods in which syphilis acts on the nervous system will be helpful in the details of treatment. If the patient is believed to be suffering from a recent and more or less acute lesion, such as a neuritis of the third, sixth, or fourth nerve, or an active giimmatous meningitis, specific treatment should be pushed heroic- ally. The patient should at once be put upon the hypodermatic use of mercury, or on inunctions, after the method already described (see page 225). As soon as constitutional effects are produced, this treatr meiit should be emphasized by the use of the iodides and hydi'iodic acid. If the lesion is of older date and more organized, — a gumma or a fibroid meningitis, for instance. — then both mercurial inunction and the iodides should be actively pn.shed. If the lesion is one of a destructi^'e character, the indirect result of disease of the vessels, due, for instance, to thrombosis or endarteritis of terminal vessels, some good may be accomplished by the persistent but moderate use of antisyphilitic treatment, but the destructive portion of the lesion will remain in spite of any treatment, which will only retard future DISTURBANCES OF OCULAR MOVEMENTS. 851 and more rapid iuroads on the vessels. If the disease, although due to syphilis, is of degenerati^^e type, si)eoific treatment will be of no avail. Such cases are helped most by tonic aud nutrient treat- ment. When it is impossible to remo\'e diplopia, and Mhen the double images cannot be discarded by the patient, various means may render this condition more bearable. In rare cases prisms can be used to fuse the images, but in true ocular paralysis this vill usually not succeed. The affected eye may be covered with a patch or a piece of ground glass, or an opaque disk of any kind may be put in the spectacle frame over the affected eye. The question of operative procedure in cases of ocular paralysis, insufdciency, and spasm is one that belongs almost exclusively to the ophthalmolo- gist, but in neurological practice it is sometimes necessary to give opinions as to the propriety of such procedures and to differentiate the cases in which they should or should not be resorted to. Some of the questions presented for decision are such as the following. It is first necessary to decide whether the insufficiency, paralysis, or spasm is due to intracranial lesion or to errors of refraction. If due to the latter, in some cases partial operations or progressive tenotomies are desirable, but these cases are not so numerous as their enthusiastic advocates would have us believe. An experience extending over many years has led me to this conclusion, although I am convinced that in a comparatively limited number of cases tenotomies and partial tenotomies are useful in relieving the nervous and other symptoms dependent upon eyestrain. If the affection of the ocular muscles is dependent on an intracranial lesion, the question arises whether an operation can do any good. In rare cases tenotomy may be of transient service, but as a rule oiDcration should be avoided, as it should be likewise in cases of degenerative disease with associated ocular disturbances. The suspension treatment used in tabes and disseminated sclerosis is said to have resulted in relief of the ocular symptoms. Michel has suggested a mechanical treat- ment to stimulate the weakened muscles, in practising which the eyeball is drawn backward and forward with force in the direction of the ordinary action of the affected muscle. Simple massage of the affected muscle has also been recommended. A galvanic current strong enough to reach the ocular muscles by direct application will most likely prove too irritating to either the external structures of the eye or the retina or to both. Possibly some good may be done in cases of partial paralyses of the peripheral type by carefully using very weak galvanic currents or faradic currents. A very small electrode covered with clean absorbent cotton which has been dipped in pure sterilized warm water should be applied over the muscles affected, the other large electrode being placed almost any- where, as at the back of the neck or at the side of the face. Another method is to apply one electrode over the closed lid. CHAPTEE IX. DISEASES OF THE TRIGEMINAL AND FACIAL NERVES, AND SMALL GROSS LESIONS OF THE PONS AND THE PREOBLONGATA. ANATOMICAL AND PHYSIOLOGICAL CONSIDERATIONS RELATING TO THE TRIGEMINUS. General Description of the Trigeminus. — The largest of the cranial nerves is the trigeminus (trigeminal nerve, trifacial nerve, fifth nerve). It-is a mixed nerve, having a motor portion (portio minor), and a much larger sensory portion {portio major). It is most in accord with recent investigations and the newer anatomical and physiological methods to consider separately the diseases of the sensory and the motor portion of the trigeminus, and they will in the main be discussed apart in different sections of the present chapter ; but it must not be overlooked that at and near their origins gross lesions may affect both, although this rarely occurs. A lesion, for instance, at the so-called "superficial origin" of the nerve, — which is in reality only the superficial origin for the motor portion, it being the point of entrance to the brain stem of the sensory portion, — if of sufficient size, will cause symptoms both motor and sensory ; and similarly a lesion might be so situated as to affect both the motor and the sensory nuclei or their intraencephalic or extraeucephalic roots, including in the latter the Gasserian ganglion. Outside of the skull the motor root joins the inferior maxillary division of the sensory j)ortion of the ner^'e, and again at this point a lesion might give symptoms of both a sensory and a motor character in the distribution of this division of the nerve. The anatomy of the trigeminus is of great complexity, both in its subdivisions and in its relations to other nerves and important structures. The distribu- tion and relations of its radicles are, as will presently be seen, exten- sive and complex. The larger, sensory portion of the trigeminus is usually described as passing into the Gasserian ganglion, but it should be spoken of rather as springing from this ganglion, which is its true source, its nucleus of origin. The motor part arises in a chief motor nucleus situated in the metepicelian floor. It probably also receives most or all of the fibres which pass downward from the so-called accessory nucleus in the mesencephalon (in the aqueductal cinerea beneath the quadrigemiua). The single axis cylinder processes of the neurons which originate in the Gasserian ganglion bifurcate, sending one set of their processes brainward to enter the lateral aspect of the pons, ramifying in the sensory nucleus of the pre- 862 ANATOMY AND PHYSIOLOGY OF THE TRIGEMINUS. 853 oblongata, some of the fibres passing downward to the superior cervical cord, and others ascending. The other branches of the bifurcating Gasseriau processes pass peripherally to form the dif- ferent sensory divisions of the nerve,— the first, or ophthalmic, the second, or superior maxillary, and the third, or inferior maxillary division. The great cell nests and roots of the trigeminus are shown iu Fig. 402. The central neuron of the motor trigeminus arises in Fig. 402. Scheme of trigeminal apparatus ; A, A, cortical centres for trigeminal movements ; B, cortical terminus of the trigeminal sensory tract ; C, thalamus to which the central trigeminal sensory tract may be in large part distributed ; D, accessory (motor) nucleus ; E, descending (mesence- phalic) root ; F, chief motor nucleus ; O, motor roots ; H, inferior maxillary nerve ; I, Gasserian ganglion ; J, sensory roots between the Gasserian ganglion and the pons ; K, ascending sensory root ; L, descending (spinal) root ; M, first or ophthalmic division of the trigeminus ; N, second or superior maxillary division. the cerebral cortex, probably in the lower extremities of the central convolutions, just behind the centres for laryngeal and i^haryngeal representation, and near the centres for the lips and tongue (Fig. 228, page 333) ; its downward course is not certainly known, but it 854 NERVOUS DISEASES. probably passes about the knee of the capsule behind the fasciculus for eye movements (Pig. 236, page 360), separates in the crusta from the bundle of Spitzka, decussates in the tegmental raphe, and ter- minates in tli(^ cells of the chief motor nucleus in the preobknigata. The i)eripheral motor neuron passes from this nucleus by way of the motor root of e,\it, (iventually to become a part of the inferior maxillary or mandibular nerve. Sensory Portion of the Trigeminus. — HeuHory Roots. The true nuclei of origin of the sensory portion of the trigeminus, as stated in the last paragraph and as shown in the diagram Fig. 402, are in the monopolar cells of the (iasserian ganglion. The large extraeucephalic sensory root of the fifth nerve is constituted by the union of the deli- cate brainward passing branches of the processes of these cells. Each of the fibres of this sensory root bifurcates after entering the pons, one branch ascending and the other descending, as first described by Eamon y Cajal. Van Gehuchten believes that the ascending branches of the sensory root pass into the descending motor root of the fifth, and with the latter to the postgeminum. This Eam6n y Cajal does not accept. The ascending branches of the sensory root, according to the latter, terminate in free ramifications in the substantia gela- tinosa. Although these fibres are extremely fine, from two to four collaterals are given off at right angles from them, and these, rami- fying between the cells of the substantia gelatinosa, form a thick plexus. The long and large spinal root of the trigeminus was formerly regarded as ascending froju the spinal cord ; but it is now known that it is comi3osed of the very numerous delicate sensory fibres which descend after their entrauce and bifurcation in the poi;s. Compared with the sensory fibres which take an ascending course, these de- scending branches are thick. They may be traced downward below the pyramidal decussation into the cord itself about as far as the second cervical segment, and it is possible that some fibres descend still farther. This is an important fact, and it is probalil>- due to this that sensation of the face is sometimes affected in lesions of the upper cervical region, as in syringomyelia. About the level of the decussation they occupy the place which Lissauer's zone has lower down, being directly lateral and dorsal to the substantia gelatinosa. This descending fifth root has a semilunar form, and consists of two layeis, a supcilicial one, formed of coarse fibres, and a deep layer, containing v(^rtical fibres which are separated by nerve cells and col- lateials. The fibres of both gi\'e origin to collaterals which ramity in the sul)stantia gelal inosa. The portion of the substantia gelatinosa in connection with the si)inal root is its end nucleus, and accoiupa- nies it thiimghout its course. The cell nest which has been called the sensory fifth nucleus is merely the l)elter developed pontile portion of this end nucleus. Collaterals from this spinal root pass in animals to the cell nests of t lie nu)toi' cranial nerves. From the end nucleus of the ANATOMY AND PHYSIOLOGY OF THE TRIGEMINUS. 855 fifth arise fibres which mingle with the fillet fibres, cross the raphe, and ascend in the tegmentum to the brain. The axis cylinders of the Fig. 403. Section of the pons at the point where the descending (spinal) root of the trigeminus bends out- ward : Centr. H. B., central tegmental tract ; Cenlr. V. Bahn, central tract of the trigeminal nerve ; Dir. sens. Cerehdlarbahn, direct sensory cerebellar tract ; Laqueus, lemniscus or fillet. The other structures represented in the illustration are indicated by their well known Latin names. (Edinger.) cells within the substantia gelatinosa constitute the central sensory tract of the trigeminus. These cells are divided into large and small, and the nerve processes, which ha^e here no collaterals, probably pass mesad to cross the raphe and then bend, taking a longitudinal direction to form this central sensory tract. (Koelliker and Eamon y Cajal.) The position, course, and relations of the sensory and motor roots of the fifth nerve are well shown in Pig. 404. Fibres pass from the sensory fifth root laterad of the prepeduncle of the cerebellum (Edinger' s sensory cerebellar tract. Fig. 4();3). Peripheral Course of the Sensor i/ Portion of the Trigeminus. The first or ophthalmic division of the fifth nei\ e passes along the outer wall of the cavernous sinus, in close relationship with the third and sixth nerves and with the ophthalmic artery and vein, dividing into 856 NERVOUS DISEASES. three branches, the frontal, the lachrymal, and the nasal. The fron- tal is the largest of the three branches, and subdivides into the supra- orbital and the supratrochlear. The entire ophthalmic nerve passes Frontal section of the preoblongata and pons of man : H, hypoglossal roots ; VI, abducens ; ¥11"^, facial nucleus; VII", facial root fibres; Vis, K^isory roots of fifth nerve; Fm, motor roots of fifth nerve ; III, oculomotor root fibres : Tr, trapezium ; Om, superior olive ; Lm, median lem- niscus; LI, lateral lemniscus; cVh?, cerebellar peduncle; 5A', decussation of the prepeduncles; Nr, red nucleus. (Koelliker.) from the skull into the orbit through the sphenoidal fissure. The second or superior maxillary division leaves the Gasserian ganglion, proceeds through the foramen rotundum, and then takes a horizontal course forward through the sphenomaxillary fossa ; next it passes ANATOMY AND PHYSIOLOGY OF THE TRIGEMINUS. 857 under the orbit and through the inferior orbital canal, emerging on the face at the infraorbital foramen. The third or inferior maxillary division, leaving the Gasseriau ganglion, passes downward through the foramen ovale to emerge with the motoi- subdivision at the base of the skull. The posterior or great sensory subdivision of this nerve divides into three branches, the auriculotemporal, the lingual, and the inferior dental. The numerous branches of the three great divisions of the fifth nerve are sufficiently indicated in the diagram with its legend (Fig. 405). Fig. 405. jnotor Sensory Inferior Dental lociBOi; '^Mental Branches of the fifth or trigeminal nerve. The main roots and subdivisions of the nerve are named on the illustration. Ophthalmic division : 1, recurrent branch to dura ; 2, frontal ; 3, su- praorbital ; 4, supratrochlear ; 5, nasal ; 6, branch to ciliary ganglion ; 7, long ciliary branches ; 8, infratrochlear ; 9, lachrymal. Superior maxillary division : 1, recurrent branch to dura ; 2, or- bital or temporomalar ; 3, Meckel's (sphenopalatine) ganglion ; 4, posterior dental ; 5, middle or external dental ; 6, anterior dental ; 7, infraorbital plexus ; 8, palpebral ; 9, nasal ; 10, labial ; n, ascending branches of sphenopalatine ganglion ; 12, superior nasal ; 13, nasopalatine (nerve of Cotunnius) ; 14, anterior palatine ; 15, infranasal ; 16, middle or external palatine ; 17, posterior or small palatine ; 18, pharyngeal ; 19, Vidian. Inferior maxillary division : 1, recurrent branch to dura ; 2, muscular ; 3, pterygoidal ; 4, otic ganglion ; 5, long buccal ; 6, auriculotemporal ; 7, chorda tympani ; 8, submaxillary ganglion ; 9, facial artery. (Hughes.) Trigeminal Cutaneous Areas. A knowledge of the cutaneous areas to which the trigeminal sensory nerves are distributed is of impor- tance to the clinician. The general areas for the first, second, and third divisions and also for the anterior division of the second cer- vical and for the occipital nerves are shown in Fig. 406. The main 858 NERVOUS DISEASES. subdivisions of these great nerve branches to the face are shown Fig. 406. in Fig. 407 Cutaneous sensory areas of the trigeminal nerve : I, first or ophthalmic division ; II, second or superior maxillary division ; III, inferior maxillary division ; C, anterior division of the second cervical nerve, which supplies chiefly the front and side of the neck. The small occipital nerve {occipitalis minor, occipiialis parvus, occipitalis extenuis, occipitalis aiUerior), which supplies the sldn behind the ear and the area directed in a pointed shape towards the cro\\Ti of the head, is not indicated hy shading or lettering. O, great occipital nen-e {occipitalis major, occipitalis Trmgnus, occipitalis maximns, occipitalis internus), representing the posterior branch of the second cervical nerve, which supplies the skin corresponding "with the upper part of the occipital hone and adjoin- ing part of the scalp, as shown by the shading which extends towards the vertex. A branch of the posterior division of the third cervical nerve also ramifies in the skin above the occipital protuber- ance, and the pneumogastric has an auricular branch which appears cutaneously behind the ear. Physiological Observations. — Uxperiments on the Descending (Spinal) Boot. Turner, experimenting in connection with Ferrier, found that the results of a destructive lesion localized in the tubercle of Eolando on one side were unusually constant. Destruction of this tubercle caused loss of all forms of sensibility in the distribution of the trigeminus on the side of the lesion, this anesthesia being due, according to Turner, to the destruction of the great descending spinal root, where it forms the superficial la)'er of the Eolandic tubercle. As regards the body and limbs, the experiments seemed to cause loss of tactile sensation on the side of the lesion and of the pain sense on the opposite side. Other results of the experiments were, on the same side as the section, contraction of the pupil, tem- l^orary narrowing of the palpebral fissure and less prominence of the eyeball, and paresis of the arm and leg of the opposite side. A few experiments practically confirmatory of the results of Turner have been performed by others. Trophic Functions of the Trigeminus. Somewhat numerous physio- logical exi)eriments and a very few cliuicopathological observations ANATOMY AND PHYSIOLOGY OF THE TRIGEMINUS. 859 Normal distribution of the trigeminal nerve to the face, showing the subareas of its three great sensory divisions. (Flower.) indicate that in some way trophic phenomena are induced by lesion of the fifth nerve. Turner in a series of experiments performed by Ferrier and himself divided the trunk of the fifth nerve, Fia. 407. its ophthalmic branch, and its intramedullary roots. In eighteen of the experiments anesthesia of the cornea was a prominent symptom, but only two of these showed symptoms of inflammation Supra-troehlear l.V — \--Tnfra-trochtear V'A i-1^ ^ /" [-YNasall.y and destructive change, al- • ^-^>- - " though in many of the cases a slight corneal opacity which showed no tendency to pro- gress was j)roduced. This, Turner believes, may have been due to nonapproxima- tion of the lids and conse- quent drying of the corneal surfaces. Only one case in which the ophthalmic branch was divided showed distinctive cor- neal change, and in this case postmortem evidence of septic men- ingitis was found. Several of the experiments seemed to demon- strate that, whether the trunk of the nerve was divided behind the Gasserian ganglion or whether the section was of the ophthalmic branch alone, the processes of health, nutrition, and repair went on notwithstanding the anesthesia of the cornea. The general conclu- sions drawn were that there were no evidences of trophic influence exerted by the Gasserian ganglion upon the cornea, that the de- structive changes in the cornea which occur from intracranial lesions are due to inflammatory irritation of the nerve, and that the so- called neuroparalytic phenomena associated with lesion of the tri- geminal nerve are evidences of irritation of the nerve, and not of paralysis. The operations on the Gasserian ganglion have, on the whole, confirmed the view taken by Turner. According to Krause, for example, after such operations trophic diseases of the eye or of the skin do not, as a rule, follow, although in a few instances slight changes in the skin have been observed. The two well known cases of hemifacial atrophy reported by Hom6n and Mendel (see page 887) point to a trophic ftinction for the fifth nerve. While the exact part played by the trigeminus in the control of trophic phenomena must be regarded as still unsettled, the clinician should remember that irritative lesions of various portions of the trigeminus may cause trophic symptoms. Ophthalmic Herpes Zoster and Neuroparalytic Ophthalmia. Many 860 NEBVOUS DISEASES. cases of ophtlialmic herpes after trigeminal lesions have been re- corded. Sometimes this disease is of so severe a character as to cause the destruction of the eye, vesication, pustulation, and ulceration of the cornea taking place. The patient suffers from darting pains about the orbit and in the eye. Perforation of the cornea, cyclitis, and shrinking of the eyeball have occurred. Anesthesia is present in the t^utire ophthalmic branch of the fifth nerve. Herpes zoster, wherever located, is usually due to disease of the ganglia in which the sensory nerves originate. In at least one case of intercostal herpes, to which reference is made by Lloyd from the personal ob- servation of Dr. William G. Spiller, who saw the case in the service of Kovacs, in Vienna, disease was found of the dorsal spinal ganglion of the nerve along which the course of the herpes occurred. The case was one of Pott's disease in the cervicodorsal region, and at the autopsy miliary tubercles were found covering the ganglion. The ganglion above the one involved in the tuberculous process was in- tact, and no herpes was present in the tract of its nerve. In other cases of herpes dilatation of the vessels of the posterior roots at or near the points where they enter the cord has been noted. In neuro- paralytic ophthalmia, another well-known trophic affection of the tifth nerve, inflammation, acute or chronic, attacks the eye and often results in its destruction. Vesication, ulceration, sloughing, and even perforation of the cornea may take place, the iris may become in- volved, and eventually the patient suifer from a panophthalmia. Anesthesia is commonly present in the conjunctiva, the cornea, and other parts supplied by the ophthalmic branch of the trigeminus. The case of combined facial and trigeminal paralysis whose photb- graph is shown in Pig. 420, page 914, suffered from a trophoinflam- matory affection, and it became necessary to remove the affected eye, which was done by Dr. de Schweinitz. The lesion in this case probably involved the nuclei or root fibres of the trigeminal nerve. Kalt has reported that certain slight trigeminal alterations which produced hemifacial atrophy also caused central choroiditic lesions, and he believes that these results are due to an interference with the trophic functions of the trigeminus. He had also several times observed that central corneal opacities, interstitial and without ero- sions or cicatrices, came on slowly in persons who had suffered only from periorbital neuralgia. The centre of the cornea where the opacity is usually encountered is alone anesthetic, or at most the anesthesia extends in a minute circle of transparent tissue around it. A similar anesthesia is sometimes observed after operations for the correction of strabismus, and may involve a large part of the cornea without producing other effects than a slight temporary loss of epithelium. The Motor Portion of the Trigeminal Apparatus.— TAe Chief Motor Nucleus. This nucleus, the masticatory nucleus of some authors, ANATOMY AND PHYSIOLOGY OF THE TRIGEMINUS. 861 is situated in the pons, mesad to the sensory nucleus of the trigem- inus. The cells of the motor nucleus are stellate, and, unlike those of the accessory nucleus, have several processes. Their axis cylin- ders pass downward without collaterals, close to the sensory root, and take their exit from the pons near it. Eamon y Cajal, although he saw collaterals of the sensory root entering this nucleus, could find no connection of the pyramidal tract with it, and he has observed no decussation of the motor fibres. A large number of root fibres from the substantia ferruginea unite with the mesencephalic root of the fifth and pass to the motor root, although many deny the relation of this structure to the fifth nerve. Some authorities be- lieve in a partial decussation of the motor roots, so that each root arises in both nuclei. Through the connection of the motor nucleus with the sensory root of the fifth the reflex movements of the muscles of mastication are possible. The motor nucleus is connected by col- laterals of the dorsal longitudinal bundle with parts below it even as far caudad as the cord. The Accessory Wucleus and Descending {MesencephaVic or Cerebral) Boot. The vesicular cells which form this nucleus are spherical or pear-shaped, and provided with thick spines. Golgi, Lugaro, and Eamon y Cajal believe that they are unijpolar, but according to Koel- liker they are multipolar. In the adult animal these cells probably contain no processes. They form a column which begins at the quadrigeminum close to the prepeduncle and becomes thicker nearer the chief nucleus. Their axis cylinder processes give origin to numerous ramifying collaterals. They do not cross the raphe. This descending root of the fifth is also spoken of under various names, as the small root, the cerebral root, the mesencephalic root, the superior root, and the anterior root. As the long root is now also properly spoken of as "descending," it would perhaps be better to designate the great root as spinal, and the root of the accessory nucleus as mesencephalic. Peripheral Course of the Motor Portion of the Trigeminus. Arising from the motor chief nucleus, the motor root passes forward with the sensory root through an oval opening in the dura on the superior border of the petrous bone above the internal auditory meatus. At the petrous apex it passes beneath the Gasserian ganglion, with which it has no connection. Outside of the cranium it joins one of the distal or peripheral bundles of the Gasserian ganglion, to form with it the inferior maxillary division of the fifth nerve. (Fig. 405. ) Muscles supplied by the Motor Division of the Trigeminus. First and chiefly the motor portion of the fifth nerve supplies the most important muscles of mastication, namely, the masseters, the tempo- rals, and the external and internal pterygoids. The branch to the internal pterygoid muscle is connected at its origin with the otic ganglion, while that to the external pterygoid is most frequently de- 862 NERVOUS DISEASES. rived from the l)uccal nerve, althougli it may be given off separately from the interior trunk of the nerve (Gray). Besides the main mus- FiG 40S ■js^nr'^-^ Fig. 409. MurjiLopical preparation from the descending (mesencephalic) root of the fifth ner^e In this pre- paration alongside the transverse sections of the root fibres two cells are represented, one with four pro- cesses, and a second one which has but one recog- nizable process, (Koelliker.) cles of mastication, others which take some part in the processes of chewing and deglu- tition are supplied by the trigeminus. The mylohyoid muscle, for instance, is supplied by the mylohyoid branch of the inferior dental nerve, and the anterior belly of the digastric by the terminal mylohyoid fila- ments. The mylohyoid muscle assists in raising the tongue, the floor of the mouth, and the mylohyoid bone, as in mastication and the initial stage of deglutition. The anterior belly of the digastric muscle, acting from aboAC, pulls the hyoid bone upward and forward, and acting in the opposite direction it assists in depressing the lower jaw. These muscles, acting in conjunction with otliers, are therefore imj)ortant in the process of mastication. Accoiding to an old view, the nerve supply to the tensor palati is from the trigeminus, although it is usually assigned to the vagus. If deiixcd from the former, the nerve branch passes in the \'agus trunk, U'a\ing it to go by way of the otic gan- glion to the muscle. As tlie tensor palati acts to tighten the soft palate and open the Eustachian tube during deglutition, it is not Enlarged view of one bipolar cell of the descending (mesen- cephalic) branch of the fifth nerve. (Koelliker.) DISEASES OF THE SENSORY PORTION OF THE TRIGEMINUS. 863 improbable that its nerve supply would be from the same source as that for some of the othei- muscles of mastication. The symptoms present in one of my own cases of combined paralysis and spasm of the trigeminus (Pig. 415) indicated the probable trigeminal origin of the accessory muscles of mastication just described. Finally, the tensor tympani muscle, which tightens the membrane of the tympanum, has its nerve supi)ly from the otic ganglion, probably by a filament which is derived from the motor portion of the fifth nerve. DISEASES OF THE SENSORY PORTION OF THE TRIGEMINUS. Varieties of Trigeminal Sensory Disease.— Diseases of the sensory portion of the fifth nerve are, in the first place, divided into those in which sensibility is abnormally increased {hyperesthesias and hyperalgesias) and those in which sensibility is lowered or lost {anes- thesias). Under the affections of hypersensibility are included (1) symptomatic trigeminal neuralgias (painful trigeminal affections due to irritative focal lesions, to neuritis or to special infections or toxins acting on the trigeminal apparatus) ; (2) the severe paroxysmal type of trigeminal neuralgia known as prosopalgia or tic douloureux; (3) migraine and migrainoid neuralgias, which are probably best treated of under trigeminal diseases, although much diversity of opinion exists as to their real nature. Certain forms of painful disease in the distribution of the trigeminus are classified under the head of trigeminal reflex disorders. These include varieties of reflex head- aches, although some of these affections classified as reflex are more properly to be regarded as diseases due to direct irritation of the branches of the trigeminus. The most important disorders of low- ered sensibility (trigeminal anesthesia) are (1) trigeminal anesthesia due to gross focal lesions ; (2) trigeminal anesthesia due to degener- ative disease attacking the nuclei and the root fibres of the ner\'e ; and (3) trigeminal anesthesia due to chronic retrogressive processes like gliosis, which attack the trigeminal apparatus in the brain stem. Hemifacial atrophy and hemifacial hypertrophy are trophoneu- roses, symptoms of sensory irritation not being prominent, although sometimes present. With our present knowledge, they are most conveniently treated of as affections of the sensory portion of the trigeminus, the weight of opinion, as will be seen later, being in favor of the view that the trophic phenomena of these diseases are due to neural or nuclear irritation. Instead of true hyperesthesias and anesthesias, forms of trigeminal piaresthesia are sometimes met with, under this head including the perverted or abnormal sensa- tions described as numbness, crawling, itching, thrilling, tingling, feelings of weight, of compression or contraction, and of heat and cold. These paresthesias are usually evidences of lighter grades of neural irritation than that causing hyperesthesia. 864 NEEVOTJS DISEASES. SYMPTOMATIC FORMS OP TRIGEMINAL NEURALGrlA. Significance of Trigeminal Pain. — In the succeeding section, prosopalgia, or tic douloureux, owing to its great importance, will be discussed separately, this affection, according to the view held by the writer, being due to a chronic sclerotic or degenerative process at- tacking the Gasserian ganglion. Other important forms of trigeminal neuralgia, diseases with trigeminal pain as their dominating feature, are, however, due to focal lesions affecting the trigeminal apparatus, such lesions, for instance, as tumor, aneurism, abscess, meningitis, exostosis, or periosteal nodes ; to neuritis affecting the trunks or termini of the nerves ; and to imperfect or perverted supply of blood to the nerve or its centres, the result of disease of the bloodvessels, or of infections or toxins circulating in the blood current. The symp- tomatic trigeminal neuralgias are sometimes affections of great sever- ity and of wide diffusion so far as the territory of pain is concerned, in some instances involving two or even all of the great sensory divisions of the nerve. A few cases of trigeminal pain are to be referred to neurasthenic and hysterical conditions and to purely functional disturbances. Irritative Focal Lesions of the Trigeminal Sensory Appa- ratus. — The effects of focal lesions of the trigeminal apparatus, as of such lesions elsewhere, will vary according as these are irritative or destructive, or both in the same case. Focal irritative lesions cause the symptomatic neuralgias under consideration ; and they give rise also to certain trophic disorders. These irritative lesions may be of the Gasserian ganglion, of the peripheral sensory nerves, of the sen- sory end nuclei in the brain stem, or of the sensory roots. Trigeminal Neuritis. — Owing to the fact that the head and face are the most exposed portions of the body, neuritis of the trigeminus occurs more frequently than inflammation of nerves in other parts of the body. Causes active in its production are diseases of the ear, teeth, and gums, of the nasofrontal sinuses and of the pharynx. Many cases of head and face pain are due to trigeminal neuritis, although such pain is not infrequently regarded as evidence of men- ingitis or of intracranial neoplasm. The trigeminus has an exten- sive distribution within as well as outside the cranium, and especially to the dura. It is quite possible to have a dural neuritis without a pachymeningitis, or e\en to have a functional disturbance of the dural branches of the fifth nerve without either meningitis or neu- ritis. When trigeminal neuralgia is symptomatic of a true neuritis, the chief symptom will be pain of greater or less severity according to the degree of the inflammation, and the pain will usually be re- ferred to the nerve distribution affected. Other symptoms will be hyperesthesia over the parts affected with the neuritis, if these can bo reached for examination, vasomotor affections such as pallor or SYMPTOMATIC FORMS OF TRIGEMINAL NEURALGIA. 865 coldness or redness, heat and edema, and trophic phenomena such as herpetic eruptions and changes in the hair. If the disease has continued for some time, the hair may change in color or fall out, as it does sometimes in true tic douloureux. If the affection is chronic and severe, neuroparalytic keratitis, conjunctivitis, corneal ulcerations, and subcutaneous and periosteal thickenings, are other atrophic conditions which may result. Various secretory disorders, such as increase or diminution of the lachrymal, the nasal, or the salivary secretions, may also form a part of the symptomatology. When the cases are of long continuance and great severity, emo- tional conditions and the evidences of general exhaustion appear. The patient, losing sleep, unable to eat, distressed and wearied by the constant pain, gradually becomes a neurasthenic wreck. Some negative points are important, particularly in distinguishing these forms of trigeminal neuritis from tic douloureux : one of the most important of these is the frequent absence of the paroxysms of facial spasm. Facial spasm may, however, be present in some severe cases of true trigeminal neuralgia (not tic douloureux), especially in those which are caused by intracranial gross lesions. Although both pain and spasm may be severe, they are not usually of the folgurant character, as in tic douloureux. According to the par- ticular branch of the nerve affected, the symptomatology may ac- quire special features. Edema of the eyelids with suffusion of the eyes may, for instance, be present in supraorbital neuritis. In some cases when branches of the dental nerve are affected the pain is reflected or radiated to the eye, the ear, or the back of the head. Dilatation of the pupil is an occasional symptom. When the intra- cranial branches of the fifth nerve are affected, the pain is usually described by the patient as boring or deep-seated, and occasionally it may be referred to one side or one portion of the head, although little dependence can be placed upon such localization of the pain in fixing the exact site of a neuritis within the skull. When vertigo or nausea and vomiting accompany severe and deep-seated pain, the existence of a dural neuritis is not improbable, although the diagnosis cannot certainly be made on this syndrome. Certain painful points or spots are usually found on various portions of the head in the territory of the branch or branches of the nerve affected. The most important of these painful spots for the different forms of ophthalmic neuralgia are (1) the supraorbital point, at or near the supraorbital foramen ; (2) the palpebral, in the upper eyelid ; (3) the nasal, at the point of emergence of the long nasal branch at the junction of the nasal bone with the cartilage ; (4) the ocular, a somewhat indefinite focus within the globe of the eye when the ciliary nerves are affected ; (5) the trochlear, at the inner angle of the orbit. For supramaxillary neu- ralgia they are (1) the Infraorbital, corresponding to the emergence of the nerve from its bony canal ; (2) the malar, on the most promi- 55 866 NERVOUS DISEASES. nent part of the malar bone ; (3) an indeterminate focus somewhere in the line of the gum of the upper jaw ; (4) the superior labial, also indeterminate ; (5) the palatine, occasionally the seat of intolerable pain. For tnframaxillary neuralgia they are (1) the temporal, a little in front of the ear ; (2) the inferior dental, opposite the point of emergence of that nerve ; (3) the lingual, on the side of the tongue ; (4) the inferior labial. (Eoss.) Trigeminal Neuralgia due to States of the Blood.— Both diffuse tiigeminal neuralgia and neuralgias confined to special branches of the nerve are sometimes dependent upon states of the blood,— upon anemias, hyperemias, and especially upon toxemias. Cases of this kind, and particularly for therapeutic reasons, must be differentiated not only from those due to irritative focal lesions, but also from the neuritic forms. It is true that neuritis may originate from a toxemia or perhaps even from a deficient or undue supply of blood to a part, but with our present ideas of the pathology of neuralgias we must recognize the existence of neuralgias of purely hemic origin. In these cases the nerve centres or perhaps both nerve centres and fibres respond with pain because they are starved, overfed, or poisoned, a true inflammation not having taken place. A list of trigeminal neuralgias based upon special causative agents acting upon the blood might be indefinitely extended, but among the most important are those due to anemia, rheumatism, diabetes, gout, lead, malaria, and syphilis. Anemic trigeminal neuralgias occur especially in overworked and badly nourished young women : they may affect any branch of the fifth nerve, but are especially liable to be of the ophthalmic or temporal variety. Eheumatism, gout, dia- betes, all may cause a true neuritis, but in some instances they give rise to extreme neuralgic pain without the other symptoms of neu- ritis, such as hyperesthesia and vasomotor and trophic changes. Lead is a somewhat infrequent cause of trigeminal neuralgias, but oftener attacks the nerves of other portions of the body. Occasionally, how- ever, a striking instance of trigeminal neuralgia due to lead poison- ing is observed, and that malaria may be a cause is one of the oldest clinical observations. Malarial neuralgia shows a particular tendency to attack the supraorbital branch of the ophthalmic nerve, causing what is sometimes called brow ague. The great distinguishing feature of trigeminal as of other forms of malarial neuralgia is its periodicity. The attacks tend to return and to augment to a certain intensity at regular intervals, as of one, two, three, or more days, following the same rules in this respect as govern the return of other forms of malarial paroxysms. In sjieaking of syphilis as a cause of true neuralgia, it must be understood that reference is not made to any of the numerous cases in which this virus causes definite specific lesions like meningitis or gummata, but to those cases in which the action exerted by the poison of the disease in the blood is to disturb SYMPTOMATIC FORMS OF TRIGEMINAL NEURALGIA. 867 and pervert the normal functions of the nerve centres. Such casef>, while perhaps not rare, are difficult of exact diagnosis, and with a history of syphilis we are likely to fix our attention upon the proba- bility of a localized lesion rather than upon the possible effects of a toxic agent in the circulation. Trousseau, and others following him, have described a form of epileptiform trigeminal neuralgia which is regarded by some as distinct from prosopalgia, or tic douloureux, and by others as a variety of this affection. We incline to the latter opinion. In this disease the patient may have daily one or many attacks of lightninglike pain, which succeed one another with great rapidity for a few seconds or minutes and then disappear. The attacks of pain may recur for days or weeks and then may dis- appear for months, or even for a longer period, but, as a rule, the disappearance is not permanent. Diagnosis, Prognosis, and Treatment of Symptomatic Tri- geminal Neuralgias. — The etiology and pathology of the sympto- matic trigeminal neuralgias have been sufficiently indicated in the description of these affections, which in our consideration of them have been largely classified from the etiological and pathogenetic standpoint. Their diagnosis is largely dependent upon a close study of their history and causation. In the first place, the different classes of neuralgia of this type must be carefully separated from one an- other : for instance, those due to focal lesions from the neuritic and toxic varieties. Safe therapeutic tests will sometimes be of great service in clinching the diagnosis. It may be found that the cases yield primarily to an antirheumatic, antilithic, or antisyphilitic treatment. The urine and blood should be examined, in doubtful cases, to determine the presence or absence of diabetes and special blood states. Diabetic neuralgias are said to show a tendency to bilateral symmetry, to attack the same portion of the nerve dis- tribution on both sides. Neuralgic affections must be carefully differentiated from the pains which indicate intracranial lesions, and especially from tumors in their initial stages. The prognosis of symptomatic trigeminal neuralgias is comparatively good, but depends upon the particular variety. Many of the constitutional forms are amenable to treatment. Those due to focal lesions may or may not be, according to the extent and the character of the lesion. Neuritis is especially intractable when it attacks the intracranial branches of the fifth nerve, but even in these cases it may some- times be reached by treatment. The epileptiform neuralgia of Trous- seau is practically incurable. The most that can be said of it is that the patient may, by good fortune, remain free from the attacks for a longer or shorter period. In the treatment of symptomatic neu- ralgias the matter of first importance is to seek and attack the cause. Anemic neuralgias are best treated by fresh air, an abundance of good food, and the use of iron, arsenic, and manganese. Mercury and 868 NERVOUS DISEASES. the iodides are the therapeutic anchors in syphilis, the salicylates in the rheumatic form, and lithium and colchicum in the gouty form. In diabetic neuralgias the remedies of most value are the salicylates and the preparations of codeine. One of the chief indications must always be the immediate relief of the pain. As the measures to accomplish this object are practically the same in the symptomatic neuralgias as for tic douloureux and migraine, the treatment as given under these affections can be consulted. PROSOPALGIA, OR TIO DOULOUREUX. Definition and Synonyms. — Prosopalgia is a form of trigem- inal neuralgia of extreme severity, paroxysmal in type, and usually having associated with the pain attacks of spasm involving the muscles of the face. We have used the term prosopalgia as best because, meaning simply "pain in the face," it does not involve any theory as to the local or other cause of the disorder. It should, how- ever, be regarded as a severe type of trigeminal neuralgia. Its most common synonyms are tic douloureux, trifacial neuralgia, facial neural- gia (not a good name, because misleading as to the nerve affected), and FothergilV s face ache or neuralgia. This form of trigeminal neu- ralgia is a special disease, and should be clearly separated from those forms of trigeminal neuralgia which depend upon inflammatory or other disease of special portions of the nerve. These have been con- sidered in the preceding section of this chapter. Clinical History. — In typical cases the disease presents a some- what uniform method of onset, development, and climax. The pa- tient, frequently in or past middle life, is without warning attacked with sharp pains in some special portion of the face, as in the upper or the lower lip, near the angle of the jaw, under the eye, or on the forehead. These pains, ordinarily intense and lancinating, may soon pass away, but they generally recur, and as the case progresses usu- ally become more severe and diffuse. Often they remain for a long time in the portion of the distribution of the nerve first attacked ; later, pain appears in other branches of the same subdivision, or it may appear in an area of another of the divisions. Beginning in one of the subdivisions of the third branch, eventually the third, second, and first may all be more or less implicated in the painful attacks. The second and first and the third and second are more likely to be conjointly involved than the third and first. This tendency to dif- fusion from the subdivisions of one of the three great divisions of the nerve to subdivisions of one or of both of the other branches throws light upon the probable nature of the disease, to a certain extent favoring the view of its ganglionic origin. As the disease progresses, various exciting causes will readily bring on the attack of pain. The paroxysm may be precipitated, for instance, by drinking, by touching the face, by moving the jaws, by the slamming of a door, TIC DOULOUREUX. 869 Fig. 410. by the noise of the falling of an object, or by anything tending to cause actual movement or to produce emotional disturbances. The patient lives in a state of constant anxiety, fearful of everything. The patient's face may become hyperemic or even suffused and swollen, or the conjunctiva alone may be injected. Excessive lach- rymation may be present. In some cases unilateral sweating, and in rare instances trophic changes, such as attacks of herpes and dis- coloration of the skin and possibly thickening of the skin, may be observed. Hearing, taste, and smell are rarely disturbed, but vision is oftener affected. The usual disturbances of vision are transitoi-y paresis of the ocular muscles or trophic changes in the retina. S^jasm in the facial muscles accomjjanies the paioxysms of pain, and this spasm is often very violent, and has given the affection one of its names, tic douloureux. In tlie illustration (Pig. 410) this sj^asm is well shown, the face being forcibly drawn to the side affected. The ocular muscles are sometimes spas- modically involved, as are also the mus- cles supplied by the motor subdivision of the fifth nerve. Occa- sionally the patients become hallucina- tory or even mani- acal. Fere reports a case in an epileptic complicated by zona in which menacing voices were heard on the affected side, but the patient was con- scious that the voices were unreal. Intense sialorrhea came on with the neurotic at tack, and the voices disappeared with them. It is probable that in this case the epilepsy predisposed to the hallucinations. As a rule, tic douloureux is more severe and recurs with gieater fre- quency in winter and sirring. Etiology. — Prosopalgia is more frequent among women than among men. It occurs usually in or after middle life, and is a not I . Case of tic douloureux : appearance of the patient's face during one of the severe paroxysms. 870 NEEVOUS DISEASES. infrequent disease of the aged. It is very rare in childhood and youth. The tendency to its occurrence is marked in neuropathic families, and especially in families in which epilepsy is present. Toxic and infectious agents probably act as exciting causes ; certainly anything which tends to lower the tone and vitality of the system will lead to tic douloureux in those who have a constitutional ten- dency to the affection. It will be remembered that Anstie held that neuralgia was the prayer of the starved nerve for blood. In this consideration of the etiology of tic douloureux I have purposely omitted the discussion of the numerous focal lesions which are usu- ally enumerated as causative factors in its production, believing that the disease is essentially an irritative degenerative affection of the Gasserian ganglion, nearly all its so-called causes being simply exciting factors in those in whom a persisting pathological state pre- disposes to the disease. Pathogenesis. — The history of the development of the disease, the paroxysmal nature of many of its symptoms, its associated phe- nomena, and the unsatisfactory results of treatment lead to the con- clusion that the true seat of prosopalgia, or tic douloureux, is in the Gasserian ganglion. Although pathological proof is still wanting, the disease is in all probability a form of degeneration of the cells of this ganglion, similar to that which occurs in the dorsal spinal ganglia in tabes, and to the degeneration of the ganglion cells of the anterior horns in chronic atrophic affections, such as amyotrophic lateral scle- rosis and progressive muscular atrophy. It is probable that in sen- sory cases the disease gradually invades all portions of the ganglion, and as one cell after another drops out the instability of the ganglion is increased, and with this the tendency to violent sensory discharges. This theory seems to me more probable than that which attributes the affection to a thalamic or cortical origin. As the central sensory neurons have their cells of origin in the Gasserian ganglion, and possibly in the thalamus, the discharging lesions which give rise to the violent paroxysms of pain have their true seat and source in one or the other of these cell masses, but most probably in the former. Pathological Anatomy. — In some cases forms of low grade neuritis have been discoA'eied in branches of the nerve affected. The vessels which supjoly the nerve with blood are sometimes affected with chronic inflammatory processes, but in a large number of cases branches of the nerve which have been removed by operation have been examined without discovering any noteworthy alterations in the ner\'e. In three cases in which Dana examined four superior maxillary nerves, striking e\'idences of arterial disease were found, and in a fourth case no bloodvessel was present in the specimen. This led him to the view that an obliterating arteritis was a factor in the disease. TIC DOULOUEEUX. 871 Diagnosis.— The diagnosis of prosopalgia is usually readily made. The only point of importance is to distinguish bet-s^-een that form which has been considered in the present section, which is due to a chronic degenerative process of the Gasserian ganglion, and the forms which are due to focal irritative lesions, such as neuritis, exostosis, cicatrices, tumors, meningitis, etc., located somewhere in the course of the trigeminal sensory apparatus. Prognosis.— The prognosis of prosopalgia is almost invariably bad. Periods of relief from suffering are obtained either by treat- ment or without reference to treatment. Unfortunately in the vast majority of cases the disease gradually grows worse, both as to the frequency with which paroxysms occur and as to their severity. On the whole, those patients do best who early submit to operation, probably because even the temporary relief which they obtain— a relief which often extends over months, or it may be years — allows time for recuperation. Treatment. — A large number of medicinal remedies have been used for the relief of prosopalgia. Those which appear to afford most relief can be classified under the two heads of constructives and anodyne sedatives. Ifearly all sufferers from prosopalgia re- ceive some benefit from rest and the use of tonic and building-up remedies like cod liver oil, preparations of iron, arsenic, manganese, and the metallic tonics generally. Strychnine sulphate in increasing doses has proved of great benefit when the treatment has been con- tinued over a number of weeks or months, and nitroglycerin is of particular value in the aged or prematurely senile, acting through its well known effect upon the vessels. Preparations of aconite, and especially the alkaloid aconitine, are also useful both in relieving the pain and in changing the character of the disease, and among other remedies for the relief of the pain are morphine, codeine, plienacetin, antipyrin, antifebrin, and ammonol. Morphine or codeine, if given in sufficient doses, will usually give relief, but opium preparations should not be given too freely, as the patient may acquire a drug habit. Hot whiskey and quinine will sometimes temper the violence of an attack. All constitutional conditions, like anemia, rheumatism, gout, diabetes, and syphilis, which predispose to the neuralgic attacks should receive attention, and should be treated with the drugs which are known to be beneficial in these affections. In special instances the salicylic preparations will prove of great value, and the best of these are the sodium salicylates and oil of gaultheria. Prom ten to fifteen grains of the former, or from ten to twenty drops of the latter, should be given three or four times daily. When, as is too frequently the case, tic douloureux does not yield to other treatment and continues to render the life of the patient almost unendurable, resort should be had to surgical treatment. Even when a permanent cure is not obtained, the few months or few years of relief afforded 872 NERVOUS DISEASES. enable the patient's general health to be built up, and give him the opportunity of enjoying life during the period of respite. The most important surgical measures are stretching, resection, or avulsion of the extracranial portions of the nerve, section of the nerve trunks in front of the Gasserian ganglion, and operation on this ganglion. For the various methods of operation surgical works should be consulted. The choice of operation must depend to some extent on the severity but especially on the diffusion of the pain. When this is confined to a single accessible portion of the nerve, neurectomy should be tried, or neurectomy and avulsion. When the neuralgia affects two or more of the great divisions of the nerve, the Gasserian or pre-Gasserian operation deserves full consideration, although even in some of these cases separate operations on different nerve trunks seem to afford the most relief. In the light of what has been said of the pathology of prosopalgia, it may be thought that no operation except that on the ganglion has a rational basis ; but this does not seem to me to be the correct view to take. While the disease is probably a degenerative and irritative process, attacking the cell bodies of this ganglion, it must be remembered that the nerve trunks themselves are composed of the peripherally distributed axis cylinder processes of these cells, and that their section may reflexly inhibit the discharging process which causes the pain or may prevent the transmission of the painful impulses. In many cases experience has taught that neurectomy and avulsion afford relief for a considerable period, but, on the whole, the extirpation of the Gasserian ganglion has afforded the most permanent relief. MIG-RAINE. Definition, Synonyms, and Varieties Migraine is a period- ical paroxysmal affection, usually hereditary, and chiefly character- ized by severe attacks of pain confined to one side or to one portion of one side of the head, and commonly associated with either nausea or vomiting or both. The synonyms for migraine are megrim, sick headache, neuralgic sick headache, paroxysmal headache, and hemicrania. Migraine in the first place presents itself in what might be called its most typical form, in which all the phenomena are of great severity, the pain extending over a laige part of one side of the face and head, and in some cases radiating to all parts of the head, although the focus of greatest severity is usually in the tem^^oral or the supra- orbital region of one side. Special varieties are determined chiefly by the limitations of the painful areas ; but the only one of 'these that will be separately considered is the migrainoid supraorbital neuralgia. Symptomatology. — MiscelJaneous Symptoms. Not infrequently the patient has decided prodromes, usually in the form of general malaise, discomfort, or depression, which may last for hours or days. MIGRAINE. 873 Photophobia, visual spectra, tinnitus, vertigo, and gastric disorder may be other prodromal signs. The attacks frequently show a great tendency to periodicity, a fact to which special attention has been called by Liveing and Sinkler. The latter has reported a number of instances indicating the tendency of the disease to recur on fixed days. Salius relates the case of an Italian monk who for three years and seven months had an attack of violent hemicrania every Monday, the attacks lasting from twenty-eight to thirty hours (Tis- sot). Usually beginning in one side of the head, the pain augments in violence, sometimes slowly, sometimes rapidly, until finally the patient is compelled to take a recumbent position. It is often of a throbbing character, the patient complaining that the head feels as if it would burst. It is increased by noise, light, jarring movements, and anything which causes emotional excitement. The appearance of the patient differs in different cases. Frequently the face is pale ; both the head and the limbs feel cold to the patient. In other instances the opposite appearance may be present, the face being flushed or even turgid, and in still other cases alternations of pallor and of flushing or turgescence may occur. In rare cases one side of the head and face may be pallid and the other flushed. These dififerences in vascularity and in temperature are among the clini- cal reasons which have led to the belief that the disease should be subdivided into an angiospastic and an angioparalytic variety. The pupils may be either contracted .or dilated, myosis usually accom- panying pallor of the face, and mydriasis flushing. Forms of oculo- motor paresis are comparatively common, and have already been referred to when discussing affections of the third nerve, page 844. Some would have us regard the cases of migraine with these oculo- motor symptoms as a special type, which has been designated ophthal- moplegic migraine, but no reason for such classification exists greater than might exist for describing an auditory form or other forms based upon the frequent presence of certain special symptoms. The mental condition of the patient varies somewhat with temperament. Frequently great apprehension is felt, and nearly always a feeling of depression. The ideas may become confused, and the patient may have hallucinations of sight or hearing. K"ausea and vomiting are frequent accompaniments of the headache, and have given it one of its commonest names, sick headache. Sickness of stomach comes on early in some, in others not until the paroxysm has persisted for a number of hours. An attack of copious vomiting, either sponta- neous or brought on by the use of emetics, often marks the climax of the attack, the patient afterwards sinking into a sleep, and the pain gradually disappearing. The pulse is usually small and tense, and is more likely to be lessened than to be increased in frequency. The duration of an attack is from eight to twenty-four hours, al- though it may last two or more days. While the affection, as has 874 NEEVOU9 DISEASES. been stated, exhibits a considerable tendency to periodicity, in many cases the paroxysms recur somewhat irregularly, varying from one week to two or three months. In children the symptoms are some- what less pronounced. Visual Spectra (Ophthalmic Migraine). Reference has already been made in several places in preceding sections to the spectra of migraine and the forms of fugacious hemianopsia with phosphenes and other visual phenomena sometimes present preceding or during an attack of migraine (pages 757 and 773). It has been stated that the central field is nearly always free from visual spectra, and also that various disturbances of the mechanism of cerebral speech occur. The dis- turbances of vision are of such dominant importance in some in- stances that it has been suggested that ophthalmic migraine should be regarded as a special form of this disease (Charcot). This so-called ophthalmic migraine may present itself in a simple form in which only headache and visual phenomena are present : Gowers refers to one curious case in which visual disturbances exactly such as pre- cede attacks of migraine occurred frequently during many years as an isolated symptom, but at no time was there any headache or pain. In other cases various symptoms of cerebral disturbance are com- bined with the headache, and visual spectra. The patient, for in- stance, may suffer from transient and incomplete aphasia, and this may or may not be associated with hemiparesis or monoparesis or with paresthesia like numbness and tingling confined to one side of the body or of the face or to the limbs of one side. In rare instances transient aphasia is the only evidence of an attack which is funda- mentally the same as that of migraine, a fact which should be re- membered, as the absence of headache and of the other phenomena of the disorder may lead to the belief that the patient is suffering from a real but limited apoplexy. Charcot has directed attention to the occurrence of ophthalmic migraine as a prodrome of general paralysis of the insane. In other rare instances migraine does not set in until after the disease has been initiated as indicated by other physical or mental symptoms. In most cases the migraine cannot be regarded as having any direct connection with the general paralysis. It is a concomitant and forerunner only in the sense that among the lesions productive of the disorder happen to be some which are so situated and of such character as to give rise to ophthalmic phe- nomena. Much space could be filled with a description of special types of visual phenomena recorded by different authorities as oc- curring in migraine. Gowers in particular has elaborately discussed this subject. Among such recorded visual spectra are the zigzag " fortification lines ;" luminous objects, or objects encircled by lumi- nous rings or fringes of the most brilliant colors ; visions of moving animals, sometimes pleasant and sometimes as disagreeable as those of delirium tremens ; and dark and bright spots, cometlike and MIGRAINE. 875 liglitniuglike flaslies, and balls of fire which sometimes dissipate into scintillating sparks or flakes. Mif/rainoid SiipraorbiM Neuralgia. The question has arisen as to the relation of some of tlie forms of supraorbital neuralgia to migraine. Putnam has particularly studied these cases, which, ac- cording to him, arrange themsehes into several groups: (1) those in which no migrainoid or other special neuropathic tendency is traceable ; (2) those in which other members of the family have had this same form of migrainoid neuralgia, with perhaps a touch of true migraine; and (3) those in which the patient's attacks and those seen in other members of the family approach very nearly to the true migraine type. He gives the history of cases illustrati-^e of these different varieties. The affection in question could perhaps, there- fore, be properly treated of either under migraine or under symp- tomatic trigeminal neuralgia. Etiology. — Heredity is by far the most important predisposing cause of migraine. I have been able to trace its occurrence through five generations. In many inherited cases it begins very early in life. According to Gowers, one third of all the cases begin between the ages of five and ten years. In a personal case with a clear his- tory of heredity extending through several generations, the child was first attacked with migraine between the ages of two and three years. Even in the majority of cases which begin after youth or manhood has been reached, an hereditary element can be found on search. Often when the existence of migraine cannot be discov- ered in the direct ancestry of the patient he has inherited a neuro- pathic constitution, as indicated by the occurrence in his forebears of epilepsy, insanity, hysteria, alcoholism, tabes, or of some other form of degenerative nervous disease. General debility, and the depressing effects of infectious diseases or toxic agents, may act as predisposing causes. In the study of the etiology of migraine, two mistakes are sometimes made : one, in confounding other forms of headache with migraine, and the other, in giving undue weight to causes which are merely exciting. The causes of symi^tomatic tri- geminal neuralgia or of headache of trigeminal origin in cases which are distinctly not of the migrainoid type are sometimes assigned as the causes of true migraine. This remark applies to not a few of the forms of headache and trigeminal neuralgia which are of toxemic origin and which have been already considered ; nevertheless, it is true that a rheumatic, gouty, saturnine, syphilitic, or other abnormal state of the blood may precipitate attacks of migraine in those who are hereditarily predisposed. Those forms of symptomatic headache which are solely due to nasal, pharyngeal, and aural diseases are certainly in the vast majority of cases not of the migrainoid type, and the same is true of most of the headaches which have been attributed to carious teeth. The relationship of eyestrain and the 876 NERVOUS DISEASES. effects of the correction of refraction errors, of tenotomy, and of visual hygiene in the relief of headaches is of interest in this con- nection. The headaches which are caused by the visual and ocular defects and which are relieved by the above measures may or may not be migraine, and it is misleading to make sweeping assertions as to the causation of migraine by such abnormalities. The truth with regard to all these so-called causes of migraine is simply that individuals who are predisposed to this disease, and who have had attacks of it of greater or less severity, are liable to have paroxysms of migraine excited and the frequency of their recurrence augmented by such causes as abnormal states of the blood, nasal, aural, and pharyngeal lesions, dental irritation, and ocular and visual defects. Intellectual capacity has been thought by some to play a part in the etiology of migraine. Certainly many men of great distinction and unusual mental powers have been affected by this disease ; but it may occur in any walk of life, and the two most reasonable ex- planations of its occurrence in the higher classes intellectually are hereditary predisposition and the commonly better habits as to exercise and fresh air of those who follow nonintellectual occupa- tions. Migraine is more common in women than in men in the proportion of three or four to one. The attacks occur with most frequency in winter and early spring. Pathology. — The pathology of migraine still remains unsettled, good authorities taking views widely diverse or apparently so, for in some instances the differing views seem simply to be different methods of stating the same opinions. Migraine may be regarded as (1) a form of trigeminal neuralgia of Gasserian or neural origin ; (2) a dis- charging neurosis either of thalamic or of cortical centres ; or (3) a vasomotor neurosis. Anstie believed that it was a neuralgia of the ophthalmic division of the trigeminus due to processes of degener- ation going on in the nucleus of origin of the nerve, a theory which would bring migraine into close relation with tic douloureux accord- . ing to the pathology of the latter affection adopted by the writer. Migraine, however, while presenting some of the features both of tie douloureux and of the symptomatic neuralgias, has others which belong to neither of these aifectious, and its pathology must there- fore, in part at least, be different. The pain of migraine is located in the distribution of the trigeminus, but in true migraine the tri- geminal apparatus is disturbed throughout, — from the Gasserian ganglion to the sensory cutaneous termini in one direction, and in the other to the end nuclei, root bundles, and cortical termini. Even if the affection in its manifestations is in part to be classed as a vaso- motor neurosis, the angiospasm and angioparalysis are phenomena associated with those of trigeminal irritation. "With Moebius, Put- nam, and others, we must agree that it is a disease which is the out- come and sign of hereditary degeneration. It is probable that the MIGRAINE. 877 underlying weakness which leads to its manifestations is distributed in all portions of the trigeminal apparatus and to that part of the gangliated nerv^ous system which is associated in action with this apparatus. With Putnam, I believe that the study of migraine, like that of other serious painful affections, should be based on broader and deeper investigation of the physiological functions which the sensory nerves subserve ; that we have in these disorders ' ' a sort of caricature of physiological processes, or bits of these processes cut off from their normal relations." Diagnosis and Prognosis. — Migraine is a disease the symptoma- tology of which is so clearly defined that in most cases its diagnosis can be readily made. It is perhajjs most likely to be confounded with headache of organic origin, particularly with that due to tumor or pachymeningitis. The diagnosis in this case can be made by close study of the various localizing and general symptoms of tumor or meningitis, and will be much aided by the use of the ophthalmoscope and the history of the case. Those forms of migraine which give visual spectra or varieties of aphasia with head pain can be diag- nosticated only by the history of other attacks of migraine or by the paroxysmal and transient character of the affection. Migraine and tic douloureux are not likely to be confounded, except in the case of imperfect and irregular types of either. Hysterical or imitative headaches in children may occasionally closely simulate migraine, particularly in children whose parents are victims of this disease. A diagnostic difficulty, to which Gowers has especially called atten- tion, is that presented when the subjects of migraine become affected with some other disease, the symptoms of the two affections then complicating one another in a confusing manner. Among the most important of these complicating disorders are Bright's disease, brain tumor, and meningitis. So far as absolute recovery is concei'ned, the prognosis of migraine is bad. In most cases it shows some tendency to improvement when middle life is reached, the attacks becoming less frequent and less severe. Treatment. — Hygienic Measures. While migraine is essentially an incurable affection, one that depends upon inheritance and the predisposition to which disappears only with the natural changes wrought in the individual, much can be done not only to palliate the paroxysms of the disease, but also to render them less frequent and to reduce their power to cause suffering. No one line of treatment seems to be applicable to all cases, and yet certain therapeutic meas- ures are of advantage in almost any case. First should be con- sidered the means to be taken to counteract the inherited predis- position, to cure the individual approximately of the tendency to the attacks. The most important measures are those which are cal- culated to maintain the nervous and general health of the patient at the highest possible level. Close attention should be paid to the 878 NERVOUS DISEASES. general hygiene and diet of predisposed children, as improper food, undue application to school studies, and sedentary habits excite attacks of migraine. The roborant treatment applicable to adults may be of an opposite character in different cases. Seclusion, rest, and full feeding may, for example, be of particular value in some cases, while fresh air, abundance of exercise, and free association with others may lie of equal service in those of different temperament and habits. Climate plays a part of great importance in the prevention of migraine, although as yet no clear data with regard to the details of climatic treatment are forthcoming. Sinkler speaks of a young lady under his care who suffered from migraine of the severest type, and in whose case no plan of treatment or regimen seemed to have any influence upon the attacks, but going to the far West for some mouths she remained free from the attacks during the entire time she was there. Outdoor life as well as change of climate plays a part in some of the cases in which the benefit is attributed solely to the latter. One of my friends, who has inherited migraine and who suffers at times from severe attacks, remained entirely free from them while camping out in the far West, where for a long time he spent several months in each year in the service of the government. During sixteen or seventeen years he never had an attack while ia camp. With regard both to this case and to the one referred to by Sinkler it is to be borne in mind that the immunity which they had from the attacks was during the summer months, but in both of these cases also the individuals suffered at times from the migraine in summer, as in other seasons, when not in the West. The forms of outdoor exercise now so popular are distinctly beneficial to the subjects of migraine. In a number of instances I have known patients who have suffered for years to have fewer attacks in periods of the same length after taking up bicycling, which, if indulged in with moderation and good sense, is highly beneficial in nervous affec- tions as well as in migraine. Sea bathing is of service, especially if the subjects of migraine attend also to diet and exercise. Treatment of the Attacl: Among the drugs which have in recent years attracted the most attention in the treatment of the paroxysms of migraine are phenacetin, antipyrin, antefebrin, caffeine, sodium salicylate, and ammonol.* The reports as to the use of phenacetin are conflicting, but are favorable for the majority of cases. Doses of from five to ten grains are most commonly used, but doses as large as a drachm or more have been successfully employed. It is not, how- ever, so generally useful as some of the other drugs deservedly popu- lar in the treatment of migraine. Antipyrin was first used in the * An excellent re.tumc of the medicinal treatment of migraine is given by Dr. Wharton Sinkler in a paper read before the Association of American Physicians and published in the Medical News, July 18, 1890. MIGRAINE. 879 treatment of migraine, or at least of headache, by White. Sinkler has collected the statistics of its nse in a large number of cases, in the vast majority of which its action was satisfactory. Some of its advocates are in favor of large doses, as from ten to fifteen or twenty grains ; others favor smaller doses, as three or four grains. My own experience is in favor of the administration of from three to six grains at comparatively short intervals. Antifebrin is, on the whole, of more value than antipyrin, and probably is somewhat less dan- gerous, and should be used in doses of from ten grains to half a drachm. One of the most valuable remedies to relieve or mitigate the attacks of migraine is caffeine, which may be given either in the form of the alkaloid or as caffeine citrate. Guarana, of which caffeine is the active principle, seems in some cases to be of more service than the caffeine itself, as evidenced by the popularity of some of the guarana mixtures. A chemical mixture of antipyrin, citric acid, and caffeine is an efficient preparation in relieving the severity of the paroxysms of migraine ; it is sold under the name of migrainin. Another really efficient remedy, but one whose re- peated use is liable to lead to abuse, is bromocaffeine. With some patients it acts as a mild cathartic as well as a sedative, and its value is probably enhanced in this way. In some instances I have found ammonol the most efficient and least depressing of the newer reme- dies for the relief of migraine and some of the forms of symptomatic neuralgia. It can be used effectively in doses of from five to twenty grains, and one of the best methods of dispensing it is in capsules. Amyl nitrite and nitroglycerin have both been recommended on physiological grounds, but if useful are of beiaeflt in only a limited number of cases, probably in the so-called angiospastic variety. Among remedies which assist in allaying nervous excitement are the bromides, chloral, croton chloral, chloralamid, trional, and sulphonal. Lithium bromide Is more efficient in equal dose than the other bro- mides. Fifteen or twenty grains of lithium bromide with or without five grains of chloral will sometimes abort a threatened attack by quieting the nervous system and inducing sleep. When prodromes habitually precede the fully developed attack for a considerable period, the use of a saline cathartic and seclusion in a quiet room may also abort an attack. When the attacks come on after eating, or when the process of digestion has been arrested, as it sometimes is when an attack of migraine is foreshadowed, no measure is so efficient as free emesis, which can be induced by draughts of hot water or hot mus- tard water, or by the administration of ipecacuanha, or by the hypo- dermatic injection of apomorphine. Much relief is afforded during the attacks by the local measures which are so commonly employed, such as firm pressure on the head, the application of towels dipped in hot water or of hot water bags, and stimulating applications like mustard plasters to the nape of the neck. With some patients cold 880 NERVOUS DISEASES. to the head is more efiacient than heat, and this is usually best applied by repeatedly dipping towels into ice water, or by the use of the ice bag. At the same time that the very hot or very cold water is ap- plied to the head the feet may be bathed in a hot mustard bath. All forms of electricity have been used in the treatment of migraine, both for the paroxysm and in the intervals between the attacks, and weak galvanic currents carefully applied to the head certainly some- times afford relief. One electrode can be placed on each mastoid process, or one on the back of the neck and the other on the fore- head. The current should be passed for one or two minutes. Mild, rapidly interrupted faradic currents applied by the hand of the operator to the patient's head also at times afford some relief. With regard to the migrainoid intermittent headache, this variety of the disease is far more amenable to treatment by quinine than is the ordinary type of migraine. The quinine needs to be given in large doses, from fifteen to thirty grains daily, and the best plan seems to be to give the whole quantity in one or two doses about four hours before the attack is due. (Putnam.) The local treatment of the nasal passages is also of great importance, as this treatment may indirectly improve the condition of the frontal sinuses. Treatment in the Intervals between the Attacks. Among medicinal remedies which have been recommended by a large number of those who have written on the subject of migraine, or who have had mucli practical experience in the treatment of the disease, cannabis indica holds a high place. This drug should be given during the intervals between the attacks, as it seems to have some influence on the disease itself if its use is long continued. James Little recommends for the intervals between the attacks a pill of sodium arsenate, extract of cannabis indica, and extract of belladonna, of each one half grain. In addition to this pill, two grains of valerianate of zinc given twice daily, and, to cut short the paroxysms, twenty grains of sodium sali- cylate in a wineglassful of water, made effervescent by a dessert- spoonful of granular citrate of caffeine, should be administered. Another prescription which may be used with advantage, composed of cannabis indica, nux vomica, and ergotine, is given on page 246. Some patients are intolerant of cannabis indica, and in others if care is not taken the cannabis habit may develop. When migraine is associated with the gouty diathesis the lithium salts and natural mineral waters should be freely employed. Haig states that when the uric acid diathesis is present he has relieved many attacks by giving from twenty to thirty drops of dilute nitrohydrochloric acid, well diluted, and repeated once or twice at intervals of half an hour. In the discussion of etiology my views with regard to the relations of eyestrain to migraine were stated. The favorable results of ocular treatment have undoubtedly been ovei'estimated, yet measures di- rected to the eyes should not be neglected. The various disorders TRIGEMINAL REFLEX NEUROSES. 881 of refraction should be corrected if sufficient to cause discomfort or annoyance, but the hope should not be held out of a radical cure of the migraine, although the evidence seems to be fairly conclusive that paroxysms of migraine are less frequent and of less severity after the relief of eyestrain. Tenotomy and partial tenotomy should be performed only when the Indications are for their performance independently of the existence of migraine. TRIGEMINAL REFLEX NEUROSES. Trigeminal Headaches. — Diseases of the trigeminus might be greatly extended if we would accept the idea of classifying under them all the affections which have been referred to irritation of peripheral filaments of this nerve, or to one or another sort of toxic action exerted upon the nerve or its centres. Not a little of modern rhinological and laryngological practice is founded upon the idea that various disorders, cephalic, ocular, respiratory, cardiac, and general, are dependent upon irritation localized to terminal filaments of the trigeminus. Among the affections which are most frequently discussed from this point of view are certain varieties of headache. Headache in one sense may be said to be almost always of trigeminal origin, as the trigeminus is the main sensory nerve of the head. Even if pain is directly due to disease or disturbance of the sensory regions of the cerebrum, these in part constitute a portion of the trigeminal apparatus. As has been shown in various places, the pain of brain tumor, meningitis, or abscess, and of other focal and diffuse ence- phalic lesions, is due directly or indirectly to trigeminal irritation. It is sometimes important to distinguish between headaches or head pains due to direct irritation of the dura, and those which seem to he dural, or at least intracranial, but are really due to irritation reflected from points outside of the skull, as this distinction may enable us to differentiate between a serious intracranial affection and one more amenable to treatment because due to a lesion of an ac- cessible region like the nose, the ear, or the throat. According to Allen, the reflex headache is almost entirely restricted to the tem- ple, the forehead, and the vertex, and this author even locates the nasal disorder with reference to the head pain. He has found in all varieties of chronic catarrh that a dull pain in the region of the forehead has been complained of, and when the disease is confined to that portion of the nasal chamber which corresponds to the middle turbinated bone the pain is referred to the temple ; beginning in the forehead and temple, in some cases it extends to the vertex and the nape of the neck. It may be accompanied with nausea and vomit- ing, and then be regarded as a true headache or attack of migraine. Allen distinguishes reflex catarrhal headache from sick headache of gastric origin by the absence of gastric disturbance ; from the tem- poral pains of eyestrain by its persistence after the correction of the 56 882 NERVOUS DISEASES. errors of refraction ; and, with less exactness, from neuralgia of the head by exclusion of the rather multiform causes which lead to this condition. "While the headaches to which Allen refers are doubtless of nasal origin, it might be questioned whether they should be re- garded as reflex headaches. It might be more correct to speak of them as headaches due to direct irritation of the terminal filaments of the trigeminus, they being reflex only in the sense that the patient refers them to an intracranial position although the cause is extra- cranial. Trigeminal Reflex Cough. — Under the name of trigeminal cough Hirt calls attention to a reflex neurosis which has also claimed the attention of others who attribute the cough entirely to irritation of the trigeminal fibres distributed to the nose, pharynx, or external auditory meatus. Subcortical varieties of the reflex neuroses, ac- cording to the site of the initiating lesion, have been described, as nasal, pharyngeal, and auricular. It is by no means a rare affection. Among the best methods of treatment are cauterization, the nasal douche, and the use of weak faradic currents to the nasal cavity or to the throat. Besides cough, forms of paroxysmal asthma and of vertigo have been assigned to trigeminal irritation, as have also several forms of vertigo. Certain facts with regard to the effects that can be produced by irritation of the trigeminal filaments in the nose or the conjunctival sac favor the view of the trigeminal reflex source of certain cases of cough, asthma, and vertigo. It has been found, for instance, that irritation of the trigeminal nasal filaments or conjunctival filaments cuts short laryngeal spasm. ANESTHESIA FROM DISEASE OF THE TRIGEMINUS. Trigeminal Anesthesia due to Focal Lesions. — Positions of the Lesions. Anesthesia more or less complete results from a de- structive lesion of any portion of the trigeminal apparatus, — from lesion of the Gasserian ganglion, of the peripheral branches of the sensory portions of the nerve, of the sensory root between the Gas- serian ganglion and the pons, of the entering root fibres in the pons, of the sensory end nucleus in the oblongata, of the descending spinal root, of the descending sensory root, of the central sensory pathway in the peduncle and the internal capsule, of the thalamus, and of the sensory cortex and subcortex. A glance at the diagram of the tri- geminal apparatus (Fig. 402) will show the positions in which the lesions just enumerated might be located. Lesions causing pressure on any of these parts will produce transient anesthesia, which may become in part permanent if the pressure interferes with the nutri- tion and leads to degeneration. Anestlwmi from Bismsr of the Trigeminal Nerve Trunks at the Base of the Brain. More or less limited or diffuse anesthesia may be produced by a tumor at the base of the brain, a basal meningitis or ANESTHESIA FROM DISEASES OF THE TRIGEMINUS. 883 Paralysis of the third nerve, and an- esthesia in the distribution uf tlie frontal and lachrymal branches of the fifth nerve. The area of anesthesia is within the dotted line. abscess, a cavernous sinus thrombosis, a peripheral neuritis of rheu- matic, syphilitic, or other origin, fractures of the floor of the skull, traumatisms cutting, crushing, or bruising branches of the nerve after theii' exits from the cranial foramina, or toxic agents acting upon any portion of the nerve from its centres to its termini. In many cases, as has already been sufficiently indicated, disturbances of the motor portion of the trigeminus or of other adjacent and correlated structures may be associated with the anesthe- sia. A somewhat frequent associa- tion is anesthesia of the ophthalmic branch of the fifth nerve, with total or almost total paralysis of the third. In Fig. 411 is an illustration of such a case reported by McConnell from the Polyclinic service of the writer. This patient had a history of syphilis, although his paralysis apparently came on as an immediate result of exposure to a draught, after which he was seized with sharp pain in the eyeball and the right frontal region. This was followed by an herpetic eruption, and still later by burning sensations, and soon the right upper eyelid was paralyzed. Anesthesia was complete over the right forehead, temx)oroparietal region, and eyelids, and the cornea was cloudy and insensible to touch, but not ulcerated. All the extraocular muscles supplied by the third nerve were paralyzed, as were also all the intraocular muscles, both cycloplegia and iridoplegia being present. In this case an inflam- mation syphilitic or rheumatic in character probably affected the sheaths and trunks of both the third and fifth nerves. Schlesinger has reported a case with complete paralysis of the oculomotor nerve of the left side with numerous iDigmented spots on the forehead the result of herpes zoster, the paralysis having occurred one week after the herpes. Trigemmal Anesthesia from Pontile and Oblongatal Lesions. Gross pontile lesions causing trigeminal anesthesia frequently also involve the sixth, seventh, eighth, and ninth cranial nerves. The forms of trigeminal anesthesia due to lesions within the brain stem — to lesions affecting the end nucleus and the widely distributed roots of the fifth nerve— have a particular interest, and have already received some consideration when discussing lesions of the tubercle of Eolando. Besides anesthesia, other symptoms, which will be pointed out when lesions of the oblongata-spinal decussation are considered, occur. 884 NEEVOUS DISEASES. The point to be remembered in this connection is that a lesion as low down as the level of the atlas gave rise to marked trigeminal anes- thesia of the opposite side. In a case recorded by Stieglitz, the right cornea and right side of the face were completely anesthetic, while the right side of the body, though paralyzed, was sensible to the slightest touch, but the sense of position of the limbs was uncertain, and on the left side anesthesia to touch, pain, and temperature was complete. In this case Turner believes that the symptoms suggested a lesion above the second cervical nerve root in close proximity to the tubercle of Eolando, although it may have been higher up in the oblongata. Anesthesia from Lesions of the Trigeminal Central Pathway. Lesions of the neurons which pass from the sensory end nucleus of the tri- geminus in the oblongata to the cerebrum give rise to anesthesia or hyperesthesia according as the lesion is destructive or irritative ; but I do not know of any cases of anesthesia absolutely confined to the trigeminal distribution from lesions of the internal capsule, thalamus, corona radiata, or cortex, although hemianesthesia, more or less com- plete, and including the face, from lesion of the posterior portion of the posterior limb of the internal capsule and of the thalamus, has been a somewhat frequent observation, and is in accord with the results of physiological experiment. Rules for the Diagnosis of the Site of the Lesion causing Trigeminal Anesthesia. With the addition of the points just given about the occurrence of anesthesia from lesion of the tubercle of Eolando and the descending spinal root of the trigeminus, the rules long since given by Eomberg for the diagnosis of the site of the lesion from the distribution of the anesthesia remain good. These are as follows : (a) The more the anesthesia is confined to slight filaments of the nerve, the more peripheral will the seat of the lesion be. (&) If the loss of sensation affect a portion of the face together with the cor- responding facial cavity, one of the divisions of the nerve is af- fected before or immediately after its passage through the cranium. (c) When the entire area of the fifth is more or less anesthetic, and there are nutritive disorders in the affected parts, the Gasserian gan- glion or the nerve in its immediate vicinity is the seat of the disease. (d) If the anesthesia of the fifth ner\-e is complicated with disordered function of adjoining nerves, it may be assumed that the disease is seated at the base of the brain, (c) If sensation is lost in the face on one side and in the half of the body and limbs on the other side, the lesion is probably situated in the lateral part of the upper ex- tremity of the pons and preoblongata. (/) If sensation is lost in the face, half of the body, and the limbs of the same side, the lesion is situated in the opposite hemisphere of the brain, most probably in or near the posterior third of the posterior segment of the in- ternal capsule. HEMIFACIAL ATEOPHY. 885 Trigeminal Anesthesia in Chronic Degenerative and Retro- gressive Diseases. — Special forms of trigeminal anesthesia are occasionally seen in connection with chronic degenerative diseases, like tabes, chronic muscular atrophy, and syringomyelia. In rare instances it may, for a time at least, be the only indication of such chronic degeneration. In a case of tabes recorded by Pierret mas- tication was difficult, and other symptoms present were anesthesia in the distribution of the trigeminus, impairment of speech, inco- ordinate movements of the tongue, tinnitus and some deafness in one ear, and constant parosmia, the patient complaining of an almost continuous bad smell. In several cases that have come under my observation trigeminal anesthesia has aijparently been a portion of the syndrome of an unusual type of syringomyelia, although the possibility of syphilitic disease in these cases cannot be overlooked. In one case a man thirty-seven years old gradually lost sensation on the left side of the face. Examination showed decided loss of all forms of sensation, involving to some degree all the sensory divi- sions of the fifth nerve. The mucous membrane of the nose and of the mouth of the same side was also anesthetic. The patient had some sensory symptoms, chieiiy paresthesias, in other parts of the body. For a short time before coming under observation he had had nocturnal headaches. His sight was poor, but this was apparently due to an old defect of refraction ; no abnormal ophthalmoscoiiic appearances were found. The pupils were small, and the iritic and accommodation reflexes were abolished. Smell was almost entirely lost on the left side. Hearing was good. He was much troubled with drooling from the left corner of the mouth, and occasionally he had a little difficulty in swallowing. The tongue exhibited slight fibril- lary tremor. Careful examination showed no motor paralysis in the domain of the fifth, seventh, fourth, or sixth nerve. In this case the trigeminal anesthesia was the dominating symptom, although the other phenomena present showed that structures outside of the tri- geminal apparatus were affected. Persistent antisyphilitic treatment failed to help this patient, whose bulbar symptoms were gradually extending when he was last seen by the writer. In 1889, in asso- ciation with Dr. S. Solis-Cohen, I studied another case of bulbar paralysis, with, among otlier symptoms, marked disturbances of sensation in the domain of the trigeminus as well as in other parts of the body. HEMIFACIAL ATROPHY. As Stated on page 863, with the little light that has been thrown on its pathology by two autopsies, hemifacial atrophy should be re- garded as a disease of the trigeminus, and should therefore be briefly considered in this connection. It is a trophic disease characterized by wasting of all the tissues of one side of the face except the 886 NERVOUS DISEASES. muscles. Its synonyms are unilateral atrophy of the face, progres- sive facial hemiatrophy, neural atrophy of the face, facial tropho- neurosis, and progressive laminar aplasia. In rare instances the muscles are involved in the atrophy, but usually this is confined to the skin, the subcutaneous tissue, and the bones. The earliest de- scription of the disease was by Parry, in 1825. Its clinical literature has grown rapidly in recent years, but thus far pathological reports have been made on only two cases, those of Homen and Mendel. The disease usually develops very slowly, commonly beginning with a whitish patch on one side of the face. Other similar patches appear, and in time change to a darker hue. The alterations in color are chiefly dependent upon the cutaneous atrophy. As a rule, the disease advances to a certain point and then remains stationary, apparently not interfering, or interfering but little, with the patient's length of life. The atrophy causes a marked lessening of the bulk of one side of the face (Fig. 412). Changes in the color of the hair take place, and even complete Fig. 412. absence of the hair in spots has been observed. 'The beard may drop out or fail to grow on the affected side. In an interesting case recorded by Lloyd the patient first noticed, several years before coming under observation, a white patch near the bridge of the nose. This gradually spread upward and invaded the hairy scalp. The skin of the af- fected area was almost de- stroyed, and the epidermis left dead- white and shrivelled. "Where the atrophy involved the haiiy scalp the hair had fallen out, causing a most unsightly appearance. The atrophy was largely confined to the upi:)er part of the face. This case in its loca- tion and phenomena presented some of the peculiarities of the circum- scribed form of morphea, but the latter does not usually involve the bone. In this case not only had the fat and connective tissue disap- peared, but the bone was also deeply atrophied. It is doubtful whether a clear distinction can always be made between morphea and hemi- facial atrophy of tlie partial form. Sometimes the sebaceous glands are atrophied with the skin. The bones of the jaw, especially those of the upper jaw, may waste, and the teeth occasionally fall out. Other symptoms of irregular occurrence are decrease or absence of perspiration, and even of the lachrymal secretion. In rare instances Hemifacial atrophy. (Hirt.) HEMIFACIAL ATROPHY. 887 disorders of taste and hearing have formed a portion of the syndrome of the disease. It is an important fact, as bearing upon the theory of the trigeminal origin of the disease, that the sufferers from hemi- facial atrophy sometimes are the victims of various forms of tri- geminal neuralgia, this usually being observed in limited portions of the nerve distributions. Neuralgic attacks, as a rule, come in parox- ysms, and in rare cases are accompanied by twitchings of the muscles supplied by the seventh. Other symptoms referable to the trigeminus are hyperesthesia, paresthesia, and even slight anesthesia. Paralysis of the face or limbs is rare. Besides the symptoms referable to the sensory distribution of the trigeminus, in other rare cases masticatory twitchings and atrophy of some of the muscles supplied by the motor branches of the trigeminus are observed. Occasionally, instead of one half of the face being involved in the atrophic process, this is confined to a more limited area, as to the lower or the upper half of one side. Recorded cases would seem to indicate that the disease is much more frequent in the female sex, and it usually occurs before the age of twenty years, not a few of the cases originating during childhood. Conclusive facts "with regard to heredity are wanting. Various local affections have been assigned as causes, as otitis, glan- dular Inflammation, and rheumatic neuritis or perineuritis due to cold. It has been observed in association with various organic and especially with degenerative diseases of the neuraxis, as disseminated sclerosis, syringomyelia, and epilepsy. Moebius has suggested the theory of external local infection. The facts point to the fifth nerve or its nuclei as the source of this affection, although the recorded cases are not sufficient to be authoritative. The disease is probably dependent upon an irritative lesion of some portion of the fifth nerve, probably of its sensory nuclei and root fibres. In one case with autopsy, by Homen, a dural tumor compressed the Gasserian gan- glion and the branches of the fifth uerAC, and in another case, by Mendel, examination revealed proliferative neuritis of the left tri- geminal nerve, most marked in its second branch, with central atrophy of the spinal root of the fifth and partial atrophy of the substantia- ferruginea. Facial hemiatrophy in this case was asso- ciated with atrophy of the left upper extremity, and the autopsy and microscopical examination showed that the left musculospiral nerve had undergone changes similar to those found in the Gasserian ganglion and the fifth nerve. The history of an insidious onset beginning early in life, the fact that the atrophic process does not implicate, or implicates to only a slight degree, the muscular tissues, and the distinctive appearances presented by the side of the face affected, are sufficient to enable a diagnosis to be made. Asymmetry of the face and head is not uncommon in idiocy and imbecility and in other cases of arrested development, but the atrophy in these cases is not of the circumscribed character and has not the special 888 NERVOUS DISEASES. featiu-es of hemifacial atrophy, especially as observed in the skin. One side of the face may be smaller than the other without any real atrophy being jDresent, and in these cases investigation will show that the various tissues composing the face are properly developed on both sides, the only difference being in general bulk and contour. Peripheral facial paralysis is readily separated from hemifacial atrophy by a study of facial movements and of the electrical re- actions. In facial paralysis atrophy is usually not pi-esent, or is very slight, and the deformity shown by the face is due either to over- a,ction of the muscles of the unaffected side or to secondary twitch- ings and contractures in late and not entirely cured cases. The prognosis as to recovery is bad, but the disease does not seem to shorten life. Ciises have lived from thirty to forty years after the first observations upon them were made. Treatment is futile, at least so far as the records up to the present time are concerned. Thyreoid feeding may be tried, as may also the use of mild galvanic currents and massage. As in other cases of disease of a degener- ative type, one of the best things that can be done for the patient is to keep up the general health by hygienic and other measures. Pads introduced into the mouth have been suggested to prevent the unpleasant appearance caused by the atrophy. HEMIFACIAL HYPERTROPHY, In hemifacial hypertrophy one side of the face is enlarged, owing to the increase of all its tissues, the muscles, however, being less A few congenital cases have been recorded. One of the most inter- esting cases of acquired hemifacial hypertrophy has been recorded by Montgomery, the affection having been preceded by an ab- scess of the cheek. The few facts known seem to point to irrita- tion of the fifth nerve or some of its central structures as the source of the disease, but, as in the case of unilateral atrophy of the face, this etiology cannot be regarded as established. In some instances hj^pertrophy of the face lias developed in connection with trigeminal neuralgia. No autop- sies have yet been recorded. Mi- croscopical examination of the dis- eased tissues shows evidences of chronic inflammation and degenera- tion. Tlie disease may begin in the gums, which may be markedly involved than other structures Fig. 413. UKiniracial hyiicrtroiihy. (Muntgomery.) TRIGEMINAL PARALYSIS. 889 Fk;. 414. hypertrophied. A marked increase of size, with other deformity, slowly takes place. In typical cases both the bone and the soft tissues are involved in the process. The skin of the face becomes changed in appearance. In several of the reported cases the alveolar processes have been enlarged. The result- ing hypertrophy cori-esponds closely with the distribution of the fifth nerve. Sensibility is not changed, and the sijecial senses, as a rule, are not af- fected. The disease must not he confounded with its oppo- site, hemifacial atroj^hy, the observer supposing that the unaffected side is atrophied and the hypertrophic side normal. The appearances of the skin and the most casual inspection will correct a case of this sort, avail than in cases of hemifacial atrophy, Hypertrophied jjum of the upper Jaw in a ease of hemifacial atrophy. (Montgomery.) Treatment is of even less PARALYSIS OF THE MOTOR PORTION OF THE TRIGEMINUS (MASTICATORY PARALYSIS). Definition and Varieties of Motor Trigeminal Disease. — Disease of the motor portion of the trigeminal nerve is either para- lytic or spastic, and is usually described as masticatory paralysia and masticatory spasm. In rare instances trigeminal paralysis and spasm are associated in the same case. Paralysis of the motor ijortion of the trigeminus, the so-called masticatory paralysis, is a disease in which the movements of the lower jaw and some of the movements of the throat are paralyzed because of a destructive lesion involving the nerve supply to the muscles controlling these movements. The paralysis may be miihderal or bilateral, and either form may be ])artM or complete. It may also be an isolated, purely motor affec- tion, or it may be associated with disease of the sensory portion of the trigeminus and of other structures. Symptomatology. — Masticatory paralysis is shown by loss or impairment of the moA^ements regulated by the masseter, temporal, and pterygoid muscles. When the paralysis is bilateral and com- plete, the lower jaw cannot be held in position (see Fig. 415). In the unilateral variety the patient experiences difficulty on one side in masticating, and in opening and closing the mouth for other pur- poses, but the masseter muscle of the unaffected side is sufficient to hold the jaw in position, or nearly in position, and for this reason 890 NERVOUS DISEASES. the paralysis may at first escape attention. In brief, the main effect of paralysis of the motor trigeminus is to interfere with the move- ments of the lower jaw. If the muscles degenerate, this can be de- termined by inspection and by manij^ulation of the masseters and temporals, and in these muscles loss of faradic contractility and reactions of degeneration, partial or complete, may be present. A few words should be said about the special movements regulated by each of the important muscles of mastication and the effects of their paralysis. While trigeminal motor paralysis generally affects all portions of the nerve, in rare instances nuclear disease, or disease isolated to the nerve branches supplying one muscle or one set of muscles, gives incomplete varieties of masticatory paralysis, and even when the paralysis is complete a knowledge of the particular actions of the different muscles throws light upon the peculiarities of the resulting disorder. The masseter muscle acts to draw the jaw slightly forward as well as upward, and, in consequence, when it is paralyzed the jaw not only drops but also slightly recedes. The tem- poral muscle acts with the masseter in closing the jaw, but its pos- terior fibres also draw the jaw backward, and this particular move- ment will therefore be impaired or lost M'hen this muscle is paralyzed. Paralysis of the external pterygoid muscles interferes with at least three actions, —that of pulling the lower jaw forward, that of carrying the ramus of one side inward (and, of course, of the other side out- ward), and that of depressing the jaw. As the internal pterygoid muscle assists in closing the jaw, and in advancing it when closed, and as it also acts with the external pterygoid to draw the ramus of its own side towards the middle line, its paralysis will cause impair- ment or loss of these movements ; but an interference with the func- tion of the internal pterygoid muscle could probably be separately determined only in the case of the movement for advancing the jaw. As the tensor palati is probably supplied by the fifth nerve, the movements performed by this muscle should be affected in complete masticatory paralysis. In one of my cases of associated masticatory paralysis and spasm, to be presently described (see page 894), the movements of this muscle were affected, as were also those of the mylo- hyoid and the anterior belly of the digastric. Paralysis of the tensor tympani, also supplied by the fifth nerve, probably causes tinnitus and inability to appreciate deep tones, but clinical observations regarding paralysis of this branch of the ner\e are wanting. In examining for paralysis in the distribution of the motor subdivision of the tri- geminus, much aid will be given by placing the fingers of both hands over the temporal and masseter muscles of the two sides of the face, when the imperfect action or entire lack of action on the affected side can be readily determined. If the paralysis is unilateral the nmscles on the affected side are flaccid during mastication, while the corresponding muscles on the other side firmly contract. TRIGEMINAL PARALYSIS. 891 Etiology and Pathogenesis.— Nothing need be said about age, heredity, sex, and other factors usually included in a study of the etiology, as in a disease so rare as masticatory paralysis these play an unimportant role. The determined or the presumable causes have in the vast majority of cases been focal lesions of the trigeminal appa- ratus,— cortical, subcortical, capsular, pontile, oblongatal, basal, or extracranial. Peripheral neuritis is a rare cause. The most fre- quent lesions have been tumors or localized meningitis at the base of the brain, but disease affecting the nuclei and roots of the nerve is only a little less common. In several personal cases focal lesions of the pons and oblongata have involved the motor trigeminus, but, with one exception, other nerves and important structures have been implicated. Such nuclear and radicular disease may be of degen- erative type, or it may be a focal encephalitis, a gummatous infil- tration, a softening from embolism or thrombosis, a hemorrhage, an enlarged vessel, or even a sclerotic nodule. Cases, however, have been reported in which degeneration of the trigeminal nuclei has been present in association with degenerative disease attacking vari- ous parts of the neuraxis. In a case of tabes recorded by Pierret, the patient appeared to be always chewing, and he was obliged to swaUow with extreme care. Speech and deglutition were difficult ; the tongue on protrusion was jerky and tremulous. Later all the muscles of the eye were paralyzed. The chewing movements con- tinued ; saliva ran from, the corners of the mouth ; the teeth did not meet on attempting to bite or to seize objects placed in the mouth. Diagnosis. — The diagnosis of masticatory paralysis is difficult only when it is of slight degree, and especially when it is unilateral. The points as to the special actions of the different muscles and as to methods of examination given under symptomatology should be here recalled. Frequently diagnosis will be assisted by the fact that the motor paralysis is associated with symptoms of involvement of the sensory branches of the trigeminus. Cortical or subcortical mastica- tory paralysis is usually associated with symptoms showing paralysis of other parts. As cortical lesions are in most cases unilateral, and as the cortical representation of the movements of each lower jaw is bilateral, that is, the centre on one side of the brain being sufacient for both sides of the body, a cortical masticatory paralysis is some- times scarcely recognizable. Degeneration reactions are observed in cortical cases, and indeed always where the lesion is situated ceph- alad of the motor nucleus. In pseudobulbar paralysis from lesion of the lenticula or internal capsule, masticatory paralysis may form a portion of the syndrome. The diagnosis will be made by a study of the associated symptoms and regulated by the absence of the symptoms of true bulbar paralysis. The diagnosis of nuclear mas- ticatory paralysis is made by the rules governing the diagnosis of nuclear paralyses of all sorts. (See nuclear facial paralyses.) Basal 892 NEEVOUS DISEASES. meningitis, tumors, hemorrhages, and abscess nearly always involve adjacent structures, and a careful study of the focal symptoms is usually sufficient to point out the position and limitations of the lesion causing the trigeminal paralysis. Schulten, for instance, re- ports a case of complete paralysis of the trigeminus in its motor as well as in its sensory portion, in which case the abducens and oculomotor nerves were both involved. Prognosis. — The prognosis of masticatory paralysis depends upon the nature, and, to a less degree, upon the situation, of the lesion when it is focal. In cases of syphilitic disease at the base, the prognosis will be relatively unfavorable, as it is also in the rare cases due to peripheral neuritis. Nuclear cases are of course unfavorable. Treatment. — The treatment of masticatory paralysis can be re- duced to a few points. It is that of focal specific disease, or local meningitis or neuritis from whatever cause. Mercury, iodides, sali- cylates, and hydriodic acid, the remedies so frequently referred to in these cases, are of course indicated. Electricity can be used, guided by the same rules that apply to other peripheral and central palsies. Strychnine, the hypophosphites, and other tonics are also useful. SPASM OF THE MUSCLES SUPPLIED BY THE MOTOR DIVISION OP THE TRIGEMINUS. Synonyms and Varieties. — Spasm of the muscles supplied by the motor division of the trigeminal nerve is known by several names, as masticatory spasm, trismus, and masseter spasm. The spasm may be tonic or clonic, axiute or chronic, although the acute variety is rare ; it may be hysterical or reflex, due in the latter case especially to irrita- tion reflected from the sensory subdivision of the fifth. One of the varieties of clonic masseter spasm is known asjaw chattering. So far as varieties of the spasm due to focal lesion are concerned, reported cases show that the disease may be situated in the cerebral cortex, the corticobulbar pathway, the oblongatal nucleus, the root fibres within the pons, or in the trunk of the nerve itself. Clinical History. — When the spasm is tonic and bilateral the jaws are held more or less firmly closed, and sometimes an actual grinding of the teeth takes place. In other cases the jaws can be partially opened by the patient, or can be forced slightly open by others, but the exercise of the force necessary to do this may cause pain, especially in the masseter muscles. When the spasm is marked, the existence of strong contraction in the bellies of the masseter and tem]ioral muscles causes them to stand out prominently, and the muscles can be felt t( > be hard and bulging by passing the flngere over them. The fixation of the jaw s gives the patient's face a set expression, and the expression of emotion, as of pleasure or grief, is evinced only in the action of the muscles supplied by the seventh pair and bj- the movements of the ocular muscles. Unilateral tonic TRIGEMINAL SPASM. 893 spasm is very rare, but has been recorded. Masticatory spasm even when confined to one side will hold the jaws of both sides together but in this case less difficulty will be experienced in partially open- ing the mouth, especially on the side which is not spastic. Differ- ences in the bulging and hardness of the muscles of both sides can also be made out in unilateral cases. Trifniuis in its narrowest sense is a tonic spasm of the muscles supplied by the trigeminus, and especially of the masseters, in consequence of which the jaws are held rigidly closed. In the infectious disease known as tetanus one of the chief manifestations is trismus, a symptom so important and frequent as to have given the affection its common name of lockjaw. Tetanus, however, is more properly considered either under general neuroses or microbic diseases. In it, besides the muscles of the jaw, those of the throat, of the neck, of the trunk, and even of the limbs in some cases, may be involved ; it is only in rare cases that the tonic spasm is confined to the trigeminal musculature. In addition, other symptoms, like pain, great weakness, and mental excitement or de- pression, are present. In the first place, cases of clonic masticatory spasm are seen in which the spasmodic movements are frequently repeated, causing a disorder sometimes spoken of as chattering jaw. The chattering is almost continuous, except when the patient is asleep or during mastication. It is a symptom of senility, and is sometimes seen in paralysis agitans and in some forms of sclerosis. In one case of this kind, an old colored man in the nervous wards of the Philadelphia Hospital, the patient had, in addition to chattering jaw, some tremor of the limbs on one side, and a tendency to assume bent and fixed attitudes. Another case of clonic masseter spasm has been reported from my Philadelphia Polyclinic service by Dr. J. W. McConnell. This patient was a woman past seventy years, from whom no family or personal history could be gleaned. Six months before coming under observation she first noticed a "peculiar quiv- ering sensation in the region of the stomach," which was followed by nausea, and sometimes by vomiting. Immediately after these symptoms a movement of the lower jaw would occur, lasting less than a minute, but frequently repeated. The woman was of wor- risome disposition, and could think and talk of nothing but her troubles. Her general health was good. Her face was intermit- tently involved in bilateral spasm or twitching of the masseter muscles. The spasm was not attended with pain. The intervals of stoppage varied from a few seconds to almost a minute, and if her attention was diverted the period was even longer. So far as known, the movements ceased during sleep, but did not entirely stop when mastication was attempted. The spasm was irregular, and an attempt to count the oscillations was fruitless. Instead of this form of clonic masseter spasm, which occurs chiefly among the aged, a variety is seen in which spasm occurs at short and dis- 894 NERVOUS DISEASES. tinct intervals and may be repeated only once or twice. Still an- other form of clonic masseter spasm is clearly of hysterical origin, and may have some bizarre features. Verhoogen has reported the case of a boy who had received from a comrade a slap on the right cheek. The following morning when the patient awoke he could not open his mouth. When asked to open his mouth a month after the accident, he separated the lips, but the jaw remained immovable, and any attempt to separate the teeth immediately provoked severe pain in the right masseteric region. With great care and gentleness it was possible slowly to open the mouth to a reasonable extent, but during this procedure the masseters were observed to contract re- peatedly. At the angle of the jaw there was an area of extreme cutaneous tenderness ; on and over both arms were areas in which the thermic sense was lost. Under chloroform the spasm relaxed, and the joint was found to be absolutely normal. The contracture, then, was purely hysterical, the slight traumatism having acted simply as a determining and localizing agent. The mother was a confirmed hysteric. Peterson has recorded the history of a woman in whose case the work about the mouth, and the necessity for keeping her mouth open for a long time while in the dentist's chair, in having two sets of teeth fitted to her upper jaw, resulted in the development of masticatory spasm. When sitting quietly, not using the jaw muscles, the masseters, temporals, and pterygoids were in continuous clonic spasm, the jaw opening and shutting slightly and moving from side to side. The chief dif&culty, however, was when she attempted to speak, when the mouth opened widely and a subluxation of the jaw downward and forward from the glenoid cavity took place. I do not know of any records of cases of masticatory spasm apparently due to cortical disease. As stated on page 336, Horsley has placed the centre for movements of the lower jaw just behind the laryngeal and pharyngeal centres. Irritation of this region should cause lateral and up and down movements of the lower jaw. In one case, reported by Hirt, spasm of the tongue and spasm of the lower jaw were asso- ciated. The lower jaw would first be jerked to and fro and up and down, and these movements would be followed by turning and rolling movements of the tongue, the mouth remaining open. The attack occurred ten or twenty times a day, and came on for the first time three days after an epilej)tic fit. Associated Paralysis and Spasm of the Trigeminus. — In rare instances trigeminal paralysis and spasm are associated. One interesting c;ise of this kind, studied in my Philadelphia Polyclinic service, has iK'cn put on record by McConnell. The patient was a man forty-six years old. On December 1, 1892, he was affected with symptoms of an acute cold, and about a month later he noticed for the first time that he could not chew as well as formerly. The weakness of the muscles of mastication increased, and in the course TRIGEMINAL SPASM. 895 Fig. 415. of two or three weeks they became powerless to such an extent that the lower jaw was not held in position against the upx^er. Ability to bring the jaws together was variable. In the latter part of February the jaw became affected with a tremor, causing chatter- ing or clonic spasm, and occasionally the jaws would snax) togetlier involuntarily. About the beginning of March he became unable to close the mouth except with external assistance. The notes of the case state that he was a fairly well nourished man, without any paral- ysis of the limbs or trunk, but with a peculiar apx^earance of the face. The chin is dropped, causing a separation of the teeth of about one quarter to one half inch, with the lower lip somewhat everted and pendulous. (Fig. 415.) Attempts to bring the jaws together cause tremor. Movements of the lips and other j)ortions of the face supplied by the seventh nerve are preserved. Sensation is also pre- served. The movements of the tem- poral, masseter, and pterygoid mus- cles are all greatly impaii-ed. The patient is unable to swallow food that is masticated and at the same time hold in his mouth the part that is not masticated. In order to swallow fluids he must push his mouth shut after the drink is taken, and drop his head towards his chest. If he does not do this, what is taken win regurgitate through his nose. Once in a while fluids get into his trachea. Warm drinks are especially irritating. The act of swallowing, which was carefully studied, is very peculiar ; a part of the fluid seems to go down by gravity, then a spasmodic action of the mus- cles of the front of the neck takes place, and some of the food or fluid is swallowed and some regurgitates through the nose. The movements performed by the mylohyoid and digastric muscles are affected, and those of the tongue seem also to be impaired. The palatal muscles contract to irritants somewhat imperfectly. The constrictors of the pharynx also contract a little less actively than usual ; the vocal cords and arytenoids move per- fectly. In drinking he seems to be unable to get the water far enough back for the constrictors to act. Laughing gives the upper part of his face a peculiar appearance, somewhat like the risus sardonicus. This case, as already stated, would seem to give some clinical sup- port to the old view that the nerve supply to the tensor palati Trigeminal paralysis and spasm in the same case. Besides the paralysis of the masseter, pterygoid, and temporal muscles, the movements performed by the digastric and mylohyoid muscles were impaired, as were also those of the tongue, the palatal muscles, and the con- strictors of the pharynx. 896 NERVOUS DISEASES. is not properly from the vagus itself, but that the nerve branches come from the trigeminus, and pass by way of the vagus trunk, leaving it to go through the otic ganglion to the muscle. Etiology. — The etiology of spasm of the trigeminal muscles is that of local spasm affecting the distribution of any of the motor cranial nerves, aud, indeed, of local spasm anywhere in the body. Most cases are due to focal lesions in the motor trigeminal pathway or to diffuse lesions affecting this nerve as well as other structures. Toxic or infectious agents acting upon the centres for the nerve may be a cause in some instances. Hysterical and neurasthenic states and the feebleness of the nervous system which comes with advancing years or premature senility are other causes. Among exciting causes the most important are sudden and excessive emotion, exposure to cold, aud injuries. In Peterson's case the spasm originated as the result of i^rolonged dental operations, and slight spasm of the mus- cles of the jaw after dental operations is not uncommon. Any focus of irritation in the sensory distribution of the fifth may give rise to the spasm. Diagnosis and Prognosis. — The diagnosis is readily made. Acute affections of the maxillary articulation, or painful and espe- cially inflammatory diseases of the jaw or of the mouth, which pre- vent it from being opened, might for a time be regarded as due to masseter spasm, and indeed such spasm sometimes accompanies pain- ful disorders of this description. Brief study of the condition of the mouth and the jaws and inspection and manipulation of the masseter and temporal muscles will clear up all doubts. In one of the varie- ties of arthritis deformans the temporomandibular articulation, the spinal joints, and, indeed, the articulations of any part of the body, may be rigidly fixed, but the mistake of supposing such a case to be one of tonic masticatory spasm could be made only by the most care- less observation. The prognosis varies according to the nature of the affection : it is best in hysterical cases, in those due to ii-ritation reflected from sensory nerves, and in cases of organic lesion that can be favorably influenced by absorbents. When the nuclei or root fibres of the nerve are involved in giiomatous or degenerative pro- cesses the prognosis is, of course, bad ; such cases progress rapidly or slowly to a fatal issue. Treatment.— The treatment of trigeminal spasm must, of course, be based upon the nature of the cases. If due to a focal lesion at the base of the brain or elsewhere in the cranial cavity, or to a diffuse inflammation, absorbent remedies, like the iodides, mercury, and ammonium chloride, will be indicated. The possibility of a reflex origin of the spasm should always be borne in mind, and sources of irritation should be sought for, especially in the distribution of the sensory portion of the fifth nerve. The nasal, aural, and pharyngeal cavities should be searched, the teeth and gums should be examined TEIGEMINAL SPASM. 897 for caries or other disease, and the presence of periosteal inflam- mation or of trouble at the inferior maxillary articulation should be determined. In rheumatic cases the salicylates and other anti- rheumatic remedies should be used. For the relief of the spasm, especially in tonic cases, various antispasmodics and sedatives may be used. Those which have proved of most value are atropine, hyoscine, coniine, and duboisine. In Peterson' s case, duboisine sul- phate in doses of one two hundredth of a grain three times daily gave the patient much relief by quieting the spasmodic movements almost entirely. Coniine hydrobromate and fluid extract of gelse- mium are remedies worthy of trial, and should be pushed rapidly to maximum doses until constitutional effects are produced. Begin- ning, for example, with one twenty-fifth of a grain of coniine hydro- bromate four or five times daily, the dose can be increased until one tenth of a grain is taken, and the fluid extract of gelsemium can be pushed until from ten to fifteen minims are taken at one time. In the administration of these drugs, for this as for other diseases, it is of course important to watch carefully the effects produced and to study the idiosyncrasies of the patient. Bromides have a decided temporary effect on the spasm, especially when it appears in a peri- odical or paroxysmal form of clonic spasm. The use of the actual cautery is of great value here, as in many other forms of local spasm. It should be applied either to the back of the neck or to one or both sides of the face over the insertion of the masse ters. The best method of using the cautery is quick, small burns somewhat fre- quently repeated, as two or three times a week. The application can be made at a certain spot on one day, and subsequently on both sides of it and near it until the first burn is entirely healed. Peter- son had made especially for his case an apparatus which kept the patient's jaw closed and allowed her to talk between her teeth without the uncomfortable tonic spasm of the depressors of the jaw, although the clonic movements of the masseters and pterygoids con- tinued. Such an appliance may be of service in other cases. The question of the best method of feeding the patient in a case of serious tonic spasm may become one of importance. This can be accom- plished by the old method of extracting a tooth if one or more of the teeth have not already been removed, or the feeding may be accom- plished with the nasal tubes similar to those used for the insane, although in nasal feeding the passage of the tube might in some instances give rise to palatal or pharyngeal spasm. Nerve stretching or resection, and myotomy, have been suggested, but no facts have been furnished which show their value. The only justifiable opera- tion with our present knowledge would be stretching of the motor subdivision of the fifth, if this could be separately reached. The nerve can be reached within the cranium by the same procedures that are employed in exposing the Gasserian ganglion. 67 898 NERVOUS DISEASES. CEPHALIC TETANUS. In cephalic tetanus the phenomena are so definitely related to tri- geminal irritation that, although the disease may be primarily due to a general infection, it seems best that it should be briefly considered. It is designated by other names, as head tetanus (kopftetanus) and tetanus hydrophoMcus. It is usually the result of a wound somewhere in the distribution of the fifth nerve, and the chief symptoms are trismus and paralysis of the face on the same side. In some cases the muscles of the nonparalyzed side of the face, the muscles of the throat, and the respiratory muscles are also affected with spasm, and in other rare instances the spasm, at first confined to the trigeminal distribution, spreads to all parts of the body, the case thus becoming one of the ordinary type of tetanus. Up to 1895 only three Ameri- can cases of cephalic tetanus had been placed on record. Accounts of these and the entire literature of cephalic tetanus have been sum- marized by Willard and Johnston, who give a table of no less than seventy-five contributions on this subject. The notable features in the case of Willard and Johnston were that the patient suffered from general traumatic tetanus, recovering after an illness of about two months ; that associated with it was a hemifacial paralysis which disappeared with recovery from the tetanus ; that the wound was an insignificant one, but involved the filaments of one of the branches of the fifth nerve ; and that decided improvement in all the symp- toms followed subcutaneous section of the nerves in the injured area. "While cephalic tetanus may follow an injury to any of the cranial nerves, it is more frequently found after such injury to the orbital and nasal branches of the trigeminus. Like other forms of tetanus, it is in all probability microbic in origin. The influence of the tetanus bacillus in the production of the disease seems to have been thoroughly demonstrated by a number of observers who have isolated the pin-shaped bacillus. The cause of the facial paralysis in cephalic tetanus has given rise to considerable discussion. In the case of Willard and Johnston, carefnl investigation was made to exclude the possibility of its being merely a coincidence due to independent causes, and the absence of middle ear disease, intracranial disease, brain abscess, etc., was thoroughly demonstrated. These writers be- lieve that in the present state of our bacterial knowledge it is most rational to refer this paralysis to a direct toxic eff'ect of the poison acting upon the filaments of the seventh and fifth nerves. The mor- tality in acute cases is as high as ninety per cent. In chronic cases — that is, cases in which the symptoms arise in the first week after the wound and tlie affection develops somewhat slowly — the prognosis is much better. Of thirty-two chronic cases collected by Willard and Johnston, twenty-four recovered and eight died. The treatment is much the same as that for tetanus of any variety. DISEASES OF THE SEVENTH OR FACIAL NERVE. 899 DISEASES OF THE SEVENTH OR FACIAL NERVE. General Description of the Facial Nerve and its Central Ap- paratus.— The seventh {facial nerve, portio dura of the seventh nerve, nervus communicant faciei) is a purely motor nerve. It is described differently by different anatomists.* It is, for instance, sometimes described as composed of a main part, the facial nerve proper, and an accessory portion, the pars intermedia of Wrisberg. The views' held by the writer with regard to the latter have already been given at length on pages 691-693, where it has been shown that the facial nerve and the intermediary nerve of Wrisberg with its peripheral extension (the chorda tympani nerve) have a segmental companionship similar to that which exists between the motor and sensory spinal nerves ; that the true origin of the pars intermedia and chorda tympani is in the geniculate ganglion, and that the former has a separate end nucleus in the preoblongata. The paralytic and spasmodic affections involving the distribution of the facial nerve, like the disorders of other cranial nerves, are best understood by keeping in mind the entke facial encephalic apparatus. Under cortical localization the position and subareas of the cortical facial centre are shown and de- scribed. The various movements of the muscles of the face supplied by the seventh nerve are represented around the foot of the central fissure. The central neurons of the facial apparatus, therefore, arise from the motor cells of the lower extremities of the central convolu- tions. Together they form a tract which passes by the corona radiata and internal capsule about its knee to the tegmentum, decussating in the latter to enter the facial nucleus of the other side. From this nucleus by a tortuous intraencephalic and extraencephalic course the nerve passes peripherally. (Pig. 416.) A probable connection of the facial nerve with the thalamus should not be overlooked, although, as this has not been fully traced, it is not indicated in the scheme. Some observations indicate that if the connection of the cortical facial centre with the seventh nucleus is broken, voluntary innervation of the muscles supplied by the seventh nerve on the same side does not take place, but emotional innervation through pain or laughing, as this is more of a reflex nature, is possible. If one thalamus is destroyed while the control tract of the seventh through the internal capsule from the cortex and pons remains in- tact, the voluntary innervation of the facial muscles can be accom- phshed, but the involuntary, as in laughing and crying, is inter- fered with on the same side. It would seem from these observations that the facial nucleus may be closely connected with the thalamus, and that by this tract the psychic reflex may be completed. The seventh pair of Willis includes the portio dura and the portio mollis, — the former being so called because of its hardness as compared with its com- panion the auditory nerve. 900 NERVOUS DISEASES. Nucleus and Root Fibres.— The nucleus of the facial nerve, about four millimetres long, is situated in the ventral portion of the tegmentum, four or five millimetres beneath the floor of the fourth ventricle to the mesal side of the descending spinal root of the tri- geminus and the anterior root of the auditory nerve, immediately Fig. 416. Scheme of the apparatus of the facial nerve : P, pons ; A, facial nucleus ; B, facial cortico- bulbar tract ; C, cortical centre for facial movements ; D, nucleus of the pars intermedia of Wrisberg ; E, descending glossopharyngeal roots ; H, nucleus of the hypoglossal nerve ; FF, trunk of the facial nerve ; K, temporofacial branch of the facial nerve ; i, cervicofacial branch of the facial nerve ; G, geniculate ganglion ; TTT, pars intermedia of Wrisberg and chorda tym- pani nerve ; M, Meckel's sphenopalatine ganglion ; 0, otic ganglion ; a, great superficial petrosal and Vidian nerves ; 6, lesser superficial petrosal nerve ; c, external superficial petrosal nerve : d, branch of the facial nerve to the stapedius muscle ; e, branch of the facial to the auricular branch of the vagus ; /, posterior auricular branch ; g, digastric branch ; h, stylohyoid branch : i, temporal branch ; j, malar branch ; i, intraorbital branch ; I, buccal branch ; m, supramaxillary branch ; «, inframaxillary branch. dorsad and laterad of the superior olive. It is composed of mul- tipolar nerve elements. Eootlets leave this collection of cells and come together at the floor of the ventricle in a compact bundle which has a remarkable course. Curving over the abducens nidus from be- hind, it overlies it like a horseshoe hung o\'er a ball ; not as a straight but as a bent horseshoe, bent so that its cephalic (efferent) branch is pointed more laterad than its caudal branch, which is the one that DISEASES OF THE SEVENTH OR FACIAL NERVE. 901 emerged from the nidus. (Spitzka.) The curve is at the same time convex mesad. This part is known as the genu faciaJis, or knee of the facial, and must not be confounded with the knee of the peripheral part of the facial within the Fallopian aqueduct. After having passed around the abducens nidus from below upward, the facial roots turn obliquely outward, and, passing through the teg- mentum and transverse fibres of the pons, reach the surface ia a posi- tion relatively between the acoustic and abducens nerves. Eecent observations of Eamon y Cajal are in accord with those of others in showing that fibres belonging to the seventh nerve decussate in the raphe behind the dorsal longitudinal bundles. He believes that the facial nucleus receives axis cylinders from the cells of the substantia gelatinosa, which substance accompanies the descending spinal root of the fifth, connection thus being made between the fifth and seventh nerves. The collaterals of these axis cylinder processes from the cells of the substantia gelatinosa are numerous. Mendel found in newborn rabbits degeneration in the posterior part of the third nucleus after destruction of muscles supplied by the upper branch of the seventh, and believed that this branch arises in the posterior part of the third nucleus and is connected through the dorsal longitudinal fasciculus with the knee of the seventh nerve. Turner, speaking of this sup- posed connection between the hind part of the third nucleus and the issuing root of the facial nerve, says that he has observed in two cases, in which the facial nucleus was degenerated and the oculomotor nuclei were healthy, a large number of normal nerve fibres passing into the otherwise atrophied facial nerve root from the opposite dorsal longi- tudinal bundle, an observation which has been confirmed by a few other observers in similar cases. A similar connection is stated to exist between the hypoglossal nucleus and the facial nerve, but direct anatomical evidence of this is thus far wanting, although some clin- ical facts lend support to the view. Minor connections are said to exist between the facial nucleus and the corpus trapezoides and the sensory trigeminal root. (Turner.) Peripheral Course of the Facial Nerve.— Siobdivisions and Gen- eral Course. The facial nerve may be conveniently subdivided into (1) an intracranial portion, (2) an intraosseous portion, and (3) an ex- tracranial portion. The intracranial portion reaches from the super- ficial origin of the nerve in the groove between the olive and the restis, at the junction of the pons and the postoblongata, to its point of entrance into the internal auditory meatus ; its intraosseous course begins in the internal auditory meatus, but is almost entirely con- fined to the winding route of the Fallopian aqueduct ; while its extra- cranial course is usually given as first from the stylomastoid foramen through the body of the parotid gland, after which it subdivides into an upper temporofacial and a lower cervicofacial branch. Some anatomists state that it runs between the parotid gland and the ante- 902 NERVOUS DISEASES. rior border of the sternocleidomastoid muscle. Dominguez y Eald^n, after making a careful study of facial paralysis, concluded that the facial nerve did not penetrate the parotid gland. This observer made se^'^■ral other interesting observations regarding the anatomy of the extracranial portion of the nerve. He found that it extends a distance of two centimetres in the space called the stylomastoid infundibulum ; that the superior part of the infundibulum is formed by the widening of the Fallopian conduit ; and that in this part of the infundibulum the facial nerve is surrounded by a dense cellular tissue and by a lymphatic space. Belations, Connecting Brunches, and DiMrihution. Within the cra- nium the relations of the facial nerve to other parts are readily traced and described. The abducens nerve at its origin lies to its inner or mesal side, the eighth nerve to its outer or lateral side, while between the facial and the auditory nerve is the slender pars inter- media of Wrisberg. It passes forward from the junction of the medi- peduncle (cms cerebelU) with the postoblongata, and is in relation Math the auditory nerve until it reaches the internal auditory meatus, where these two nerves part company, ^^'ithin the Fallopian aque- duct important nerve branches are given off, while others communi- cate with or lie in contact with the facial. Soon after its entrance it passes outward and forward through the bone above and between the cochlea and the vestibule, making then a sharp, almost rectangular bend, which constitutes the so-called knee of the facial (genu nervi facialis). From this point it proceeds backward and slightly down- ward to its exit at the stylomastoid foramen. At the position of the genu is a gangliform swelling (ganglion genicuU, intumescentia gangli- fonnis, geniculate gaiiglion), from which spring the pars intermedia and chorda tympani. The thiee superficial petrosal nerves all communi- cate with this ganglion. Distally to the geniculate ganglion a branch to the stapedius muscle is given off. From the geniculate ganglion the chorda tympani passes with the facial until it branches off to join the lingual nerve, and secretory nerves pass with the chorda tympani to go to the salivary glands. A communicating twig to the pneumo- gastiic is also given off in the descending course of the facial before it reaches the stylomastoid foramen. Just after the nerve emerges from the Fallopian aqueduct at the stylomastoid foramen it gi-^^es off a posterior auricular nerve, and a little later it communicates with the auricular branch of the pneumogastric. It supplies the retrahens aurem, sends a slender t^ ig upM ard to the attollens aurem, and ends in a long, slender branch which passes backward to supply the pos- terior belly of the occipitoftoiitalis. The facial nerve supplies all the muscles of the face except the ocular muscles and the muscles which receive their supply from the motor portion of the fifth nerve. It is hardly ccirrect to say, as is often stated, that it is the motor nerve of all the muscles of expression in the face, as the masseter and even DISEASES OF THE SEVENTH OR FACIAL NERVE. 903 Other muscles supplied by the trigeminus, and the ocular museleis also, are certainly concerned ^\ith facial expression. It supplies the occipitofrontalis and platysma muscles ; the muscles of the eyelids except the levator palpebrje and the unstriated muscular fibres • the muscles of the eyebrows ; the extrinsic muscles of the ear ; the mus- Fic. 417. The facial nerve : 1, trunk of the ner\ e after emerging at the stylomastoid foramen ; 2, its pos- terior auricular branch ; 3, anastomosis of the latter with the great auricular nerve of the cervical plexus ; 4, 5, 6, branches to the contiguous muscles ; 7, 8, branches of the facial to the digastric and stylohyoid muscles ; 9, temporofacial division of the nerve ; 10, branch to the temple, anastomosing with the auriculotemporal nerve ; 11, temporal branches ; 12, 13, infraorbital branches ; 14, 15, cer- vicofacial division of the facial nerve ; 14, buccal branches ; 16, mandibular branches ; 17, cervical branches ; 18, auriculotemporal nerve ; 19, 20, supraorbital nerves ; 21, terminal branch of the lach- rymal nerve ; 22, infratrochlear nerve ; 23, branch of the temporomalar nerve ; 24, external branch of the nasal nerve ; 25, infraorbital nerves ; 26, anastomosis between the buccal branch of the inferior maxillary nerve and the buccal branches of the facial nerve ; 27, mental branches of the inferior dental nerve ; 28, great occipital nerve ; 29, 31, branches of the great auricular nerve ; 30, smaU occipital nerve ; 32, superficial cervical nerve, anastomosing with the facial nerve. {Hirsch- feld-Sappey.) cles of the nose ; and the muscles of the mouth,— orbicular, trans- verse, angular, radiating, and labial. It also sends branches to the posterior belly of the digastric and stylohyoid muscles. According to some authorities, it supplies the tensor tympani through the otic ganglion and the levator palati and azygos uvulte ; but it is more 904 NERVOUS DISEASES. correctly held that the supply of the tensor tympani is from the fifth, aud that of the levator palati and azygos uvulse from the vagus by branches which pass for a short distance with the facial. The branches of the facial nerve are shown in the two illustrations Pigs. 416 and 417. PARALYSIS IN THE DISTRIBUTION OP THE FACIAL NERVE. Definition, Synonyms, and Varieties.— Paralysis in the dis- tribution of the seventh or facial ner\e is an affection, usually pe- ripheral, which involves all the muscles of the face except those supplied by the trigeminus and ocular nerves, and also the other muscles not of the face which have been described as supplied by the facial nerve. Among the synonyms of facial paralysis are Bell's palsy, prosopoplegia, hemiplegia facialis, and mimetic facial paralysis. It is one of the most frequent and therefore one of the most important forms of paralysis. It may be unilateral or bilateral, although the latter form is very rare, and it may be complete or incomplete. We may have a number of special varieties, according to the exact site of the lesion in the facial apparatus, and it will be most convenient to consider these first. Clinical History of Different Types of Facial Paralysis.— Cerebral Facial Paralysis, Cortical and Subcortical. "While peripheral facial paralysis of a nearly complete type, due to lesion within the Fallopian aqueduct, is by far the most frequent form of this disease, a facial paralysis may be due to a lesion situated anywhere in the facial apparatus, as delineated in the scheme Fig. 416. It may, in other words, be cortical, subcortical, caijsular, pontile, nuclear, or radicular ; and after the nerve has emerged from the brain stem it may be one of several distinct peripheral varieties, according as the situation of the lesion is in the intracranial, intraosseous, or extra- cranial j)ortion of the nerve.* "V^'hen facial paralysis is of cortical origin it is usually associated with paralysis of the limbs and with orolingual paresis or ajihasia ; but rare cases of cortical facial mono- plegia, and even of cortical paralysis, limited to particular portions of the facial ner-^^e supply, have been recorded. In both cortical and subcortical facial paralysis the lower portion of the face is chiefly in- volved, but it is not true, as is sometimes stated, that the muscles of the upper distribution of the facial entirely escape ; indeed, the oculo- facial group of muscles is nearly always to some degree weakened. It is said to be characteristic of the cerebral types of facial paralysis that, although the patient is unable to keep his eyes closed, he winks reflexly, and although the voluntary movements of the mouth are paralyzed on one side, the emotional movements are usually retained, * Turner has presented in an excellent m.inner in the Edinburgh Hospital Reports, vol. iv., 1896, the diagnostic features of facial paralysis from focal lesions. PARALYSIS IN THE DISTRIBUTION OP THE FACIAL NERVE. 905 while in the peripheral type both are abolished. Little difference exists between cortical and subcortical cerebral facial paralysis. The subcortical type is extremely rare, and yet cases ha^^e been reported due to foci of disease either in the centrum semiovale or in the in- ternal capsule. Parisot, as stated on page 572, has described a case of facial monoplegia, the only muscle involved being the depressor of the left angle of the mouth, in which the lesion was confined to a limited portion of the internal capsule just posterior to its knee. In both the cortical and subcortical types the muscles do not waste, or waste but slightly from disuse, and the electrical reactions are not changed. In facial pseudobulbar paralysis (see p. 353) the weak- ness of the upper facial group of muscles is not complete, so that the characteristic lagophthalmus of j)eripheral facial palsy is not seen. Facial Paralysis due to Pontile Lesions. A lesion in the upper por- tion of one side of the pons may cause facial paralysis which will have some of the features of a cerebral monoplegia, but usually also others which enable a focal diagnosis to be made. As the descend- ing facial tract has not yet decussated, the paralysis of the face will be on the side opposite to the lesion, and it will be associated with other phenomena according to the extensions and, to some degree, the character of the lesion. Usually some contralateral paralysis of the limbs is present, because of implication of the pyramidal tract. Conjugate deviation of the eyes or irregular impairment of ocular movements and some sensory involvement are often also present. In the section on small focal lesions of the pons and preoblongata the parts involved in such a lesion and the resulting symptoms are in- dicated. When the lesion is in the lower part of the pons, it is usually so situated as to involve both the nucleus and the root fibres of the facial, and gives one of the forms of alternate hemiplegia, the facial nerve being paralyzed on one side and the limbs on the other. Not uncommonly also the abducens nucleus and radicles are included in the lesion, and hence paralysis of the sixth nerve and conjugate deviation of the eyes to the side of the palsy are frequent symptoms. Nuclear Facial Paralysis. Nuclear facial paralysis almost invari- ably is bilateral or becomes so. Most frequently it is a portion of the syndrome of some of the forms of bulbar paralysis, and the bulbar involvement may or may not be associated with evidences of degener- ation in the spinal cord. The facial nidi, like the nidi of the other cranial nerves, may be attacked in cases of progressive muscular atrophy, amyotrophic lateral sclerosis, tabes, and syringomyelia. While completeness of paralysis, and the involvement of the upper as well as the lower fibres of the facial, are not entirely opposed to nuclear disease, complete nuclear paralysis comes on late, after long continued degenerative processes, and not suddenly or rapidly, as in peripheral cases. It develops insidiously, the muscles gradually weakening and wasting, and commonly without a preceding histoiy 906 NERVOTTS DISEASES. of rheumatism, injury, ear disease, tuberculosis, or other cause of gross lesion. Both sides are likely to be attacked uniformly. In nuclear cases the reflexes may be increased until the disease has nearly destroyed the facial nucleus, or the curious phenomenon known as crossed reflex action may be present. Turner has seen weakness of the orbicularis palpebrarum in three cases of nuclear ophthalmo- plegia, in one of which the frontalis was also so much paralyzed that the patient was unable to frown, and he refers to several similar cases recorded by other observers. Congenital cases of bilateral paralysis of several cranial nerves, including the facial, have been reported and attributed to the lack of nuclear development. Peripheral Facial Paralysis due to Intracranial Basal Lesions. The symptomatology of complete or nearly complete peripheral facial paralysis — the most usual and therefore the most important type of this affection— will be presently given in detail, but before doing this a few words need to be said about the manner in which the symptoms are modified according as the lesion is situated in the intracranial, intraosseous, or extracranial portion of the nerve, or in a more or less limited part of each of these peripheral subdivisions. A lesion at the base of the brain, usually a tumor or a gummatous meningitis, may involve the intracranial course of the facial. Such gross intra- cranial lesion will be likely to affect, in addition to the facial nerve, the eighth pair, the nerve of Wrisberg, and the medipeduncle, the pyramidal tract and the abducens being more rarely involved. The symptoms are those of complete peripheral palsy, with the addition of others like deafness, loss of taste, vertigo, and forced movements, and possibly hemixilegia of the opposite side and abducens paralysis of the same side. Some good authorities hold that loss of taste is not present in these cases, but I believe that it is probably present and sometimes escapes observation. If the pars intermedia is a por- tion of the gustatory apparatus — the central continuation of the chorda tympani — it will almost certainly be implicated in such a lesion. Occasionally double facial paralysis from intracranial lesion, and especially from a gummatous meningitis of the posterior fossa, is observed. In these cases the most striking association is that of bilateral deafness with the diplegia facialis. With regard to the involvement of the vestibular ner^e (or cms cerebelli) I have had a few experiences showing the occurrence of marked vertigo in cases of intracranial peripheral facial paralysis. In one case, in which the symptoms pointed to a syphilitic tumor at the base, the patient had suffered from severe head pains with slight intermis- sion for two years, when total paralj^sis of the left side of the face made its appearance, accompanied by loss of hearing and noises in the ear of the same side. Spells of giddiness of a peculiar char- acter came on with the paralysis. On attempting to walk she would soon be compelled to run, and on getting into a run she would fall PARALYSIS IN THE DISTRIBUTION OF THE FACIAL NERVE. 907 on her face, unless she could stop herself by catching hold of some object. She felt as though she and the floor under her were going around. These vertiginous spells gradually grew less frequent and severe as the patient's general health improved. For three months she had double vision. For six months she had some difficulty in swallowing, fluids being sometimes regurgitated through the nose. The uvula pointed slightly towards the right, and the velum hung lower on the left than on the right side. On touching it with a probe it was retracted upward and towards the right. Taste was generally defective, but it could not be made out distinctly to be abolished on the anterior part of the left half of the tongue. She complained of dryness of the mouth. Smell was defective, but no differences could be made out between the paralyzed and the healthy side. Sensation, as determined by the esthesiometer and the faradic battery, was slightly but undoubtedly diminished, and on the affected side both faradocontractility and galvanocontractility were much diminished. Eeflex movements could not be produced by irritating the skin of the face. Facial Paralysis due to Lesions in the Intraosseous Portion of the Nerve. In considering lesions of the intraosseous portion of the facial it will be necessary to take into consideration the functions of the pars intermedia of Wrisberg, the geniculate ganglion, the various petrosal nerves, the stapedius nerve, and the chorda tympani. For most practical purposes the symptoms of intraosseous facial paralysis can be considered with reference to two subdivisions of the nerve, namely, one from the intracranial opening into the Fallopian aqueduct to and including the geniculate ganglion, and the other from the geniculate ganglion to the stylomastoid foramen. When the nerve is involved between its entrance to the aqueduct and the geniculate ganglion, the chief symptoms will be those of complete facial paralysis, including loss of taste. According to Erb, paralysis of all external branches of the facial, abnormal acuteness of hearing, and disturbance of the sense of taste, with paresis of the velum palati and abnormal dryness of the mouth, indicate that the lesion is in the vicinity of the ganglion geniculi. Althaus has di\'ided the Fallopian aqueduct into three parts : (1) an external section, w^hich is below the origin of the chorda tympani ; (2) a middle section, which includes the chorda tympani and the stapedius nerve; and (3) an internal section, which embraces the geniculate ganglion, where the large pe- trosal nerve is given off, and also near at hand the small and exter- nal petrosals. When the nerve is involved between the geniculate ganglion and the giving off of the chorda tympani the symptoms will be complete peripheral paralysis, with loss of taste and special audi- tory symptoms if the nerve to the stapedius muscle is also involved. The involvement of this nerve causes some abnormal acuteness of hearing. As shown on page 708, contraction of the stapedius muscle 908 NERVOUS DISEASES. decreases the tension of the membrane of the tympanum and laby- rinthine pressure. Its paralysis, therefore, would prevent relaxation and cause hyperacusis because of the abnormal membranic tension. The Sense of Taste in Facial Paralysis. The subject of taste has been so fully considered in the section on affections of taste that it will be only necessary to refer here very briefly to the connection of facial j)aralysis with loss of taste. The views of the writer, as already stated, are that the nerves of taste are derived from the nerve of Wrislierg and the glossopharyngeal nerve, and that the fifth nerve is in no sense a true nerve of taste, as is held by many. It is quite certain, however, as has already been pointed out, that the facial nerve, in its course within the Fallopian aqueduct, contains fibres which have to do with taste, but we do not believe with Turner and Ferguson that it is proved that the taste fibres for the anterior two thirds of the tongue pass through the Vidian and great superficial petrosal nerves to the facial trunk, from which they pass by way of the chorda tympani to the lingual branch of the third division of the trigeminus. The fact that the chorda tymi^ani lies alongside of the facial in part of its course is all that is necessary to be known to ex- plain the occurrence of disorders of taste in lesions of the facial trunk. When loss of taste is present in nuclear facial paralysis it is highly probable that the terminal nucleus for the nerve of Wrisberg, or the nucleus of the gustatory division of the glossopharyngeus, is involved in the lesion. Facial Paralysis due to Lesions external to or just within the Stylonuts- toid Foramen. The chorda tympani is given off about one quarter of an inch within the stylomastoid foramen, and it is possible to have a paralysis of the facial from a lesion not ex- tending farther centrad than this point. In such a case the symptoms would indicate paralysis of all the external branches of the facial and of the posterior auricular nerve, without loss of taste. When the nerve is attacked at or jirst outside of the foramen the i:)aralysis will simjily involve all the external branches of the facial. Paralj/sis limited to Sjieeial External Branches of the Facial 2^rrve. A paralysis limited to the temporofacial or temporocervical dis- tribution of the facial or even to some one of its branches is occasionally observed, al- though such an affection is extremely rare. These cases are usually traumatic. In one of my cases the patient was a young Italian who was stabbed in front of the right ear, causing paralysis of the occipitofrontalis aiul paresis of the orbicularis palpebrarum of the same side. Another patient, who was struck on Fig 418 Paralysis in the upper distribu tion of tile seventh nerve. PAEALYSIS IN THE DISTRIBUTION OF THE FACIAL NERVE. 909 the head in a brawl, had paralysis of the occipitofrontalis and orbicu- laris palpebrarum, and with this were associated symptoms ot severe cerebrospinal traumatism. A third patient, a little Vjoy, had fallen from a height, striking on his right temple and the side of his head. Examination showed comj^lete loss of power in the right half of the occipitofrontalis muscle, but no paralysis of the palpebrarum or of any other muscles of the eye and face. In consequence of this loss of power there was inability to raise the eyebrow of the right side, with an absence of the natural arch of the brow, which was a percep- tible distance below the line of the left. The expression of the face was that of a one-sided frowning. (Fig. 418. ) Symptoms of Complete Peripheral Facial Paralysis (Bell's Palsy). In atypical case of Bell's palsy all the muscles of the face supplied by the seventh nerve are com- pletely paralyzed. One -^'"^'- '^^^■ side of the face has in consequence a drooped, smoothed out, immobile appearance (Fig. 419). The contours of the cheek and the angle of the mouth, prominent in health, nearly disappear. On attempting to talk, laugh, or frown, the con- trast of the two sides of the face is striking, giving a grotesque and un- natural look. The absence of furrowing in the fore- head is conspicuous, as is also drooping of the eye- brow and the lower lid. These evidences of paral- ysis, which are chiefly afforded upon simple in- spection, vary consider- ably in different cases. Great differences in the transverse furrowing of the forehead when the face is at rest and when it is in motion ai-e observed. In the young, in many females, and often in men w^ho use the frontalis muscle but little, the difference in furrowing so marked on the two sides in most cases of facial paralysis is scarcely noticeable, although it will always come out to a greater or less extent on testing the patient by having him look upward. With regard to the state of the muscles no mistake need be made in a case of Bell's Tj-pical facial paralysis, or Bell's palsy. 910 NERVOUS DISEASES. palsy if a little care is taken in tlie examination of the patient. This examination should be made systematically, bearing in mind the numerous muscles both on the outside of the face and elsewhere which are supplied by the seventh nerve. The patient should be put through a series of volitional exercises, such as looking upward without moving the head ; closing the eyes separately and together ; drawing the mouth upward and outward, or in both dii-ections at the same time ; dilating the nostrils separately, which, however, is not always possible even in normal individuals ; puckering the lips ; puffing or blowing ; and depressing and pulling outward the lower lip. We must go a step farther, and examine as to taste, as to the state of the palatal muscles and of the uvula, and as to hearing. The electrical reactions in facial paralysis are of importance, and will be further considered under diagnosis. At the very beginning, even of a severe case, the electrical reactions may be retained, but in a few days faradocontractility decreases rapidly and usually in about a week has disappeared. Changes to the galvanic current can also be noted early. At first galvanic excitability is somewhat increased ; soon changes both modal and serial (page 194) are present. The order of the response to the cathode and anode may be reversed, or various changes in the reaction formula may be demonstrable. Bilateral Facial Paralysis. Bilateral facial paralysis, or double facial paralysis, is comparatively rare. In the complete type all the muscles supplied by the portio dura are involved on both sides. The affection may be peripheral, nuclear, cortical, or subcortical. Prob- ably the nuclear variety is of the most frequent occurrence, but when observed it is usually in association with other forms of paralysis or with evidences of degenerative disease in other parts of the body. Some years since, a case of double facial paralysis attended the ser- vice for nervous diseases of the Philadelphia Polyclinic for several months. The right side of the face was first attacked, the trouble be- ginning with pain and sensitiveness in the face. In about two weeks the left side of the face was also paralyzed, and the patient became deaf in the ear of the left side. The symptoms in cases of double paralysis are simply the duplication of those phenomena which have been described as present on one side ; but, owing to the fact that the muscles of both sides are involved, certain peculiar conditions are brought about, as was illustrated in the case of this patient. In the first place, all the muscles of the external surface of the face supplied by the seventh being paralyzed on both sides, the face assumes a curious mask -like appearance. Whatever emotions the patient may experience, the expression will ha\'e the same dull, monotonous, un- changing look. E\en the appearance of the eyes and ocular move- ments fail to relieve this expression, demonstrating that facial ex pression is far less dependent upon the eyes than is supposed. The patients, at least in some stages of the disorder, have great difficulty in PARALYSIS IN THE DISTEIBUTION OF THE FACIAL NERVE. 911 chewing and swallowing food. This patient, for instance, was obliged to place her hands against and around her lower jaw and cheeks in eating to prevent the food from falling out ; she had also some difB- culty in swallowing, and was obliged to throw her head far back to assist in this act. (Bassette. ) The electrical reactions in double facial paralysis vary as in the unilateral type, according as the affection is cortical, corticobulbar, nuclear, or peripheral. In typical peripheral cases the nerves and muscles fail to respond to the faradic current, and if the case is of a serious character will giAe complete degenera- tion reactions ; in the nuclear cases the reactions are those of partial degeneration. In complete bilateral palsy, according to Turner, there is no palatal movement on using the vowel sound ' ' ah, ' ' and the pronunciation of words requiring closure of the nasopharynx is rendered imperfect ; hence "rub" is pronounced " rum," and "egg" "eng." Turner here probably refers to those cases of double facial paralysis in which the lesions are situated between the geniculate ganglion and the superficial origin of the nerve. Special Features in the Symptomatology of Facial Paralysis. Eeflex movements are abolished in facial peripheral paralysis. Eeflex con- traction may occur in the paralyzed muscles, either through the fifth nerve by touching the skin or eyelashes, or through the optic nerves by making a rapid movement towards the eyes. While secretory disorders of the face are not manifest, it has been found that sub- cutaneous injection of pilocarpine does not cause sweating of the para- lyzed side. Spontaneous movements, not of the nature of secondary spasms, may occur in the muscles during recovery. Sometimes asso- ciated movements occur in the paralyzed muscles. When, for in- stance, an attempt is made to close the eye, the angle of the mouth is drawn outward and upward, and, conversely, when an attempt is made to draw the angle of the mouth to one side, the eyelids con- tract. (Eoss.) What are called the secondary contractures of facial paralysis are among the most annoying and intractable symptoms of old cases of this disease. These, although known to the older ob- servers, were first minutely described and discussed by Hitzig. Com- monly they appear first in the third or fourth month in the form of a slight tonic contraction in the muscles of the mouth. Eventually the muscles of the paralyzed side become the seat of almost persistent tonic spasm, more or less frequent attacks of twitching or clonic spasm occurring at irregular Intervals. In time the face becomes spasmodically drawn towards the paralyzed side, and its appearance may deceive the careless observer, as in the early period of Bell's palsy the face is of course drawn away from the paralyzed side. These secondary contractures and spasms have been noted by me as occurring in varying degree in a number of cases of facial paralysis. Hitzig refers the symptoms to an abnormal excitability of the ob- longata, which becomes developed in an unknown manner in conse- 912 NERVOUS DISEASES. quence of peripheral facial paralysis. I believe with Erb that the condition is not one of " electrical muscle tetanus" induced by elec- trical treatment, as it occurs in cases in which no electric treatment has been emiiloyed. Transient states of spasm in cases of this kind are by no means uncommon. It is generally held that, the facial nerve being purely motor, no sensory or vasomotor disturbances occur in facial paralysis, although the existence of gustatory and secretory symptoms is universally admitted. Frankl-Hochwart, from a study of twenty cases in ITothnagel's clinic, found five cases of sensory, two of vasomotor, and three of combined sensory and vasomotor dis- turbances. The sensory disturbance was slight in degree, and did not always involve the mucous membrane. He found that these dis- turbances usually disappeared much sooner than the motor trouble. Eeduction of sensation was present after several years in only one inveterate case. Frankl-Hochwart believes that these disorders show that the facial nerve of man contains some sensory and vasomotor fibres, as does the same nerve in animals. Goldzieher observed in two cases of facial paralysis that the ej'e of the affected side remained dry during weeping, and Jendrdssik from observations on four other cases of facial paralysis obtained the same results. Both observers incline to the opinion that the lachrymal gland is supplied by the facial nerve, and not by the fifth as is usually taught. Jendrdssik has attempted to work out the exact method of the supply. He be- lieves that fibres are given off from the trunk of the facial nerve as high up as the geniculate ganglion ; these fibres run along the great superficial petrosal nerve to the sphenopalatine ganglion. One group of fibres is distributed to the soft palate, whilst another unites with the second branch of the trigeminus and another runs into the orbital nerve. The orbital nerve unites with the lachrymal nerve, and the combined nerves give off filaments to the lachrymal gland. As peripheral facial paralysis usually comes under observation early, facial atrophy is not, as a rule, a marked phenomenon ; in fact, it would seem to occur late, e\'en in old cases, probably because in most instances some fibres remain nndestroyed. Notable wasting in cases of very long standing has, however, been recorded, as in one by Bernhardt. The patient was a man twenty-four years old when studied. A paralysis of the facial muscles of the right side was first noticed two weeks after a natural birth. Most of the muscles of the right side supplied by the seventh nerve were atrophic, and did not respond to faradic or galvanic excitation. The two orbicular mus- cles, namely, the orbicularis oris and the orbicularis palpebrarum, usually regarded as supplied solely by the l^icial nerve, seem some- times to escape partially, or are relatively much less affected than the other facial muscles. Mann, for instance, found that in two cases undoubtedly peripheral the orbicularis oris escaped, although all the other muscles supplied by the facial were completely paralyzed. PAEALYSIS IN THE DISTRIBUTION OP THE FACIAL NERVE. 913 The same observer had noted, what has also been recorded by a number of others, that the orbicularis palpebrarum was not so seri- ously afi'ected as the other muscles in peripheral cases. It is well known that it largely escapes in cerebral cases. Even when the or- bicularis palpebrarum is markedly affected it shows a tendency to recover earlier than the other muscles, and one or two cases have been reported in -n-hich the orbicularis oris has also recovered its functions before the other facial muscles. Some hold that the fron- tales as well as the orbicularis palpebrarum are less severely affected than the other parts of the musculature ; but this is doubtful. It is not true, as suggested by Gowers, that preservation of the function of the orbicularis oris in facial paralysis always indicates that the disease is cerebral. The position of the tongue in peripheral facial paralysis is a matter of some interest. In some cases it is protruded in a straight line, in others it deviates to the paralyzed side. Hitzig states that in the lighter forms the tongue is always put out straight, but that in severe and protracted cases it deviates to the sound side, if at all. If it does, and the angle of the mouth on the paralyzed side be drawn to its proper place, the tongue will straighten. His explanation is that the tongue is accustomed to keep at an equal dis- tance from each oral angle, and when it finds that it is nearer one angle it deviates to the other side until its median position is re- stored. Paralysis of the soft palate, in the light of the most recent investigations, is probably a disease of the vagus nerve, or of its nucleus (nucleus ambigims). Association of Facial Paralysis with other Cranial Nerve Affections. In very rare instances an extension of facial paralysis from one side of the face to the other has been noted. Occasionally one or more branches of the trigeminal nerve may be simultaneously involved with the facial nerve in a paralytic affection. It is supposed that in some of these cases at least this association of disease of the two nerves is the result of spread of inflammation by contiguity of tis- sues. Cases of herpes zoster facialis and herpes zoster cervicalis occurring with facial paralysis show one of the methods of com bination of seventh and fifth nerve disease. The illustration (Fig. 420) shows facial and trigeminal paralysis combined in the same case, the lesion probably being nuclear. This patient was a man fifty-four years of age, with an uncertain history of syphilis, but with a certain record of drinking and of rheumatism. Between March, 1884, and January, 1888, he had three apoplectiform attacks causing more or less paralysis in the left half of the body. In the last, which occurred in January, 1888, he was left with complete facial palsy on the left side. It is uncertain whether at this time or later the affection of the motor branches of the fifth nerve from which he also suffered was developed. Some time in 1889 his left eye was re- moved by Dr. de Schweinitz because of a trophoinflammatory affec- 58 914 NERVOUS DISEASES. tioii. The illustration shows great wasting and marked deformity of the entire left side of the face. Fig. 420. The appearance is strikingly differ- ent from that of the case of facial paralysis shown in Fig. 419, although the same side is paralyzed in both instances. The face in the case shown in Fig. 420 appears to be, and is in I'eality, smaller upon the left side, and the nose is slightly twisted to the left. A distinct hollow is seen in the position of the left temporal muscle, and the face is much flattened over the position of the left masseter. Etiology. — The etiol- ogy of facial paralysis varies according to the focal variety of the affec- tion. Chief among the causes of peripheral facial paralysis (Bell's palsy), with which we have been mainly concerned in the present section, are exjiosure to cold and draughts, extension of in- flammation or suppuration from disease of the ear, syphilitic dis- ease at the base of tlie brain, and traumatism. By far the largest number of cases occur from exposure. The patient, usually some- what run dowu in general health, exposes one side of the face be- fore an open window or door, or in a vehicle, or on a bicycle, or in some similar way is subjected to severe local draught, and at once, or soon after, finds the face paralyzed. In this way a neuritis or perineuritis is probably set up in the branches and extracranial por- tion of the trunk of the nerve, the inflammation usually extending for a little distance into the aqueduct. The nerve is probably par- ticuhii'ly affected in the space formed by the wddening of the Fal- lopian conduit. Occasionally facial paralysis comes on in a patient with rheumatic symptoms in other parts of the body and without a history of special exposure ; in other words, the rheumatic poison attacks the facial nerve at its origin or somewhere in its course and causes a neuritis as it assaults nerves and other structures in vari- ous parts of the body. The designation "rheumatic" is sometimes applied to the cases which result directly from chilling or catching Facial and trigeminal fiaralysis, with atrophy. PARALYSIS IN THE DISTRIBUTION OF THE FACIAL NERVE. 915 cold. This may or may not be a proper method of description. Undoubtedly in some patients with a rheumatic predisposition facial neuritis, like other forms of neuritis, is more likely to originate from slight exposure. Syphilitic disease of the vessels, membranes, or temporal bone at the base of the brain is a not infrequent cause of facial paralysis, and its clinical peculiarities have been spoken of when discussing the peripheral lesions of the intracranial portion of the nerve. The disease is most frequently a gummatous meningitis, although either tumor or true neuritis may of course be the exact specific lesion. Diseases of the ear, especially suppurative otitis media, are universally classed among the most important causes of facial paralysis, and are causes of special importance in children. The trunk of the facial nerve is separated from the tympanic cavity only by a thin partition of bone, and this may be readily worn through by carious or destructive inflammatory processes. Great differences of opinion exist as to the importance of otitis media in causing facial paralysis. Statistics are of little value in deciding a question of this kind : one observer, for instance, reported three cases of facial paral- ysis out of four hundred and eleven cases of otitis ; another did not have a single case of such palsy among fifty cases of otitis ; and still another saw only eight cases out of six hundred and eighty-six cases of otitis. (Bernhardt. ) In rare instances local treatment of the ear has been followed by a facial neuritis and paralysis. Fractures of the floor of the skull, direct injuries to the ear, surgical operations in the neighborhood of the parotid gland, blows and cuts in the face, and pressure by forceps are among the causative traumatisms. Oases of paralysis of the facial nerve following the extraction of teeth have been observed by Frankl-Hochwart and others. A few cases have been seen in the course of diabetes. Heredity undoubtedly plays a part as a predisposing cause. It occurs more frequently in males than in females, and the majority of those who suffer are between the ages of twenty and fifty years, although the affection may, of course, be present at any age. The palsy attacks both sides of the face in nearly equal proportion, although some statistics seem to show that the right side is somewhat more frequently the site of the disease than the left. In extremely rare cases, hemorrhage into the sheath of the nerve or around the nerve trunk has been recorded. Gowers sug- gests that some of the cases of abrupt origin and complete type are due to hemorrhage within the Fallopian aqueduct, and he believes that thrombosis in a vessel of a nerve is a conceivable mechanism, especially where the condition of the patient favors the occurrence of thrombosis, as when facial paralysis occurs soon after childbirth. Nuclear facial paralysis is usually due to slow degenerative processes, although focal lesions sometimes attack both nuclei and root fibres of the nerve. Gliomatosis of the bulb is a disease which may attack the facial nuclei and radicles, as it does those of the other bulbar 916 NERVOUS DISEASES. nerves. Pontile, subcortical, and cortical facial paralysis is usually dependeot uj)on a focal lesion, such as a tumor, hemorrhage, or focus of softening. Double facial paralysis is due to degeneration of the nuclei of both sides, to basal meningitis which spreads from one side of the brain to the other, to a double neuritis attacking conjointly or successively the nerve trunk or branches, and, when supranuclear, to multiple lesions, as tumors, abscesses, hemorrhages, or embolisms. In rare instances suiiranuclear bilateral facial paralysis has followed injuries to the head which have caused fractures or hemorrhages on both sides of the head or fracture on one side and hemorrhage on the other. Hysterical facial paralysis usually occurs with other stigmata of hysteria, and is commonly partial. Hemiparesis of one side of the face with hemianesthesia of the same side of the body and other hysterical stigmata are likely to be present. Pathological Anatomy. — Autopsies and microscopical exami- nation in a few cases of peripheral facial paralysis of the complete type have been put on record. In one by Minkowski the patient had an attack of typical complete rheumatic facial paralysis, but committed suicide eight weeks after the beginning of the trouble. Minkowski found a true degenerative neuritis, with disintegration of the medullary sheaths, but without evidences of interstitial in- iiammation. An important practical feature in this case was the intensity of the inflammation at the outer end of the Fallopian aque- duct in the peripheral distribution of the nerve, this intensity de- creasing as the nerve was traced backward to the geniculate ganglion. The central portion of the nerve to the geniculate ganglion and in- cluding it was normal. Others have also found a parenchymatous neuritis extending peripherallj- from the site of the lesion without any interstitial change in the nerve. The pathological evidence does not permit us to say that in the rheumatic form of facial palsy the nerve is compressed by inflammatory material either in, or at its exit from, the Fallopian aqueduct. This evidence is very meagre, and locates the change chiefly in the nerve branches distributed over the face and in the outer part of the Fallopian aqueduct ; while the state of the nerve is a parenchymatous and not an interstitial inflam- mation. (Turner.) AYith regard to various aspects of the pathology of facial paralysis, there are to be noted, as stated by Turner, the forms associated " («) with chronic degenerative atrophy of the cells of the facial nucleus ; (p) with implication of the nerve roots by lesions situ- ated in the tegmentum pontis ; (e) with destruction of the nerve roots by gummatous or other new growths inA'olving the dura of the base of the skull ; (d) with the form associated with other peripheral palsies, as sequelte of diphtheria, in which no pathological change at all has been detected ; and, lastly, the form which is observed in the true myopathies." Diagnosis. — The diagnosis of the existence of a facial paralysis PARALYSIS IN THE DISTRIBUTION OF THE FACIAL NERVE. 917 is, of course, readily made. The affection could not be confounded with any other, except by the most careless observation. The points of distinction from a paralysis in the distribution of the motor por- tion of the trigeminus have been indicated when discussing the symptomatology of this disease, as huxe also those of hemifacial atrophy. The most important diagnostic points usually are to dis- tinguish between a cerebral and a peripheral facial paralysis, and, with regard to the latter, to have some clear idea as to the site and extensions of the lesion. Most of these differential points have been indicated in discussing the symptomatology of the different focal varieties of facial paralysis. A practical distinction, not always to be depended upon, between a peripheral and a cerebral paralysis is the completeness of the paralysis in the former type. In cerebral cases the remaining palsy is nearly always of the muscles supplied by the branches of the nerve to the lower part of the face. The frontal, corrugator, and orbicular palpebral muscles usually recover so fully that the paralysis attracts little or no attention, although, as has been stated, a minute study of the movements of the muscles will demonstrate some paresis. The electrical examination of a case of facial paralysis will settle the diagnosis of its peripheral nature. Most peripheral cases give typical reactions of degeneration, all the changes, modal and serial, sooner or later being present. In ^-try light forms of the disease, dependent probably upon mild neuritis, the reactions to both the faradic and the galvanic current remain nearly or quite normal. Even partial degeneration reaction may be present in a type of the disease of medium severity, but this is rare, and usually the presence of partial degeneration reaction points to nuclear disease. Normal electrical responses indicate either a cere- bral lesion or one in the pons above the decussation of the nerve. Prognosis The prognosis of perii^heral facial paralysis is va- riable. Probably the majority of cases make almost complete recov- eries. In a considerable percentage, howe^^'er, recovery is only ap- proximately complete, and in a few no improvement whatever takes place. In those dependent upon an inflammation attacking the nerve trunk the prognosis as to the amount of recovery is, of course, de- pendent upon the degree of destruction and degeneration ; and the same remark is applicable to cases which occur in the course of suppurative and focal affections, like tumor and hemorrhage. Nu- clear focal paralyses, like all other nuclear diseases, are of grave prognosis. Syphilitic cases are relatively favorable. When the palsy is associated with middle ear disease the prognosis is best stated as uncertain. When the secondary spasm and contractures of Hitzig set in, the prognosis as to complete recovery is unfavor- able, although even in these cases much improvement may take place. In the earlier stages of the common variety of facial palsy due to peripheral neuritis it is difdcult to give an exact prognosis. The 918 NERVOUS DISEASES. physician should be upon his guard, and, if possible, postpone a positive opinion for two or three weeks, although in a general way a favorable prognosis can usually be given. Electricity is of value in deciding the final outcome of such cases. " If from a week to ten days after the onset of the paralysis there is no quantitative dimi- nution, but rather an increase, to faradic stimulation, the statement may be made that recovery will take place in three or four weeks. If at about the same time after the onset the faradic irritability is distinctly quantitatively lessened, recovery is likely to take place in from six weeks to two months. Should the faradic excitability be entirely lost one week to ten days after the onset, recovery is likely to be delayed for some months. In this case, in addition to the loss of faradic reaction, there is likely to be qualitative galvanic altera- tion, causing the reaction of degenei-ation. It is improbable that in such cases complete recovery will take place. If the faradic excita- bility remains in abeyance three, four, or more months after the onset, the prognosis as to recovery should be guardedly given. In such cases the onset of secondary contracture and overaction is highly probable." (Turner.) Treatment. — The treatment of facial paralysis must in the first place depend upon its etiology. If the cause is rheumatic or syphi- litic, remedies directed to this cause should be employed. In most cases of the variety due to exposure early treatment with calomel and with moderate doses of salicylates and bromides will be found useful ; these can be assisted in their action by the use of diapho- retics and baths. A few leeches to the mastoid or below the ear are serviceable in the acute stage. Counterirritants in the same neigh- borhood may also be used. Turner, however, calls attention to the fact that in the more severe forms of facial paralysis, especially those associated at the commencement with considerable pain, care ought to be exercised in the use of counterirritants. He records a case in which the injudicious use of croton oil provoked intense cellulitis over the parotid region, and he believes that in such cases the careful use of small mustard leaves in front of the ears, repeated several times, may be of greater service than the application of a blister. My own experience is in accord with that of this observer. When disease of the ear is present, this should be treated according to the rules and methods applicable to the treatment of such diseases, in- dependently of the existence of the paralysis. When the disease tends to become chronic, the iodides may be given in moderate doses, and occasionally the administration of large doses of iodide for a short time seems to start the nerve on the way to recovery. Both strychnine and electricity may be used after the acute stage has sub- sided, but, as a rule, never before ten days or two weeks have elapsed. In using electricity for any form of facial paralysis the weakest cur- rent that will cause a visible contraction is sufficient ; either anode FACIAL, SPASM. 919 or cathode may be used to the muscle or nerve i^eriphery, but the best plan is at first to use the anod(> to the nape of the neck or under the ear, and the cathode to Aarious points in the distribution of the muscles and nerve branches. It is best to begin with two or three milliamperes of current strength, and to increase until a visible con- traction is produced. Great care should be taken in applying the electrodes or removing them not to do so abruptly. The resistance should not be increased or cells introduced without consideration, as often a current previously weak or imperceptible will suddenly ap- pear in full force and harm may be done in this way to the retina or by producing vertigo. AVhen no response can be obtained with a fair number of cells and an amount of resistance which should give a decided current, the electrodes and cords should be carefully ex- amined. The lack of current may be dependent upon some temporary disturbance in the battery. One of the electrodes can be used inside of the mouth with advantage in some cases. A clean electrode is of course essential, as for instance one freshly covered with absorbent cotton. The electrode placed at the nape of the neck or under the ear should be larger than that used for treating the face. The cathode should be a motor point electrode, or at least one small enough for the individual muscle to be treated with it. The treatment should not be too long : five minutes will commonly be sufficient : much harm can be done by overtreating. In the early period of electrical treatment the paralyzed muscle may respond and contract with a weaker current than is required by the muscles on the unaffected side, and the normal response, even in mild cases, is often changed, so that the contraction produced by closing the circuit at the anode or positive pole will exceed that produced by doing the same at the cathode. As the muscles begin to reco\'er, the response to galvanism begins to diminish and that to faradism to return, hardly noticeable at first, but gradually increasing. If there is any tendency to con- tracture, all electrical treatment is temporarily contraindicated, for although this is not the cause of the contracture it may tend to in- crease it. It is a mistake to go on using faradism week after week, as is sometimes done by general practitioners, in a case of facial paralysis in which the muscles refuse entirely to respond to this cur- rent. A strong faradic current will of course produce contraction in the masseter or other muscles supplied by the fifth nerve, which might mislead a very careless observer. FACIAL SPASM. Definition and Synonyms.— By facial spasm is meant spasm im- plicating the muscles supplied by the seventh or facial nerve. In the sense in which it is used here, facial sj^asm does not include spasm at- tacking the muscles of the motor distribution of the trigeminus or the ocular muscles. In its most common form it usually combines both 920 NERVOUS DISEASES. clonic and tonic movements. It has various synonyms, as painless tic, histrionic spasm, mimic or mimetic spasm, and convulsive tic. Besides the forms which go by these names, other special forms of facial spasm are met with, as, for instance, the secondary contractures of Hitzig described in the last section ; the facial spasms of diplegia, particularly of the type known as bilateral chorea and double atheto- sis ; forms of hysterical spasm ; and forms which appear to be of the nature of obsessions or monomanias, the patients having the habit of twitching some part of the face, the habit often growing and becoming permanently implanted upon the nervous system. Symptomatology. — Common Type of Painless Tic. In the ma- jority of cases the disease comes on gradually, at first perhaps affect- ing only one or two muscles or sets of muscles. Probably at the beginning the muscles most frequently affected are either the or- bicularis palpebrarum or the elevators of the angle of the mouth. The spasm is, as a rule, unilateral at first, and it may continue throughout to be unilateral, or may become bilateral only after a number of years. In some cases, however, even when chiefly uni- lateral, certain of the muscles on both sides of the face may be at- tacked with spasm at the same time, as for instance the corrugator supercilii. the orbiculares of the eyelids, and the frontal muscles, when, so far as the rest of the face is concerned, the spasm is con- fined to the muscles on one side. In other words, those muscles on both sides of the median line which most frequently act together physiologically, and which are probably nearly equally innervated from each side of the brain, are those which are most likely to be affected with bilateral spasm. In not a few eases, after many years, all portions of both sides of the face become involved, although they are rarely equally involved. The side first affected is usually the one which to the last is most affected. In the most common type of facial spasm, a form which has been termed idiopathic, the spasm attacks only one or two of the muscles at first, and those at infrequent in- tervals. Perhaps the patient or his friends observe a slight twitch- ing of the orbicularis palpebrarum, of the levator anguli oris, or of the zygomatics. These twitchings become more pronounced, occur more frequently, and spread to neighboring groups of facial muscles. After an indefinite time a marked admixture of tonic and clonic spasm is usually observed, the attack beginning with twitchings, but during its course some of the muscles becoming strongly contractured. The clonic si^asni is at times imposed upon the tonic spasm, the mus- cles of the face, for instance, being drawn to one side, and the eye being spasmodically closed, while at the same time slight or severe jerking movements affect the muscles at intervals. The spasm is usu- ally strictly confined to the distribution of the portio dura, but occa- sionally the muscles supplied by other nerves may be affected. If the muscles of mastication, or the stylohyoid, mylohyoid, and digas- FACIAL SPASM. 921 trie muscles, or the velum palati, are affected along with the facial, this indicates that the case is not one of the usual type of mimic spasm, but is due to some widely distributed organic lesion, affecting also the trigeminal, vagus, and perhaps other nerves. Sometimes the muscles on the paralyzed side gradually grow atrophic, but the process of wasting is usually so extremely slow that it can scarcely be determined until the disease is of many years' standing. In some cases this atrophy does not seem to take place, and e\-en hyper- trophy may result from the constant overaction of the spasmodically aifected muscles, ^yith regard to atrophy, I have seen at least three types : (1) cases in which the muscles remain for a long time, if not altogether, unchanged ; (2) cases in which the muscles waste with exceeding slowness ; and (3) cases in which a comparatiAely rapid wasting takes place. While there is usually no marked paralysis in cases of facial spasm, yet occasionally some paresis is present, but does not attract attention. The electrical reactions either are not changed or are those of partial degeneration. Vasomotor changes are not, as a rule, present. The spasms come on under excitement or after fatigue, and thej- can be induced sometimes by mechanical irritation of the muscles, or by having the patients try to use the muscles of the face. Rest and darkness have an iniiuence in dimin- ishing the spasm. The description which has been given applies especially to the common type of slowly progressive and continuous facial spasm, the pathology of which is as yet not clearly known. Cases of other types give special peculiarities, and therefore they should be separately considered. Cortical and Subcorneal Facial Spasm. Several cases of cortical facial spasm have been put on record. One of the earliest and the most remarkable of these is the case recorded by Berkley. In this case the spasm was confined to the zygomatics of the right side of the face. Berkley on autopsy found in the precentral convolu- tion of the right side, about one and a half inches above the margin of the Sylvian fissure, a nodule of calcareous degeneration, nearly circular in shape, and about three sixteenths of an inch in diameter. Its depth was about one half the thickness of the cortical gray mat- ter. A large number of cases of cortical facial monospasm have been reported in recent years, few of them, however, being of pure types. Parts of the body other than the face are generally sooner or later involved. Facial spasm is not infrequently the signal symptom in cortical or subcortical disease. In a case recorded by Seguin and Weir the first symptom noticed was a spasm in the right cheek and neck, the head and face turning to the right. For about three years the twitching spasms affected only the muscles of the face. Later the patient had attacks in the right upper extremity and right lower extremity, and these attacks were accompanied with unconsciousness. His speech gradually became thick. A growth of the shape and size 922 NERVOUS DISEASES. of the end of the forefinger was found, entirely in the white sub- stance. In this case, as in similar ones, the concomitant symptoms were of value chiefly in the diagnosis of the location of the lesion causing the spasm. Facial Spasm due to 8mall Gross Lesion of the Nucleus or Nerve TrunJc. Spasm in the muscles of the face — those supplied by the portio dura — may be produced by a small gross lesion anywhere from the facial nucleus to the peripheral distribution of the nerve. Cases have been reported in which tumors, aneurisms, or foci of softening or degeneration have caused this symptom. These lesions have been so situated as to affect the nerve in the substance of the pons, at its superficial origin, or in the auditory meatus. In one case, for instance, an aneurism, in another a tumor of the pons, in another a gummatous meningitis, and in another an abscess of the petrous bone gave rise to facial spasm either with or without accompanying symptoms. In facial spasm due to gross lesion, whether cortical, subcortical, nuclear, or neural, the spasm is likely to be coarse and more irregular in type than in those cases of painless tic which are most frequently seen, and which we are inclined to believe to be due to nuclear instability dependent upon nuclear degeneration. Blepharospasm. Blepharospasm is occasionally a more or less in- tractable spasmodic affection. It is caused by a spasm, usually tonic, of the palpebral orbicular muscle. Sometimes a clonic or a clonico- tonic form of blepharospasm manifests itself by an unpleasant un- controllable blinking or winking of the eyelids. One form of clonic blepharospasm is sometimes called nictitating spasm; it is, in fact, simply an abnormal winking or blinking. In the worst forms of this affection the eyelid is so tightly closed as to be painful to the patient. If the eyes should be open or partly open, the slightest exposure to light or irritation will cause them to be snapped shut, and so to remain in spite of the voluntary efforts of the patient and even physical efforts to open them. Blepharospasm may be due to various causes, as to peripheral irritation from a foreign body in the eye, an inverted eyelash, a slight conjunctivitis, granular lids, or a phlyctenular ulcer. The instillation of various myotics and mydri- atics used by the ophthalmologist sometimes causes blepharospasm. Eserine, for instance, may gi\-e rise to clonic fibrillary contractions of the eyelids, and cocaine sometimes produces a tendency to spasm of the levator palpebrte. Sometimes no direct tangible cause of the blepharospasm is to be found in the condition of the eye or its cover- ings, the most intractable cases being of this type : thus it may be from irritation of tlie ophthalmic branch of the fifth nerve, or from irritation reflected from a tooth or from some other portion of the face or head. Other cases ha\-e been attributed to ulcers in the mouth and nose, or to irritation of the pharynx. The so-called functional or hysterical blepharospasms often obstinately resist treatment. On FACIAL SPASM. 923 tlie other liand, they may be temporarily relieved by pressure upon the branches of the fifth nerve which go to the orbit, or upon the branches of the facial which go to the frontalis, corrugator supercilii, or levator palpebrse. In very rare instances blepharospasm may be of central and even of cortical origin, due to irritation of that por- tion of the facial centre in the cortex which is concerned especially with the orbicular movements. As bilateral consentaneous move- ments are represented in each side of the brain, irritation of one hemisphere might in rare instances gi\e rise to double blepharo spasm. A lesion would, however, have to be very small indeed so to affect the cortex or subcortex as to cause spasmodic closure of the eyelids without affecting other parts of the face. As blepharospasm has distinctive clinical features, its diagnosis, prognosis, and treat- ment will be here briefly considered. The diagnosis is to be made by a careful inspection of the patient. It could be confounded only with a paralytic or spasmodic ptosis. The prognosis is variable. Cases due to peripheral irritation, to the instillation of drugs, to unequal exposure to light, or to similar removable causes, usually make speedy recoveries. Some cases obstinately resist all medicinal and mental therapeutics, and for these surgery is the only resource. The surgical operations which have proved most beneficial are such as stretching or resection of branches of the fifth nerve and stretch- ing of the branches of the facial to the orbicularis palpebrarum. Some of the cases of blepharospasm are due to reftaction errors and the resulting irritation of the conjunctiva. Children sometimes suffer from a persistent form of cramp of the eyelids for which no known cause can be discovered. Etiology. — In discussing the etiology of facial spasm it is im- portant to separate cases of the most common type from others, as they constitute a distinct clinical entity. In this class the etiology is obscure. I have seen at least a score of such cases, and yet have never been able to come to any satisfactory conclusion as to their etiology or pathology. ITot infrequently they occur in patients with a neuropathic heredity, although I know of only one instance of apparently direct transmission, and that may have been a coin- cidence. This is a case referred to by Gowers of a mother and daughter who were both affected with facial spasm late in life. Of course not a few cases of spasm involving the face or other portions of the body have been recorded as occurring in different members of the same family, but these are not instances of true painless tic. The disease usually comes on after middle life, most frequently between the ages of fifty and sixty, although it may be observed in rare in- stances at almost any age. It is more common in women than in men. Exhausting diseases, emotion, great fatigue, and injuries are assigned as exciting causes. It has been observed during pregnancy, and cold and exposure in some instances have seemed to be factors. 924 NERVOUS DISEASES. The reflex variety of facial spasm is most frequently due to trigem- inal irritation, as when it arises from a decayed tooth or from in- jury to a nerve anywhere in the face or head. The causes of the cortical, subcortical, pontile, and basal forms of facial spasm have been sufficiently discussed when treating of these varieties of spasm. The causes are, in brief, irritative focal lesions of all sorts, as tumors, abscesses, localized meningitis, aneurism, embolism with softening, focal hemorrhages, exostoses, etc. Pathology and Morbid Anatomy. — So far as known to me, no case of painless tic of the ordinary type with autopsy and microscopi- cal examination has been put on record. The disease would seem to be due to some affection of the facial nucleus, or possibly of the cor- tical facial centre. The ganglionic disease is most probably of a de- generative and progressive type. Exceedingly slow degeneration of the facial nucleus would seem to account best for some of the cases ; in others, in which atrophy does not take place even late in the affection, degeneration of the cortical centre for the face would seem more probable. As the aggregation of nerve cells which constitute a "centre" decreases, the centre itself, regarded as a whole, be- comes less stable and less uniform in its method of action. The facial nucleus in the oblongata, for instance, if more or less degener- ated, will transmit the current of cortical impulses with less and less smoothness, and spasm instead of uniform physiological action wiU result. As already indicated, some forms of facial spasm are due to small gross lesions, or are reiiex, hysterical, or of habit causation. Diagnosis. — The diagnosis of facial spasm is of course to be made by the fact of the existence of spasm in a few or in all of the muscles supplied by the seventh nerve. It is necessary first to deter- mine that the case is one of the progressive degenerative type, and this diagnosis is chiefly made by a history of the slow, insidious progress, by the concurrence of clonic and of tonic spasm in the same attacks, by the tendency to diffusion over part of the face, and by the obstinate resistance of the spasm to all methods of treatment. This and some other forms of facial spasm must be distinguished from the secondary spasms and contractures which follow Bell's palsy. It is most important to look for a previous history of true peripheral facial paralysis. When facial spasm is hysterical, other evidences of hysteria are usually present ; when it is a habit chorea, the his- tory of the case will be the chief assistance. Hemifacial atrophy, which is a disease of the fifth and not of the seventh nerve, must not be confounded with a case of facial spasm or paralysis in which some atrophy has taken place. It is not impossible to have either facial spasm or facial paralysis associated with true hemifacial atrophy, but the combination is so exceedingly rare as to make it scarcely worth while to take it into account. Prognosis. — The prognosis in the ordinary tyjae of facial spasm FACIAL SPASM. 925 is always serious. Although many cases of the disease of this type have fallen under my observation, either directly or in consultation with others, I have never seen or known of a case of recovery. To my mind this form of facial spasm is simply one of the forms of de- generative disease of which we have so many examples. Cases due to reflex irritation may recover when the source of irritation is re- moved. The removal of carious teeth may give relief, although when cases have apparently been of reflex origin the removal of the exciting cause does not always cure the affection. This is probably due to the fact that a spasm habit has been set up. Treatment. — Treatment of facial spasm is, as a rule, unsatisfac- tory. If due to a cortical lesion, as to a tumor, spicule of bone, or other irritative lesion, this may possibly be removed. Excision of the cortical facial centre has been practised with reported benefit. In Weir and Seguin's case the removal of a subcortical sarcoma gave relief for a considerable time. Mercury and iodides should be used where syphilis is suspected, or even in other cases of focal lesion of unknown origin, as these absorbents have some efficiency in nonsyphilitic cases. The treatment of the progressive form is un- satisfactory, although relief is sometimes obtained. The medical measures resorted to are both local and internal. Of local remedies the most important are cold, heat, and electricity. Mitchell has strongly recommended the use of local cold, as freezing the cheek with ice or with rhigolene or chloride of ethyl spray. Very hot ap- plications and strong counterirritation over the place of emergence of the nerve from the stylomastoid foramen may be tried. The actual cautery may also be applied in this position, or at any point or points along the course of the nerve. The only electrical method worthy of trial is the use of a weak galvanic current, applied after the stabile method. The anode can be applied under the ear or at various points over the distribution of the nerve, and the cathode at some indifferent place, as at the back of the neck or the sternum. This is the unipolar method, and offers some hope of relief. Mor- phine, or atropine, or both combined, may be administered hypoder- matically. Internally the most useful remedies are the metallic tonics, such as chloride of gold and sodium, oxide or nitrate of silver, and the salts of zinc, copper, and arsenic. Strychnine in increasing doses has been used with reported success. Two of the most valuable narcotic sedative drugs for this as for any other form of spasm are conium and gelsemium. Coniine hydrobromate can be administered in doses of from one fiftieth up to one tenth of a grain three or four times daily. Gelsemium is best used in the form of a fluid extract, beginning with four or five minims and increasing until the patient takes from ten to fifteen or more. Stretching of the nerve has been employed, the immediate result being facial paralysis with cessation of the spasm, but in most instances the spasm returns. 926 NERVOUS DISEASES. Diagram showing the relations of the pons, preoWongata, and postoblongata to the fourth ventricle, iter, quadrigeminum, and cerebel- lum : Q, quadrigeminum ; V, fourth ventricle. SMALL GROSS LESIONS OP THE PONS AND PREOBLONGATA. Structures of the Pons and Preoblongata.— In this aud the two preceding chapters the diseases (jf the cranial nerves liom the third to the eighth inclusive ha\e Iw-en considered. These nerves either arise, or in large part take Fig. 421. their intraencephalic course to reach the surface of the brain, in those subdivisions of the enceph- alon which, in accordance with the terminology adopted in this work, are designated as the pons and the preoblongata. (Fig. 421.) So many structures are compacted into the small space included within the pons and preoblongata that small gross lesions affecting them must affect various impor- tant structures besides the cra- nial nerves, and in this way give rise to special syndromes. It wiU facilitate the focal diagnosis of lesions in this region to have some readily applied topographical scheme by which the most frequent combinations of symptoms can be understood at a glance. A series of semidiagrammatic illustra- tions which will be found useful in the study of the focal diagnosis of lesions of the pons and preoblongata have therefore been prepared. In these illustrations the combined pons and preoblongata are repre- sented as divided into thirds in two directions, so that the'attention of the diagnostician can be focussed upon any one of nine segments. They can be used both as supplementary and as complementary to the facts already mentioned under the symptomatology and diagnosis of the cranial nerves to which allusion has been made. Ventral, Lateral, and Dorsal Views of the Pons and Pre- oblongata. — Ventral, lateral, and dorsal views of the appearances presented by the pons and preoblongata are given in Figs. 422, 423, and 424. These are represented as divided into thirds by horizontal dotted lines which on the different surfaces correspond with one another as determined by sections of actual specimens, the planes of the sections being at right angles with the cerebrospinal axis. The third nerves (///) are seen emerging between the cephalic third and the crus, and at the junction of the pons and the postoblongata are the abducens (VI) and more laterally the facial (VII) and eighth (VIII) iierA'cs. On the lateral aspect of the cephalic third, near the crus, the trunk of the fourth nerve (JT") appears, and the fifth nerve (V) in the middle third, while the seventh and eighth nerves are SMALL GROSS LESIONS OF THE PONS AND PEEOBLONGATA. 927 Fig. 422. Fig 423 Fig. 422. — Subdivision of the ventral aspect of the pons into thirds, showing the relations of important structures to each subdivision. Fig. 423.— Subdivisions of the lateral aspect of the pons and preoblongata. The nerves in this and the preceding illustration are indicated by Roman numerals. Fig. 424. Fig. 424.— Subdivisions of the dorsal aspect of the preoblongata, showing the surface structures. The nuclei and nerves in this and the next figure are indicated by Roman numerals. Fig. 425.— Subdivisions of the dorsal aspect of the pons and preoblongata, showing the position of the nuclei and root fibres of the cranial nerves from the fifth to the eighth. Va, descending (mesencephalic) root of the fifth ; Vs, sensory nucleus of the fifth ; Vm, motor nucleus of the fifth ; Vd, descending (spinal) root of the fifth ; Str, acoustic strise. 928 NEEVOUS DISEASES. seen in the lower margin of the lateral as well as of the ventral third. In the cephalic division (A) of the dorsal aspect (Fig. 424) are seen the postgeminum or posterior tubercles of the quadrigeminal body, and the fourth or pathetic nerve at its origin and in part of its course. The middle third (B) includes the prepeduncle and a portion of the floor of the fouith ventricle. Both the middle and caudal thirds are partly traversed by the medipeduncle, and the caudal third (C) by the acoustic striae. Relative Positions of the Nerve Nuclei and Course of the Root Fibres. — With the aid of Tig. 425 the relative positions of the nuclei of the third, fifth, sixth, seventh, and eighth nerves are made evident. The nuclei of the third nerve are situated in the gray matter along the course of the Sylvian aqueduct cephalad of sub- division A, and the nucleus of the fourth nerve adjoins the nuclei of the third in the upper portion of this cephalic segment, lying chiefly beneath the postgeminum. Both the sensory and motor nuclei of the fifth nerve are in the middle third, while the nuclei of the sixth and seventh and a large part of the eighth are in the cau- dal or lower third. Hence, when nu- clear symptoms referable to any one or more of these nerves are present, the topography of the lesions causing them can be understood and readily stated with reference to these subdivisions. The root fibres of the nerves which spring from these nuclei have, it must be remembered, within the substance of the preoblongata and pons, courses of considerable extent and complexity be- fore they appear on the ventral and the lateral aspect of the pons. In Fig. 426 the dorsoventral courses pursued by the root fibres of the third, fourth, fifth, sixth, seventh, and eighth nerves are approximately indicated. In this illus- tration lines are shown, drawn longi- tudinally and at right angles to those already used in making the subdivisions A, B, and C, thus giving in lateral ■\-iew nine segments, the thirds A, B, and C each being subdivided into thirds, — three ventral, three dorsal, and three intermediate (that is, interme- diate between the dorsal and the ventral segments). The root fibres as well as the nuclei of the third nerve chiefly lie cephalad of all the A lateral diagrammatic view of the course of tlie root fibres of the cranial nerves from the third to the eighth. The diagram is shown sub- divided into thirds longitudinally (D, E, and F) as well as horizontally (A, B, and C). SMALL GROSS LESIONS OF THE PONS AND PREOBLONGATA. 929 Fig. 427. Fig. 428. above subdivisions. In the cephalodorsal segment (A) are seen tlie root fibres of the fourth nerve and the descending (mesencephalic) root of the fifth. In the dorsal and in- termediate segments of the middle third (B) both the spinal and the mesence- phalic roots of the fifth nerve are seen, as are also a few of the curving roots of the seventh nerve ; while in the dorsal and intermediate segments of the caudal subdivision (C) are crowded most of the root systems of the sixth, seventh, and eighth nerves. Structures shown in Transec- tions of the Pons and Preoblongata. — Making now dorsoventral sections through the middle of each of the sub- divisions A, B, and C, the ai:)pear- ances of such transections, as seen under low powers of the microscope, would be much as shown on the left half of Figs. 427, 428, and 429. Pig. 427 shows the appearance of a sec- tion through the middle of the sub- division A, Fig. 428 of one through the middle of the subdivision B, and Fig. 429 of one through the middle of the subdivision C. In these figures are brought into view the appearances in section not only of the root fibres and nuclei of the nerves, but also of various important longitudinal and transverse tracts, — the superficial and deep transverse fibres of the pons, the pyramidal tract, the fillet, the pe- duncles, some of the most important of the nuclei of the cranial nerves and root fibres, and certain special nuclei and tracts, as the superior olive, the lateral nucleus, the dorsal longitudinal bundle, and the central tegmental tract. The merest glance will show that in all positions the most important parts in- volved in lesions of the ventral and of the intermediate segments will be the superficial and deep transverse fibres and the pyramids. The fillet hes about the junction of the intermediate and dorsal segments, 59 Fig. 42>). Figs. 427, 428, and 429.— Transec- tions ol the pons and ineoblongata (Fig. 427 through about the middle of the subdivision A, Fig. 428 through B, and Fig. 429 through C, of Figs. 422, 423, 42.5, and 426). These figures show the relations and position of the most important structures: O.S., su- perior olive ; C.I., central tegmental tract; L.c. and c, locus ceruleus ; XI. v., dorsal longitudinal fasciculus; L./., lateral fillet ; L.n., lateral nucleus. The numerals refer to nerve nuclei and roots. 930 NERVOUS DISEASES. varying in its median and lateral positions in different cephalocaudal sections. Nuclei and root fibres are most prominent in dorsal seg- ments, while the pyramidal tract dominates the symptomatology of veutrally situated pontile lesions. Lesions of the Pyramidal Tract in the Pons. — The pyramidal tract is the great tract from the motor region of the cerebral cortex. Hence destructive lesions of this tract will always give paresis or paralysis of the opposite extremities. When the lesion is in the cephalic portion of the pons, before the decussation of the pyramidal fibres for the trigeminal, abducens, and facial nerves, some ocular and especially some facial paresis may be present. This loss of power in the face must be distinguished from that caused by lesion of the facial root fibres or nuclei. The paralysis of the face is cen- tral, and has features similar to that shown in the arm and leg. It is usually incomplete, although it may be more marked than when caused by a lesion situated higher in the pyramidal tract or in the cortex. It does not give the electrical reactions of peripheral facial paralysis. Irritative lesions of the pyramidal tract in the pons and elsewhere may give rise to monospasm, or even to unilateral con- vulsions, chiefly affecting the limbs and face of the opposite side. Often, in lesions of the ventral portion of the pons, the cranial nerves at, just before, or just after their superficial origins will be involved, giving various forms of so-called alternate hemiplegia. Functions and Lesions of the Superficial and the Deep Transverse Fibres of the Pons. — The superficial transverse fibres of the pons which lie ventrally to the pyramids contain chiefly cere- bellar fasciculi. In the middle third of the pons they run nearly horizontalljr, having a more oblique course in the lower and upper thirds. They connect special portions of opposite halves of the cerebellum, and also portions of the lateral lobes of the cerebellum with the opposite cerebral hemispheres. The symptoms given by lesions of special bundles of these superficial transverse fibres are not yet thoroughly known. I ha\'e reported a case in which, ap- parently as the result of a small hemorrhage involving these fibres as well as some of the deeper parts of the pons, the patient had atrophy of one lateral lobe of the cerebellum and of the opposite hemicerebrum. Passing to the intermediate segments, as shown in the transections Figs. 427, 428, 42".), it will be seen that the pyrami- dal tract occupies part of this region, which also contains the deep transverse fibres and, near the junction of the intermediate and dor- sal thirds, the fillet. A lesion centrally situated in the substance of the pons will, therefore, give symptoms the result of the destruction of these deep trans\'erse fibres, and, if the lesion extends ventrally and dorsally, of both the pyramidal tract and the fillet. The deep transverse fibres cimstitute largely the structure knoAvn as the tra- pezium, or trapezoid bodj-. In large part, at least, it is the path of SMALL GROSS LESIONS OF THE PONS AND PREOBLONGATA. 931 the cochlear nerve. Fibres of the trapezoid body pass to the Aarioiis auditory nuclei, and also to the roof nucleus of the cerebellum, and connect with the superior olives both of the same and of the opposite side. According to some authorities the trapezoid fibres unite with the fillet, and according to others they intersect it. While the lower or caudal border of the trapezium corresponds nearly to the same border of the pons, cephalad it reaches only as high as the place of emergence of the sensory root of the fifth nerve, and therefore it would be chiefly invohed in lesions of the U\o lower thirds of the pons, as given in the diagrams. Functions and Lesions of the Lemniscus, or Fillet. — As the fillet, or at least its most mesal portion, is a part of the great sen- sory tract, its lesions cause disorders of sensation. Numerous cases have been reported in which deeply situated pontile lesions have given rise to anesthesias, and especially to impairment or loss of the senses of pain and temperature ; and numerous studies of de- generation following focal lesions ha\e also shown the part played by the lemniscus as a sensory tract. The acoustic tract runs in the lower lateral division of the fillet to the postgeminum, so that lesions of the lateral fillet, like those of the trapezoid body, sliould cause affections of hearing. Functions and Lesions of the Superior Olive. — The superior olive, which generally extends the whole length of the pons, is closely approximated to the dorsal surface of the trapezium, and is located, therefore, near the junction of the dorsal and intermediate segments. A function that has been assigned to the superior oli^e is to act as a reflex centre for correlating the movements of the head and eyes with auditory impressions, and its lesions might therefore be expected to interfere with such correlations, causing a lack of response by the head and eyes to sounds coming from various directions. The con- nections of the superior olive which have been traced are with both accessory nuclei of the auditory nerve, with one or possibly both cerebellar roof nuclei, with the nucleus of the sixth nerve on the same side, with the dorsal longitudinal fasciculus of the oppo- site side, with the lateral columns of the cord, and with the post- geminum. Lesions confined to the Preoblongata. — In the dorsal or pre- oblongatal portion of the region we are considering the structures are complicated. Here in various positions are the nuclei and root fibres of the fourth, fifth, sixth, seventh, and eighth nerves, and, iu addi- tion, certain special fasciculi, as the dorsal longitudinal bundle and the central tegmental tract. Dorsal lesions in different fore-and-aft segments will, therefore, give varying forms of paralysis of the face, of trigeminal paralysis, motor and sensory, and of single or asso- ciated ocular palsies. As the third, fourth, and sixth are all nerves to the ocular muscles, and as in various movements of the eye these 932 NERVOUS DISEASES. muscles act to a greater or less extent together, botli on the same side and across the median line, the nuclei of these nerves must be anatomically connected, and lesions of their associating and corre- lating fibres will give special disorders of ocular movements. Some of the connections, it is believed, are by the dorsal longitudinal bundle. Many of the curving strands in the pons and oblongatas run from the nuclei (jf the motor cranial nerves, partly to the oppo- site dorsal longitudinal bundle and partly to this fasciculus on the same side. Cases illustrating Segmental Localization in the Pons and Preoblongata. — The records of one or two cases may serve to empha- size some of the points just made with regard to localization of small gross lesions in the pons and preoblongata. In one of my cases autopsy showed a lesion the location and limitations of which are indicated in the illustration Figs. 430 and 431. A transection through the pons within the limits of subdivision B of the diagrams just given revealed a ventral lesion near the mesal line in the right half of the pons. This in the fresh specimen appeared to be limited as shown in the drawing Fig. 430. Subsequently micro- scopical sections were cut and mounted by Dr. A. O. J. Kelly, from which, among other draw- ings, the one shown in Fig. 431 was made. The microscopical section demonstrated that the area of softening and degeneration extended much farther than appeared in the fresh specimen. Fig. 4.31. Fig. 430. Fig. 430.— Drawing showing the position and apparent size of a pontile lesion in the fresh specimen. The patient had paralysis of the left rectus externus and paresis of the right rectus externus, with restriction of ocular movements, paresis which deepiened into paralysis of the left extremities, exalted reflexes, and great emotionality. A photograph of this patient is shown In Fig. I'.n.), p. S-J7. Fig. 431.— Microscopical appearances of the lesion in the case shown in Fig. 395 (p. 827). The section was made near the position of the lesion as shown in the fresh specimen. (Fig. 430.) The destruction and degeneration invoh-ed both pyramidal tracts, the deep transverse fibres, the superficial transverse fibres, and the root fibres of tlie right and left, aliducens nerves. The destruction was much greater on the right than on the left. A summary of the symptoms shown by the patient is given in the legend to Fig. 430. SMALL GROSS LESIONS OF THE PONS AND PREOBLONGATA. 933 Fig. 4:i2. In a second case the lesion was a circumscribed softening most ex- tensive near the ventral snriace of the pons at its cephalic extremity. It tapered and became more dorsally situated as it extended to^^•ards the postoblongata. About the middle of tlie pons it slightly crossed the mesal line. The lesion did not quite reach the postoblongata. The appearances presented by this specimen in the fresh state are shown in Figs. 433, 434, and 435, and the microscopical appeaiauces in Fig. 436. The different symptoms presented by the patient are summarized in the legend to Fig. 432. Another case of central softening of the pons has also been reported by me. None of the cranial nerves were suiierficially involved, although the lesion was unusually large. The clinical history showed headache, a vei- tiginous seizure followed by partial right hemiplegia, left convergent strabismus, de- fective articulation, and paralysis of the left arm three weeks after the attack. Another seizure was accompanied by excessive emo- tionality, profuse perspiration, difficulty in breathing and swallowing, inability to speak and to thrust out the tongue or open the mouth wide, and paralysis of both arms and legs ; and at last conjugate deviation to the right. In a case of tumor of the pons, the chief symptoms of focal lesion were hemi- paresis, partial right ptosis, diminished sen- Diagram showing the an- teroposterior dimensions of a pontile lesion in a case in which the chief symptoms were right facial x*aralysis, paresis of the right arm and leg, paralysis of the left internal rectus, paral- ysis of consentaneous ocular movements to the left, and ex- alted reflexes. The microscop- ical appearances of this lesion in transection are shown in Fig. -136. Fig. 433. Fig. 4?A. Fig. 435. Figs. 433, 434, and 435.-The appearances in the fresh state of the pontile lesion in three tran- sections (through \. B, and C, in Fig. 432). It will be seen that the lesion as it descends approaches more and more the dorsal aspect of the pons. sation on the left side of the face and right limbs, conjugate deviation of the eyes and rotation of the head to the right, persistent epistaxis, and a tendency to hemorrhage from the mucous membranes. The autopsy revealed a gumma about half an inch in diameter, dis- tinctly limited to the left cephalic quarter of the pons. Conjugate deviation of the eyes and head is a not infrequent accompaniment of 934 NERVOUS DISEASES. Fig. 4?,6. Microscopical appearances of a t"_ "i-.' ii" i i- i the middle of the pons through the lesion of the case shown in Figs. 432, 433, 434, and 435. lesions and especially of tumors towards the cephalic extremity of the pons. In another case of tumor of the pons observed by the author the important symptoms were right external strabismus, with con- traction of the right corner of the mouth ; persistent cough ; stagger- ing ; left hemiparesis with left partial hemianesthe- sia ; severe constipation ; difficulty of articulation ; and late in the history of the case difficulty of swal- lowing and paralysis of the limbs. On autopsy a large cyst filled with bloody fluid and detritus was found occupying the lower half of the pons and the upper half of the j)Ostoblongata, extending a little lower and higher on the right side than on the left. The floor of the fourth ventricle bulged slightly. A man about twenty-six years of age, with a history of syphilis, was admitted to the nervous wards of the Philadelphia Hospital. About two weeks before admission he observed that the right side of his face was paralyzed and insensitive. ^Mien admitted, examination showed complete paralysis of the right facial or seventh nerve, also of the muscles supplied by the motor division of the fifth nerve. The patient was also anesthetic on the right side of the face, including the conjunctiva and cornea. Tlie hearing, as determined by the watch, \\'as good on the left side, but on the right it was necessary to bring the watch close against the ear before its tick could be heard. He had, howrxer, no tinnitus. Taste was lost on the right side both on the anterior and on the posterior portion of the tongue. He had neither paralysis nor anesthesia of any part of the body below the neck. Tlie symptoms in this case were probably due to a lesion of the lateral aspeit of the pons, although they might be ex- plained l)y a lesion within the substance of the pons and preoblon- gata. so situated as to destroy tlie sensory and motor root fibres of the fifth, the facial and glossopharyngeal root fibres, and some of the aeinistic root fibres, or perha]is fibres of the auditory tract in the tra-i)ezoid body or tli(» lateral fillet. The electrical reactions in the inuseles of the face were those of peripheral paralysis. Vaso- motor plieiionieHM. sucli as pallors, flushings, and the epistaxis and mucous heinori'hages rel'eiied to above, may be present in pontile lesions, as may also special temperature changes. These are prob- ably due to implication of vasomotor and heat centres. CHAPTER X. DISEASES OF THE GLOSSOPHAEYNGEAL NEKVe (MOTOR AND SENSOEY DIVISIONS), AND OF THE PNEUMOGASTRIC, SPINAL ACCESSORY, AND HYPOGLOSSAL NERVES ; SMALL GROSS LESIONS OF THE POST- OBLONGATA AND OBLONGATA-SPINAL TRANSITION ; AND SOME FORMS OF BULBAR PARALY'SIS. ANATOMY AND PHYSIOLOGY OF THE GLOSSOPHARYN- GEAL, PNEUMOGASTRIC, AND ACCESSORY NERVES. Interrelations of the Glossopharyngeal, Pneumogastric, and Accessory Nerves. — The glossopharyiigeus and vagus arise from a uucleus which histological lesearch has not yet separated into the parts which belong to each of these uer\es respecti\'ely. It is com- monly taught, even in recent anatomical works, that the glossopha- ryngeus, the vagus, and the aceessorius arise from a common nucleus, but the investigations of Grabower and Oppenheim seem to make it clear that the aceessorius nucleus is distinct from the nucleus of the vagus. While a similar separation has not been determined for the glossopharyngeus and the vagus, it is at least demonstrable that the glossopharyngeal nucleus is in the more cephalic portion of the so- called vagoglossopharyngeal nucleus. One of the great root bundles in the postoblongata, usually spoken of as a vagoglossopharyngeal root, Obersteiner believes to be almost purely glossopharyngeal, holding that while some of the fibres of this root may belong to the vagus, the number of these is inconsideral>le. The glossopharyngeus and the vagus supply sensory and motor fibres to adjacent and closely related regions, and the functions of these ner\-es in some cases in- terblend or have a certain degree of interdependence, as shown, for instance, in the relationship between such processes as those of deglutition and digestion or of deglutition and respiration. Many general works on neurology, and especially those in German, con- sider together affections of the vagus and aceessorius under the head of vagusaccessorius diseases ; some even go so far as to speak of glossopharyngeusvagusaccessorius diseases ; but it -"'ill fulfil a better purpose to discuss their diseases separately, although the anatomy and physiology of these nerves may be treated of together. Subdivisions of the Glossopharyngeal Nerve.— When dis- cussing the affections of taste, the anatomy of the glossopharyn- geus was to a large extent considered (pages 686-688), most attention being paid to its gustatory division. As there stated, it is generally conceded that the glossopharyngeus springs from three oblongatal 935 936 NERVOUS DISEASES. regions. According to Obersteiner, the three separate functions of the glossopharyngeal nerve, namely, taste, motility, and general sensation, may without hesitation be assigned to its three separate nuclei. The same author points out the anatomical similarity between the spinal descending root of the trigeminus and the great root of the glossopharyngeus, believing that the latter is also descending and, like the former, is concerned with impressions of common sensibility. It is sometimes spoken of as the slender column of Lockhart Clarke. It lies to the outer side of the glossopharyngeal and pneumogastric nerves and near the floor of the fourth ventricle, and is a slender column of longitudinal fibres which appear lounded on transection and very small in size. This column extends cephalad as far as the most cephalic portion of the nucleus of the glossopharyngeus, and caudad to the deep portion of the lateral column of the cord into the cervical region, although it is impossible to state the exact spinal termination of the bundle. Formerly it was called the ascending root of the vagus and glossopharyngeus nerxes. By Meynert it was spoken of as the common ascending root of the lateral mixed system. In function it has been supposed to be in some way connected with the process of breathing ; hence it has been termed the respiratory column of Krause. Section of this bundle on both sides arrests the respiratory movements. Spitzka has, however, denied the connec- tion of this bundle with the vagus, and the views of Obersteiner have been previously given. About the level of the entrance of the glosso- pharyngeus into the postoblongata the fibres of this bundle may be observed in a transection to alter their course. In sections from slightly lower levels the fibres of the bundle are cut transveraely, but in the region mentioned they bend horizontally, and may be dis- tinctly seen passing towards the ventral border of the postoblongata. The origin, root fllwes, and nuclei of the sensory portion of the glos- sopharyngeus have been sufficiently considered in the pages to which reference has just been made. Investigations making a clear dis- tinction between the subdivision of the nerve which administers to taste and that which is related to common sensibilit>' are not as yet forthcoming. The most that can be said with regard to the ganglia of the roots, the sensory root fibres, and nuclei, is that they are afferent, and are concerned both with t;xste and with common sen- sation, the motor portion, of course, being efferent. The peripheral course of the glossopharyngeus and its branches is given on pages 687 and 6S,S. Summary of the Functions of the Glossopharyngeus.— The glossopharyngeal nerve sends branches to the mucous membrane of the tongue, i»harynx, and middle ear, as well as to the stylo- pharyngeus muscle, and possibly also to the middle constrictor of the pharynx. I!y its small superficial petrosal branch it furnishes secretory and vasodilator fibres (through the otic ganglion and the ANATOMY OF THE GLOSSOPHAEYNGEUS ANB VAGUS. 937 auriculotemporal nerve) to the parotid gland. It is connected with the inferior maxillary division of tlie fifth (through the otic, ganglion) with the facial, with the pneumogastric (its trunk and branches)' and with the sympathetic. (Quain's Anatomy.) According to some observers, it is a motor nerve for the glossopalatinus, the levator veli palatini, and the azygos uvuhe, but for the last two at least the nerve supply is more probably from the \'agus. It is generally conceded that the glossopharyngeus is the nerve of common sensibility for the upper part of the pharynx, and perhaps for the tympanic cavity and a part of the palatal region. Stimulation of the sensory fibres of the glossopharyngeus may excite movements of deglutition reflexly through the muscles of the palate and pharynx. Both the gusta- tory fibres and the fibres of common sensibility may through their stimulation excite reflexly a flow of saliva. Ventral and Dorsal Subdivisions of the Nuclei of the Glosso- pharyngeal and Pneumogastric Nerves.— The glossopharyngeal and pneumogastric nuclei ha^e in the first place rent ml and dorsal subdivisions. The central cell nests give origin to the motor or efferent root fibres of these nerves, and taken together form the so- called nucleus ambiguus, or common nucleus. The dorsal nuclei are the end nuclei (the postoblongatal termini) of the sensory or afferent fibres of the vagoglossopharyngeal sensory nerve roots. Dorsal Vagoglossopharyngeal Nucleus. — This nucleus is a long column of cells. At its most caudal portion it is dorsal to the hypoglossal nucleus at the point where the central spinal canal is still closed ; more cephalad it is lateral to the nucleus of the hypo- glossus, forming the ala cinerea of the floor of the fourth ventricle. This nucleus by some observers is differentiated into three i^arts for the glossopharyngeus, vagus, and accessorius respectively, but Turner believes that this segmentation is not certainly determined. It has long been taught that this dorsal nucleus is sensory, a view which has been confirmed l;iy the more recent investigations of Eamon j Cajal, Turner, and others. Eisenlohr believes that this dorsal nucleus is the centre for the superior laryngeal nerve, and Holm that it is a respiratory centre. More exactly, Holm's conclu- sions are, (1) the centre for the trachiobronchial reflex is probably located in the dorsolateral division of the dorsal nucleus of the vagus, — the small ganglionic cells of the nucleus; and (2) the re- spiratory centre consists exclusively of the ventromesal division of the dorsal nucleus of the vagus, — the large celled group of the nu- cleus. Marinesco as a result of his general study of the subject concludes that the dorsal nucleus is not essential to respiration, but that it contains motor neurons for the muscles innervated by the pneumogastric, and is therefore a motor nucleus, although the cells are not of the same type as those of the nucleus ambiguus or of the hypoglossal nucleus. Pie calls the dorsal nucleus the nucleus of the 938 NERVOUS DISEASES. nonstriated muscles, in contrast to the nucleus ambiguus, which he designates as the nucleus of the striated muscles innervated by the pneumogastric, —the muscles of the larynx, for instance. Nucleus Ambiguus. — According to Koelliker, this nucleus ex- tends from the level of the lowest vagus fibres, proximally as far as the exit of the upper glossopharyngeal root fibres. It begins in about the same region as the hypoglossus nucleus, but extends farther cephalad than the latter. It occupies an anterolateral posi- tion in the postoblongata, and is usually roughly divided into three portions, the upper for the glossopharyngeus, the middle for the Fig. 437. Section through the bulb of a four-day old mouse, showing the nuclei and radicles of the glossopharyngeus, vagus, and hypoglossus : A, hypoglossal nucleus ; B, commissural nucleus; C, olive ; D, descending sensory root of the trigeminus ; E, E, motor roots of the vagus and glosso- pharyngeus ; F, nucleus ambiguus ; G, terminal portion of the descending vestibular nucleus; H, transverse section through the fasciculus solitarius ; L, fibres jmssing to the olive; a, pyramid; b, coUaterals of the jiyramid and of the white substance external to them ; d, collaterals of the remains of lateral column ; e, sensory collaterals to the nucleus ambiguus ; f, recurrent fibres of the motor root which pass to the trigeminus root ; j. crossed motor root fibres of the vagus and glossopharyngeus ; h, collaterals of the sensory root of this nerve to the nucleus accompanying the fasciculus solitarius. (Ramon y Cajal.) vagus, and the lower for the accessorius. It will presently be seen, howe^'er, that according to recent investigations the accessorius nucleus lias no connection with the nucleus ambiguus. The nucleus ainl)iguus is Cdiiipo.sed of large motor colls from which pass long axis c.\ linders which take a Inrnding course to reach the surface of the postoblongata, wlicre tliey become the root bundles of the glosso- pharyngeus and the vagus. These cells and the course taken by their processes are beauiifully shown in the illustration Fig. 437. ANATOMY OF THE GLOSSOPHARYNGEUS AND VAGUS. 939 According to Turner, the nucleus ambiguus innervates among other structures tlie levator palati and internal thyroarytenoid muscles, and probably also the muscles of the phaiynx. In lS7!t Spitzka dis- covered deeply embedded in the oblongata in this region a cell nest to which he gave the name of nidus lari/iigci, near which is another nest of smaller elements, the nidus pharyngei. Springing from the nucleus ambiguus, the root fibres of the glossopharyngeal and pneu- mogastric ner\-es traverse the oblongata to emerge by the side of the prominence formed by the restis, in their course passing through the descending root of the fifth nerve. They ha-\ e numerous filaments of origin, and it is difficult, if not impossible, to tell Mhich extra- bulbar roots belong to the ninth and which to the tenth nerve. It can be said with certainty only that the uppermost belong to the ninth and the lowermost to the tenth. Central Neurons of the Motor Portion of the Glossopharyn- geus and Vagus. — All the cerebral connections of the glossopharyn- geus and vagus have not yet been traced. Their central neurons arise in some portion of the cortex, and probably pass near the pyramidal tract downward, reaching after decussation the nucleus ambiguus. Probably each portion of these nerves related to a sj)ecial function has its own cerebral region of representation. The locations of the cerebral centres of laryngeal and pharyngeal movement have already been considered (see cortical localization, page 8.37). The Aagal and glossopharyngeal neurons concerned with these movements doubtless arise in the portions of the cortex there indicated, namely, near the base of the precentral fissure for laryngeal movements, and just caudad of this location for the movements of the pharynx. Nothing of a positive character is known regarding cortical centres (if such centres exist) for movements of the oesophagus, and of the stomach, intestines, heart, and other viscera to which pneumogastric fibres are distributed. Peripheral Course of the Vagus. — General Course. The periph- eral course of the glossopharyngeus has been given in Chapter VII. (page 687). Superficially the pneumogastric nerve arises by nu- merous radicles from a groove between the olive and the restis, just below the so-called superficial origin of the glossopharyngeus (Fig. 438). The flat trunk formed by the union of its roots passes out- ward across the flocculus of the cerebellum, and leaves the cranium by way of the jugular foramen. It passes down the neck in the same sheath with the carotid artery. The right and the left vagus differ somewhat in the courses which their trunks take in the neck and thorax, a point that should be remembrred in connection with the consideration of extrinsic focal lesions affecting the trunk of the nerve. The right A-agus passes in front of the first portion of the subclavian artery, bet^'een the latter and the subclavian vein. It then runs downward on the side of the trachea to reach the posterior 940 NERVOUS DISEASES. aspect of the right bronchus. The left vagus enters the thorax behind the left common carotid artery, between the latter and the left sub- clavian artery. Near the arch Fii-i. 438. of the aorta it bends suddenly backward and crosses the root of the subclavian artery on the left side of that vessel under cover of the pleura. Crossing the left side (in frontj of the transverse part of the arch of the aorta, it bends backward to reach the posterior aspect of the left bronchus. (Morris's Anatomy.) The right vagus is distributed on the posterior surface of the stomach, and the left vagus on its anterior surface. Ganglia of the Vagus. The vagus has on its trunk two ganglia, an upper, or ganglion of the root (ganglion superins, ganglion jugulare), and a lower, or ganglion of the trunk {gan- glion inferius, plexus gangli- f arm is, jj?(».ri'.s nodosus). The former is placed within the jugular foramen opposite the jugular ganglion of the glos- sopharyngeus, and the gan- glion of the trunk is situated a little lower on the trunk of the nerve (Fig. 438). The superior cer-\-ical ganglion of the sympa- thetic is l)ehind and a little external to the vagus, while the glosso- pharyngeus is in front of it. A portion of the spinal accessory nerve joins the ganglion of the trunk, some of the fibres I'un- ning over the ganglion into the pharyngeal and superior laryngeal branches of the vagus. CommKiiicafing Branches of the Vagus. The vagus has important connections with the glossopharyngeal, the spinal accessory, the hypoglossal, the cervical sympathetic, and the first two cervical nerves. (Fig. 4.39.) A twig from tlie pneumogastric joins the glos- sojihai'yngeal nerve immediately below the petrous ganglion. Fine filaiiK'iits pass from the accessorius to the ganglion of the root of the vagus within the jugular fora,men, and below, the remainder of the accessorius joins the ganglion of the root. Fine filaments also pass Apparent origins of the spinal accessory, pneu- mogastric, and glossopharyngeal nerves : g, jugular ganglion of the glossopharyngeus ; gg, ganglion of the root of tlie vagus (ganglion superius, ganglion jugulare) ; gg p, ganglion of the trunli of the vagus (ganglion inferius, plexus nodosus, plexiform gan- glion). The Roman numerals indicate the cranial nerves and the cervical nerves in their order. (After Van Gehuchten.) ANATOMY OF THE PNEUMOGASTRIC NERVE. 941 between the ganglion of the trunk of the \'agus and the hypoglossal Fig. 439. nerve as the latter winds around this ganglion. A few twigs pass between the superior cervical ganglion of the sympathetic and the ganglion of the trunk. The branches of distribution of the vagus also communicate exten- sively with the sympathetic sys- tem at lower levels. An incon- stant twig passes from the loop formed by the anterior primary divisions of the upper two spinal nerves to the ganglion of the trunk of the vagus. Branches of Distribution of the Vagus. For a detailed descrip- tion of the method of distribution of the numerous branches of the vagus, works on anatomy should be consulted. Eeference will here be made only to a few facts re- garding the branches most im- portant to the clinician. The branches of distribution as usually given are the meningeal, auricu- lar, pharyngeal, superior laryn- geal, inferior laryngeal, cardiac, pulmonary, esophageal, and ab- dominal. The meningeal branch probably contains chiefly sensory and vasomotor fibres. The auric- ular branch is in part a sensory nerve, by its subdivisions sup- plying the posterior part of the auditory meatus and the adjoin- ing part of the external ear. An- other branch runs with the poste- rior auricular branch of the facial. The pharyngeal branch is one of the principal motor nerves of the pharynx. After subdivision into numerous filaments, it communi- cates with other filaments from the glossopharyngeus, the exter- nal branch of the superior laryngeal, and the sympathetic, to form the pharyngeal plexus, from which branches are distributed to the mus- The last four cerebral nerves, the facial nerve, the sympathetic, and the upper two cervical nerves. 1, facial nerve ; 2, glossopharyngeal ; 2', anastomosis between a branch of the facial anfl the glossopharyngeal : 3, vagus : 4, accesbory ; 5, hypoglossal ; 6, first cervical ganglion of the sympathetic ; 7, first and second cervical nerves ; ^, cavernous plexus of the sympathetic on the internal carotid artery ; 9, tympanic nerve from the petrous ganglion of the glossopharyngeal ; 10, its connection with the carotid plexus ; 11, branch to the Eustachian tube ; 12, 13, branches to the oval and round windows of the ear ; 14. 15, branches joining tlie small and superficial petrosal nerves ; 16, otic ganglion ; 17, auricular l)ranch from the jugular ganglion, connected by filaments with the petrous ganglion and the facial nerve; 18. anastomosis of the accessor}- \\-ith the vagus ; 19, anastomosis of the first cer- vical nerve with the hypoglo.ssal ; 20, anasto- mosis of the second cervical nerve with a branch of the accessory ; 21, pharyngeal plexus ; 22, superior laryngeal nerve ; 23, its external branch ; 24, second cervical ganglion of the sympathetic. (After Hirschfeld-Sappey.) 942 NERVOUS DISEASES. cles and mucous membrane of the pharynx. The superior laryngeal is the chief nerve of sensation to the larynx, although it also supplies branches to the cricothyroid and arytenoid muscles. The inferior or recurrent laryngeal ner\'e is the great motor nerve of the larynx. The cardiac, pulmonary, esophageal, and abdominal branches of the vagus contain both sensory and motor fibres. Edinger speaks of the vast number of sensory fibres which are found in all parts of the body, — in the liver, kidneys, lungs, etc., — fibres which are necessary for the reflexes on which life itself depends. The vagus nucleus in tlie fish forms a lobe, probably because the nerve to which it gives origin is distributed also to the external surface of the body like any sensory spinal nerve. Nerve Supply to the Heart. — The nerves to the heart come from the cardiac plexuses, and are derived both from the vagus and from the gangliated system. Among the most important of these nerves is the depressor nerve of Cyon. So-called accelerator nerves, which are said to have their origin in the cervical spinal cord, reach the heart by the last cervical and the first thoracic ganglion of the sympathetic system. The depressor nerve in the rabbit arises by one branch from the superior laryngeal, and usually also by a second root from the trunk of the vagus itself, and passes down the neck to the car- diac plexus. In the horse and in man fibres analogous to those of the depressor re-enter the trunk of the vagus to descend to the heart. This depressor nerve is an afferent (sensory) nerve. The ordinary rhythmical movements of the heart are associated with the activity of nerve ganglia which exist in the substance of the heart, the so-called intracardiac ganglia. The true inhibitory nerve of the heart arises from the inferior cardiac nerve, and is distinct from the depressor nerve of Oyon. Its stimulation slows the action of the heart and augments the force of its beat. Nucleus of the Accessorius. — As stated, the vagus and acces- sorius are usually described as originating in a continuous nucleus, the lower portion of the nucleus ambiguus. Obersteiner says that the roots of the accessorius vagi (the proximal roots of the acces- sorius) have exactly the same origin as the vagus itself, from which they cannot be separated within the brain. The observations of Gralif)wer and Oppenheim ha\e, howe^•er, thrown great doubt upon the origin of the vagus and the accessorius in one nucleus. Oppen- heim thinks that Grabower has estal)lished the fact that the motor innervation of the larynx is entirely from the vagus. The conclu- sions of Grabower in his last ^laper (1896) were based upon the lesions found in a case of tabes, which were degeneration of the left recurrent laryngeal nerve, of the cxtrabulbar portion of the roots of l)()tli tenth ner\t's. of the roots of both ninth nerves, and of the spinal roots of both fifth nerves. The nuclei of the third, fourth, and sixth nerves were also atrophied. The roots of both eleventh ANATOMY OF THE SPINAL ACCESSORY NERVE. 943 nerves and the nuclei and intrabulbar portion of the roots of the tenth and eleventh nerves were perfectly preserved. The symptoms were disturbances in the territory of the trigeminus, oculomotorius, abducens, glossopharyngeus, acusticus, and the laryngeal branches of the vagus, but there were no symptoms referable to the accessorius distribution. The laryngoscope showed a complete paralysis of the left recurrent laryngeal nerve. Grabower has shown tliat an ence- phalic accessorius nucleus does not exist, that from where the nucleus of the accessorius terminates to where the motor nucleus of the vagus (nucleus ambiguus ) begins is a space of more than nine millimetres, and that there is not the slightest connection between the vagus and accessorius nuclei. Peripheral Course of the Spinal Accessory Nerve. — The so- called bulbar portion of the spinal accessory, which from recent investigations, as stated, should be considered a part of the vagus, consists chiefly of very fine nerve fibres, while the spinal portion is composed almost entirely of large fibres. In the postoblongata the former portion has the same origin as the vagus, whereas the distal roots arise from cells which have no connection with the vagal nucleus. The nucleus of the spinal portion of the spinal accessory nerve is constituted of a continuous series of cells which forms a part of the ventrolateral group of cells of the ventral horns of the cord. The fibres arising from this group of cells pass almost directly outward and backward, others for a certain distance longitudinally, and then outward and backward to emerge at the lateral columns of the cord, usually between the fifth cervical nerve and the first. In exceptional cases the lowest nerve filaments which make up the spinal portion of the accessory nerve may pass out from the cord as low down as the seventh cervical nerve. The different filaments composing the nerve are not exactly in the same anteroposterior line, the higher of these filaments arising closer to the dorsal nerve roots, with one or two of which they may be connected. These widely separated roots come together to form a rounded bundle, which, taking a cephalic course, and augmenting in bulk as it passes cepha- lad, traverses the foramen magnum and reaches the cranial cavity. Just after entering the skull it turns outward to pass into the middle compartment of the jugular foramen, where it is combined in the same sheath of dura as the vagus, and also with the so-called bulbar portion of the spinal accessory. These three nerve bundles form a single trunk in this portion of the jugular foramen. It now turns downward, outward, and backward to pass out of the skull again be- tween the occipital artery and the internal jugular vein. The spinal portion of the nerve passes under covering of the sternocleidomastoid muscle, to which it gives deep branches, communicating here with fibres direct from the second cervical nerve. Emerging at the pos- terior border of the sternocleidomastoid muscle, the nerve crosses 944 NERVOUS DISEASES. obliquely the posterior triangle of the neck to the under surface of the trapezius, where it is joined by branches from the third and fourth cervical nerves, forming with them the so-called subtrape- zoidal plexus. Both the trapezius and the sternocleidomastoid muscle, it will be seen, are supplied from the spinal i^ortion of the spinal accessory and to a much less degree directly from the cervical nerves. AFFECTIONS OF COMMON SENSIBILITY DUE TO DISEASE OF THE G-LOSSOPHARYNGEUS. The relations of the glossopharyngeus to disorders of taste having been fully considered, it will only be necessary here briefly to dis- cuss affections of common sensibility and of motility due to disease of this nerve. As has been stated (page 937), it is generally con- ceded that the glossopharyngeus is the nerve of common sensibility for the upper part of the pharynx and perhaps for the tympanic cavity and a part of the soft palate. If this be true, disease in any portion of the pathway for common sensibility of this nerve should cause anesthesia of these regions ; but accurate clinical data are wanting. It is probable that in either the jugular or the petrous ganglion of the glossopharyngeiis are situated the cells of origin of the glossopharyngeal nerves of common sensibility, and if Ober- steiner's view is correct it is also probable that in the general nucleus for the glossopharyngeus a separate cell nest is the end nucleus for the peripheral neurons. Destructive disease of the ganglion of origin or of the end nucleus would, of course, cause anesthesia of the parts to which the nerve is supplied, as would also disease of any portion of the peripheral nerve trunk ; but cases have not been recorded in which restricted anesthesia has indicated lesion of such a limited portion of the glossopharyngeus. Irritation of the ganglia, root fibres, or peripheral distribution of the nerve would cause hyper- esthesia or neuralgia of the upper portion of the pharynx, the tym- panic cavity, and a part of the palatal region. Another symptom would be absence of reflex irritability of the pharyngeal mucous membrane. The only well studied diseases in which pharyngeal anesthesia is a marked symptom are the postinfectious paralyses, and especially postdiphtheritic paralysis ; and e^'en in these affections the anesthesia is not iisually an isolated symptom, and is commonly not restricted to what is supposed to be the glossopharyngeal sensory distribution. PARALYSIS IN THE DISTRIBUTION OF THE GLOSSO- PHARYNGEUS. A\'hile great uncertainty still exists as to the exact distribution of the motor portion of the glossopharyngeus, assuming that it is the motor nerve for the stylopharyngeus muscle and possibly also for the GLOSSOPHARYNGEAL PARALYSIS. 945 middle constrictor of the pliarynx, it follows that lesion of the motor nucleus in the postoblongatn, or of the periphei'al distribution of the nerve, will cause paralysis of these muscles. Interference with deglu- tition will be the most prominent symptom of this paralysis. Usually the other muscles, like the levator palati, azygos uvulte, and glosso- palatinus, are paralyzed with the middle constrictor of the pharynx and the stj-lopharyngeus, so that from any actual records of cases it is impossible to separate the symptoms which are solely attributable to the glossopharyngeal paralysis. As the pharyngeal muscles, be- sides the part played by them in swallowing, also exert an important influence in vocal modulation, and especially as regards the higher tones, changes in the voice will be other symptoms. In all the re- corded cases of disease of the sensorj- and motor portions of the glossopharyngeus (not including the gustatory division) motion and common sensibility have been affected together. This, as is well known, is particularly the case in the diphtheritic paralyses. It is a somewhat striking fact that in the postinfectious diseases taste is usually not affected, which argues in fa^or of separate nuclei for the parts of the nerve lelated to taste and common sensibility. In chronic bulbar paralysis the motor glossopharyngeal nucleus is fre- quently invoh'cd. Lloyd suggests that one reason why so little has been observed of symptoms of glossopharyngeal paralysis is that all symptoms produced by lesions of this nerve are deepseated, and therefore readily overlooked unless searched for with the most careful tests. "A patient, for instance, might readily have an anesthesia of one side of the pharynx and loss of taste on one side of the posterior third of the tongue, without this being very perceptible to himself or very readily detected by his physicians. It is doubtful whether the unilateral lesion would seriously interfere with the act of swal- lowing. This act, beiug largely i-eflex, no doubt depends to some extent upon the integrity of the sensory fibres in the glossopharyngeal nerve, but the irritability might readily be blunted, we may suppose, or even abolished on one side, without the act of swallowing being more than slightly embarrassed. It is impossible to say, owing to lack of observation, to what extent speech, especially the formation of gutturals, might be impaired by complete paralysis of the glos- sopharyngeal nerve. It is probable that this nerve conveys the muscular sense from parts of the pharynx and fauces, and the abo- lition of this we might suppose would cause some incoordination of the movements necessary for speech ; but of this vt have no positive clinical evidence. As the nerve supplies common sensation to and about the epiglottis, its paralysis would tend to cause choking by permitting small particles of food to find their way into the wind- pipe." Nothing need be said about the treatment of affections of the glossopharyngeal nerve. The principles of treatment are the same as those for the other cranial nerves. 60 946 NERVOUS DISEASES. DISEASES OF THE VAG-US. Diseases of the Vagus as a Whole. — It has been shown that the pueumogastric is a great sensory and motor nerve, and that some of its branches (sensory ( ir motor) act as special ner\'es to the great viscera of the thorax and abdomen, — to the heart, lungs, stomach, intestines, liver, and perhaps other organs. The separate sensory and motor affections of this great nerve will be presently considered, but it is necessary here to say a few words about lesions affecting either the nerve or its nucleus in its entirety. It is, of course, e^i- dent that a lesion absolutely destructive of either the nucleus or the trunk of a nerve which is the source of innervation of organs so im- portant to life as the lieait and the lungs ^^■ould cause death, but in not a few instances lesions are of such a character and of such an extent as to involve in greater or less degree the entire nucleus or entire nerve trunk without such fatal result. Such a lesion will cause a syndrome composed of sensory, motor, and visceral symptoms irregularly grouped. The subsequent presentation of the sensory, motor, and special symptoms of lesions of the vagus will be sufficient to indicate what might be expected in the case of a lesion irregu- larly in\'olving the entirety of the nucleus or trunk of the nerve, but reference may be briefly made to a few of these cases. Diseases involving the pueumogastric as a whole are gross focal lesions, chronic degenerative diseases, or neuritis. Many cases of focal lesion involving the vagus have been put on record. Mays collected from literature a very large numljer of these cases, which included aneu- risms, tumors, enlarged glands, wounds accidental and surgical, de- generation, and inflammation. The symptoms recorded in these and in cases collected by others are those both of irritation and of paralysis, in various combinations, — such phenomena as pharyngeal and laryngeal anesthesia and hyperesthesia, neuralgias of the same regions, angina pectoris, faucial paralysis and sj^asm, pharyngeal and laryngeal paralysis and spasm, cardiac neuroses, such as tachycardia, brachycardia, cardiac arhythmia, respiratory neuroses, and nervous disorders of the digestive apparatus. Cheyne-Stokes breathing is probably due to interference with the function of the pneumogastric centres. The epigastric aura of many epileptic fits, and the globus hystericus, are probably also to be referred to disturbance of the vagus. (Gowers.) Numerous instructive instances of the results of lesions interfering with the pneumogastric in its entirety have been recorded, as where the nerve has been tied by surgeons with the left carotid, when respiration and cardiac action are soon arrested. True paralysis of the heart and of respiration sometimes rapidly super- venes as the result of powerful impression made by toxic or in- fectious agents upon pneumogastric centres. In the comparatively numeious recorded cases of progressi\'e degeneration of the vagal DISEASES OF THE VAGUS. 947 nucleus in the course of diseases like tabes, one function of the nerve after another is lost, such symptoms as laryngeal and pharyngeal anesthesia and paralysis usually being prominent long before a fatal issue is reached. Vagal Neuritis.— The vagus is at times attacked by neuritis. The presence of multiple neuritis -nas noted in four out of ninety- eight cases of disease -n'ith degeneration of the pneumogastric nerve tabulated by IMays to show tlie relation between disease of the vagi and consumption and iither pulmonary affections. In the nervous wards of the Philadelphia Hospital, where alcoholic multiple neuiitis is frequently seen, the patients occasionally die with respiratory and cardiac symptoms which point to inflammatory or toxic involvement of the vagi or their centres. Several such cases have fallen under my observation, and Lloyd refers to similar cases. He speaks, for in- stance, of a patient suffering with alcoholic multiple neuritis in all four extremities, with wandering delirium and tachycardia, who tiled suddenly from heart failure. He refers to the fact that in alcoholic multiple neuritis tachycardia is a very common symptom, the heart often beating at the rate of from 100 to 120 or even more. In these cases the heart is rebellious to cardiac stimulants, such as digitalis and strophanthus. Sharkey also has called attention to the fact that the vagus is disturbed in multiple neuritis, and this disturbance gives rise to marked and even fatal cardiac symptoms. AUyn records a case of extensive multiijle neuritis with involvement of the vagus in which the patient recovered. Among the pneumogastric symptoms were pain and oppression over the heart, and collapse, with cool moist skin and extremely weak and irregular pulse. According to Sharkey, a few observations have shown that the terminal distributions of the nerves of the heart are liable to alterations which probably play an important part in some cases of serious cardiac disease. He suggests that the sympathetic as well as the vagus may be involved, and that such involvement may account for the visceral neuralgias and for disturbances of secretion and metabolism. Ferguson has reported the case of a woman aged forty who a short time after an attack of influenza had passed off began to ha^'e paroxysms of pain of the most agonizing character. She died after a period of great suffering which lasted ten weeks, and the postmortem examination of the nerves and the ganglia throughout the abdomen showed them to be highly inflamed. Marked degeneration of the nerve tissue was found on microscopical examination. In a case of influenza recorded by Sansom the patient had shooting pains in the epigastrium. The case, although alarming, ended in recovery. Vagal neuritis was probably present. The phrenic as well as the vagus, and even more frequently than the latter, is affected. Close watch should always be kept on the action of the heart and the character of the breathing in multiple neuritis. (AUyn.) 948 NERVOUS DISEASES. DISEASE OF THE SENSORY PORTION OF THE VAGUS. Varieties of Pneumogastric Sensory Disease. — The sensory branches of the j^neumogastric, wherever situated, may be affected by disease of the same character as affects other sensory nerves. As in the case of the sensory division of the trigeminus, for in- stance, we may have hyperesthesias, anesthesias, and paresthesias, symptomatic or essential neuralgias, and special forms of sensory disturbance. Pneumogastric Neuralgias. — Every portion of the sensory sup- ply of the pneumogastric has been in recorded cases the seat of neu- ralgia, — pain which has not been traceable to an organic cause, or at least not to a gross lesion directly irritating the nerve or its centres. In rare cases such j^ain affects the posterior portion of the auditory meatus and adjacent portions of the ear. Neuralgia of the pharynx and soft palate is an affection of somewhat rare occurrence, and is proljably due to a disturbance of both the sensory portion of the glosso -pharyngeal nerve and the vagus. The various regions sup- plied by the sensory branches of the superior laryngeal nerve may also be the seat of severe neuralgias. The "laryngeal crises" are not, like most of the other so-called ' ' crises' ' of tabes, wholly of a sensory, or at least of a painful, character. The effects of these crises are chiefly spasmodic and respiratory, but seveie laryngeal pain might be a part of their symptomatology. In cases of tabes which have been examined at or near the time of such laryngeal crises the mucous membrane of the larynx immediately before the attacks has been found extremely hyijeresthetic. The patient some- times feels a scalding sensation or experiences the sensation of a foreign body lodged in the larynx. (Eoss.) Severe paroxysmal gastralgia (stomach pain) may be a pure pneumogastric neuralgia, but such forms of neuralgia are extremely rare, except as they occur in the gastric crises of tabes. While pain in the stomach may be directly traceable to irritation of terminal filaments of the pneumo- gastric, it is, as a rule, caused by lesions of the mucous membrane or other nonnervous structures of the stomach. The gastric crises of tabes are among the most distressing phenomena of this dis- ease ; not infrequently they are early manifestations. The torturing pains of the gastric crises of tabes are probably due in large part or altogether to sclerotic degeneration of the dorsal nucleus of the vagus. They ha^•(^ Ix'en occasionally attributed to sympathetic dis- ease. The intercostal and spinal sensory nerves associated with the pneumogastric ma>' take part in the production of the pain. In the case i-eeorded l)y Grabowei' the patient had violent crises both laryngeal and gastric, the latter becoming so excessive that the patient vomited almost all that lie ate and died from exhaustion. In this case it will be remembered (see page 942) that among other DISEASE OP THE SENSORY PORTION OP THE VAGUS. 949 lesions was found degeneration of the left recurrent laryngeal nerve and of the extrabulbar portion of the roots of both tenth nei'ves. Angina Pectoris of Neural Origin.— The large majority of cases of angina pectoris are due to various organic affections of the heart the pericardium, or the aorta, or to sclerosis of the coronary artery', aneurism of the arch of tht' aorta, chronic aortic stenosis or insuf- ficiency, fatty degeneration of the heart mu.scle, or chronic adhesive pericarditis. Even in these cases the disease may in a sense be re- garded as a pneumogastric neurosis, as the pain, usually excruciating in character, is due to irritation of the cardiac sensory fibres. It -nill be remembercxl that the depressor nerve of Cyon is a sensory ner\'e. In rare cases the symptoms of angina pectoris result froni purely neural lesions, such as a neuritis of the vagus, irritati^-e diseases of the vagal centre, or a toxic agent affecting these centres. Leroux has recorded a case in which angina pectoris was present, and in which the autopsy showed the right vagus compressed by enlarged glands. Cases have been recorded in which anginal attacks were associated with small tumors of the vagus. When a tumor in^'olving the cardiac plexus causes angina it is just as correct to assign the lesion to the vagus as to the sympathetic, as the cardiac plexuses are formed by the union of nerve branches from both sources. Besides the pain which is the dominant feature of angina, other symptoms, such as changes in the rapidity and rhythm of the action of the heart, with a sense of distress, suffocation, or dissolution, are referable to dis- turbances of the pneumogastric. Laryngeal Hyperesthesia. — Hyperesthesia of the mucous mem- brane of the larynx, which must, of course, depend upon direct or reflected irritation in the sensory laryngeal branches of the vagus, is most commonly the result of inflammation of the laiyngeal sti'uc- tures. It is freciuently present in carcinomatous, tubercular, and various forms of chronic cataii'hal disease of the larynx. In cases of chronic alcoholism it is of comparatively frequent occurrence, and in these cases probably depends, in some instances at least, upon a neuritis of alcoholic origin, pain as well as hyperesthesia sometimes being present. When the sensibility of the larynx is heightened, various reflex phenomena, such as coughing, or local spasm, or even epilepsy, may occur. Laryngeal Anesthesia. — Laryngeal anesthesia occurs as an in- dependent affection due to a focal lesion in the course of the sensory branches of the superior laryngeal nerve ; it may be due to agents acting upon the nerve centres or nerve termini ; or it may be one of the symptoms of tabes, here being due to degeneration of the laryngeal portion of the vagal nucleus. Partial anesthesia is not infrequently simply a part of the symptomatology of a chronic in- flammation of the larynx. Anesthesia following the infectious dis- eases, as diphtheria, is most frequently dependent upon the action 950 NERVOUS DISEASES. of a toxine upon the nerve centres, tracts, or termini. Anesthesia of the larynx is not infrequently one of the stigmata in hysteria. The extraordinary tolerance with which hysterical women bear examina- tions of the pharynx and larynx is well known both to laryngologists and to neurologists. The presence of laryngeal anesthesia is deter- mined by such examinations, and also by certain symptoms which are the results of the existence of this anesthesia. Eeflex coughing, for instance, does not take place, and catarrhal secretions and foreign matter of any sort are more likely to be retained in the larynx and thus give rise to inflammation, with all its symptoms and sequences. Gastric Anesthesia. — Anesthesia in the territory of the gastric branches of the vagus gives rise to polyphagia, a condition in which an unusual quantity of food must be taken before the feeling of hunger is api^eased, or in which the feeling of repletion is never obtained however much food is taken. Experiments have shown that on section of the vagi animals continue to eat until the esopha- gus is filled with food. (Eoss.) Pneumogastric Paresthesia. — Almost any form of perverted sensation may be present in the sensory domain of the pneumogas- tric. Uncomfortable and strange sensations in the region of the stomach, liver, or spleen, sensations of tingling, of burning, or of irritation of any sort in the larynx or trachea, a constant tendency to swallow, or a feeling as if s\^allowing were continually taking place, the sensation of a foreign body in the larynx, — these and many other paresthesias may be due to local organic lesions, but in some in- stances they are due to functional or organic disorders of the sensory division of the vagus. Treatment of Vagal Neuritis and Sensory Diseases of the Vagus. — If the existence of neuritis of the pneumogastric is recog- nized, great care should be taken not to push too far those remedies, like the salicylic compounds and coal tar products, which are so effi- cient in relieving the symptoms of ordinary neuritis. The proba- bility of paralysis of cardiac action and respii'ation must be taken into account, and remedies like digitalis, strophanthus, ammonium carbonate, and even alcoholic stimulants may need to be used. Car- diac tonics and stimulants do not seem to l)e as ef&cient under these circumstances as they are ordinarily. With this caution, the treat- ment of vagal neuritis will be that of neuritis elsewhere, — the use of mercury, the iodides, the salicylates, strychnine, and narcotics and sedati\(3S sufficient to give the patient reasonable comfort. Anes- thesia, in the distribution of the pneumcigastric is to be treated by electrical applications when the anesthetic parts can be reached iu this way, as in cases of pharyngeal and laryngeal anesthesia, and in other cases by constitutional remedies or measures designed to re- lieve the causative focal lesions. Foi' the electrical treatment of the pharynx and laiyux special electrodes may be required. MOTOR DISORDERS OF THE PALATE AND PHARYNX. 951 DISORDERS OP THE PALATAL AND PHARYNGEAL MUSCLES SUPPLIED BY THE VAGUS. The pneumogastric supplies motor fibres to the voluntary muscles of the soft palate, with perhaps one or two exceptions. Views differ as to the supply to the tensor palati, and possibly some other muscles of the pharynx. According to comparatively i-ecent investigations, the motor fibres of the levator palati are contained in the roots of the vagus. Good authority, however, as already shown, fuAors the view that the tensor palati is supplied l)y the fifth. The facial nerve in all probability does not take any part in the motor innervation of the palate. It is very commonly stated that of the muscles of the palate the levator palati and azygos u^'uliB, at least, are supplied by the facial ner\e, and some clinical lecords apparently support this contention. Cases of peripheral facial paralysis in which the levator palati and azygos uvulte were paralyzed moi-e or less completely have been carefully recorded l>y competent observei-s. An illustration of the combined paralysis of the levator palati and azygos uvulte is given in Fig. 140. Complete peripheral facial paralysis was present in this case, which is reported by Sanders. The patient was also deaf in the ear of the paralyzed side. The symptoms therefore pointed to a peripheral lesion, but probably one which was intra- cranial or at least proximal to the position of the geniculate ganglion. If, as I believe, the nerve-supply of the velum palati and azygos uvulae is from the vagus, the best explanation of a case like that of Sanders is that the branch from the Aagus joins the facial and travels with it to the position of the geniculate ganglion, then passing by way of the great superficial petrosal nerve to its final destination. A gross lesion, therefore, involving the facial trunk auywhei-e from its superficial origin to the geniculate ganglion would also implicate the vagal branches to the velum palati and azygos uvulae, and prob- ably also the auditory nerve, giving just such a combination of symp- toms as is recorded in the case reported by Sanders. When a lesion producing facial paralysis is distal to the geniculate ganglion, it will probably be found that the paralysis of the velum palati and azygos uvuliB does not form a part of the syndrome. Besides the muscles of the soft palate, the vagus also supplies the pharyngeal muscles, except those alreadv considered, which derive their supply from the glossopharyngeus. It is also the chief motor nerve of the larynx. The cricothyroid muscles, which may be regarded as accessory to the thyroarytenoids, are supplied by the superior laryngeal nerve, and the other larvngeal muscles are supplied by the inferior or recur- rent laryngeal. Commonly paralyses of the voluntary muscles of the mouth and throat supplied by both the glossopharyngeus and the vagus occur conjointlv- This is, of course, what would be expected when it is remembered that these nerves have a common nucleus, 952 NERVOUS DISEASES. or at least nuclei in such close contiguity that they have not yet been anatomically separated, that their roots are blended at their super- ficial origin, and that the first portions of their peripheral course are largely the same. Degenerati\'e nuclear disease will, therefore, most likely in\'(^lve both the glossopharyngeal and the vagal nuclei if ^ve regard tliese as distinct ; and focal lesions either of the substance of the postoblongata or of its surface or its membranous or bony enve- lopes will to a greater or less extent invade both nerves. It is for this reason that the symptomatology of pharyngeal paralysis (dys- l)hagia paralytica) is usually that of both vagal and glossopharyngeal disease. This form of paralysis has already been partly described under affections of the motor portion of the glossopharyngeus, where it has been shown that when not due to focal lesions it is most fre- quently a sequence of an infectious disease, like diphtheria, or a part of a degenerative affection, like tabes or bulbar paralysis. In this connection, therefore, it will only be necessary to say that paralytic dysphagia is a pneumogastrie disease so far as the muscles concerned are distinctly supplied by the pneumogastrie, — in other words, so far as they are supplied by the branches of the pharyngeal plexus in general which belong to the pneumogastrie. Paralysis of the faucial muscles may be caused by hypertrophic tonsils. Paresis of the velum palati may be caused by enlarged cervical glands and by hy- pertrophic tonsils, affections which, according to Eethi, are more fre- quent than is commonly supposed. It is important to remember that degeneration of the azygos uvula on one side may be present, causing deviation of the uvula, without nerve lesion. If the faucial paralysis is limited to the pneumogastrie supply (that is, does not implicate the glossopharyngeal muscles), the symptoms will be in part those of a general pharyngeal paralysis. If bilateral, owing to the involvement of the palatal muscles, the voice will become more or less nasal, the patient will have a sense of fulness in the mouth, the uvula will be inert and prolialily will hang down so as to touch the surface of the posterior part of the tongue. Some difBculty of deglutition will be present, but it will not be of the same character as that which is present in general pharyngeal paral- ysis. A few words need to be said about the features assumed by the paralysis when special palatal muscles or groups of muscles are in- volved. When the legator palati is paralyzed alone, the soft palate ou the affected side is pendent and inert, and irritation does not cause the retraction and upward arching of the uvula, which, how- ever, becomes tense laterally through tlie action of the tensor palati, its posterior edge being pulled somewhat downward by the action of the palatophaiyngeus. The effect of combined paralysis of the l('\ator palati and azygos UAiilte is shown in the illustration (Fig. 440) to which reference has been made above. The half of the velum ou the paralyzed side is lower, but is not laterally displaced. With MOTOR DISORDERS OP THE PALATE AND PHARYNX. 953 Distortion of the uvtila in a case of peripheral paralysis of the right side of the face. (After Sanders.) regard to the position of the uvnhi, reports differ. Accordino- to Sanders, as illustrated in Fig. 440. the tip of the uvula is turned towards the paralyzed side ; and this writer reports several other well studied cases in which the u-sula was affected in a similar manner. Other cases, however, have been recorded in which the deviation was towards the nonparalyzed side, and it is difficult to account for these discrepancies. Prob- ably many of the observations have been carelessly made. The explana- tion of the distortion towards the para- lyzed side offered by Sanders is that the palatopharyngeus muscle, being unopposed by the le\-ator palati, exerts a greater effect in drawing the uvula towards the side of the paralysis. When the levator and tensor palati muscles are both paralyzed, the velum is more pendent than when the paralysis aifects the former alone, and the velum is also laterally displaced l)y the action of the tensor of the opposite side. Irritation of the soft palate on the af- fected side causes no retraction. Speech is decidedly nasal, and fluids regurgitate through the nose. Paralysis of the palotopharyngeus causes an altered appearance of tlie isthmus of the fauces. The pos- terior pillars are widely separated and immoliile. Spasmodic affec- tions of the muscles of the palate and pharynx supplied by the vagus are rare. It is possible, however, to have such spasm from a tumor or other irritative lesion affecting the nuclei or the branches of the vagus which go to the muscles under consideration. Pharyngeal spasm is also sometimes an accompaniment of acute or subacute pharyngitis. Clonic spasm or at least twitching movements of the soft palate have been observed in ad-\'anced cases of paralysis agi- tans. (Eoss.) Pharyngeal and palatal spasm is sometimes a func- tional or an hysterical phenomenon. Occasionally it takes the form of a pharyngophobia. The patient has an obsession as regards swallowing, with perhaps some spasmodic phenomena in the pha- ryngeal muscles. Spasm of the pharyngeal muscles supplied by the vagus and glossoj)haryngeus is a part of the symptom picture of hydrophobia and pseudohydrophobia. Courmont has observed a case of veritable tonic spasm of the pharynx absolutely analogous to laryngeal crises, but without laryngeal, esophageal, or gastric phenomena. The symptoms were so intense that alimentation be- came impossible and death appeared imminent. The manifesta- tions ceased abruptly under the influence of suspension, and hence it was inferred that the spasms must have been due to peripheral lesion. 954 NERVOUS DISEASES. LARYNGEAL PARALYSES. Varieties. — The larynx has a somewhat complicated system of muscles and curtilages (Fig. 441), with a comparatively simple neural su^iply, which, as already shown, is by two branches of the vagus, namely, the superior laryn- PiQ. iril. geal and the inferior or recur- rent laryngeal nerve. Laryn- geal paralj'sis results from destructi^'e lesions or func- tional disturbances of these ner\'es, their nuclei, or their corticoljulbar pathway. It may be a superior laryngeal paralysis or an inferior laryn- geal paralysis, and these neu- ral types may have several subdivisions according to the degree of involvement of the nuclei or branches of these nerves. The paralysis may be comptlete, or it may be in- complete, acute or chronic, uni- Muscles of the larynx: ], right ala of the thyroid i t . i 1 1 t , 1 A fl, cartilage, turned fonvard; 2, superior horns; 3, inferior ""C''" OV Ollatcrai. AllOtner horn, marked by the cricothyroid articulation ; 4. the Subdivision of laryngeal pa- other portion of the latter on the side of the cricoid i -. • • j. '■ j a cartilasc; 5, arytenoid cartilage, surmounted by the ^^^J^'^^ ^^ intO respiratory &nd corniculate cartilage ; 6, epiglottis ; 7, the two laminse p>honatory tvpCS. A COm- of the nryepiglottic fold, separated so as to expose the paratlvelv limited number mascles ; 8, the lower part of the vocal membrane ; 9, -^ cricothyroid muscle ; 10, posterior cricoarytenoid mus- of laryngeal mOA'CmCUtS iS rC- cle ; 11, lateral cricoarytenoid ; 12, thyroarytenoid ; 13, nuircd in the actof breathing, thyroepiglottic muscular fibres ; 14, aryepiglottic mus- . . cuiar fibres ; 1.5, arytenoid muscle. (Leidy.) lu Order that air may be in- spired, it is simply necessary that the glottis should open. The posterior cricoarytenoid muscles are ''glottis openers," and cricoarytenoid paralysis is therefore sometimes spoken of as pure laryngeal respiratory paraly.sis. After inspiration the cricoarytenoids relax, allowing the glottis to open and the air to pass out. Expiration is a passive and inspiration an active phenomenon. Eespiration is largely reflex and involuntary ; but phonatiou is a true Aoluntary act and chiefliy connected with ex- piration. In i^houatimi the vocal eurds are apposed near the median line, the muscles taking jiart in this action being the lateral cricoary- tenoid and the intei-arytenoid (arytenoid) muscles, supplied by the inferior or recurrent laryngeal nerve. In this act it is necessary that the vocal cords should be made tense. This tension is regu- lated by the actions of the ]>osterior cricoarytenoid muscle, supplied l)y the superior laiyiigeal, and the thyroarytenoid muscle, supplied LARYNGEAL PAllALYSES. 955 by the recurrent laryngeal. A phonatc.iy paralysi.s is therefore one in which the muscles last enumerated, those which approximate and render tense the A'ocal cords, are paralyzed. A mixed respiratory and phonatory paralysis is one in which both functions are im- paired or lost. According to Bosworth, "it is quite a mistake to think that high tension of the vocal cords involves the necessity of their being stretched to their utmost by the arytenoid cartilage and the receding angle of the thyroid, thus turning their edges into ab- solute parallelism ; more probably the tension of the vocal cords involves their edges being held in a state of firmness and rigidity, whether the chink be a straight line or an oval opening." * Paralysis of the Inferior (Recurrent) Laryngeal Nerve. — Tarieties of Bccurrent Laryngeal Parahjsifs. Paralysis of the inferior or recurrent laryngeal is of more serious moment than that of the superior laryngeal, owing to its largt'i- functions. As the result of an extensive lesion of the recurrent laryngeal ner\-e. all the muscles of the larynx, except the posterior cricothyi'oids, may be paralyzed, the picture being one of nearly complete unilateral or bilateral laryn- geal pai'alysis. According to Exner and others, the muscles to which the inferior laryngeal nerve are distributed receive additional inner- vation from the suj)erior laiyngeal, ^^•hich accounts for some of the unusual phenomena at times observed in laryngeal paralysis. A portion of the inferior laryngeal uerve has been resected without producing complete paralysis of the muscles which are usually re- garded as receiving their entii'e nerve supply from the recurrent laiyngeal neiwe. Unilateral cases are chiefly caused l)y focal lesions, and bilateral cases l>y nuclear degeneration ; although, in rare in- stances, e\-en the complete bilateral type may Im- dm- to focal lesions, as when both sides of the median line of the postoblongata are in- volved, or when symmetrical lesions or extensive^ central lesions attack both recurrent laryngeal trunks. Partial forms of recur- rent laryngeal paralysis are somewhat rarely obser\ed, ixs unilateral or bilateral laryngeal aliductor paralysis, or unilateral or bilateral laryngeal adductor paralysis, and paralysis of particular laryngeal muscles. Paralysis of the thyroarytenoid muscles (paralysis of the internal tensors) is a common affection, liecaiise these muscles are situated immediately beneath the mucous membrane of the surface of the vocal cords, and hence become implicated in inflammatory processes attacking them. Bilateral Recurrent Laryngeal Paralysis. In bilateral recurrent * An elaborate discussion of tlie anatomy and pliysiolosy of the larynx is not called for in a neurological work. It is only necessary to call attention in a general way to the motor mechanism of the larynx, and espec-ially to ity neural relations. For a discussion of the numerous problems connected with respira- tion and phonation, laryngological articles and treatises should be consulted. 956 NERVOUS DISEASES. laryngeal paralysis the voice is lost (complete aphonia). Attempts to talk result in a strained whisper, and at e^ery few words the patient is compelled to recover breath. Other symptoms may ac- company those which have been mentioned, but they are collateral or secondary and are not essentially part of the paralysis. The patient, for instance, may haA'e an irritative cough. This paralysis can be at once recognized on examination with the laryngoscope. The vocal cords are seen to be practically immovable, lying about midway lietween extreme aljduction and extreme adduction, in the so-called "cadaveric position." Unilateral Bean-rent Laryngeal Paralysis. Eecurrent laryngeal paralysis is most frequently unilateral, and most commonly due to pressure upon the nerve trunk. The patient suffers from weakness of the voice rather than from true hoarseness. In time the unaffected cord compensates to a greater or less extent for the one that is para- lyzed, and little change in the voice is noted in ordinary conversa- tion ; but the patient tires sooner in speaking, and the vocal range is lessened. In unilateral recunent paralj'sis one cord is observed in the cadaveric position, while the other is jjlaced normally and seems to respond normally to currents of air. The cord of the normal side sometimes passes across the median line to meet its crippled fellow. The rima glottidis becomes oblique, being deflected from before back- ward to the paralyzed side. In addition to the symi)toms just men- tioned, which are those that strictly belong to this form of laryngeal paralysis, are others, due to the same lesion as that which causes the paralysis of the larynx. As aneurism of the aorta is one of the most frequent of these lesions, the various .symptoms of this affection sooner or later appear. Spasm of the larynx sometimes accompanies the paralysis when the lesion irritates as well as compresses or de- stroys the nerve. A number of cases have been recorded in which death has resulted from laryngeal suffocation brought on by paralysis of the recurrent laiyngeal in cases of thoracic aneurism. An illus- tration of unilateral recurrent laryngeal paralysis, causing complete paralysis of the left vocal cord, is shown in Fig. 442. The case was one in which the paralysis was due to an aneurism of the transverse aorta. The patient had a brassy cough, and suffered from hoarse- ness amounting at times to almost complete extinction of the voice. (Stewart. ) Paralysis of the Posterior Crieoaryienoid 2Iuscles (Laryngeal Abductor Paralysis). As the posterior cricoarytenoid muscles abduct the vocal cords at every expiration, ])aralysis of these muscles, if isolated, gives rise to one of the pure forms of laryngeal respiratory paral- ysis. Patients suffering from the bilateral form of abductor laryn- geal paralysis have attacks of paroxysmal dysjinea, which become serious and more frequent as time progresses. Expiration and pho- nation are not affected, and attention is therefore not called to the LARYXGEAL PARALYSES. 957 Fig. 442. disease by any change in the patient's voice. The laryngoscope shows the vocal cords motionless, close to the median line (Pig 443). Unilateral abductor paralysis is readily detected on Liryngoscopic examination. While the cords are normal during expiration and phoua- tion, during inspiration one cord is normally abducted and the other re- mains motionless. This form of paral- ysis can be mistaken only for one of the more complete types of recurrent laryngeal paralysis in which one of the cords assumes the cadaveric position. The chink of the glottis runs some- what obliquely from before backward, while the arytenoid cartilage on the normal side passes in front of its fel- low. Even when paralysis of the re- cmTent laryngeal nerve is eventually complete, the abductors frequeutly show a tendency to be first affected ; indeed, it has been held that they are always first paralyzed, but this has been shown in several carefully studied cases not to be true. Paralysis of the Lateral Cricoarytenoid Muscles (Lary)tgectl Adductor Paralysis). Bilateral laryngeal adductor paralysis is an extremely Drawing of the larynx showing the position of the left vocal cord, as .seen from above, due to pressure on the left recurrent laryngeal nerve by an aneu- rism of the transverse aorta. (Stewart and Jilajor.) Fig. 4-43. Fig. 444. Fig. 443.— Bilateral abductor paralysis : position of the cords in deep inspiration. (Porcher.) Fig. 444.— Unilateral adductor paralysis : position of the cords in attempted phonation. (Porcher.) rare affection except as a part of complete recurrent laryngeal paral- ysis. Some of the recorded instances of this affection were more probably hysterical. The chief symptom is complete loss of the voice. According to Bosworth, this form of paralysis cannot l:ie distinguished by laryngoscopic examination from complete recurrent laryngeal paralysis. While, theoretically, it would be supposed that the cords would recede from the middle line, they are probably ap- 958 NERVOUS DISEASES. Fig. 445. Paralysis af the arytenoideus muscle. (Porcher.) proximated by the iinparalyzed thyroarytenoids. Unilateral laryn- geal addnctor i);ualysis is extremely rare. The difference between the cadavei'ic position produced by unilateral recurrent laryngeal paralysis and the abduction which results from this form of paralysis is very slight. The only symptom is impairment of voice. The laryngoscoi:)e shows one of the cords extremely abducted. (Pig. 444.) Paralysis of the Arytenoids. — The arytenoid muscle which passes from one arytenoid cartilage to the corresponding opjjosite cartilage is sometimes paralyzed, and especially by chronic inflammatory and catarrhal processes attacking the larynx. The varalysis, when unilateral, can be recog- nized with the laryngoscope. The posterior portion of the glottis is displaced towards the paralyzed side, and the action of the epiglottis is impaired. The paralysis of the thyroepiglottic muscle allowing the epiglottis to be dra\\'n forward, the glottis fails to be safely closed during deglutition, and food or drink passes into the larynx above the vocal cords. Another effect of lesion of the superior laryngeal is the production of anesthesia in the upper part of the larynx. In consequence of this anesthesia the foreign matter may not give rise to retiex coughing until some of it has passed, below the vocal cords, and for this reason pneumonia may result. The aryte- noid cartilages are movable during at- tempts at phonation, if the xsaralysis is confined to the superior laryngeal sup- ply. The glottis has the appearance of a waving line on laryngoscopic exami- nation. Bosworth says of paralysis of the superior laryngeal nerve that he does not know of any lesion which will produce the curious glottis observed when both superior laryngeal nerves are paralyzed,— namely, that in which the chink is divided by the approxima- tion of the tips of the vocal processes. The appearance when the paralysis is unilateral is shown in Fig. 446. Laryngeal Paralysis associated with Hemiplegia.— A few cases of laryngeal paresis or paralysis apparently due to cortical lesion have been placed on record. When, however, the large number of hemiplegics and monoplegics is considered, these cases are com- paratively rare, although it is possible, as has been suggested, that forms of laryngeal paresis are sometimes overlooked, especially if they are unilateral. A few years ago I had a considerable number of hemiplegics in the nervous wards of the Philadelphia Hospital examined laryngoscopically, and only three or four presented decided pathological conditions of the larynx of nervous origin. Simerka has carefully studied the subject of laryngeal paralysis m hemi- plegia, reviewing the literature and summarizing a number of cases. He shows that there are a few well observed cases with autopsy of unilateral laryngeal paralysis from limited lesion of the cortex. These present fixation in extreme abduction of the vocal cord opposite Unilateral paralysis of the superior laryngeal nerve. 960 NERVOUS DISEASES. to the side of the lesion. Fixation of one vocal cord in the median line or in the cadaveric position has also been observed, probably a contraction due to cortical irritation. Simerka examined for Pierre Marie twenty-three hemiplogics who, on account of disturbance of sjieech or for some other leason, would seem to have had some laryn- geal trouble. The time which had elapsed since the attack varied from one to eighteen years. In nineteen of these eases no involve- ment of the vocal cords was observed, and in four there was some disturbance of the right vocal cord Three of these patients had right-sided hemiplegia, the fourth left-sided hemiplegia. Association of Laryngeal Paralyses with Tabes and other Degenerative Diseases.— Some of the most interesting cases of laryngeal paralyses and some about which our knowledge is most complete are those which occur in connection with tabes and other forms of chronic degenerative disease. Almost every variety of laryngeal paresis or paralysis has been observed in connection with tabes. Of thirty-three cases studied by Krause, thirteen showed gross functional disturbances, paresis and paralysis of all varieties coming and going with great irregularity. In some of these cases the motor disorder is an ataxia rather than a paralysis or a paresis. Besides tabes, laryngeal pareses of different types have been observed in cases of multiple sclerosis, and of course in progressive bulbar paralysis. Krause has pointed out the occurrence of unilateral or bilateral median positions of the vocal bands in some of these degen- erative cases, and believes that they are in many instances produced by spastic contraction of the adductors rather than by paralysis of the abductors. This view of Krause is, however, not generally ac- cepted ; even he admits the occurrence of true abductor paralysis either central or peripheral, but believes that in some cases at least the laryngeal condition is due to spasmodic contraction of the adduc- tors. Others have shown that in the laryngeal paralyses associated with tabes and other degenerative diseases paralysis of the abductors is likely to occur first, and after this paralysis of the internal tensors. Association of Laryngeal Disorders with Functional Neu- roses. — Krause found various forms of laryngeal paralysis associ- ated with certain well known functional neuroses, such as chorea, hysteria, hysteroepilepsy, and railway spine. In chorea he observed tremulous action of feebly distended vocal bands and paresis of the abductors in almost all instances. In no case were true choreic movements exhibited by the laryngeal muscles. In cases of hysteria and hysteroepilepsy, hemianesthesia of the mucous membrane of tlie nose, soft palate, pharynx, and trachea, mostly on the left side, was fouml, with hemianesthesia of the larynx, and in one instance there was perverse action of the vocal bands, consisting of approxi- mation on inspiration and widest separation during expiration and phonation. In two cases of railway spine with widespread cuta- LARYNGEAL PARALYSES. 961 neous anesthesia there was anesthesia of the mucons membranes of the upper air passages, except at a few irregular spots Etiology and Pathogenesis.-In the discussion of etiology the laryngeal paralyses can be considered together. These affections may be due to focal lesion at the origin or in the course of the vagus or of its laryngeal branches. Any lesion attacking these structures may cause the affection. Among the most frequent lesions are enlargement of the thyroid body, of the glands of the neck or of the bronchjal glands, mediastinal or other intrathoracic tumors esophageal growths, pleuritic adhesions, and fibroid induration of the apices of the lungs. One of the most freciuent causes is aneurism of the aorta, or of the carotid, innominate, or subclavian artery. Hyper- trophy of the heart or large pericardial effusions may, by'displacing the heart, cause pressure on the recurrent laryngeal nerve. The left recurrent laryngeal nerve is especially exposed to pressure from aneurisms, mediastinal tumors, and enlarged bronchial glands. The nerve of the right side is more likely to be included in fibroid indu- ration of the apices of the lungs or in pleuritic adhesions. Gunshot or other injuries to the nerves, and surgical injuries to the nerves such as are produced by operations on the neck, are other causes. Tumors, meningitis, aneurisms, and hemorrhages at the base of the brain are other causative lesions. In a case reported by Daland, in addition to an unusual lesion of the internal capsule (the cicatrix of an old hemorrhage) a small aneurism of the right vertebral artery was found, which from its position might have pressed upon some of the root bundles of the vagus. In a case referred to by Krause of glio- sarcoma of the striatum and left temporal lobe there was paralysis of the right half of the larynx. This case confirms the existence of a cerebral centre for the laryngeal muscles. Any form of laryngeal paralysis may be due to an infectious or toxic cause. Such paralysis is frequently seen during diphtheria, or during the convalescence from this disease. Like other nerves, the recurrent laryngeals may be attacked with neuritis, the result of exposure to cold or of the influence of agents acting upon the blood. In one case of spinal syphilis Krause found the left vocal band immobile near the middle line, but it became active again in connection with return of function in the left extremities under treatment by inunction. In six cases of plumbic paralysis no laryngeal manifestations were noted, but in one case there was paralysis of the left vocal band, and in another there were conspicuous tremulous movements of the vocal bands with adductor paralysis. Lublinski has reported on six cases of post- typhoid laryngeal paralysis observed by him. In one severe case paralysis came on in the fourth week ; in the others after deferves- cence, as in most cases previously reported. In one case a right sided recurrent paralysis followed pleuropneumonia. Usually the condition comes on in convalescence, with inspiratory dyspnea, but 61 962 NERVOUS DISEASES. witliout alteration of tlie voice. In one case of paralysis of the recurrent nerve the soft palate was also paralyzed. Cases of paral- ysis of the vocal cords following influenza have been reported. Forms of functional paralyses are sometimes due to excessive speak- ing or other abuse of the voice. Pathological Anatomy. — The pathological anatomy of laryngeal paralyses has been almost sufficiently considered in the last paragraph when referring to their most frequent causative lesions. A few in- vestigations have been made of the muscles, nerves, and nerve cen- tres. In an interesting case reported ))y Onodi, of bilateral aneurism of the aorta, in which the right vocal band was immobilized in the cadaveric position, while that of the left, side was practically in the middle line, section showed that the right recurrent nerve was injured in its totality by the aneurism of the left side. Onodi succeeded in preparing the muscles, isolated, with their nerves detached, and sub- mitted them to microscopic examination. He found a degenerescence of all the muscles and nerves on the right side, while on the left the most serious alterations had implicated the posterior cricoarytenoid muscle and its nerves, the intei-nal thyroarytenoid muscle being less implicated, and the lateral and transverse to a still less extent. In 1886 Cohen presented to the American Laryngological Association the larynx and some microscopic sections of nerve tissue from a case of bilateral paralysis of the j)Osterior cricoarytenoid muscles which he had exhibited in 1879. The larynx showed the fixed, spastic posi- tion of the vocal bands in the middle line that they had occupied for nearly ten years during life. The posterior cricoarytenoid muscle of the left side was quite atrophied, that of the right side much less, but the bundle of fibres of the arytenoid going from the base of the left cartilage to the top of the right was equally atrophied, and all the remaining muscles were apparently normal. The right recurrent laryngeal nerve, near the point where it leaves the pneumogastric, showed marked atrophy in one half of its area ; the left nerve ex- hibited no pathological change. A small triangular cavity, from two to four millimetres in extent, was found in the outer section of the lenticula. Diagnosis. — The diagnosis of the existence of a laryngeal paraly- sis, and also of its special type, is finally made with the laryngoscope. The existence of some of the forms of laryngeal paralysis is often un- suspected for a long time. This is particularly true of partial uni- lateral palsies either of the complete recurrent type or of one of the recurrent subtypes. The patient suffers perhaps from occasional shortness of breath and slight difficulty in talking, or is easily tired by conveisation, but is not aware of the real nature of his trouble until an aggravation of his laryngeal sym^jtoms or the awaking of new symptoms leads to a laryngoscojiic examination. The patient may, for example, suffer from deep-seated localized pain and have LARYNGEAL PARALYSES. 963 unilateral dilatation of the pupil, and because of these attention will be more strongly directed to the partially latent or overshadowed laryngeal symptoms. The laryngoscope is used, and a unilateral paresis or paralysis of the vocal bands is discovered. The focal diag- nosis of laryngeal paralysis— the fixing of the site of the lesion causing it — is usually to be made by a consideration of the associated clinical phenomena. Care needs to be taken not to confound a true neural paralysis of the laiyngeal muscles with a paralysis or pseudo- paralysis due to inflammatory or other pathological processes in the larynx. Hooper has called attention to the fact that anatomical rather than neural factors are often present to produce the abnormal positions of the vocal bands frequently attributed to paralysis, and especially to paralysis of individual muscles. These factors are the relative sizes and other peculiarities in the structures of the larynx. Prognosis. — The prognosis of laryngeal paralyses varies with their causes and type. Some forms of focal lesions causing them, as tumors, glandular enlargements, or pleuritic adhesions, may improve under medicinal or surgical treatment, or may be of such a character as not to permit of any improvement. A neuritis may be cured, although the forms of neuritis which attack the vagus and its branches are among the most serious and fatal. With regard to aneurism of the arch of the aorta and the other large bloodvessels of the thorax, it need only be said that the prognosis is that of the aneurism itself ; but occasionally in these cases the pressure is for a time partially relieved by treatment or by the particular course which the disease may take so far as relates to the production of pressure and displacement. Cases associated with tabes and other forms of progressive degenerative diseases are of course of unfavor- able prognosis, although they often make very slow headway, and sometimes, like the other symptoms of these affections, remain at a standstill for a considerable period. The forms of paralysis with most favorable prognosis are the hysterical, and those which are due to infectious and toxic processes : diphtheritic laryngeal paralysis, for instance, has a comparatively favorable prognosis. One impor- tant practical point of prognosis should not be forgotten, namely, that in some of the severe types of laryngeal paralysis the patient's life may be suddenly endangered. In paralysis of the superior laryngeal, for example, as has been shown, food or drink getting into the anesthetic upper chamber of the larynx may be carried downward into the trachea or bronchi before reflex irritation is ex- cited, and pneumonia or bronchopneumonia may be the result. A long time is required for the regeneration and reuniting of the laryn- geal as of other nerves which have been severed in surgical opera- tions or as the result of injuries. The time set by some authorities, based upon recorded cases in which such union has taken place, has been about a year or a little more. In cases of peripheral paralysis 964 NERVOUS DISEASES. after the muscles liave completely atrophied, even although partial restoration of the nerve takes place, the muscles may not regain their bulk and functions. The importance of prompt action in some cases where death is threatened is well illustrated in a case reported by Hartwig of bilateral abductor paralysis. When the patient came under observation he was suffering from labored respiration and well marked inspiratory stridor on exertion. Immediate tracheotomy was urged, but was put off by the patient. On the fourth day after his admission to the hospital the man was seized with a paroxysm of dyspnea, and death seemed imminent, but was averted by trache- otomy. Treatment. — The treatment of laryngeal paralyses must depend upon their cause. In a few instances tumors and glandular enlarge- ments can be removed by the surgeon ; much more frequently they are malignant, or are so extensive, infiltrating, and deep-seated as to make an entirely successful operation impossible. When the palsies are postinfectious or toxic, great benefit will be derived from the administration of strychnine, either by the mouth or hypodermati- cally, and especially by the latter method. As good results seem to be achieved when the injections are made in parts more or less remote from the larynx as when made in its vicinity. Insufflation of salts of strychnine into the larynx has been practised, but the method is one not to be commended. When dependent upon aneurism, indu- ration of the larynx, enlargement of the heart, or other formidable organic lesion, little of direct benefit can be secured by treatment. No treatment is of curative value in the cases associated with neur- axial degeneration. Electrical treatment of laryngeal paralyses has long been practised, and in particular cases has much to commend it. The treatment may be either extralaryngeal or intralaryngeal. When the former method is employed, one or both of the electrodes are applied as closely as possible to the parts of the larynx affected. When the faradic battery is used, the current may be of consider- able strength. The galvanic battery interrupted at intervals may also be used, but it should be remembered that applications of gal- vanism to the neck are not unassociated with danger, owing to the effect upon the pneumogastric. Strong currents and currents abruptly interrupted should not be carelessly used, as syncope may be produced. Intralaryngeal applications should be resorted to only by those who have some expertuess in manipulation, but when used by skilful operators they sometimes result in marked temporary, and in rare cases more or less permanent, improvement. A laryn- geal electrode is introduced into the larynx with the assistance of the laryngoscopic mirror, and a weak current applied. Elec- trical treatment is of special value in hysterical palsies of the vocal cords : a single application will sometimes restore the voice. Vocal gymnastics may also be employed, especially in functional cases. SPASM OP THE LARYNGEAL MUSCLES. 965 When infectious cases are on the road to recovery, a favorable result may be hastened by using electrical treatment in addition to the administration of strychnine. When suffocation is threatened, it may be necessary to resort promptly to tracheotomy, as in the case of Hartwig, to which reference has been made under prognosis. As the threatened fatal result is often due to transient causes, such treat- ment may prove successful and prolong the patient's life for an indefinite period. When paralysis is due to neuritis, the internal treatment ordinarily applicable to neuritis should be resorted to, but with special care, as such remedies as the salicylic compounds, the iodides, and the bromides, which are useful in so many forms of neu- ritis, may have unusually depressing effects in laryngeal cases. The depressing results of these drugs can in a measure be counteracted by conjoining the use of strychnine with the special antineuritic remedies. In syphilitic cases the use of mercury by inunction or hypodermatically should be resorted to ; or iodides by the methods employed in other cases of syphilis. When laryngeal paralysis is a part of the syndrome of bulbar paralysis, and is associated with dysphagia and other serious symptoms, it may be necessary to resort to artificial feeding with tubes through the nose or the mouth in order to prolong the life of the patient. SPASM OF THE LARYNGEAL MUSCLES. Varieties and Clinical History. — Spasm of the larynx is rare as an isolated affection, although comparatively common, both in children and in adults, as a reflex phenomenon in various forms of disease of the respiratory apparatus. It may be acute or chronic. When acute it usually presents itself as a paroxysmal affection in the course of some other disease, such as whooping cough, laryngeal tuberculosis, or syphilitic or other inflammatory disease of the vocal apparatus. Spasm of the larynx is most frequently bilateral, but may in rare instances be imilateral, in these cases being, as a rule, due to the direct irritation of either the superior or the inferior laryngeal nerve. Even when the irritation is unilateral, the effects in some instances may be exhibited on the muscles of both sides. Spasm of the larynx may be of any of the groups of muscles, but adductor spasm is the most frequent form. The adductors, being physiologically the most powerful of the laryngeal muscles, are most likely to be strongly brought into play in such actions as cough- ing, and hence are most liable to spasm as the result of direct or in- direct irritation. Laryngeal spasm may be treated of as it occurs in adults or in the special types as it occurs in children. One of the most common varieties of laryngeal spasm in children is the so-called laryngismus stridulus. Spasm of the glottis as it occurs in adults is in most instances reflex in character. "Laryngeal spasm may be excited by the entrance of food, drink, or other foreign 966 NERVOUS DISEASES. substances into the larynx ; by irritating topical applications, as by means of the sponge or probang ; and by the presence of movable tumors. It also occurs in connection with tuberculosis and syphilitie disease of this organ. In the latter cases it is altogether probable that the spasm is excited by the entrance of solid or liquid food into the cavity, the act of deglutition being seriously interfered with by these affections. In the same way, any affection which interferes with this act may be attended with laryngeal spasm, such as pharyngeal paralysis, ulcerative processes in the pharynx or esophagus, as well as tumefaction in any portion of the fauces. In these cases the laryn- geal spasm becomes a grave symptom according to the extent to which the food is thus diverted into the air tract. Aside from the above cases, the disease probably is largely confined to those instances in which the muscular contraction is a reflex phenomenon excited by some diseased condition either in the larynx or in some other por- tion of the upper air tract." (Bosworth.) Oppenheim has re- corded a case of a peculiar form of spasm of the larynx due to focal lesion. A tumor of the cerebellum compressed the pons and ob- longata. The roots of the vagus and accessorius were hyperemic, flattened, and atrophic. During life there had been trembling of the head and of the upper extremities on voluntary movements only. But there had been a continuous rhythmic tremor of the soft palate, as well as of the outer and inner musculature of the larynx. The larynx was continually drawn up and lowered. The rhythmic contraction of the cricothyroid muscle could be felt externally ; and on laryngoscopic inspection continuous trembling of the inner laryngeal muscles and the movements of the arytenoid cartilages could be seen. These manifestations, which produced disturbances in deglutition, as well as in speech and voice, had been observed in varying intensity for a period of about two months. A case has been recorded by Baginsky of clonic rhythmic spasm of the ab- ductor muscles of the larynx, the rate of the movements being from fifty to fifty-four per minute. The movements were con- stant, almost regular clonic spasm of the vocal bands and arytenoid cartilai;es recurring. The short abduction movements brought the vocal bands to about the cadaveric position, but no farther. They followed rather regularly at the close of the expiratory movement, and were in part associated with it, but they did not extend into the inspiratory movement. Eapid respiration and voluntary in- spiratory stridor arrested the clonic spasm for a few minutes, after which it recurred with greater intensity. Baginsky suggests the term nystagmus of the Aocal bands, the manifestations being anal- ogous to nystagmus of the eyes. The spasm was observed in an hysterical patient sixty years old. The patient had a history of hysterical manifestations extending back for more than forty years. This included recurrent hemorrhages, paralysis and anesthesia of SPASM OP THE LARYNGEAL MUSCLES. 967 the extremities, aphonia, paroxysmal dyspnea, spasmodic cough, frequent emesis, convulsion, photophobia, and double blepharospasm. Purundarena Labat records an unusual case of laryngeal spasm under the name of chorea of the larynx. The patient, a woman twenty years of age, had had an attack of the grippe, after which she had in a great measure lost her voice and was subject to a peculiar dry cough of an especially irritating character, which continued during the day but was entirely absent during the time of sleep. Examination with the laryngoscope revealed most curious, sudden, rapid, and irregular contractions of the inferior vocal cords. These peculiar clonic convulsiform movements led to a diagnosis of laryn- geal chorea. Suspecting that the cause of the laryngeal neurosis might be of reflex origin from disease of the nasal mucous mem- brane, the Schneiderian membrane was touched with a solution of muriate of cocaine, and it was found that during the time of action of this drug the clonic contractions of the larynx ceased as if by en- chantment. On the contrary, when an application of a small quan- tity of the caustic paste of Mackenzie was made to the hypertrophied mucous membrane of the nasal fossae there was so great a reaction produced in the larynx that the patient passed three or four days of misery, respiration being impeded and the dyspnea being greatly increased. After complete removal of the hypertrophied membrane by means of the galvanocautery, the symptoms disappeared and the cure was complete. Etiology and Pathogenesis. — ^Numerous experiments long since demonstrated that if the superior laryngeal nerve be divided and its central end be stimulated, bilateral spasm of the glottis will follow. In these cases when the stimulation is sufiiciently strong the impres- sion is conveyed to the laryngeal centre in the postoblongata and is thence irradiated to the centres of the other side, the resulting spas- modic phenomena implicating the muscles supplied by both the supe- rior and inferior laryngeal nerves. When the recurrent laryngeal is cut and its efferent fibres are stimulated, the spasm is usually con- fined to the muscles supplied by this nerve on one side, unilateral abduction of the vocal cords occurring. Pressure or irritation of the roots of the vagus or the trunk of the vagus before the laryn- geal nerves are given off may lead either to unilateral or bilateral spasm or to paralysis of one side and spasm of the other. Serious or even fatal obstruction of the larynx may in this way ensue. Anything producing marked irritation of sensory nerves ma>' cause this irritation to be reflected to the laryngeal centres and nerves, and it is for this reason that acute laryngeal spasm is so frequently met with in children during dentition or when suffering from affec- tions of the respiratory or the gastrointestinal tract. Its frequent occurrence in whooping cough is well known, and, although com- monly recovered from, is not unattended in special instances with 968 NERVOUS DISEASES. great danger. Among the exciting causes of laryngeal spasm in the adult are the introduction into the larynx of any substance capable of producing irritation, as the accidental admission of food or drink into the glottis, the inhalation of irritating vapors, the passage of a probe into the larynx, or any irritating substance used for topical applications in the treatment of catarrhal or other affections of the throat and larynx. In syphilitic and tuberculous disease of the larynx, and in diphtheria, laryngeal spasm is some- times caused by the interference with deglutition, this permitting the passage of irritating foreign substances into the larynx and trachea. Various bulbar affections and various diseases of the last four cranial nerves, whether bulbar, cerebral, or peripheral, may in like manner indirectly be the cause of laryngeal spasm. The faucial and pharyngeal paralysis present in these cases interferes with the act of swallowing, and allows the passage of foreign substances into the laryngeal tract. Paroxysms of epilepsy and eclampsia are not infrequently induced by attacks of spasm of the larynx, pharynx, and masticatory muscles. This being the case, it is not improbable that in rare instances spasm confined to the laryngeal muscles is of cortical origin. Diagnosis, Prognosis, and Treatment. — The diagnosis of the different forms of laryngeal spasm is to be made by a close study of the etiology and symptomatology of the affection in the lines of the statements already made. Both in children and in adults spasm of the larynx may be sometimes confounded with laryngitis, especially the subglottic form ; indeed, in this affection some spasm may be present. It is necessary, however, to distinguish between a disorder purely neural and such an inflammation. The presence of fever, of croupy cough, and of secretion from the mucous membrane of the larynx will assist in the diagnosis. The discovery of sources of reflex irritation in the nose, throat, pharynx, gums, teeth, or upper air passages will be of assistance. The prognosis of laryngeal spasm is dependent upon the nature, severity, and extent of the lesion causing it. While in many cases serious, it is, on the whole, more favor- able than that of the marked types of laryngeal paralysis, although some cases of laryngeal spasm in children end fatally. The con- dition of the general health of the patient has an important bearing upon prognosis. Treatment should be directed to the cause. When laryngeal spasm is associated with serious focal lesions at the origin or in the course of the laryngeal nerves, when it is one of the phe- nomena of progressive degeneration, or when it is associated with malignant or serious disease of the respiratory channels, little can be done in the way of treatment, although surgical procedures and the administration of absorbent remedies may sometimes accomplish beneficial results. Diseases of the respiratory passages which are amenable to treatment should receive close attention. RESPIRATORY DISTURBANCES DUE TO VAGAL DISEASE. 969 RESPIRATORY DISTURBANCES DUE TO DISEASE OF THE VAGUS. The Nervous Mechanism of Respiration.— The nerve supply to the trachea and bronchi is directly from the pneumogastric (re- current laryngeal) and the gangliated system ; that to the substance of the lungs is from the anterior and posterior pulmonary plexuses, which are formed chiefly by the union of numerous branches from the pneumogastric and from the gangliated system. The neurosal affections of the lungs are therefore due to lesions and disturbances of the vagus or of the " sympathetic." The fibres from the sympa- thetic to the lungs and bronchi are chiefly vasomotor ; and the pul- monary sympathetic neuroses are therefore probably vasomotor affec- tions. The pneumogastric mechanism is by no means the only one whose disarrangement leads to respiratory disorders which can be properly regarded as of nervous origin. Besides the vagal centres in the oblongata, other respiratory nerve centres are probably situ- ated in the cortex of the brain, and certainly in the spinal cord. The spinal accessory, phrenic, and thoracic nerves are important acces- sory nerves of respiration, and their nuclei are therefore in this sense respiratory centres, lesion or disturbance of which may lead to various disorders of breathing. The conducting portion of the respiratory apparatus is also of great importance, and includes an extensive series of fibres, as follows : (1) afferent fibres from the sur- face of the body which generally influence the respiratory cortical centres ; (2) afferent fibres from certain parts of the body which in- fluence the respiratory centre in the oblongata ; (3) affero-acceler- ating fibres which are contained in the trunk of the vagus and go to the respiratory centre ; (4) affero-inhibitory fibres to the respira- tory centre which pass in the superior and inferior laryngeal nerves, and probably, also, in the splanchnic nerves ; (5) efferent fibres which connect the cortical motor centres with the respiratory centres in the oblongata, and probably also directly with the spinal centres ; (6) tracts which connect the respiratory centre in the oblongata with the spinal centres ; (7) connections of the spinal nuclei with the muscles of respiration by the thoracic, phrenic, and spinal accessory nerves, and by the nasal branches of the facial, and some of the fibres of the superior laryngeal nerve. (Eoss.) Space will not permit us to discuss in detail the effects of lesions of different portions of this complicated mechanism. These eflfects are, however, easily under- stood from this physiological summary. Varieties of Respiratory Neuroses.— The respiratory affec- tions due to lesions and disturbances of the vagus may be classified as tachypnea, abnormal frequency of breathing ; Iracliypnca (or span- opnea), abnormal slowness of breathing, or shortness of breath ; and respiratory arhytlimia, in which the breathing is irregular. The term 970 NERVOUS DISEASES. dyspnea, or difficult breathing, is applied without much precision to almost any form of rapid, slow, or irregular breathing ; apnea properly refers to that condition in which the blood is unduly oxy- genized, an excess of oxygen in the blood preventing proper stim- ulation of the respiratory centre in the bulb ; and orthopnea is a con- dition of difficult and labored, often rapid breathing, from which the patient can get relief only by assuming the upright position. As- phyxia is a condition which is caused by arrest of respiratory move- ments owing to deficiency of oxygen in the blood which impairs or destroys the excitability of the respiratory motor centre in the oblongata. Gheyne-StoJces respiration is a peculiar form of breathing with a gradually ascending and descending rhythm and a periodical pause, which is usually explained on the theory that when the ex- cita1)ility of the respiratory centre is greatly diminished the blood must become surcharged with carbonic acid in order to excite it, "the increased inspiratory efforts thus induced diminish the venous state of the blood, and the respiration becomes less powerful, until it is finally arrested for a time until the blood becomes again sur- charged with carbonic acid. ' ' (Ross. ) It will be seen that all these forms of respiratory disturbance might be properly included under the three heads of tachypnea, brachypnea, and respiratory arhythmia. Tachypnea. — Striibing has reported a number of interesting cases both of tachypnea and of brachypnea (spanopnea). In tachy- pnea the respiratory movements are greatly increased in frequency and diminished in depth. In one of two cases the attacks ceased after the restoration of a retroflexed uterus. In another case the patient suffered from extreme nervousness and mental deficiency. In this connection the cases of so-called hysterical asthma or hys- terical breathing must be borne in mind. These, indeed, may per- haps be regarded as due to functional disturbance of the vagus, although they must be separated from cases of tachypnea due di- rectly to lesion of the pneumogastric or to special refiex causes. Cases of this kind in which the patients have a series of rapid and forced respirations have fallen under my observation. Great excite- ment usually attends these attacks of rapid breathing, the patients often fearing a fatal termination. Coates has reported several cases in -s\hich patients with tachypnea of nervous origin were supposed to be suffering from phthisis, but in which careful examination showed no organic lesion of the lungs. A few cases in which dyspnea was caused by a lesion diiectl,\' affecting the vagus have been put on record. Brachypnea. — In two of Striibing' s cases the patient suffered from attaclvs of slow and deep breathing. In one of these cases the paroxysms were so severe as to amount to orthopnea with sub- jective dyspnea. In another case the attack seemed to be due to irritation of the inspiratory inhibitory fibres of the superior laryngeal EESPIRATOEY DISTURBANCES DUE TO VAGAL DISEASE. 971 nerve during the act of swallowing. In a third case it appeared as asthma, and seemed to be excited reflexly by irritation of the tri- geminal fibres in a case of chronic rhinitis with hypertrophy of the turbinated bone. The irritation was probably reflected in this case from the trigeminus to the pneumogastric centres. Nervous Asthma.— Some forms of so-called nerv^ous asthma may certainly be regarded as neuroses of the vagus. In consequence of disturbed innervation of this nerve, tonic spasm is supposed to take place in the circular muscles of the bionchi, and esijecially in those of finer calibre. In this way an emphysema is produced. This bronchial spasm forms an impediment much more easily overcome by inspiration than by expiration, and hence the disturbances of breathing are more marked during expiration. (Hirt.) Mays, who regards asthma, in one of its most usual forms at least, as certainly a spasmodic neurosis of the pneumogastric, recommends the use of hypodermatic injections of strychnine and atropine in its treatment. He begins with one fiftieth of a grain of strychnine and the one hun- dred and fiftieth of a grain of atropine daily, gradually increasing the former to one twenty-fifth or one twentieth of a grain and the latter to the one hundredth of a grain. After a thorough impression is made on the disease the drugs are administered every other day, and as the patient improves are gradually abandoned. Measures to control the cause of the attacks and to build up the general system should also be adopted. Another treatment of spasmodic asthma which has much in its favor is galvanization of the pneumogastric. For the treatment of the attacks Hirt recommends pyridin, which ^yas first suggested by See. Inhalations of amyl nitrite and the ad- ministration of one of the preparations of lobelia are also efficient at times in giving relief. Lesions of the Pneumogastric and Pulmonary Consump- tion.— According to Mays, disease of the vagus is the cause of pul- monary consumption. Whether his views are accepted or not (and I am not inclined to accept them), the facts which he has collected are of great interest. He has tabulated a very large number of cases with pulmonary disease, in which the vagus of one side or both vagi were affected by disease or injury. His tables show that lesion of the vagus was undoubtedly associated with disease of the lungs in nearly all the cases. With the addition of cases investigated by a few other observers, he presents definite records of one hundred and four cases of phthisis, fifty-four cases of pneumonia, and fifteen cases of other forms of lung disease, in which the oblongata or vagi were disorgan- ized. In favor of his view he argues that both alcohol and syphilis, on account of their destructive affinity for the nervous system in gen- eral and for the pneumogastric nerves in particular, have the power of inducing this disease. "The testimony which has been collected, ' ' he says, "thus far lends no encouragement to the belief, then, that 972 NERVOUS DISEASES. pulmonary consumption is a disease which is created by a specific virus, but rather that it is a condition which evolves slowly out of preexisting pulmonary disorders. For it is manifest that in every one of the tabulated histories of cases given in the previous pages the nature of the lung disease depended on the acuteness or the chronicity of the vagus lesion. Division, injurj', or acute disease of the vagi always results in oedema, hypersemia, haemorrhage, or bronchitis, but never in phthisis, — the last disease only being produced when the vagi were subject to a slow process of devitalization, such as would take place from long continued pressure or protracted disease. From these data one can legitimately infer that all the morbid phenomena occurring in the lungs are but different steps in the same process which may primarily begin in a simple oedema or catarrh and termi- nate in pulmonary phthisis." CARDIAC DISTURBANCES DUE TO DISEASE OF THE VAGUS. Physiology of the Cardiac Nerves. — If the depressor nerve of the heart is divided, and the proximal end stimulated with a faradic current, a gradual but marked fall of pressure in the carotid artery occurs, and if the end connected with the heart is electrically stimu- lated the beat of the heart is retarded, and its action may even be stopped in diastole. After division of both pneumogastric nerves the beat of the heart may be quickened by stimulating the cervical spinal cord, thus acting upon the so-called accelerator nerves. Dis- orders of cardiac movement may depend upon disease or disturbance of either the depressor or the accelerator nerve, or of inhibitory nerves distinct from the depressor although like it derived from the vagus. Stimulation of the depressor nerve causes pain, proving that this is a sensory nerve to the heart. Tachycardia. — Tachycardia is a persistent, rapid beating of the heart. It may be a part of the syndrome, or, in rare instances, the only symptom of vagus lesion or disturbance. Attacks of tachycardia may last for a period varying from a few seconds or minutes to sev- eral hours. Frequently the paroxysms are initiated by flushing or throbbing. The pulse may reach as high as two hundred beats, al- though commonly it does not rise to more than one hundred and fifty. The patient suffers from intense anxiety, and may experience nausea and be excessively prostrated. Although the pulse is very rapid, the heart beat may be weak. In four cases reported by Kelly the essen- tial feature of each case was the tendency to paroxysmally recurring attacks of extraordinary rapidity of the heart's action without suffi- cient cause. Kelly, after summarizing and comparing the views of a considerable number of obser\'ers, concludes that the majority of cases of essential paroxysmal tachycardia are due to a transitory paresis of the vagus, and that the seat of the disturbance is in the oblongata. CARDIAC DISTUEBANCES DUE TO VAGAL DISEASE. 973 In the series of cases of pneumogastric disease tabulated by Mays are four of tachycardia. Kelly attempts to explain essential parox- ysmal tachycardia by the neuron theory* suggested by Dercum and others iu explanation of the phenomena of hysteria, hypnotism, and allied conditions. Sudden and excessive demand upon the functional capacity of the nerve cells of the vagus nucleus, or the slow action of fatigue or defective nutrition, may, according to this view, cause excessive neuronal motility, and, this leading to unusual retraction of the cell processes and the consequent breaking of the nerve cir- cuit, the heart is no longer properly controlled. The diagnosis of essential paroxj^smal tachycardia must be made by excluding all cases of permanent tachycardia due to known lesions, and also those cases which arise reflexly. The best permanent effect may be anticipated from the avoidance of excessive exertion and from paying particular regard to the general nutrition and welfare of the body. As tachy- cardia is one of the most important symptoms of exophthalmic goitre, attention is naturally turned to the vagus in attempting to arrive at a satisfactory explanation of this disease. Hirt includes exoph- thalmic goitre under diseases of the vagus, although a careful read- ing of his article shows that he seems to be uncertain whether it should be so regarded. Sattler proposed to assume in exophthalmic goitre a circumscribed lesion in the region of the vagus centre, by which the inhibitory action on the heart is diminished or suspended ; but, as remarked by Hirt, he does not consider that the absence of other vagus symptoms can be held to disprove this, as this inhibitory action actually can be suspended and the other functions of the nerve remain intact. The symptoms of Graves's disease have been produced by cutting the restiform body. According to Putnam, even the re- sults of thyreoidectomy (and, it might be added, of the internal thy- reoid treatment) do not necessarily prove that the goitre is the cause of the other symptoms. "The thing which is needed for a cure in * As this book approaches completion new views regarding nerve cells are announced. These views, which are the outcome of Apathy's studies on the nervous systems of the leech, earthworm, rabbit, etc., were presented by Thomas H. Montgomery, Jr., Ph.D., at the meeting of the Philadelphia Neu- rological Society, October 25, 1897, and will be published in the Journal of Nervous and Mental Disease. According to Apathy, the nerve cell is the pro- ducer of neurofibrils, while the ganglion cell produces the force which is to be conducted. Some of the neurogliar cells, of the leech at least, produce neuro- fibrils, some neurogliar fibrils, and some both kinds of fibrils. A neurofibril, which arises in a nerve cell, passes out of one of its processes, and may then tra- verse several gangUon cells, and finally end in or around a muscle or sense cell. The neurofibrils take part in the network of the cells, and none terminate or arise within the ganglion cells. The cell process of a ganglion cell contains both cellulipetal and cellulifugal neurofibrils. Apdthy speaks also of direct anasto- mosis of nerve processes. Should these teachings be accepted, the present con- ception of the "neuron" will require to be abandoned or greatly modified. 974 NERVOUS DISEASES. every case, and in every stage of the disease, is an adequate physio- logical rest for the disturbed nerve centres, and any influence may secure this which removes a good number of peripheral stimuli, or any influence which increases the stability of the central nervous system. That the diseased and engorged thyreoid may be a centre for these abnormal stimuli cannot be doubted." As bearing upon this question of the pneumogastric origin of exophthalmic goitre, the theory recently advanced by Hale White that the recurrent laryn- geal neive has trophic functions for the thyreoid gland is of interest. In two cases of recurrent laryngeal paralysis from aneurism of the aorta marked atrophy of this gland occurred. It is, however, not my intention to discuss exophthalmic goitre at length, but simply in completion of the survey of the affections of the vagus to direct attention to some of the views which seem to support the theory that it is either primarily or secondarily a disease of the vagus. The most reasonable view of the pathology of this disease would seem to be that which regards it as of glandular origin, — in other words, that the nervous as well as other symptoms are the outcome of the perversion of the functions of the thyreoid gland ; but this is by no means settled. Brachycardia. — Brachycardia (or bradycardia) is an affection in which the beat of the heart is slowed. In extreme cases the beat may fall to ten strokes or less. The most important accompanying symptoms are those which result from the abnormal manner in which the blood is distributed. Brachycardia is frequently paroxysmal, although a persistent slow pulse is not unusual. General weakness, impairment or loss of consciousness, syncope, and even convulsions, are sometimes associated symptoms. Senile epilepsy is said to be a not infrequent result of paroxysms of brachycardia in the aged suf- fering from arterial sclerosis. Brachycardia, like tachycardia, may be of an essential paroxysmal type, or it may be symptomatic. The symptomatic form has been noted in numerous diseases of the ner- vous system, such as encephalic tumor, meningitis, or hemorrhage, and disseminated sclerosis. Organic disease of the heart or blood- vessels is another comparatively common cause, and it may be due to toxic or infectious agents acting upon the pneumogastric nerve or its centres. Exhaustion and toxemia play the most important r61e in its causation, in all probability acting through the vagus, although the exact mechanism of its production cannot be given. An attack of brachycardia has terminated in death and the most painstaking autopsy has failed to detect a lesion. The diagnosis of the existence of brachycardia is, of course, not difficult. It is made simply by a careful examination of the pulse. So far as the paroxysms are con- cerned, the prognosis of brachycardia is probably somewhat more serious than that of the more distressing tachycardia. Atropine in decided doses should be employed if good reason exists for referring CARDIAC DISTURBANCES DUE TO VAGAL DISEASE. 975 the brachycardia to irritation of the vagus ; otherwise the treatment should be symptomatic. Cardiac Arhythmia.— Certain peculiarities of cardiac rhythm due to paresis or other disorder of the vagus are classed under the head of cardiac arhythmia. The arhythmia is determined both by studying the heart directly and by examination of the pulse. Among the varieties of cardiac arhythmia indicated by the pulse are those characterized by the deficient, the intermittent, and the alternating pulse. A beat may be wanting either because the heart fails to con- tract fully or because the beat is not transmitted from the heart to the point where the pulse is taken. The alternating pulse is one in which its volume varies from beat to beat, although no distinct loss of beat occurs. Sometimes the heart beats are separated by intervals of unusual length. Finally, the heart, because of faulty innervation, may exhibit so great an irregularity in frequency, and so much violence in its action, that the disordered movement may deserve the name of delirium cordis. Many forms of cardiac arhythmia are, of course, dependent upon organic disease of the heart or of other organs. Among affections which cause symptomatic cardiac arhythmia are atheroma of the coronary arteries, valvular diseases, fibroid myocarditis, and all other diseases which directly or indirectly produce malnutrition of the heart ; while among the causes which act more directly upon the pneumogastric are toxic and infectious agents. The pneumogastric is also directly or reflexly affected by disorders of digestion, by sudden blows, and by violent emotion. A focal lesion, such as a tumor, hemorrhage, or area of softening, may affect the vagal centres or the trunk of the nerve and thus cause arhythmia. A pulse which loses a beat at irregular intervals is frequently ob- served in neurotic patients who have gouty or lithemic tendencies. Irritable Heart.— Under the name of " irritable heart" Da Costa has described an affection in which the main symptoms are increased frequency of heart action and suddenly recurring attacks of palpita- tion and pain referred to the lower portion of the precordial region. The action of the heart is not only rapid, but at times is arhythmic ; the first sound is short and sometimes sharp, resembling the second sound, and at other times it is deficient and hardly recognizable. In a sense every form of cardiac arhythmia might be described as irri- table heart, but the "irritable heart" here referred to has peculiar features. Primarily, it is probably a functional disturbance of the vagus, but in the end degeneration of the cardiac muscle may take place. It should be treated in the first place by the careful avoidance of everything which tends to provoke cardiac excitement. Emotional outbreaks and abrupt unusual exertion should be especially avoided. Even after the affection has been long established, much good can be done by prolonged physical and mental rest. Irritable heart re- sponds in some cases to cardiac depressants, and in others to cardiac 976 NERVOUS DISEASES. tonics. Probably these differences in response depend in part upon indi\'idual idiosyncrasies, and in part upon the degree in which the affection is structural or still simply functional. While any toxic agent may so affect the pneumogastric nerve as to cause an irregular or irritable heart, the effects of tobacco in this direction are so posi- tive, and are of so much clinical importance, that it may be best to say a few words about the "tobacco heart." Chronic nicotine poisoning, as it is found in smokers, and only occasionally in tobacco M'orkers, is not always well adapted to throw much light on this sub- ject, for, whereas it is well known that the nicotine when brought into direct contact with the nerves paralyzes them rapidly, it is by no means common to find paralysis of the vagus in the course of nicotine intoxication. As a rule, it is true that the heart's action is increased, yet cases occur in which there is a slowing, so that we are led to think of a stimulation of the vagus such as happens after drinking cold water, when the pulse rate may be reduced to thirty or twenty beats. (Hirt. ) Nervous Palpitations. — Under the name of "nervous palpi- tations" several disorders, usually simple symptomatic affections, are described. The neurasthenic, hysterical, anemic, and debilitated, for example, under slight excitement or exertion, are very likely to suffer from annoying palpitations, — rapid, irregular beatings of the heart, which may be both objective and subjective. They can, in some instances at least, be regarded as functional disorders of the pneumogastric ; or they are due to withdrawal of the normal cerebral control from the vagus centres ; or they may be dependent upon an increased afflux of blood to the vagal centres as a result of functional and transient vasomotor paresis. When distress accompanies the palpitation, camphor or Hoffmann's anodyne may be given in full doses, and in some cases the persistent administration of small doses of tincture of aconite or of tincture of digitalis will be found useful. Any other treatment must be directed to the apparent cause, which is often gastric disturbance or emotional excitement. DISTURBANCES OF THE DIGESTIVE ORGANS DUE TO DISEASE OF THE VAGUS. As the pneumogastric nerve is distributed to a large portion of the gastrointestinal tract, to the liver, and probably to other organs concerned in the digestive processes, lesions and disorders of this nerve probably cause a considerable number of diseases not yet well studied. Paralysis of the esophagus may be due to a destructive lesion of one portion of the pneumogastric which supplies this struc- ture. It is exceedingly rare as an isolated condition, but is somewhat fre(iuently associated with palatal and pharyngeal paralysis. When the esophagus is paralyzed, the food which passes into it remains in its cervical portion or is regurgitated into the mouth. When it DIGESTIVE DISTURBANCES DUE TO VAGAL DISEASE. 977 remains in the esophagus it may by pressure cause dyspnea and other evidences of interference with laryngeal respiration. Usopha- gismus, or spasmodic stricture of the esophagus, may be caused by iniiammatory or any other form of irritative disease of the pharynx or esophagus, or it may be due to a focal irritative lesion affecting the nerve supply of the esophagus. It is exceedingly rare as a result of central lesion. Hysterical spasmodic stricture of the esophagus is a somewhat common disorder. Globus hystericus is referred by some authorities to such spasm. Besides paralytic and spasmodic affec- tions of the esophagus, gastralgia and nervous dyspepsia of various types belong in this category. True gastralgia is a painful affection of the stomach for which no adequate organic cause can be found. It is characterized by sudden and severe paroxysms of pain in the epigastric region, radiating in various directions, usually upward and backward. The pain is intermittent, or at least varies in in- tensity from time to time. Often it can be relieved by firm uni- form pressure. Widespread vasomotor changes may accompany the paroxysms, the face becoming pale or even livid, and the extremities cold. The pulse is often small and feeble. The patient has a feeling of anguish, with great apprehension of impending dissolution, much like that which is experienced in severe attacks of angina pectoris. The attack sometimes terminates with vomiting. The diagnosis is to be made by the absence of evidences of organic disease of the gas- trointestinal tract. Sometimes pain is relieved by the ingestion of food, in which respect the affection differs from other organic dis- eases, such as ulceration and inflammation of the stomach. It is more common in youth than in advanced years, and in females than in men ; and it is often associated with anemia, chlorosis, or hys- teria. Attacks of gastralgia bear some resemblance to the gastric crises of tabes which are among the most distressing tabetic epi- sodes. Such crises were present in the case of Grabower, already referred to, in which the autopsy and microscopical examination showed, among other lesions, degeneration of the vagus nucleus. In the treatment of gastralgia the cause must first be sought and at- tacked. This may reside in the general condition of the patient, who may need to be treated for anemia, hysteria, or neurasthenia. Arsenic in small doses long continued is one of the most serviceable remedies for permanent effect. The diet should be carefully regulated, but this does not mean that the patient should be "dieted," in the sense that the total amount of food taken should be largely restricted. Often benefit is obtained by feeding the patient more than the usual number of times daily, seeing, however, that the food is carefully selected and is of the most digestible character. Blisters to the epigastrium sometimes prove serviceable, both in relieving special attacks and in preventing their early recurrence. For the relief of the paroxysms it is nearly always necessary to resort to hypodermatic 62 978 NEKVOUS DISEASES. injections of morpMne. By some, nervous dyspepsia is regarded as a pneumogastric neurosis, a disease due either to want of sensory in- nervation or to lesion or disturbance of the terminal filaments of the pneumogastric in the stomach. The term nervous dyspepsia as used in recent literature is chiefly due to Leube, and, accepting his views, any of the so-called gastric neuroses may be combined in a case of nervous dyspepsia. These gastric neuroses are disturbances of sen- sation, secretion, and motion. As described by Hirt, nervous dys- pepsia, which is esijecially common in females and neurasthenic men, is characterized "by a loss of appetite, painful sensations in the region of the stomach, frequent vomiting, and still more frequent belching ; besides these, the patients generally suffer from other nervous symptoms,— dull headache, vertigo, palpitation ; they are easily tired, complain of a lump in their throat (globus hystericus), at times have a voracious appetite, and obstinate constipation is sel- dom absent. In rare cases periodical spells of vomiting have been noted (twenty to thirty in the twenty-four hours), accompanied by acute circumscribed swellings of the skin (angioneurotic cedema.)" The treatment should be particularly directed to improving the nu- trition and the nervous tone of the patient. Good food, fresh air, sea bathing, hydrotherapy, and sufficient recreation are important measures. Arsenic is the most important internal remedy. PNEUMOGASTRIC DISORDERS INVOLVING- DIEPERENT VISCERA. Lesions involving to a greater or less degree the entire trunk of the vagus or its centres, and toxic or other influences affecting them, may cause serious disturbances both in cardiac action and in respira- tion. Usually the most important cardiac affection has been tachy- cardia, and the most imj)ortant respiratory disorder tachypnea with emphysema, often with catarrhal symptoms. What appears to be a true spasmodic asthma may be associated ^ith tachycardia. A case of conjoint cardiac and pulmonary affection was found by Tuczek to be due to pressure exerted upon the trunk of the vagus by a rapidly swelling lymph gland. Van E'oorden has observed a number of functional disturbances in hysterical females in the three separate areas supplied by the vagus, namely, (1) for the pharynx and larynx, hyperesthesia or anesthesia, and occasionally aphonia ; (2) for the stomach, hyperesthesia, sometimes manifesting itself by pain and at other times by frequent \'omiting ; (3) for the heart, slowing and irregularity of its beat. He distinguishes four varieties of arhythmia as indicated by the pulse : (1) an intermission of a beat or a half beat in an otherwise normal pulse ; (2) rapid and sudden change in frequency ; (3) great irregularity in the pulsations, and (4) regular arhythmia, as double or triple pulse. In all Van Koorden's cases the stomach was the main cause of complaint. ACCESSOEIUS PARALYSIS. 979 DISEASES OP THE SPINAL ACCESSORY NERVE. Varieties.— The spinal accessory nerve (the anatomy of which was discussed in the previous section) is a purely motor nerve, and hence its diseases can be classed under the two general heads of pa- ralysis and spasm, according as the lesion affecting the nerve is de- structive or irTitative. In rare instances paralysis and spasm in the distribution of the accessorius may be combined in the same case, the destructive effects of the lesion in such a case being, of course, only partial. A spasm may be complete or incomplete ; in other words, it may involve both the sternocleidomastoid and trapezius muscles, or either of these muscles may be affected separately. As the nuclei of those portions of the spinal accessory nerve which are related to the sternocleidomastoid and the trapezius muscles are more or less separated, and as the branches of this nerve distributed to these mus- cles distinctly part company for a considerable space before reaching their ultimate destination, and as the two muscles, while often and perhaps usually acting together, do sometimes have different physio- logical actions, it follows that limited destructive or irritative lesions may cause paralysis or spasm confined to either muscle, although in the majority of cases the affections of these muscles will be combined. Both paralysis and spasm of the accessorius are not infrequently combined with similar diseases affecting closely related cranial and spinal nerves, as the hypoglossal and vagus and the upper cervical nerves. ACCESSORIUS PARALYSIS. Symptomatology of Accessorius Paralysis. — Isolated Paral- ysis of the Sternocleidomastoid Muscle. Limited sternocleidomastoid paralysis may be either unilateral or bilateral. In paralysis limited to the sternocleidomastoid muscle of one side the patient's head is held obliquely, with the chin elevated and turned towards the para- lyzed side. The ability to move the chin towards the nonparalyzed side is impaired; the sternocleidomastoid muscle, acting singly, draws the head towards the shoulder and clavicle of the same side, while the chin and face are carried towards the opposite side, away from the affected muscle. When the disease has lasted some time an actual flattening and loss of substance can sometimes be readily dis- cerned. In the early stages of the affection little change is noted in the sternocleidomastoid muscle of the unaffected side, but when the disease has become chronic, contraction of this muscle occurs and the head is permanently carried in a twisted position, giving one of the paralytic forms of chronic wry neck. When both sternocleidomas- toid muscles act together the face and head are bent forward towards the breast. When, therefore, bilateral paralysis of these muscles is present, if the head is kept quiet it may remain straight, but when 980 NERVOUS DISEASES. efforts are made to rotate it this can be done only with great difficulty, particularly when the chin is elevated. The prominences of the neck caused by these powerful muscles, usually so evident, are absent, so that the anterior lateral portions of the neck have a flattened appear- ance. The patient loses largely the power of making forward and backward nodding movements. Isolated Paralysis of the Trapezius. The trapezius muscle has ap- parently a double nerve sujoply, only its upper portion being from the accessorius, while its lower part is supplied from the cervical cord. This is an important anatomical factor, and probably accounts for some of the peculiarities of trapezius paralysis and atrophy. In amyotrophic lateral sclerosis or chronic progressive muscular atrophy only the lower portion of the trapezius muscle may suffer, or at least the upper part does not degenerate until a very late period. Properly speaking, therefore, the nucleus of the spinal acces- sory, as this nucleus is generally recognized, is not attacked. "With the exception, however, of pointing out the peculiarities of the nerve supply to the trapezius and their results, it will be most practical to speak of trapezius paralysis under the head of accessorius disease. The bulky trapezius muscle has several sets of fibres which join to produce movements in different directions. The upper fibres draw the shoulder upward and backward, the middle directly backward, and the lower backward and downward. As the upper fibres of the trapezius draw upward the outer end of the clavicle and the point of the shoulder, when these are paralyzed the clavicle will fall and project somewhat, making the supraclavicular space deeper and more prominent than natural, and at the same time the acromion process falls downward and forward and the body of the scapula will be pulled downward and forward by the action of the unaffected mus- cles. The same set of fibres acting from below flex the neck to the same side, extend the head, and turn the face to the opposite side, but unilateral paralysis of the muscle will not cause any special de- formity, as the muscle of the other side and the muscles of the same side which are associated with the trapezius in action will tend to keep the head erect and in the middle line. Elevation of the arm above the horizontal line is extremely difficult, even when the paral- ysis is confined to the upper portion of the trapezius. The reason for this is that the deltoid loses to some extent its base of support or point of resistance. Close examination, however, shows some altera- tion in the shape of the neck, and some loss of power, especially on deep inspiration, in this act the head naturally tending backward as the lungs expand. The middle fibres draw the scapula inward towards the spine, producing at the same time a rotation of the scapula on the thorax, the result being an elevation of the point of the shoulder. If, therefore, these are paralyzed, the scapula inclines to fall outward. The lower fibres of the trapezius draw the scapula ACCESSORIUS PARALYSIS. 981 downward and inward, at the same time rotating and raisin- the point of the shoulder. When, therefore, they are paralyzecL tlie result IS that the scapula falls outward (Fig. 447). The rhomboid muscles being unopposed, they draw the lower end of the scapula inward and backward and at the same time somewhat upward In bilateral paralysis of the trapezius muscle the head tends to fall for- ward and both shoulder blades to drop outward. Fig. 447. Posterior view of periplieral paralysis of trapezius. (Eichliorst.) Complete Accessorim Paralysis (Combined Paralysis of the Sternoclei- domastoid and Trapezius Mvscles). Most frequently both the sterno- cleidomastoid and trapezius muscles are paralyzed together. The lesions affecting these nerves are usually such as to destroy the entire nucleus, or to compress or destroy the nerve before the branch to the trapezius parts company with that to the sternocleidomastoid. When both muscles are paralyzed together the symptoms described for each are present, but the symptomatology has some special features. In unilateral paralysis of both sternocleidomastoid and trapezius— unilateral spinal accessory paralysis— the head is rotated towards one side, the face and chin being turned upward towards the other, but at the same time it falls somewhat forward to the affected side, the clavicle and scapula assuming to a greater or less extent the positions already described as present in cases of isolated piaral- ysis of each of the muscles. In the act of elevating the arm the patient throws his trunk towards the opposite side, and with the as- sistance of the action of the levator anguli scapulae and of the rhom- boid muscles he can succeed in elevating the shoulder and moving the scapula towards the vertebral column. When the coml^ined paralysis is bilateral the head is so largely devoid of support that it 982 NERVOUS DISEASES. cannot be held erect. The paralysis of the sternocleidomastoid mus- cles allows it to fall backward and that of the trapezius muscles to fall forward. When the patient is sitting or standing, the head may tumble about in various directions. The patient is often observed placing his hand under his chin and pressing his head backward a little beyond the middle line. By carefully holding himself erect and maintaining this posture he can hold the head in this position, but a slight movement will cause it to fall forward on the chest. As soon as the head has passed to a certain point in its forward movement it drops suddenly to the breast with the movement which Lloyd has compared to the snapping shut of the blade of a penknife. Bilateral paralysis of these two great muscles from a focal lesion is extremely rare. It is comjiaratively common in cases of chronic muscular atrophy or amyotrophic lateral sclerosis. Etiology and Pathogenesis.— One of the causes of peripheral spinal accessory paralysis is injury. This may be accidental or in- tentional, and of any character, as a blow, a fall, or a gunshot wound. According to Seeligmiiller, watcrcarriers are particularly liable to suffer from accessorius paralysis, for the double reason that they are exposed to frequent wettings and that they carry their buckets sus- pended from their shoulders, and in this way the nerve trunk, the nerve endings in the muscles, or the muscles themselves are injured. (Hirt.) Accessorius paralysis is said to arise occasionally from injury of the nerve or its nucleus during difficult labor. Syphilis, rheumatism, diabetes, and infectious diseases are all causes of spinal accessory paralysis and spasm. The nuclei of the spinal accessory nerve may be attacked by inflammatory, gliomatous, or degenerative processes ; the nerve roots at their origin may be implicated in a meningitis, in a cervical tumor, an exostosis, or vertebral caries, or in an aneurism or other lesion about the level of the foramen magnum. An injury, a growth, or an inflammation may involve the nerve any- where in its peripheral distribution. The nerve endings in the nuclei may be affected by some toxic or infectious process. A lesion in- volving the nucleus of the nerve would produce paralysis and event- ually atrophy, and if irritative would cause spasmodic phenomena. Degenerative and retrogressive lesions (gliosis) usually cause only paralysis and atrophy. Occasionally such nuclear lesion picks out the sternocleidomastoid or the trapezeus distribution alone. Lesions involving the nerve filaments or ner\'e trunk in its intravertebral course are usually associated with other symptoms of cervical dis- ease, symptoms indicating involvement of the nerves of the cervical plexus, for instance, or the phrenic nerve. Wo have no data regard- ing accessorius paralysis due to cortical or subcortical lesion. Diagnosis, Prognosis, and Treatment. — The diagnosis of ac- cessorius paralysis, whether isolated to the sternocleidomastoid or the trapezius or affecting the entire distribution of the nerve, is made SPASMODIC TORTICOLLIS. 983 by a critical study of the symptoms which indicate impairment or loss of physiological action of the muscles concerned. The positions of the head, of the clavicle, and of the scapula will be of particular assistance in making this diagnosis. Paralysis in the domain of the accessorius can usually be readily differentiated from spasm in the distribution of the same nerve. The only difficulty likely to arise would be in overlooking to a certain degree paralysis when both spasm and paralysis are associated in the same case. The prog- nosis will depend upon the character of the lesion. If the affection is due to nuclear degeneration it is, of course, unfavorable ; but if dependent upon a peripheral lesion, neural or muscular, persistent treatment may prove successful. The treatment must be directed by a study of the cause of the paralysis. Nuclear cases can some- times be stayed in their progress by the use of strychnine and by tonic and hygienic measures. SyiDhilitic and other focal lesions may be benefited by absorbent remedies. In perij)heral lesions the use of counterirritants, of electricity, and of strychnine either internally or by hypodermatic injection, is most efficient. SPASM IN THE MUSCLES SUPPLIED BY THE SPINAL AC- CESSORY NERVE (SPASMODIC TORTICOLLIS). Varieties of Spasmodic Torticollis. — Torticollis, or wry neck, may be due to a variety of causes. The most common form is the so-called rheumatic wry neck, in which the patient suffers from an inflammation, usually acute or subacute, involving the nerves, mus- cles, and perhaps other tissues of the neck. The spinal accessory nerve or the muscles supplied by it may, like other stiuctures, be involved in an affection of this kind, but the rheumatic disorder is more properly considered in other connections. The forms of spasmodic torticollis which properly belong to the discussion of dis- eases of the spinal accessory nerve are those which are due to lesions or disturbances of this nerve, its centres, or its encephalic tracts. Several varieties of motor disorder properly classed as spinal acces- sory spasm can be recognized. The disease may be actde or chronic, clonic or tonic. The clonic form may be either unilateral or bilateral. Theoretically the tonic form may also affect the muscles of either one or both sides, but as a matter of clinical experience it is almost invariably unilateral and generally limited to the sternocleidomas- toid. Partial or complete forms of spinal accessory spasm occur. In the former either the sternocleidomastoid alone, or the trape- zius alone, or only a single portion (usually the upper portion) of the trapezius, may be affected, giving rise to stermcleidomastoid spasm or trapezius spasm. The clonic and tonic forms of the spasm are combined in the same case in one of the best known varieties of the disease. Symptomatology.— In the unilateral tonic variety of accessorius 984 NERVOUS DISEASES. spasm the head is rotated so as to draw the occiput towards the shoulder of the side affected by the spasm, the chin being turned up- ward and towards the opposite side. Long continuance of this tonic spasm leads to a marked cervical spinal curvature. When the tra- pezius alone is affected by tonic spasm the head will be drawn back- ward and the point of the shoulder will be elevated. Attempts to bend the head forcibly forward will cause pain in the affected muscle. The symptomatology of the unilateral form of clonic spasm of the muscles supplied by the spinal accessory nerve will vary somewhat according to the severity of the spasm. In the severe type the face may be involuntarily twisted to the left and the chin thrown upward towards the side opi^osite to the spasm, while the occiput is drawn downward and towards the side of the spasm ; sometimes the shoulder and arm take part in the spasm. Sometimes these violent spasms are rhythmical and repeated with greater or less rapidity. After the head is forcibly rotated to one side and backward as de- scribed, the muscles relax, it returns to the usual straightforward position, and a second spasm occurs, and so on throughout a long series. Early in the history of the case the intervals between the sj)asms may be comparatively long, but if the disease continues and increases in severity they become shorter and shorter. In one of my cases the spasms amounted to fifty and upward in a minute. In some cases the patients can arrest the spasm by a voluntary effort, but often this is impossible. The patients, however, in all except the most violent cases, after the disease has continued for some time seem to acquire a certain degree of toler- ance. The spasms are usually less when the patient is sitting down, and sometimes can be controlled entirely when in the recumbent position ; as sleep approaches they become less severe, and they usu- ally disappear entirely during ijm, ''i^W . I sleep. In Fig. 448 is shown a It X\ \ . ^ ksi^ ^ good example of true torticollis, f-^ ^1_ ■ -'"^ ■"'**'^l recorded by Walton. The spasm spasuiudic torticollis, showing proiSl^nTO of *^^ ^'^^^ Sternocleidomastoid is the sternomastoid muscle. (Walton.) plainly visible. A Congenital form of spasmodic torticollis is always a tonic spasm. The condition is usually noticed soon after biitli. Sometimes the affection is due to rupture of either or both of the nuiscles supplied by the spinal accessory, and in these cases Fig. 448. ^ A| / SPASMODIC TORTICOLLIS. 985 Fig. 449. It may be possible to observe by palpation the site of the rapture. If the condition is not remedied, permanent deformity is left, owing to the shortening of the muscles. An illustration of this variety of spasmodic torticollis is seen in Pig. 449. Spasm in the muscles supplied by the spinal accessory nerve may be associated with various other forms of motor spasm, especially those which affect the cranial motor nerves. Thus it is seen in combination with facial (seventh nerve) spasm, with masticatory spasm, with spasm of the tongue, and with spasm in the muscles supplied by the upper cervical nerves. Bilateral spasm of the accessory nerve is usually confined to the sternocleidomastoids. In this affection the head is jerked forward and downward, the chin being turned towards the sternum. If it is of the tonic variety, the head will be held in this position. If it is of the clonic variety, the head will be pulled downward by the spasm in the muscles, and thus relaxing will be carried to the erect position again by the normally acting muscles, when the spasmodic movement will be again repeated, and so on with a more or less frequent and continued series. Unless the lesion causing the spasm is destructive or degenera- tive, the electrical changes will not be present in the muscles affected, except, perhaps, in rare cases some hyperexcitability to the galvanic current. One of the varieties of head banging or head nodding {eclampsia nutans, salaam convulsion') is sometimes spoken of as bilateral clonic wry neck. It is met with almost exclusively in young chil- dren. It is a paroxysmal affection, the attacks of spasm lasting from a few seconds to a few minutes. It may recur, however, a number of times in the same day. Often during the attacks the child seems more or less bewildered, but consciousness is not lost. Etiology and Pathogenesis. — When speaking of the etiology of accessorius paralysis, reference was made to focal lesions, which, according as they were destructive or irritative, might cause either paralysis or spasm. Accessorius spasm may be due to focal irri- tative lesions in a number of locations, as (1) in the spinal cord anywhere above the fifth or sixth cervical segment ; (2) an intra- spinal but extramedullary lesion, of membranes, bone, or nerves, in the upper portion of the vertebral canal ; (3) in the postoblongata ; The usual attitude in the so-called eon- genital eases of spasmodic torticollis. (Bradford and Brackett.) 986 NERVOUS DISEASES. (4) in tlie main trunk of the accessory nerve as it passes downward to the sternocleidomastoid and trapezius muscles ; (5) in any of the nerves which anastomose with the spinal accessory and are closely connected with it in the spinal cord ; (6) in the cortical centres which preside over lateral deviation of the head. In one of my cases it seemed to me that the spasm was reflex, due to injury and subse- quent inflammation of either the major occipital or the minor oc- cipital nerve. The spasm had come on in this case after an injury to the back of the head. Both the occipitalis major and the occipi- talis minor have close connections with the spinal accessory nerve, and are also topographically in close relation, the former with the trapezius and the latter with the sternocleidomastoid muscle. Both the sternocleidomastoid and trapezius muscles have their main nerve supply from the second and third cervical segments. The occipitalis major nerve is the internal branch of the poste- rior di\dsion of the second cervical nerve ; and the occipitalis minor also arises from the second cervical nerve. The occipitalis major nerve pierces both the complexus and trapezius muscles near their cranial attachments. The occipitalis minor in its course curves around the posterior border of the sternomastoid and then ascends along this muscle for some distance. Both of these nerves are, therefore, closely connected both inside and outside of the spinal canal with the nerve supply to the sternocleidomastoid and tra- pezius, and, in addition to having some direct anatomical relations with the muscles themselves, possibly supply them with some fila- ments. The motor nerve supply from the occipital nerves is also such as to show how their irritation might give rise directly or by anastomosis to varying spasmodic phenomena. The posterior divi- sion of the second cervical nerve, from which the major occipital originates, supplies the inferior oblique muscle ; and the external branch of the major occipital joined by the external branch of the posterior division of the third cervical nerve supplies the com- plexus, splenius, and trachelomastoid muscles. Ffere has reported a case of spasm of the neck associated with optical illusions which he believed was due to a cortical irritation, both motor and sensory. Another case has been recorded in which the spasm was associated with auditory disturbances. Diagnosis. — In the diagnosis of accessorius spasm it is some- times important to distinguish it from spasm of adjacent or related muscles. It might be a c|uestion, for instance, whether the spasm was of the sternocleidomastdid of one side or of the splenius capitis of the other. In a case which came to my service at the Phila- delphia Polyclinic, the chin did not turn upward and to the left, as is the case in spasm of the sternocleidomastoid, but rather outward. In spasm of the splenius capitis the chin is directed rather towards the corresponding side. The diagnostic symptoms of spasm of the SPASMODIC TOETICOLLIS. 987 splenius capitis as given by Erb are as follows : " In this affection the head is drawn backward towards the affected side, the chin is some- what depressed and directed towards the corresponding shoulder, and at the spot where the splenius appears beneath the anterior border of the trapezius a hard roll can be felt. (The diagnosis of this form of spasm of the trapezius is founded on the fact that in this last the head is rotated towards the opposite side. In spasm of the sternocleidomastoid the chin is raised and rotated towards the opposite side, while the mastoid process is drawn forward and downward.) This spasm is for the most part of a tonic character (with remissions and occasional spasmodic contractions, or appears in the form of a permanent contracture." Some forms of spasmodic horizontal rotation of the head need to be differentiated from acces- sorius spasm. In spasm of the obliquus capitis inferior, for instance, the head is rotated either intermittently or persistently around its vertical axis without any elevation of the chin or depression of the mastoid process. The patient suffering from this form of spasm is sometimes obliged to hold the head in its natural position in order to look at a fixed object or to speak ; or he may be obse^^'ed to correct the peculiar position of the head with the hand when walking. (Erb. ) "When the head is thus rotated intermittently the affection is spoken of as tic rotatoire. It may be an hysterical or a hysteroneurasthenic phenomenon. One of my patients when overexcited or depressed was liable to violent attacks of this form of rotatory spasm. Her head would be rotated horizontally with great rapidity and force, the spasm sometimes being simply this form of motion, and at other times accompanied by a rapid spasmodic crossing of the arms, and occa- sionally by movements of the legs and body. I have known this distressing rotatory spasm to be kept up for three hours. During the attack the patient remained clear-headed, and, considering the vio- lence of the movement, comparatively placid. The spasm could be stopped or abated by forcibly holding the head ; at other times this procedure would lead to greater violence of action in the trunk and limbs. The patient would sometimes converse during the continu- ance of the spasm, the rotation diminishing a little while she was talking. Strong mental impressions were very effective both in in- ducing and in stopping the spasm. When it had once occurred it had a tendency to recur about the same time the following day ; and this could often be prevented by giving a nerve tonic or other medicine, with a positive assertion that it would prevent the attack. Prognosis.— The measures usually most serviceable in the treat- ment of spasm in the distribution of the spinal accessory will be given, but it is necessary to say that it is one of the most intractable of all spasmodic diseases. Absolute cure is brought about in very few cases, except those which are of hysterical origin or are mani- festly due to a rheumatic neuritis. 988 NERVOUS DISEASES. Treatment. — If spasm in the muscles supplied by the accessorius is due to an irritative lesion in the course of the nerve, the treatment should be directed to the removal of this lesion or to rendering it as harmless as possible. If dependent upon a neuritis, meningitis, or a tumor, mercury and the iodides may prove of great benefit, and this even in cases in which no syphilitic lesion is present, although the results to be obtained from this treatment are, of course, more marked when syphilis is the cause. The salicylates are of special value when spasmodic torticollis is due to a true neuritis. Among other meas- ures of proved value in these cases is the use of derivatives and counterirritants. Blisters, mustard applications, thapsia or capsicum plasters, and, above all, the use of the actual cautery, have proved highly efficient in recorded cases. The application should be made to the nape of the neck or over the course of the nerves. The actual cautery in several cases has proved in my hands to be one of the best methods of direct treatment. The only objection to its use is the dread in which it is sometimes held by patients or their friends, but this can generally be overcome. I prefer the method of superficial application. A small blunt applicator should be used, and this heated to whiteness is passed rapidly over the skin for the dis- tance of from half an inch to an inch. Treatment can be repeated every day or every other day for the first week or two, making the application in different positions from the middle of the nape of the neck towards the side on which the spasm occurs. Some of the older works advocate the use of deep applications to each side of the spinal column in the cervical region, afterwards maintaining suppuration for some weeks, but this is a more uncomfortable method than that of making superficial burns and frequently repeating them, and the reported results are not better than those which have been obtained in the less annoying mode of treatment. In one of my cases of very severe type this treatment succeeded after other meas- ures had been tried for many months. Among remedies emj)loyed for the direct purpose of controlling the spasm are preparations of atropine, hyoscyamns, conium, gelsemium, morphine, cannabis indica, and Calabar bean. On the whole, I have obtained the best results from the use of preparations of gelsemium and coniine pushed to their constitutional effects. I have used both conium hydrobromate and hyoscine hydrobromate with temporary benefit, the former in doses of from one thirtieth to one fifteenth of a grain, and the latter in amounts varying from one hundred and fiftieth to one hundredth of a grain. Hypodermatic injections both of atropine and of morphine have had their advocates, and the administration of these remedies will usually temporarily abate the spasm. The patient is always in danger of establishing a drug habit in an affection so recalcitrant to all treatment. Other remedies which have been used with transient and varying benefit are the bromides, chloral, and chloralamid, in SPASMODIC TORTICOLLIS. 989 comparatively large doses, and Inhalatious of amyl nitrite. Salts of gold, silver, zinc, copper, iron, and arsenic, with nourishing diet and hygienic measures calculated to improve the general health, should be employed in conjunction with the remedies especially directed to the relief of the spasm. All sources of reflex irritation should, if possible, be removed. Now and then a striking success will be scored by the treatment of diseased teeth or gums, or of an affection of the ear or of some other part of the face and head. The electrical treatment of this form of spasm has been a matter of much inter- est, and many reports have been made upon the results. Faradism, galvanism, and franklinism have all been used. The best method of electrical treatment is the steady application of the anode of a gal- vanic current over the accessory nerve, the cathode being placed at some indifferent spot. Poore's method of treating writer's cramp with the galvanic current and rhythmical exercise of the affected muscles is well worthy of trial. Apparatus to hold the head in proper position may be of service if conjoined with other treatment, such as faradization of the antagonistic muscles. Nerve stretching, myotomy, neurotomy, and neurectomy are operations which may be performed for the relief of spasmodic torticollis. Both neurotomy and neurectomy have been employed with success ; but in a greater number of instances they have failed. The fact that the spinal acces- sory is not the only nerve supply to the muscles chieflj^ accounts for the failure of the operation. One surgical operation which has met with some success in the hands of Keen and others is resection of the posterior branches of the upper cervical nerves. The operation, according to Eisien Eussell, is the only measure which offers a reason- able prospect of permanent relief in severe cases. Eussell found considerably more individual variation with regard to the nerve root supply of the neck muscles than of those of the limbs. Where the lateral inclination of the head, by which the shoulder and side of the head and face are approximated, exists, the first and second cervical nerve roots are those to which attention should be directed, while in those instances in which the chief movement of the head is one in which the occiput is drawn backward, so that the face looks more or less upward, the third and fourth cervical nerve roots should engage attention. Either primarily or secondarily other muscles besides those supplied by this nerve become involved in the spasm. Among the muscles supplied by the upper three cervical nerves are, for instance, the inferior oblique, the rectus capitis posticus major, the splenius, and the three posterior rotators. Good authorities have argued that not a few of the cases are of cortical origin and should be treated by trephining and the removal of lesions supposed to be present in the cortex or subcortex, or by excision of the unstable cortex ; but the facts are not sufficient to encourage the endorsement of this treatment. 990 NERVOUS DISEASES. DISEASES OF THE HYPOGLOSSAL. NERVE. The Hypoglossal Nucleus. — The hypoglossal nerve arises from a large mass of cinerea, sometimes called the chief nucleus, which is in part situated on the ventral side of the most encephalic portion of the central spinal canal and in part in the gray matter of the floor of the fourth ventricle. The spinal portion of this nucleus is a por- tion of the ventral horn which remains attached to the central gray matter after the decussation of the pyramidal fibres. (Obersteiner, Koelliker. ) Oephalad it reaches to the acoustic striae. It contains very large multipolar cells like those found in the ventral horn of the cord. It is evident from its microscopic structure that the hypoglossal nerve is almost entirely, if not purely, motor in its functions. The hypoglossal nucleus is solely a nucleus of origin. The axis cylinders of its large cells form efferent fibres which pass into the nerve of the corresponding side. According to Obersteiner, some fibres arise in the nucleus of the opposite side ; but this has been denied by other investigators. Certain afferent hypoglossal fibres are derived from the pyramids, forming mainly what are known as the fibrce proprke. Other efferent fibres come from the reticular formation, and possibly from the fillet. ^Turner.) Ac- cording to Turner, besides the above connections and relations of the hypoglossal nucleus, fibres enter the nucleus from the dorsal longitudinal bundle, and commissural fibres exist between the two nuclei. According to Eamon y Cajal, a decussation of the axis cyl- inders of the cells of the hypoglossal nucleus does not occur ia the newborn mouse. Turner believes that these nuclei do not give origin to any hypoglossal fibres. In the mouse and rabbit the twelfth nerve arises only in the chief nucleus. He agrees with Koelliker in greatly doubting the connection of the twelfth with Boiler's nucleus or Duval's accessory nucleus.* The twelfth centre in mice receives sensory fibres from the cells in the terminal nucleus of the ninth and tenth nerves, fibres from the substantia gelatinosa, accompanying the spinal root of the fifth nerve, and fibres from the common central tract of the fifth, ninth, and tenth nerves. Eamon y Cajal has not been able to observe direct collaterals passing from the roots of the fifth, tenth, and ninth to the twelfth centres, the connections seeming to be by the axis cylinders from cells in the terminal nuclei of these nerves. Peripheral Course of the Hypoglossal Nerve. — The axis cyl- inder processes of the ganglion cells of the hypoglossal nucleus just * What is termed the nucleus of Rcjller is a round but not distinctly circum- scribi'd clump of small nerve cells which lies close up against the ventral side of the large-celled nucleus. Duval's accessory hypoglossal nucleus is a collection of large nudtipolar cells placed ventrolaterally to the chief nucleus. DISEASES OP THE HYPOGLOSSAL NERVE. 991 described pass obliquely forward and outward between the latero- ventral regions of the postoblongata, to appear on its upper surface as a series of a dozen or more fine roots, which emerge in the groove between the anterior pyramid and the olive. These filaments com- monly unite into two separate bundles, which pierce the dura oppo- site the anterior condyloid foramen, becoming a single trunk to pass outside of the skull through this foramen. In the first part of its extracranial course it is very deeply situated to the inner side of the Fig. 450. Diagram of the hypoglossal nerve, its connections and branches: H, hypoglossal nerve; P, pneumogastric nerve ; S, superior cervical ganglion of the sympathetic ; L, Imgual nerve ; IC, IIC mc, the three upper cervical nerves ; 1, communicating branches from hypoglossal to ganglion of the trunk of the vagus ; 2, connecting filaments with the loop of first and second cervical nerves ; 3, branch to the sympathetic ; 4, descendens noni ; 5, branch from second and third cervical nerves (communlcantes noni); 6, branch to thyrohyoid; 7, terminal mascular branches; b, commmii- cating branch to the Ungual branch of the fifth. (Ross.) pneumogastric. It winds around the lower ganglion (ganglion of the trunk) of the pneumogastric, and descends, gradually inclining forward, between the internal carotid artery and the jugular vein, to the lower border of the digastric muscle. Here it curves and passes forward above the hyoid bone. Towards the end of its peripheral course it rests on the hyoglossus muscle and is accompanied by the ranine vein of the tongue. At the anterior border of the hyoglossus 992 NERVOUS DISEASES. it communicates with the lingual branch of the fifth. In the ante- rior condyloid foramen it gives off a few small branches which are distributed in the dura around the foramen magnum and to the occipital diploe. These fibres, usually classed as hypoglossal twigs by some authorities, are regarded by others as derived from the lingual, and by still others as fibres from the pneumogastric, the first cervical, or the sympathetic. Its communicating branches are with the superior cervical ganglion of the sympathetic, with the loop between the first and second cervical nerves, with the ganglion of the trunk of the vagus, with a small lingual branch of the vagus, and with the lingual branch of the fifth. It has three distinct sets of branches of distribution : (1) branches to the vessels (vascular branches) ; (2) descending cervical branches ; and (3) muscular branches. The vascular branches pass to the mesal aspect of the jugular veins, where they are sometimes joined by communicating filaments from the cervical sympathetic. The cervical branches of the hypoglossus {descendens hypoglossi) run downward on or within the carotid sheath, and are joined by communicating branches from the second or third cervical nerve, which form with them a loop {ansa hypoglossi or ansa cervicales). A small branch passes to the omohyoid before it supplies this loop. Branches are given off from the ansa to the sternohyoid, sternothyroid, and posterior belly of the omohyoid. Twigs from the first two nerves pass in the muscles behind the manubrium sterni and in rare cases communicate with the phrenic within the thorax. (Morris's Anatomy.) A branch leaves the hypo- glossal trunk as it approaches the hyoid bone to pass to the thyro- hyoid muscle. This is composed in part of fibres from the upper cer- vical nerves. The nerve also gives off branches to the stj^loglossus, hyoglossus, and genioglossus. Terminal branches supply the genio- glossus and the intrinsic muscles of the tongue. Both anatomically and physiologically it is somewhat difiicult to discriminate between the branches of distribution which are derived from the hypoglossus nucleus and those which come from the nuclei of the upper cervical nerves. Quain thus summarizes the above facts : "The hypoglossal nerve proper supplies only the muscles of the tongue, with the ex- ception of the palatoglossus and the pharyngeoglossus. Fibres de- rived from the first three cervical nerves, which are associated with the hypoglossal for a part of their course, are distributed to the infra- hyoid muscles and the geniohyoid. Others of uncertain origin pass to the skull and dura mater and to the internal jugular vein. The hypoglossal forms connections with the pneumogastric, lingual, upper three cei\ical nerves, and sympathetic." The hypoglossal nerve is the chief motor nerve to the tongue, and also to the muscles which elevate and depress the hyoid bone. A dorsal root for the hypo- glossal nerve has been found in some lower animals, — this nerve in them, therefore, more closely resembling a true spinal nerve. HYPOGLOSSAL PARALYSIS. 993 uni- ures HYPOGLOSSAL PARALYSIS. Paralysis of the hypoglossus (glossoplegixi) may be either unilateral or bilateral, but it is much more frequently the former In lateral hypoglossal paralysis the tongue at rest presents no feat of importance. On protrusion it deviates towards the paralyzed side (Fig. 451), the reason for this being that the movements of 'pro- trusion are ot a pushing or propelling character, and hence the tongue deviates to one side by the unopposed action of the muscles of the healthy side. The movements of the tongue within the mouth are also interfered with, the patient in consequence having difficulty in mastication and deglutition. The food is not carried backward into the pharynx with tacility, although this may not be very noticeable in cases of one-sided paraly- sis. When the paralysis is Fig. 451. bilateral all the movements of the tongue are affected, and if the paralysis is complete the tongue lies motionless within the buccal cavity. As this form of paralysis is almost in- variably the result of nuclear degeneration, atrophy and fibrillary twitchings are usu- ally present in addition to the immobility (see Lingual Atro- phy). When the patient is lying on his back the tongue may fall backward into the throat and partially close the glottis, thus interfering with respiration and leading to par- tial asphyxia and stertorous breathing. In incomplete bilateral pa- ralysis of the tongue the extraordinarily intiicate and complicated movements of the tongue, performed with such facility in health, are more or less interfered with according to the extent of the paralysis. Mastication and deglutition are of coarse much more seriously interfered with in bilateral than in unilateral paralysis. Food, drink, and saliva may collect in the cavity of the mouth and throat, annoying the patient and even at times threatening his life because of the interference with respiration. Speech is affected in both unilateral and bilateral hypoglossal paralysis. In bilateral cases the loss of speech may be complete. Careful studies have been made in the degree of impairment of articulation at different stages in progressive hypoglossal paralysis. "Articulation becomes indis- tinct, diflBculty being first experienced in singing and in pronouncing 63 Unilateral paralysLs of the tongiie fprobably due to degeneration of the hypoglo.ssal nucleus of one side) in a case of beginning bulbar paralysis. 994 NERVOUS DISEASES. the letters s, sh, 1, e, i, and, at a later period, k, g, r, etc., while if the paralysis be bilateral, complete, and associated with atrophy, vocal speech becomes quite inarticulate and unintelligible, this condi- tion being named anartheca.^^ (Eoss.) It is difficult to separate the etiology and pathogenesis of paralysis and spasm of the hypoglossus. The nerve at or near its origin may be involved in various patho- logical processes, such as meningitis, tumor, aneurism, or caries. In rare instances an abscess or a hemorrhage from one of the vertebral arteries has involved the nerve trunk. Occasionally the nerve is the seat of a neuritis of rheumatic, syphilitic, or unknown origin, but it is less frequently affected in this way than most of the other cranial nerves. Habershon has reported a case of cancer of the cervical vertebra with paralysis of the right hypoglossal nerve. Autopsy revealed a cancerous mass invoh'ing the basilar process. The nucleus of the hypoglossus is not infrequently the site of degenera- tive changes. The result of this is both paralysis and atrophy, the paralysis being proportionate to the degree of loss of substance in the tongue ; but the effects of such degeneratiA^e disease will be more fully considered under lingual atrophy and bulbar paralysis. HYPOGLOSSAL SPASM. Hypoglossal spasm, known also as lingual spasm and aphthongia, is a comparatively rare affection. It is especially rare as an independent disorder, but it sometimes forms a part of the symptomatology of such more general affections as epilepsy, chorea, and hysteria. Trigeminal and hypoglossal spasm are not infrequently associated in the same case. Hirt reports a case in which the muscles of mastication took part in the affection in such a way that before the actual hypoglossal spasm occurred the lower jaw was for a half or a whole minute spas- modically jerked to and fro and up and down. "After these move- ments had ceased the mouth remained half open, and the turning and rolling movements of the tongue commenced and lasted for about one minute. These attacks reciurred ten to twenty times a day ; they came on for the first time three days after an epileptic fit." (Hirt.) Hypoglossal spasm may form a part of the syndrome of bilateral athe- tosis in one of the forms of infantile diplegia already described. Choreiform and tremulous movements of the tongue, which belong pathologically to the same general category as lingual spasm, are sometimes symptoms of progress! Ae bulbar paralysis and of dissemi- nated sclerosis. The symptoms of hypoglossal spasm vary as the affection is clonic or tonic or a combination of both. Muscles inner- vated by the nerve in one of tlie described forms of the disease are thrown into a state of cionic or tonic convulsions when the patient attempts to speak, the affection being more or less similar to writer's cramp. The spasm may implicate other groups of muscles than those supplied by the hypoglossus. In some cases the tongue becomes fast- LINGUAL ATROPHY. 995 ened to the hard palate by a tonic spasm whenever the patient tries to speak, but in other cases it is attacked with clonic spasms, and the sternohyoid, thyrohyoid, and sternothyroid may likewise be implicated in the convulsion. (Eoss.) Hypoglossal spasm, like hypoglossal paralysis, may be due to focal lesion anywhere from the nucleus to the peripheral distribution of the nerve. A few cases have been recorded in which the seat of the disease was apparently in the cerebral cortex about the lower extremity of the central fissure. The diagnosis is readily made, the tongue being the chief organ supplied by this nerve and therefore the one most affected, although the spasms may, as has been stated, attack the sternohyoid, thyrohyoid, and sternothyroid muscles. It would seem impossible that any other affection should be mistaken for this. The only diffi- culty would be in distinguishing hysterical from organic cases, and this would have to be done by a search for hysterical stigmata and a careful consideration of the probability of the presence of a focal lesion. Its treatment is that of local spasm elsewhere. LINGUAL ATROPHY. Mainly as the result of degeneration of the hypoglossal nucleus the tongue may be atrophied in whole or in part, although in rare cases, as just stated, this atrophy may accompany paralysis from peripheral lesions. The most distinctive forms of lingual atrophy are those which are in association with such progressive degenerative and retrogressive diseases as amyotrophic lateral sclerosis, chronic muscular atrophy, progressive bulbar paralysis, and syringomyelia. In the majority of these cases the nuclear degeneration, and con- sequently the atrophy of the tongue, are bilateral, and attain their maximum only after the disease has endured for several years. The characteristic features of lingual atrophy are wasting of the muscles of the tongue, with fibrillary tremors, and in some instances trophic phenomena, such as ulceration. Hemilingual atrophy as an isolated affection is extremely rare. Little needs to be said about its symp- tomatology more than has been said under hypoglossal paralysis. The tongue on one side is wasted, wrinkled, tremulous, and wanting in power. Lingual movements, speech, mastication, and deglutition are all more or less impaired. Among the most frequent predis- posing causes of hemilingual atrophy is syphilis, although it is probable that it may arise from the influence of any toxic agent. Among the pathological causes to which it has been ascribed are traumatism, disease of the vertebral artery, new growths in the ob- longata, and softening from an embolus or a thrombus in the region of the hypoglossal nucleus. While, as has been stated, hemilingual atrophy is usually part of the syndrome of a progressive degenera- tive disease, the degeneration in rare cases attacks only the hypo- glossal nucleus. Westphal demonstrated an interesting specimen 996 NERVOUS DISEASES. Fig. 452. from ii patient who had had external ophthalmoplegia and complete paralysis of both eyeballs. He had also a bulbous appearance of the tongue, and an atrophy of the anterolateral portion of its left side. The specimen showed the right hypoglossal muscles to be well devel- oped, while the others were only fragments. On the right side the root was distinctly seen running to the nucleus, but nothing could be seen on the left, except with a very high xjower, and then only a few nerve fibres. He also found a gray degeneration through the whole length of the cord. Fig. 452 is an illustration of hemilingual atrophy in a well marked case of syringomyelia. The di- agnosis of hemiatrophy of the tongue can, as a rule, be readily made by a careful examination of the organ. The tongue may be congenitally smaller on one side than on the other. Lingual hemihypertrophy is ex- ceedingly rare, and its presence might at first lead to the idea that the unaffected side of the tongue was atrophied. Fibrillary twitching is in favor of nuclear dis- ease, but is not abso- lutely pathognomonic, as twitching has been recorded in peripheral disease. The localiza- tion of the lesion causing the lingual hemiatrophy, as well as the diagnosis of its nature, may be largely assisted by a study of the accompanying symptoms. When hemiplegia of the side of the body opposite to the ati'ophied tongue is present, the lesion is probably gross, and one of such size and chai-acter as to involve the pyrami- dal tracts before tlieir decussation. Sensory and other symptoms are likely to be present in such cases. When scattered but con- siderable portions of the musculature of the body are affected con- jointly with atrophy of the tongue, the lesion is probably one of a disseminated or diffused degeneration. The prognosis is unfavor- able, and no treatment is of avail except in peripheral cases, in which absorbents and electricity may be of some service. Unilateral atrophy of the tongrue in a case of syringomyelia. POSTOBLONGATAL AND OBLONGATA-SPINAL I.ESIONS. 997 G-ROSS LESIONS OF THE POSTOBLONGATA AND OBLONGATA-SPINAL TRANSITION. General Remarks on the Diagnosis of Lesions of the Post- oblongata.— The method of diagnosticatiuo- small gross lesions in the pons and preoblongata was discussed in the last section of Chapter IX., where was given a series of topographical schemes and semidia- grammatic illustrations of the most important structures of these re- gions. Ha,ving considered the cranial nerves which take their origin from the postoblongata, it will be well, in pursuance of the same plan, to discuss briefly the localization of similar lesions in the post- oblongata and oblongata-spinal transition. Points of diagnosis to which attention cannot be easily and readily directed when consider- ing the separate nerves and neural cell nests can tlius be elucidated. That such a discussion is not without practical value has been illus- trated by cases which ha^e fallen under my personal care, and by not a few which have been recorded in neurological literature. Oper- ations for the removal of encephalic growths have been performed on regions of the cranial vault when autopsy has revealed tumors so situated as to press upon or imade the postoblongata ; lesions of the Gasserian ganglion or of the trunks of the sensory subdivisions of the trigeminus have been diagnosticated when the real seat of the disease was in the descending (spinal) root of the fifth nerve and in the postoblongatal portion of its course ; so serious a diagnosis as that of hydrophobia has been made when the real source of the so- called hydrophobic symptoms was an isolated lesion of the region of the oblongata-spinal transition ; and the diagnoses of intracerebral hemorrhage and of acute bulbar paralysis have been made in cases of hemorrhage from the vertebral artery. As said by Krauss, to whom we are indebted for some valuable work on this region, the study of the transition from the spinal cord to the brain is perhaps the most difficult task in the anatomy and histology of the nervous system, requiring time and care to trace the origin and direction of the nerve bundles, the appearance of new masses of gray matter, and the coalescence of different tracts. The symptoms of gross lesions affecting this region are often as confusing as the structures are com- plicated ; and yet it is not impossible to lay down rules which will assist in approximately fixing lesions in any one of five or six posi- tions in the space which lies between the furrow separating the pons and postoblongata and the most proximal roots of the first pair of cervical nerves, just above which is the great pyramidal (motor) de- cussation. (Fig. 453.) In order to do this it is necessary to have at command a knowledge not only of the superficial anatomy, but also of the structures shown by transections made in at least four or five planes of this area. Descriptions of the external features of the ventral and dorsal aspects of the oblongata, of the floor of the fourth 998 NBEVOUS DISEASES. ventricle, of the region of transition from the spinal cord to the oblongata, of the interior structure of the latter, and of the deep origins and roots of the cranial nerves, have been given in Chap- ter I. (pages 73-86) ; and it will, therefore, be necessary to recall here, with the assistance of some semidiagrammatic illustrations, only the most important of the structures there described, indicating at the same time the parts which they play in symptomatology. Fig. 454. ( Vd' ) ^^^m A vIK ki B d \n% xii / C \l 1 1 D n li Pig. 453. — Subdivision of tlie ventral aspect of the postoblongata into fourtlis. The fourths are separated by the letters a, &, c, d, e. The diagrams of transections of the postoblongata which fol- low (Figs. 455, 456, 457, 458, 459) are made through about the middle of the sections A, B, C, and D. P, pons ; 0, olive ; p, pyramid ; r, restis ; /, roots of the first cervical nerve ; I, lateral column ; fc, anterior colunui. The Roman numerals indicate the cranial nen'cs. Fig. 454. — Subdivisions of the dorsal aspect of the postoblongata : n, nucleus ambiguus ; Vs, sensory nucleus of the fifth nerve ; Vd', descending (mesencephalic) root of the fifth ; Vd, descend- ing spinal root of the fifth ; Vm, motor nucleus of the fifth ; w, descending glossopharyngeal root. The Roman numerals indicate the nuclei and nerve roots. Topographical Subdivisions of the Postoblongata. — In Figs. 453 and 454 the postoblongata is represented as subdivided into fourths by the lines a, h, c, . 10, 1897. (803,849.) Berry, G. A., Edinb. M. J., v. 32, 1887. (369, 371.) 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"Wolfe, Arch, f Augenh. u. Ohrenh., v. 3, 1871. (743.) "Wolff, L., Therap. Gaz., Detroit, 1889. (356.) "Wood, G. B., A treatise on the practice of medicine, 5lh ed., Phila., v. 2, 1858. (250.) "Wood, H. C, Med. Week. Par., v. 1, 1893. (176.)— Therapeutics: its principles and practice, 8th ed., Phila., 1892. (339, 257.)— Smithson. Contrib. Knowl., Wash., 1880. (356.) ■Woodhead, G. S., Practical pathology, Phila., 1892. (600.) , and Tuke, J. Batty, Practical pathology, 3d ed., Edinb. and Lond., 1892, and article on Pathology in Diet. Psych. Med., ed. by D. Hack Tuke, Phila., v. 2, 1892. (398, 433, 433.) "Worcester, "W. L., Am. J. Insan., Utica, N. Y., v. 44, 1887. (348.) "Wyllie, J., The disorders of speech, Edinb., 1894. (349, 630, 632, 636, 638, 640, 649, 655, 666, 660, 666.) "Tates, G., Med. Times and Gazette, 1870, v. 2. (606.) 'S'eo, G. P., Phil. Tr., Lond., 1884. (343.) , Ferrier, D., and. Brain, Lond., v. 3, 1880-1. (343.) Zaoher, T., Arch. f. Psychiat.. Berl., v. 22, 1891. (358, 663, 563.) Zenker, Jahresb. d. Gesellsch. f. Nat. u. Heilk., Dresden, 1861. (550.) Ziegler, E., A text-book of pathological anatomy and pathogenesis, trans, by D. Macalister, N, v., 1887. (301.) Ziehen, T., Arch. f. Psychiat., Berl., v. 21, 1890. (353.) Ziehl, Pr., cited by Turner in Edinb. Hosp. Rep., ^'. 4, 1896. (694.)— Arch. f. path. Anat. u. Physiol., Berl., v. 117, 1889. (695.) Zimmerman, "W., Arch. f. Ophth., v. 62, 1896. (781.) Zuckerkandl, E., Ueber das Riechcentrum, Stuttgart, 1887 ; Anat. Anz., Jena, y. 3, 1888. (347.) GENERAL INDEX. Abducens nerve, peripheral course of, 807. nucleus, 82, 806. Abscess, cerebellar, symptoms of, 547. dural, 273. encephalic, 543. active and latent periods of, 543. association with intracranial afifec- tions, 544. with lung disease, 546. clinical history, 543. diagnosis, 551. from aural disease, 553. from encephalic hemorrhage, 552. from encephalitis, 553. from meningitis, 551. from sinus thrombosis, 551. from tumor, 551, etiology, 548. focal symptoms, 546. general symptoms of active period, 543. multiple, 555. pathogenesis, 550. pathological anatomy, 550. prognosis, 553. treatment, 554. of postoblongata, 1005. Acceleration of nerve function, 118. Accessorius, nucleus of, 942. paralysis, 979. diagnosis, 982. etiology, 982. pathogenesis, 982. prognosis, 982. symptomatology, 979. treatment, 982. spasm, 983. Accessory acoustic nucleus, 81. Accommodation, centre for, 801. spasm of, 825. Achromatopsia, 758. Aconite, 250. Aconitine ointment, 251. Acoustic nerve nuclei and root fibres, 81, 711. neurasthenia, 720. nucleus, 711. strise, 75. tract, 111. Acrania, 314. Acrocephalie head, 149. Acromegaly, pituitary gland in, 368. Actinomycosis, 497. Acute bulbar myelitis, 1006. paralysis, 1006. diffuse nonsuppurative encephalitis, 535. Acute encephalic softening, 475. focal disease of the brain, 556. encephalitis, 532. hydrocephalus, 282. leptomeningitis, 292. purulent, 278. tubercular, 280. Adenomata, 502. Adiposis dolorosa, 368. jEsthesioblasts, 26. Agathin, 244. Age in relation to nervous diseases, 134. Agenesis, 125. Ageusia, 698. Agraphia, difl'erentiation of, 662. motor, 639. transcortical, 640. Akinesis, 604. Ala alba medialis, 76. cinerea, 76, 80. Albicantia, 4, 60. Alcoholic amblyopia, 782, 784, 785, 786. Alcoholism, diagnosis from encephalic hem- orrhage, 468. Algesimeter, 155. Allochiria, 152. Alogia, 655. Alterative tonics, 238. Alternate hemiplegia, 572. in basilar meningitis, 277. of ocular type, 836. Alternator, therapeutic, 191. Alum poisoning, resemblance to bulbar paral- ysis, 137. Ambiguous layer, 328. Amblyopia, crossed, 759. drugs causing, 783. from diathetic and infectious diseases, 784. toxic, 782. diagnosis, 786. morbid anatomy, 785. pathology, 785. prognosis, 786. symptomatology, 784. treatment, 786. varieties, 782. Ametropic choroiditis, 792. Amimia, 652. musical, 652. Amnesic aphasia, 655. Ampere, 180. Amusia, 641. Amygdala, 56. functions of, 359. Amyl nitrite, 256. Amylene hydrate, 241. Anacusia, 715. 1033 1034 GENERAL INDEX. Anal reflex, 176. Analgesia, 152. Analgesics, 235. Anarthria, 654. Anastomotic vein of Trolard, 425. An elect rotonus, 179. Anemia, cerebral, 273. leptomeningeal, 273. meningeal, 274. meningoencephalic, 274. of the brain, 436. diagnosis, 437. etiology, 436. pathological anatomy, 437. prognosis, 437, symptomatology, 436. treatment, 438. of retina and optic disk, 779. Anencepbalus, 313, 597. Anesthesia, 152. from lesions of the trigeminal central pathway, 884. gastric, 950. in hemiplegia, 581. laryngeal, 949. retinal, 792. trigeminal, 882. varieties, 152. visual, 792. Aneurism, encephalic, 446. basilar, 448. diagnosis, 449. etiology, 449. pathology, 449. prognosis, 450. symptomatology, 447. treatment, 450. miliary, 447. Aneurismal periarteritis, 442. Angina pectoris, neural, 949. Angiomata, 499. Angiosarcoma, 500. Angular gyre, lesions of, 339, 755. Ankle clonus, 171. Anopsia, 766. Anosmia, 674, 676. Anosphresia, 674. Ansa lenticularis, 65, 110. Antispasmodics, 237. Ape fissures, 35. Aphasia, 628. amnesic, 655. anatomic opathological varieties, 630. and pantomime, 652. clinical diagnosis, 661. varieties, 631. combined, 631. concept, 631, 636, conduction, 640. cortical, 630. differentiation of, 662. definitions and synonyms, 630. etiological diagnosis, 658. in encephalic abscess, 546. infrapictorial sensory, 631. mixed, 631. mixt'il concept and motor, 336. mixed sensory and concept, 633. motor, 631, 634. of intonation, 641. pathological etiology, 658. pictorial, (t;iO. prognosis, 663. Aphasia, pure, 631. sensory, 631. subcortical, 630. suprapictorial, 631. systematic examination for, 660. total sensory motor, 631. transcortical, 630. treatment, 664. with limited pantomime, 654. Aphasics, disorders of pantomime among, 651. Aphemia, 349. Aphthongia, 994. Aplasia, 125. Apnea, 970. Apomorphine, 258. Apoplectic attack, pain preceding, 580. Apoplexie foudroyante, 462. Apoplexy, conservative agency of, 473. diagnosis of, from encephalic tumor, 524. hemorrhagic, duration of, 462. ingravescent, 458. Apparatus, electromedical, 179. Arachnitis, 274. Arachnoid, 95, 261. Arachnopia, 261. Arbor vitae, 68. Architecture of the nervous system, 100. Arcuate fibres, 62. posterior external, 109. tracts of oblongata and pons, 85. Argyll -Roberts on pupil, 162, 811. Aristotle's experiment, 156. Arnold, little bridge of, 74. Arsenical pill, compound, 249. Arterial fibrosis, 445. pressure and pulse, 178. Arteries, acute purulent inflammation of, 442. cerebral, 96. of nerves, 98. of the brain, 417, 41S, 419. of the oblongata, 421. of the pons, 421. Arteritis, varieties of, 442. Arthropathies, 176. in hemiplegia, 586. Articulative paresis, 349. Arytenoids, paralysis of, 958. Ascending secondary degeneration, 564. Asemia, 652. Asphyxia, 970. Associated movements. 165, 576. in diplegia, 610. Association areas, 332. fibres of the cerebrum, 62. tracts and cortical centres, 650. Asterion, 147. Asthenic bulbar paralysis, 1010. Asthenopia, 792, muscular, 810. Asthma, nervous, 971. paroxysmal, SS2. Ataxia, 170. Ataxic lymphopathy, 176. Atheroma, 442. Athetoid movements in diplegia, 610. phenomena, 578. Athetosis, 578, Atrophic bulbar paral^-sis, 1006, Atrophy, cerebellar, 382. hemifacial, 885. hemiplegic, 584. GENEliAL INDEX. 1035 Atrophy, lingual, 995. of the brain, 597. of the cochlear nerve, 719. of the optic nerve, 786. postneuritic, 789. primary olfactory, 678. secondary olfactory, 679. optic, 791. tabetic, of the vestibular nerve, 734. Auditory apparatus, 709. focal lesions of, 718. lesions and disturbances of, 716, disturbances, diagnosis of, 724. end organs, peripheral, 709. ganglion, 81, 709. hyperalgesia, 717. localization, 344. neuroses, reflex, 721. radiations, 330. tract, 715. Aula, 31. Aulix, 52. Auricular point, 147. Auriculobregmatio radii, 148. Autoin feet ion, 140. Autointoxication, 140. Automatic centres, 117. Autopsies of the brain, 392, 397. Auxesis, 594. Axis cylinders, 11. Azygoa uvulae, paralysis of, 952. B. Bacteria of meningitis, 287. Baresthesiometer, 158. Basal centres for optic reflexes, 753, for vision, 753. cinerea, lesions of, 369. ganglia, functions and lesions of, 352. Basilar aneurism, 448. leptomeningitis, 275. Basion, 147. Baths, forms of, 213. Batteries, constituents of, 183. faradic, 189. galvanic, 181. Bechterew's nucleus, 730. Belladonna, 250. Bell's palsy, 909. Biceps jerk, 171. Bicycling for nervous patients, 218. Bilateral hemiplegia, 588. representation in the cortex, 339. Binaural reflex, Gelle's, 163. Binauricular arc, 147. diameter, 148. Binocular vision, 809. Birth palsies, etiology of, 615. Blastodermic layers, 23. Blepharospasm, 812, 922. Blindness, literal, 634. psychic, 635. verbal, 634. Bloodvessels, cortical, 96, 416. nerves of, 425. of nervous system, 95, 96. Border centres, 340. Brachycardia, 974. Bracby cephalic head, 149. Brachypnea, 970. Bradycardia, 974. Brain, abscess of, 543. Brain, anemia of, 436. arteries of, 96, 417, 418, 419. atrophy of, 597. autopsies, 392, 397. Bridgman, Laura, 558. cavities of, 54. chemical constituents of, 123. chief subdivisions of, 2. Chinese, 44. circulation of, 417. commissural structures of, 58. compression of, 428. concussion of, 427. edema of, 438. embolism of, 476. envelopes of, 95. fissures and gyres of, 39. focal diseases of, 416. ganglia of, 54. hardening of, 413. hyperemia of, 274, 431. hypertrophy of, 594. interior lymphatics of, 98. mantle, 406. membranes, hyperemia of, 431. methods of entering, 398. parasites of, 504. pathological changes in, viewed chemi- cally, 124. preservation of, 413. pressure, 426. principles, typical, 123. removal of, from skull, 395. sclerosis of, 597. separation of, into component parts, 405. softening of, 475. specific gravity of, 412. stem, 406. substance, compressibility of, 428. tracts of, 54. transportation of, 413. traumatisms of, 429. tumor of, 493. vascular disturbances of, 416. veins of, 424. volume of, 412. weight of, 4QS. weights of, or eminent men, 411. Erauch-R-omberg sign, 170. Bregma, 147. Bregmatolambdoid arc, 147. Broea's centre, 350. Bromamide, 244, 245. Bromides, 240, 242. Brow ague, 866. Bulb, arterial supply of, 422. Bulbar paralysis, 1006. acute, 1006. asthenic, 1010. atrophic, 1006. chronic progressive, 1007. nuclear, 1006. resemblance to alum poisoning, 137. Bulbocavei'nous reflex, 175. Bulbocerebral gustatory pathway, 698. Burdach, column of, 90. Butyl chloral, 246. C. Cacosmia, 674. Cactus grandiflorus, 248. Caff"eine, 255. Calamus scriptorius, 76. 1036 GENERAL INDEX. Calcar, 33. Calcarine fissure, 39. Callosal gyre, 59. Callosum, 3, 58, 59. absence of, 364, degeneration in, 365. lesions of, 364. Calomel, 256. Cannabis indica, 246. Capillaries, occlusion of, 492. Capillary hemorrhage, 462. Cappa, 52. Capsules, functions and lesions of, 352. Capsulogangl ionic hemorrhage, 452. Carcinoma, 501. dural, 502. multiple, 502. Cardiac arhythmia, 975. centres, 116. disturbances due to vagal disease, 972. nerves, physiology of, 972. Cardiants, 238. Carrefour sensitif, 103,359. Cataphoresis, 179, 202. Catelectrotonus, 179. Cauda equina, 7. Caudate cells, 327. Caudatum, 33, 55. embryonic relations of, 57. functions and lesions of, 352. Caudex, 406. Cavernous sinus, 304. thrombosis, 307. Cavities of the brain, 54. Cell or cells, Deiters's, 16. dry electrical, 182. fusiform, 329. galvanic, 181. glia, 16. Golgi's commissural, 91. granule, 330. hecatomeral, 93. heteromeral, 93. intermediary, 13. large pyramidal, 329. Lenhossek's, 94. Martinotti's, 330. motor, 19. nerve, 9. of po:^terior roots of spinal cord, 92. projection. 13. psychic, 15. regeneration of, 129. sensory, 19, 104. spider, 16. tautomeral, 92. Cellular terminology, 12. Central amblyopia, forms of, 759. apparatus of ocular muscles, 795. auditory tract, 712. cerebral arteries, distribution of, 420. fissure, 386, 388. angle of, .'iSO. determination of, 387. nucleus of oblongata, 83. tegmental tract, 84. degeneration of, 562. Centre or centres, automatic, 117, cardial.', 1 16. ccr<_'l)olIar, 1 15. cerebral, 115. eiliospinal, 807. concept, 345, 623, 645. Centre or centres, cortical, 104, 115, 331, 756. Broca's, 350. for accommodation, 369, 801. for convergence, 801. for deglutition, 116, 117. for elevation of upper eyelids, 339. for laryngeal and pharyngeal represen- tation, 337. for masticatory movements, 336. for oculofacial movements, 801. for phonation, 1 1 7. for pupillary movements, 801, 802. for smell, 347. for space, 117. for spatial senses, 354. for speech, 339, 348. for taste, 348. for vision, 753, 756. for word hearing, 339, 345. for word seeing, 339. for writing, 339, 349. geographical, 344. graphic, 349. gustatory, 348. higher cerebral, 117. in the oblongata, 115, 116. in the pons, 115. macular, 343. monarchical vasomotor, 116. motor graphic, 628, 647. speech, 62S. naming, 345, 628. of representation for face movements, 336. for lower extremities, 335. for movement of toes, 335. for specialized movements, 340. primary auditory, 344, 628. visual, 342, 628. propositionizing, 349. respiratory, 116. retinal, 343. secondary auditory, 344, 628. visual, 342, 628. spinal, 115. temperature, 354. utterance, 349. vital, 116. Centrifugal secondary degeneration, 128. Centripetal secondary degeneration, 128. Centrum ovale, functions and lesions of, 352, 360, 361. hemorrhage into, 459. Cephalic index, 148. tetanus, 89S. Cepbalocele, 314. Cerebellar affections, congenital, 382. centres, 115. conducting tracts, 71. cortex, minute anatomy of, 374. disease, clinical phenomena of, 381. hemorrhage, 459. heterotopia, 596. lesions causing secondary degeneration, 564. olive, 71. peduncles, fibres of, 72. lesions of, 379. surface, subdivisions of, 68, tracts, 109. direct, 75. Cerebellum, 67. GENERAL INDEX. 1037 Cerebellum, anatomical relations of, 373, 598. atrophy of, 382, 598. central lobe of, 68. connections of, 107. decussating commissures of, 72. dendritic tracts of, 72. direct sensory tracts of, 72. experiments on, 377. facts regarding, 376. functions of, 373. ganglia and deposits of, 70. lateral lobes, divisions of, 69. lesions of, 378. lesiona of, 373. longitudinal commissure of, 72. method of outlining, 393. middle lobe, lesions of, 378. posterior commissure of, 72. postmortem examination of, 404. Cerebral abscess. (.S'ee Encephalic abscess.) anemia, 273. arteries, cortical, 418. centres concerned in speech, 628. commissures, lesions of, 366. coordinations of ocular movements, 830. deafness, 662. hemorrhage, 451, 459. artery of, 421. heterotopia, 596. lobes, separation of, 407. paralyses of children, 604. cerebral and spinal lesions in, 620. defects in the visual fields, 613. diagnosis, 619. etioiogy, 614. of postnatal cases, 615. special clinical types, 616. in epilepsy, 611. infectious and postinfectious, 621. mirror writing in, 613. pathogenesis, 614. pathological anatomy, 617. prenatal causes, 614. prognosis, 624. surgical measures in, 627. symptoms and conditions, re- sidual, 608. of period of onset, 607. treatment, 625. of residual conditions and symptoms, 626. tumors as a cause, 622. root of trigeminus, 861. vesicles, 29. relation to fully developed brain, 33. zone of language, 643. Cerebrin, 228. Cerebritis, 530. Cerebrospinal fluid, character of, in different diseases, 426. meningitis, 281, 283, 290. epidemic, 283. prognosis, 294. tubercular, 281. Cerebrum, association fibres of, 62. lobation of, 37. lobes of, 34. methods of making transections of, 398. projection of interior structures on sur- face, 404. Chemical constituents of the brain, 123. effects of microbic and toxic agencies, 139. processes and nervous action, 124. Chemistry of the nervous system, 122. Cheyne-Stokes breathing, 458, 970. Chiasm, lesions of, 760. Chief auditory nucleus, 81. motor trigeminal nucleus, 860. Children, cerebral palsies of, 604. Chin jerk, 171. Chinese brain, 44. Chloral, 242, 254. Chloralamid, 242. Chloralose, 242. Chloride of silver battery, 182. Chloroform liniment, compound, 252. Cholesteatomata, 503. Chorda tympani nerve and taste, 686. supposed connections with the tri- geminus, 695. Chorea, electric treatment of, 204. Choreic movements in diplegia, 610. Chromidrosis, 176. Chromophobic cells, 328. Chronic encephalitis, 540. hemiplegia, points in diagnosis of, 589. hydrocephalus, 315. leptomeningitis, 297. progressive bulbar paralysis, 1007. Ciliary ganglion, 798. nerves, 798, 799. spasm, 812, 825. Ciliospinal centre, 807. Cimicifuga, 250. Cinchonidine salicylate, 247. Cingulum, 362. Circle of Willis, 417, 442. Circumference of skull, 147. Cisterna magna cerebello-meduUaris, 99. Clarke's column of the spinal cord, 89. Claustrum, 56. embryonic relations of, 57. functions of, 359. Clavate tubercle, 77. Climate, influence of, on nervous diseases, 135, 211. Coca, 250. Cocaine hydrochlorate, 254. Cochlea in analysis of sounds, 708. Cochlear central tract, 712. nerve, 81, 707. atrophy of, 719, 720. course and terminal nuclei of, 710. diseases, 707. clinical history, 715. diagnosis, 723. etiology, 721. prognosis, 725. treatment, 726. distribution in brain stem, 711. syphilitic disease of, 721. root, 796. Cochleovestibular disease, 728. diagnosis, 743. etiology and pathology, 742. prognosis, 744. treatment, 744. Codeine, 245. Coelia, 30. Colchicura, 250. Cold applications, 225. Collaterals, 13. Collodion with cantharides, 252. 1038 GENERAL INDEX. Color blindness, 161, 757, 758. changes in hemianopsia, 161. gustation, 153. sense, loss of, in hemianopsia, 770. Columnar layer, 24. Commissural cells of Golgi, 91, 93. fibres, 62. structures of the brain, 58. Commissures, cerebral, lesions of, 366. Common sensibility, affections of, 944. Complications of encephalic hemorrhage, 462. Compressibility of brain substance, 428. Compression of the brain, 427. Commutators, 187. Conarium, 5, 64. connection with temperature apparatus, 369. lesions of, 368. Concept aphasia, 631, 636. centres, separate existence of, 645. Concussion of the brain, 427. Conducting tracts, cerebellar, 71. Conductors, electrical, 181. Congestion, dural, 262. of the brain, 273. Coniine hydrobromate, 255. Conium, 236. Conjugate convergence paralysis, 826. deviation, due to cortical and subcortical lesions, 831. to lesions of the pons and ob- longata, 338. to pontile lesions, 831. of eyes and head, 166, 732. in encephalic hemorrhage, 455. varieties and mechanism of, 831. Consensual iritic reactions, 822. Contraction, 166. Contractures, 166, 573. in diplegia, 609. secondary, mechanism of, 575. Contralateral paralysis in supradural hemor- rhage, 270. Convergence centre, 801. paralysis, 826. spasm in, 826. Convolutions, 40. retroinsular, 350. table of, 50. Convulsions, 166. genera], in hemiplegia, 590. in cerebral paralyses of children, 619. in encephalic tumor, 513. Corona radiata, lesions of, 360. Corpus ciliare, 71. striatum, 55, 352. trapezoides, 68, 79. Corrosive sublimate wash for stomach, 252, Cortex, cerebral, 3. ambiguous layer of, 328. Flechsig's subdivision of, 332. layer of large pyramidal cells, 329. layers of, 325. microscopical localization in, 363. minute anatomy of, 322. molecular layer of, 327. polymorphic layer of, 329, 364. lemniscus tract, 87. Corti, ganglion of, 81, 709, 730. organ of, 709, 729, 730. Cortical arteries, subdivisions of, 419, 420. bundle, anterior, 108. centres. {See Centres.) Cortical gustatory area, lesions of, 703. hemorrhage, 457. lamination, 324. lesions causing conjugate deviation, 831. causing disorders of ocular move- ments, 829. latent, 351. localization, 332. polioencephalitis, 531. sensory expanse, 104. tumors, 517. Co rtico afferent fibres, 114. Cough, trigeminal reflex, 882. Cranial capacity, determination of, 412, fossae, diffuse abscess in, 548. methods of reaching, 392. index, 148, 390. investigations, 146. nerve roots, 79. nerves, deep origins of, 80. enumeration of, 667. nuclei of motor, 82. nuclei, 79. sensory nerves, ganglia of, 103. roots of, 80. Craniocerebral determinations, 385. topography, 383. Craniometrical lines, 385, 386, 387. methods, 147. Cremasteric reflex, 175. Creolin for lavage, 253. Cricoarytenoid paralysis, 956, 957. Crista acustica, 729. Crossed amblyopia, 759, pyramidal tract, 90, 107. Croton chloral, 246. oil liniment, 252, Crura, 4, 72. Cms, degeneration in, 562. lesions of, 372. Crusta, 86. Cuneate funicles, 74. nucleus, accessory, 77, Cupping apparatus, 227. Curara, 255. Current combiner and commutator, 188. controllers, 186. sinusoidal, 191. Cutaneous and muscular sensation, represen- tation of, in cortex, 340. pupillary reflex, 824. reflexes, 169. in hemiplegia, 579. sensibility, 155. Cyclocephalus, 314. Cyclopia, 314. Cycloplegia, 811. Cyrtometer, 390. Cysticercus cellulosse, 504, 505. Cysts in the brain, 504. Daltonism, 758. Darkschewitsch's nucleus, 801, 802. Deafness, congenital, 721. due to tabetic atrophy, 720. hysterical, 721. paradoxic, 716. simulated, 724. detection of, 725. verbal, 632. GENERAL INDEX. 1039 Decubitus in encephalic hemorrhage, 456. Decussation, motor, 107. sensory, 101. Degeneration, acute, 127. calcareous, 127. colloid, 127. cystic, 504. fatty, 127. fibroid, 127. following encephalic lesions, 560. granular, 127. in callosuin, 365. in eras, 562. inflamiuatory, 557. of central tegmental tract, 562, of lemniscus, 563. of motor tracts, secondary bilateral, 559. pigmentary, 127. primary and secondary, 127. reaction, 194. secondary, 555. after cerebellar lesions, 564. ascending, 12S, 564. descending, 128, 557. distinguished from involution, 558. initiation of, 557. occurring after acute focal lesions, 556. of crossed pyramidal tracts, 559. of postgeniculum, 358. progress of, 557. spinal, vascular origin of, 129. traumatic, 557. Wallerian, 128. Degenerative diseases and laryngeal paral- yses, 960. diagnosis from encephalic tumor, 525. with disorders of ocular movements, 841. Deglutition centre, 117. Deiters's cells, 16, 709. nucleus, 82, 718, 730. Dejerine's method of making brain autopsies, 397. Delirium in encephalic hemorrhage, 455. Dentate gyre, 60. Dentatum, 71. Descending root of trigeminus, 861. Developmental influences, 133. Deviation, ocular, 810. Diacoele, 31. Diaplexus, 52. Diatela, 52. Diatheses, 137. Dielectric, 181. Diet, 211. in rest treatment, 221. Digestive disturbances due to vagal disease, 976. Diplegia, 165, 565, 604. choreic and athetoid movements in, 610. contractures in, 609. differentiation of prenatal and postnatal cases, 623. epilepsy in, 611. postparaplegic, movements in, 609. spastic, diagnosis from pseudoparalytic rigidity, 621. varieties of, 605. Diplopia, 809. homonymous, 813. lateral, 813, 814. Diplopia, tests for ocular paralyses, 813. vertical, 813, 814. Direct pyramidal tract, 107. Dolichocephalic head, 149. Dorsal longitudinal bundle, 72, 79, 84, 929. or internal nucleus, 81. Dosage, efficient, 232. electric, 188. Doses of newer drugs, 2;U. Drugs, abuse of, 232. causing amblyopia, 78-!. untoward effects of, 232, 233. Duboisine sulphate, 254. Da Bois-Reymond coil, 189. Dura, 95. arteries of, 259. experiments on, 273. functions of, 259. irritation of, causing spasm, 273. Dural abscesses, 273. carcinoma, 502. congestion, 262. epilepsies, 273. hematoma, 264. clinical history, 264. definition, 264. diagnosis, 266. etiology, 265. pathology and morbid anatomy, 266. prognosis, 267. symptoms, 265. treatment, 267. hemorrhage, 269. lesions in, 271. mode of origin and treatment of, 271. hyperemia, 262, inflammation, 259, 262. nerve supply, 260. sinuses, 303. tumors, 272. Duret's experiments on animal skulls, 429. Duval's accessory nucleus, 990. Dynamometers, 167. Dysacusia, 717. Dysarthria, 660. Dyschromatopsia, 758. Dysesthesia, 152. Dysgraphia, 641. Dyslexia, 641. Dysraimia, 641, Dyspepsia, nervous, 978. Dysphagia paralytica, 952. Dysphasia, 641. Dyspnea, 970. E. Ear, electrical application to, 200. Echinococcus of the brain, 504, 506. Eclampsia nutans, 985. Ectocinerea, 52. Edema of the brain, 438. clinical history, 439. diagnosis, 441. etiology, 440. morbid anatomy, 440. pathogenesis, 440. pathology, 440. prognosis, 441. treatment, 441. varieties, 439. Edinger-Westphal nucleus, 801, 803. Eighth nerve, subdivision of, 707. 1040 GENEKAL INDEX, Elaeomyenchysis, 258. Elbow jerk, 171. Electric dosage, 188. excitation of nerves, 119. Electrical applications, 199. currents, density of, 180. reaction, peculiarities in, 196. Electricity, 125. action on living tissues, 179. care and method in use of, 201. diagnostic uses of, 193. frictional, 206. in neurological therapeutics, 201. miscellaneous uses of, 204. nature of, 181. static, 206. Electrization, muscular, 200. Electrodes, 192. Erb's, 189. head, 192. static, 208. Electrodiagnosis, 193. Electrodiagnostic technique, 197. Electrolysis, 179. Electromedical apparatus, 179. Electromotive force, 179, Electrophysics, 179. Electroprognosis, 193, 198. Electrosensibility, 197. cutaneous, 198. Electrotherapeutics, 199. Electrotonus, 179. Embolism, encephalic, 476. clinical history, 476. course, 478. diagnosis, 481. from hemorrhage and throm- bosis, 489. etiology, 479. focal types, 478. initial symptoms, 476. pathogenesis, 480. pathological anatomy, 480. prognosis, 482. prophylaxis, 483. softening from, 476. treatment, 483. Eminentia teres, 76. Encephalic abscess, 543. multiple, 555. aneurism, 446. arterial systems, 417. bloodvessels, diseases of walls of, 441. capillaries, occlusion of, 492. circulation, 416. embolism, 476. endarteritis, 446. hemorrhage. 451. histology and physiology, relations to focal brain diseases, 321. infarction, 492. lesions fullowed by degeneration, 560. malformations and aberrations, 259, 313. parts, classification of, 52. softening, acute, 475. chronic, 476. multiple, 490. tumors, 493. vessels, diseases of, 416. visual apparatus, 746. Encephalitis, 530. acute diffuse nonsuppurative, 535. focal, 532. Encephalitis, acute focal, clinical history, 533. diagnosis, 534, etiology, 533. pathological anatomy, 534. prognosis, 534. treatment, 534. chronic, 540. diagnosis from encephalic abscess, 553. diffuse, clinical history, 536. diagnosis, 638. duration and course, 537. etiology, 537. pathological anatomy, 537. prognosis, 539. treatment, 539. disseminated, 539. suppurative, 542. Encephalospinal conducting paths, 100. Enchondromata, 501. Endarteritis and nephritis, diagnosis from encephalic tumor, 522. chronic, 445. Endothelioma, 499. Entocinerea, 52, Entotic noises, 717. Ependymitis, cause of ventricular effusion, 283. Bpicoele, 32. Epidemic cerebrospinal meningitis, 283. Epidural hemorrhage, 269. Epilepsies, dural, 273. Epilepsy in cerebral paralyses of children, 611. in porencephaly, 603. Epileptiform trigeminal neuralgia, 867. Equilibration, affections of, 728. clinical history, 732. diagnosis, 743. etiology, 742. prognosis, 744. treatment of, 744. in relation to quadrigeminal body, 370. to red nucleus, 373. Ergotin, 257. Ergotinin, 257. Erythroxylon. 250. Eserine sulphate, 254. Esophageal spasm, 977. Esophagus, paralysis of, 976. Esophoria, 810. Esotropia, 810. Esthesiometers, 154. Etiology, general, 125. Exalgin, 245. Exciting causes of nervous diseases, 132. Exencephalus, 313. Exercises, systematized, 217. Exner's plexus, 363. Exophoria, 810. Exophthalmic goitre, 973, 974. Exophthalmus, 159. Exotropia. 810. Extensor jerk, 171. External capsule, 56. functions of, 359. hydrocephalus, 269, 315. leptomeningitis, 274. pachymeningitis, 262, 263. Extraciliary fibres, 72. E.xtracts, animal tissue, 228. Extreme capsule, 56. functions of, 359. Eye, electrical applications to, 200. ground, normal, 774. GENERAL INDEX. 1041 Bye, musculature of, 796. cortical representation of, 3;-{7. Eyeballs, affections of rotation, 833. Eyelids, centre for movements of, 339. Eyestrain, diagnosis from enoepiialic tumor, 526. relation to headache, 876. F. Face movements, cortical representation of, 336. Facial hemiatrophy, 885. hypertrophy, 888. length, 148. nerve, 899. neuralgia, 868. paralysis, 904. association with other cranial nerve affections, 913. bilateral, 910. cerebral, 904. complete peripheral, 909. diagnosis, 916. etiology, 914. in hemiplegia, 569. nuclear, 905. pathological anatomy, 91 6. peripheral, 904. pontile, 905. prognosis, 917. sense of taste in, 908. treatment, 918. spasm, 919. cortical and subcortical, 921. diagnosis, 924. etiology, 923. neural (trunkal), 922. nuclear, 922. pathology and morbid anatomy, 924. prognosis, 924. symptomatology, 920. treatment, 925. Falciform lobe, 36, 350, 673. Falcula, 95. False projection, 810. Falx, 95. Faradic apparatus, 189. Faradism, 179. Faradization, general, 201. Fascia dentata, 36, 347. Fasciculus, oortioo-protuberantial, 108. retroflexus, 111. solitarius, 81. Fasciola cinerea, 60. Faucial muscles, paralysis of, 962. Fibrae proprise, 362, 990. Fibres, nerve, 17. Fibromata, 501. Fields of conjunction, 363. Fifth nerve, diseases of. (See Trigeminal nerve.) Fillet, 84, 87, 1000. Filum terminale, 5. Fimbria, 33, 60. Fissural arrangement, variations in, 42. Fissures, according to Bcker, 39, 40, 41, 42. to Wilder, 41, 42. ental correlatives of, 46. AVernicke's, 45. Flavors, 675. Flechsig's tract, 90. Flocculus, 69. Flocculus, commissure of, 67. connections with vestibular nerve, 731. Focal diseases of the brain, 321. symptoms of thrombosis, 487. types of encephalic embolism, 478. Foot rheotome, 185. Foramen of Monro, 31. Forced movements, 165, 577. Formalin preparations, 414. Formatio reticularis, 78. Formulas, 241. electrical, 194. Fornix, 59. functions of, 347. lesions ol', 366. longus, 672. Fothergill's face ache, 868. Four root theory of nerves, 795. Fourth nerve, nucleus and root fibres of, 804. paralysis, double, 827. symptoms of, 826. peripheral course of, 805. ventricle, floor of, 74, 75. Fovea inferior and superior, 76. Franklinism, 179, 206. Frontal lobe, lesions of, 351. Functional neuroses and laryngeal disorders, 960. Fundus oculi, 774. Galvanic batteries, 181, 183. Galvanofaradization, 202. Galvanometer, 188. Ganglia, collateral, 7. of the brain, 54. of the cerebellum, 70. of the cranial nerves, 103. Gangliated system of nerves, 7. Ganglioblasts, 26. Ganglion, auditory, 81. ciliary, 798. geniculate, 692, 902. habenulae, 673. interpeduncular. 111. of Corti, 81, 730. of Scarpa, 81, 729, 730. subthalamic, 67. Gasserian ganglion, 28. operations on, 696, 872. Gastralgia, 977. Gastric anesthesia, 950. crises, 977. Gaultheria, oil of, 247. GeI16's binaural reflex, 163. Gelsemium, 237. Geniculate body, external, 63, 358. internal, 5, 63, 358, lesions of, 358. ganglion, 692, 902. Genufacialis, 76, 82, 901. Geographical centre, 344. Gerlier's disease, 738. Glabella, 147. Glabellum, 147. Glia cells, 16. Gliomata, 500. Gliomatosis, 130. Globus hystericus, 977. pallidus, 66, 110. Glonoin, spirit of, 257. Glossolabiolaryngopharyngeal paralysis, 1006. 66 1042 GENERAL INDEX. Glossopharyngeal nerve, anatomy of, 935. central neurons of, 959. diseases of, 9'.i5. distribution to the tongue, 688, 689. functions of, 936. gustatory division of, 686. oblongatal nuclei of, 686. paralysis of, 944. peripheral course of, 687. physiology of, 935. roots, 686, 796, 935. subdivisions of, 935, 937. the main nerve of taste, 688. Glossoplegia, 993. Gnathion, 147. Golgi's commissural cells, 91. method of brain preparation and stain- ing, 415. sensitive cells, 327, 328, 330. Goll, column of, 90. Gonion, 147. Gowers, intermediate process of, 89. Gowers's tract, 90. Gracile funicles, 74. tubercle, 77. Graphic centre, 349. Gray matter of brain, analysis of, 122. oil, 256. Green blindness, 758. Grenet cell, 182. Guaiac, 250. Gudden's commissure, 753. Gummata, 496. Gustation, colored, 153. Gustatory affections in tabetic cases, 703. of nuclear origin. 701. apparatus, peripheral focal lesions of, 700. area, cortical, 703. cells, 683. end organs, peripheral, 683. localization, 348. pathway, bulbocerebral, 698. symptoms, 698. Gyral arrangement, variations in, 42. Gyres, table of, 50. H. Haab's cortical pupillary reflex, 824. Ilabena, 52. Habenula, 63, 672. Hallucinations of hearing, 717. of smell, 675. visual, 794. Hamilton's method of brain section, 400. Head and eye movements, cortical represen- tation, 337. sizes and shapes of, 149. temperatures, 177, 178. tetanus, 898. Headache, anemic, 427, 436. hyperemic, 431. in encephalic tumors, 509, 526. in leptomeningitis, 276. in pachymeningitis, 263, 264, 268. in thrombosis, 485. nerves involved in, 260. paroxysmal, 872. reflex, 881. sick (see Migraine), 872. syiuptomRtic, 875. trigeminal, 881. due to eyestrain, 876. Hearing, accessory nerves of, 708. affections of, 707. clinical history, 715. diagnosis, 723. due to diseased cochlear nerve, 707. etiology, 721. pathological anatomy, 722. prognosis, 725. treatment, 726. disorders of, in hemiplegia, 582. essential nerve of, 707. hallucinations of, 717. hysterical affections of, 721. methods of testing, 163, 723. Heart disease a cause of vertigo, 737, irritable, 975. nerve supply to, 942. tobacco, 976. Heat centres, 355, 356, 357. Hecatomeral cells of spinal cord, 93. Hematoma, dural, 264. Hemeralopia, 792. Hemiachromatopsia, 758. Hemiageusia, 698. Hemianesthesia from lesions of internal cap- sule, 341. from lesions of thalamus, 382, 581. in hemiplegia, 581. with pareses or paralyses of ocular mus- cles, 838. Hemianopsia, 159. altitudinal, 767. association with disorders of ocular move- ments, 769. with disturbances of speech, 769. with hemiplegia, 582, 764. with loss of color sense, 770. with verbal amnesia, 770. binasal, 761. bitemporal, 761. diagnosis, 772. double, 344. from lesions of calcarine cortex, 343. heteronymous, 760, 762, 763. homonymous, 762, 764. horizontal, 767. nasal, 760. prognosis, 772. special forms of, 766. transient, 765. treatment, 772. unilateral nasal, 761. Hemicrania, 872. Hemidrosis, 176, Hemifacial atrophy, 885. hypertrophy, 888. Hemilingual atrophy, 995. Hemiopia. 159. Hemiopic pupillary reaction, "Wernicke's, 160, S23. Hemiplegia, 165. alternate, 572. of the ocular type, 836. amount and order of recovery in, 566. and laryngeal paralysis, 959. anesthesias in, 581. association with hemianopsia, 764. bilateral, 588. chronic, 565. diagnosis, 589. prognosis, 591. treatment, 591. clinical types, 568. GENERAL INDEX. 1043 Hemiplegia, contractures and rigidities, 573. cutaneous reflexes in, 579. disorders of mentality in, 587. position and movement in, 573. special senses in, 582. double, 565, 588, electrical treatment of, 592. etiological diagnosis of, 5Sy. facial and Ungual paralysis in, 569. general convulsions in, 590. infantile cerebral, 606. Jacksonian epilepsy in, 590. joint affections, 586. pain and hyperesthesia in, 580. paralysis of sphincters in, 587. paresthesias in, 580. prophylaxis of, 591. relative involvement of different parts in, 567. sensory disorders in, 580. surface temperatures in, 583. tendon and muscle phenomena in, 579. treatment of, 591, 593. trophic phenomena in, 5S6. twitching and abnormal movements in, 578. types of, pathological significance, 571. vasomotor and secretory phenomena in, 582. Hemiplegic atrophy, 58J:. Hemorrhage, capillary, 462. cerebral, 459. cortical, 451. diagnosis from embolism and thrombosis, 489. dural, 269, 271. encephalic, 451. apoplectic onset, 453. clinical history, 452. common sites of, 452. diagnosis, 465, 466. from acute focal lesions, 470. from alcoholism, 468. from asphyxia, 468. from encephalic abscess, 552. from toxemias, 467. differential diagnosis, 469. durations and complications of, 462. etiology, 463. exciting causes of, 464. groBS appearances in, 464. miscellaneous phenomena in, 456. multiple, 460. pathological anatomy, 464. predisposing causes of, 463. premonitory symptoms of, 453. prognosis, 472. temperature in, 471. threatening symptoms of, 466. treatment, 474. varieties, 451. epidural, 269, 451. intermeningeal, 270. into subcortex and centrum ovale, 459. intracerebral, 451. meningeal, 269. primary ventricular, 457. secondary ventricular, 458, 469. subdural, 269, 270, 451. with reflex spasms, 260. Bubpial, 451. supradural, 269, 270, 451. Hemorrhagic internal pachymeningitis, 262, 264. Heredity, 133. Herpes zoster, 860. ophthalmic, 859. Heteromeral cells of the spinal cord, 93. Jleterophoria, 810. Heterotopia, 596. Ileterotropia, 810. Hippocamp, 33. Hippocampal sulci, 39. Hippus, ih;i. Homologies between spinal and cranial nerves, 795. Hot applications, 226. Hutchinson pupil, 270. Hyaline degeneration, 445. Hydatid cysts, 504. Hydrastinine, 246, Hydriodic acid, 249. Hydrobromio acid, 242. Hydrocephaloid disease, 293, 309, 436, Hydrocephalus, acute, 282. chronic, 315. clinical history, 315. diagnosis, 318. from encephalic tumor, 524. etiology, 317. pathology, 317. prognosis, 318. treatment, 319. from eysticerci, 505. Hydrochloric acid for lavage, 253. Hydroencephalocele, 314. Hydrotherapy, 212. Hygiene, general, 211, Hylas, 31. Hyoscin bydrobromate, 243. Hyoscyamine, 254. Hyperacusia, 715, 717. Hyperageusia, 698. Hyperalgesia, auditory, 717. Hypercryalgesia, 152. Hyperemia, dural, 262, 263. leptomeningeal, 273. meningnencephalic, 274. of the brain, 274, 431. diagnosis, 434. etiology, 431 . pathological anatomy, 433. pathology, 432. prognosis, 434. symptoms, 431. treatment, 435, varieties, 431. of the membranes of the brain, 431. of the retina and optic nerve, 777. Hyperesophoria, 810. Hyperesthesia, 152. in hemiplegia, 580. laryngeal, 949. visual, 792. Hynerexophoria, 810. Hyperkineses, 604, Hyperosmia, 674. Hyperphoria, 810. Hyperthermalgesia, 152. Hypertrophy, hemifacial, 888. of the brain, 594. Hypertropia, 810. Hypnal, 243. Hypnone, 243. Hypnotics, 234, 1044 GENERAL INDEX. Hypnotism, 225. Hypodermatic medication, 253. Hypoglossal nerve, diseases of, 990. periplieral course of, 990. roots, 795. nucleus, 990. paralysis, 993. spasm, 994. HypophospMtes, 249. Hypophysis, 65. lesions of, 367. tumor of, 368. Hysteria, diagnosis from encephalic tumor, 527. simulating tubercular meningitis, 294. Hysterical affections of hearing, 721. of smell, 679. of taste, 704. ocular paralysis, 846. Ideational region of brain, 36. Imminence of contracture, 574. Immunity, 229. Indusium griseum, 59. Infantile cerebral palsies. {See Cerebral pa- ralyses of children.) Infarction, encephalic, 492. Inferior stephanion, 147. Inflammation, 126; dural, 262. in encephalic tumor, relief of, 529. varieties of, 126. Inflammatory degeneration, 557. Inframaxillary neuralgia, painful spots for, 866. Infundibulum, 4, 62. stylomastoid, 902. Ingravescent apoplexy, 458. Inhibition, 117. Inion, 147. Inoccipitia, 314. Insanity, diagnosis from encephalic tumor, 525. Insomnia in encephalic tumor, 510, Inspection in study of nervous disease, 144. Insufficiencies of ocular muscles, 810. Insula, 36, 350. Insulator, 181. Interbrain, 63. Interealatum, 65, 87. Intermediary cell, 13. nerve of Wrisberg, 691. Internal capsule, 56. lesions of, 341, 358. subdivisions of, 358, 359. pachymeningitis, 262, 264. Interpeduncular ganglion, 111. Intracerebral associating tracts, lesions of, 362. hemorrhage, 452, 469, 470. Intraciliary fibres, 72. Intracranial percussion note in encephalic tumor, 514. veins, disease of, 312. Intraocular muscles, 796. spasmodic afi'eGtions of, 821, 825, 826. supplied by third nerve, affections of, 821. Inunction, mercurial, 225. Involution distinguished from secondary de- generation, 558. Iodoform collodion, 252. ointment, 252. Iridoplegia, 811. Iris, mobility of, 162. Iritic reflex in thrombosis, 487. Irritable heart, 975. Jacksonian epilepsy, 590. Jaw chattering, 892. jerk, 171. Joint affections in hemiplegia, 586, Junod's boot, 227. K. Knee jerk, 172. apparatus, 173. in hemiplegia, 579. method of taking, 172. physiology of, 174. reinforcement of, 173. Kola, 251. pill, compound, 251. Krause, respiratory bundle of, 81. L. Labyrinthine anemia, 722. inflammation, 721. Labyrinthitis, Voltolini's, 739. Lacs sanguins, 97. Lactic acid for lavage, 253. Lambda, 147. Lamina cinerea, 31. Landmarks, skull, 147. Language zone, 643. Laryngeal abductor paralysis, 956. adductor paralysis, 957. and pharyngeal representation, 337. anesthesia, 949. disorders and functional neuroses, 960. hyperesthesia, 949. muscles, spasm of, 965. nerve, inferior, paralysis of, 955. superior, paralysis of, 958. paralyses, 954. and degenerative diseases, 960. diagnosis, 962. etiology, 961. pathogenesis, 961. pathological anatomy, 962. prognosis, 963. treatment, 964. with hemiplegia, 959. spasm, 965. diagnosis, 968. etiology, 967. pathogenesis, 967. prognosis, 968. treatment, 968. Laryngismus stridulus, 965. Larynx, muscles of, 954. spasm of, 965. Latent cortical lesions, 351. Lateral medullary tract, 84. nerve roots, development of, 27. nucleus of oblongata, 83. sinus, method of outlining, 393. thrombosis, 308. Lavage, 227, 253. Leclanch6 cell, 182. GENERAL INDEX. 1045 Lemniscus, 84, 87. degeneration of, 563. functions and lesions of, 931. sensory fibres in, ;;72. Lenhoss^k's commissural cell, 94. Lenticula, 55. embryonic relations of, 57. functions and lesions of, Ij52. lesions of, causing pseudobulbar paral- ysis, 353. Lenticular bundle, 65. ganglion, 798. loop, 110. Leptomeningeal hyperemia and anemia, 273. Leptomeningitis, 127, 274. acute, 275. condition of cranial nerves in, 293. diagnosis, 292. general symptoms common to all types, 275. headache in, 276. purulent, associated with brain ab- scess, 278. tubercular, 280. basilar, 276. chronic, 297. causes of, 298. changes of the membranes in, 298. clinical history, 298. conditions of vessels in, 301. diagnosis, 301. etiology, 300. in the insane, 298. pathological anatomy, 300. prognosis, 302. treatment, 302. epidemic cerebrospinal, 275, 283, 290. external, 274. general etiology of, 285. idiopathic, 275. latent cases of, 278. lesions in special varieties of, 289. nonpurulent, 275. of the convexity, 277. optic neuritis in, 276. pathogenesis of, 287. pathological anatomy common to all types of, 288. prognosis, 294. purulent, 275, 296. respiration in, 276. serous, 275, 278. suppurative, 275. symptoms, 280. treatment, 295. tubercular, 275, 280. varieties, 275. verticalar, 275. vertigo in, 276. with encephalic abscess, 544. Leucomaines, 138. Levator palati, paralysis of, 952. palpebrse superioris, paralysis of, 819. Levels of the nervous system, 114. Ligamentum denliculatum, 96. Limb measurements, 150. Limbic lobe, 36, 347, 673. Lingual atrophy, 995. paralysis in hemiplegia, 569. spasm, 994. Lipomata, 501. Lissauer, column of, 90. Lithium biborate, 250. Lobar sclerosis of the brain, 600. Lobe, limbic, 36, 347. Lobes of the cerebellum, 68. of the cerebrum, 34, 35, 36. Lobules, table of, 50, Local remedies, 225. Localizing symptoms, different classes of, 351. Lockhart Clarke, intermediolateral tract of, 89. Locus ceruleus, 76. nigra, 87. Longitudinal sinus, 304. thrombosis, 307. tracts of oblongata and pons, 84. Lowentbal's tract, 90. Lower extremities, centre of representation of, 334. jaw movements, cortical subarea for representation, 336. Lumbar puncture in treatment of serous lep- tomeningitis, 297. Lungs, disease of, in encephalic abscess, 546. Luys, body of, 67. Lymph spaces and vessels of the nerves, 99. Lymphatics of the interior of the brain, 98. of the nervous system, 95, 98. Lymphopathy, ataxic, 176. Lyre, 60. M. Macrencephalia, 594. Macrocephalus, 594. Macula acustica, 729. Macular bundle, 750. representation, 343, 755. Magnets in treatment of nervous affections, 210. Malarial neuralgia, 866. Malformation, developmental, 125. of the brain and its envelopes, 313. Mammillary eminences, 4. Mantle layer, 24. Marantic thrombosis, 309, 311. Martinotti's cells, 330. Massage, 215. in hemiplegia, 593. Masseter spasm, 893. Massey current controller, 186. Masticatory nucleus, 860. paralysis, 889. diagnosis, 891. etiology and pathogenesis, 891. prognosis, 892. symptomatology, 889. treatment, 892. spasm, 892. Mastoid process, method of outlining, 393. Maximum occipital point, 147. Medicommissure, 58. Medicornu, 33. Medipeduncle, 5, 379. Medulla oblongata, 73. . Medullated nerve fibres, 17. Megrim, 872. Membranes of the brain, anemia of, 436. classification of diseases of, 262. diseases of, 259. of the nervous system, 95. Meniere's disease, 740. diagnosis, 743. etiology, 742. paroxysmal form of, 741. pathological cause of, 740. 1046 GENERAL INDEX. M^ni^re's disease, prognosis, 744. transient apoplectic form of, 741. treatment, 744. Meningeal artery, 259. hemorrhage, 269. diagnosis from ventricular hemor- rhage, 470. Meningitis, 126. cerebrospinal, 281, 283, 290, 296. microscopical appearances in, 291. diagnosis from encephalic abscess, 551. from encephalic tumor, 52.'!. epidemic, cerebrospinal, 28.'i. clinical history, 284. condition of cranial nerves in, 291. diagnosis, 293. lesions in, 290. prognosis, 294. treatment, 296. varieties, 285. serosa, 278. serous, 279. tubercular cerebrospinal, 281. diagnosis, 292, prevention, 297. prognosis, 294. treatment, 297. Meningocele, 314, 319, 320. Meningocephalitis, 127, 532. Meningoencephaloeele, 314. Meningomyelitis, 127. Mental disease and speech disturbances, 655. diseases due to infectious processes, 139. disorders in hemiplegia, 587. examination of patients, 142. phenomena, time relations of, 143. Mercurial inunction, 225. Mercuric chloride, 256. Mercury, used hypodermatically, 256. Mesal groove, 75. Mesencephalic root of the trigeminus, 861. Mesocephalie head, 149. Mesoccele, 31. Metacoele, 32. Metallic tonics, 238. Metatela, 52. Metepicoele, 32. Metepicoelian floor, 74, 75. Methods of investigation, general, 142. Methylal, 243. Methylene blue, 245. Metopion, 147. Meynert's commissure, 753. method of brain dissection, 406. Microbic agencies, chemical effects of, 139. origin of nervous diseases, 138. Microcephalic heads, 149. Microcephalus, 314. Microscopical localization in cortex and sub- cortex, 363. Migraine. 872. definition, synonyms, and varieties, 872. diagnosis, 877. from encephalic tumor, 526. etiology, 875. hygienic measures in, 877. ophthalmic, 874. ophthalmoplegic, 873. pathology, 876. prognosis, 877. symptomatology, 872. Migraine, third nerve affections in, 844. treatment, 877, 878, 880. visual spectra in, 874. Migrainoid supraorbital neuralgia, 875. Miliary aneurism, 447. Milliampere, 180. Mineral baths, thermic, 213. spring resorts, 214. Mirror writing, 656, Mixed lateral tract, 90. Mobility of the iris, 162. Modal galvanic changes, 194. Molecular layer of the cortex, 327. Monarchical vasomotor centres, 116, 354. Monocular vision, 809. Mononyms, 47, 49. Monoplegias, 165, 565, 589. Monro, foramen of, 31. sulcus of, 52. Motion, sensations of, 158. Motor aphasia, 349. cells, 19. cortex, subdivisions of, 334. decussation, 107. lesions of, 1001. disorders, 165. localization, 331. nerve points, 200. roots, development of, 25. projection system, lesions of, 360. tracts, secondary bilateral degeneration of, 559. trigeminal disease, definition and varie- ties, 889. Movement treatment, 217. Mucous tumors, 499. Mueller's muscle, 797. Multiple encephalic abscess, 555. hemorrhage, 460. softening, 490. vision, 793. Muscle jerk, 171. phenomena, 171. in hemiplegia, 579. Muscles, extraocular, 796, 817, 818. intraocular, 796, 821. of the larynx, 954. representation in cell?, 10. supplied by motor division of trigemi- nus, 861. Muscular electrization for paralysis, 200. sensation, representation in cortex, 340. sense, localization of, 342. sensibility, tests for, 155. Musculature of the eye. 796. Myasthenia gravis pseudoparalytica, 1010, Mydriasis, 810. Myelocele, 313. Myelocoele. 32. Myelcspongium, 24. Myosis, 810. Myotonic reaction, 197. Myxomata, 499. Myxosarcoma, 499. N. Naming centre, 36, 345, 628. Nasal neuroses, 680. Nasion, 147. Nasubregmatic arc, 147. Nasolambdoidal line, Poirier's, 391. Nasooccipital arc, 147. GENERAL INDEX. 1047 Negative variation, 119. Nerve or nerves, abdueens, nucleus and root fibres of, 806. peripheral course of, 807. acoustic, nuclei and root fibres of, 81. arterial supply of, 98. cardiac, 972. cells. 9. Apathy's views of, 973. difi'erentiation of, 20. regeneration of, 129. shapes and sizes of, 10. structure of, 11. types of, 11. centres, action of, in transmission of nerve impulse, 121, 36o. bilateral arrangement of, 116. chorda tyrapani, 695. ciliary, 798, 799. cochlear, 81. diseases of, 707. conduction, l-t. cranial, deep origins of, 80. diseases of, 827. eighth, subdivision of, 707. electrical excitation of, 119. endings, motor and sensory, IS. facial, diseases of, 899. fibres, medullated and nonmeduUated, 17. fifth, diseases of, 852. four root theory of, 795. fourth, 804. diseases of, 826, 827. function, acceleration of, 118. gangliated system of, 7. glossopharyngeal, 686, 935. hypoglossal, 990. impulses, transmission of, 119. intermediary, of Wrisberg, 688, 691, 692. lateral motor, 795. lymph vessels of, 99. ocular, 795, 797. oculomotor, common, course of, 803. end organs of, 799. of bloodvessels, 425. of hearing, accessory, 708. essential, 707. of Jacobson, 688. of taste, 683. of the heart, 942. of the ocular muscles, 797. olfactory, diseases of, 667. optic, diseases of, 746. pathetic, 805. diseases of, 826. peripheral, 22. pneumogastric, 935. roots, cranial, 79. formation of, 27. lateral, development of, 27. motor, development of, 25. sensory, cranial, 80. development of, 26. seventh, diseases of, 899. sixth, 806. diseases of, 827. somatic, 8. spinal accessory, 935, 943. diseases of, 979. splanchnic, 8. third, course of, 803. diseases of, 815, 821. tree, 13. Nerve or nerves, trigeminus, diseases of, 852. trochlear, 805. diseases of, 826, 827. trunks, 22. vasoconstrictor and vasodilator, 425. vestibular. 81, 707, 730. disease of, 728, 732. Wallerian degeneration of, 128. Nervous action and chemical action, 124. asthma, 971. dyspepsia, 978, impulses, nature of, 118. palpitations, 076. structures of sense organs, 21. system, architecture of, 100. chemistry of, 122. development of, 23, general anatomy of, 54. general physiology of, 100. levels of, 114, 115. lymphatics of, 98, 99. segmental character of, 33. sketch of, 1. sympathetic, 7. tissues, 9. chemical characteristics of, 122. degeneration of, 127. dynamics of, 118. Neural canal. 23. crest, 26. Neuralgia, migrainoid supraorbital, 875. occipital, 448. pneumogastric, 948. relations to weather, 136. trigeminal, symptomatic forms of, 864, 866. Neuralgic sick headache, 872. Neurasthenia, acoustic, 720, Neuraxial cavities, 30. Neuraxis, 1. Neuraxon, 13. Neure, 13. Neurite, 13. Neuritis, olfactory, 678. optic, 779. trigeminal, 864. vagal, 947, 950. Neuroblasts, 24. Neurocyte, 13. Neurofibrils, 973. Neuroglia, 16, Neurological therapeutics, electricity in, 201. Neuromata, 501. Neuron, 13, Neuroparalytic ophthalmia, 859. Neuropathic constitution, 133. Nictitating spasm, 922. Night blindness, 792. Nitroglycerin, 256, 257. Nodose periarteritis, 442, 444. Nomenclature, anatomical, 47. Nonconductors, electrical, 181. Nonparalyzed side in hemiplegia, 588, Nose, electrical applications to, 201. Nuclear bulbar paralysis, 1006. ophthalmoplegia, 834. Nuclein therapy, 230. Nuclei or nucleus, abdueens, 806, accessory acoustic, 81. trigeminal, 861. ambiguus, 82, 937. auditory, 81. caudate, 33, 55, 352. 1048 GENERAL INDEX. Nuclei or nucleus, central, 83. chief motor of trigeminus, 860. clavate. 111. cranial, 79. cuneate, 77, 111. dentate, 71. dorsal or chief auditory, 730. vagoglossopharyngeal, 937. fastigii, 71. globosus, 71. gracilis, 77. habenular. 111. hypoglossal, 990. lateral, 83. chief, 803. lenticular, 55. masticatory, 860. of cochlear nerve, 710. of Darkschewitsch, 802. of Deiters, 82, 718, 730. of Edinger-Westphal, 802. of facial nerve, 900. of motor cranial nerves, 82. of the accessorius, 942. of the fourth nerve, 804. of the glossopharyngeus, subdivisions of, 937. of the pneumogastric nerve, subdivisions of, 937. of the roof of the cerebellum, 71. of the sixth nerve, 82, 806. of the third nerve, 799. of the vagus nerve, centres in, 116. Perlia's central, 801. pontis, 79. preolivaris externus, 712. red, 65, 67. tegmental, 71. terminal sensory, 103. vestibular,'730. Nux vomica, 246, Nyctalopia, 792. Nystagmus, 159, 812. Obelion, 147. Oblongata, 4, 72. arcuate tracts of, 85. arteries of, 421. centres of, 115, dorsal aspect of, 74. interior structures of, 77. nerve tracts in, 83, 84, 85. special ganglia and nuclei in, 83. ventral aspect of, 73. Oblongata-spinal transition, lesions of, 997. Obstetrical paralysis, peripheral, 622. Occipital neuralgia, 448. Occlusion of encephalic capillaries, 492. Occupation and nervous diseases, 135. Ocular deviation, forms of, 810. disturbances, interrelationships with ver- tigo, 736. movement, cerebral coordinations of, 830. disorders due to cortical lesions, 829. duo to limited subcortical le- sions, 83U. of toxic origin, 840, 843, 844. with constitutional diseases, 842. with dej;enerativc diseases, 841. with diathetic diseases, 842. with hemianopsia, 769. Ocular movement, disturbances of, 795, 809, diagnosis, 848. etiology, 840, focal diagnosis, 828. ♦ pathological anatomy, 846. prognosis, 849. symptomatology, 809. treatment, 850. muscles, nerves of, 797. paralyses and insufficiencies of, 810. physiological action of, 809. nerves, anatomy and physiology of, 795. isolated affections of, 815. paralyses caused by gross lesions at the base of the brain, 839. congenital, 844. due to orbital lesions, 840. miscellaneous causes of, 846. of hysterical origin, 846. studied by diplopia tests, 813, Oculofacial movements, centre for, 801. Oculomotor nerve, general course of, 803, nerves, end organs of, 799. neurons, 799. nuclei, scheme of, 807, paralysis, fascicular, 836. irregular varieties with hemiplegia, 837. radicular, 836, recurrent, 845. relapsing, 845, Odors, 675. Ohm, 180. Olfactory apparatus, 667. central portion of, 670. congenital absence of, 678, focal lesions of, 676. peripheral portion of, 668. atrophy, primary, 678. secondary, 679. bulb, molecular zone of, 671. diseases, 674, 676. filaments, 670. glomerules, 670. localization, 347. neuritis, 678. neuroses, 680. paths and centres, 667. projection fibres, 347. radiations, 330. symptoms. 675. terminology, 674. tract, 348. Olive, inferior, 83. superior, 79, 83, 931. Operculum, 51. Opbryon, 147. Ophthalmic ganglion, 798. herpes zoster, 859. migraine, 874. neuralgia, painful spots for, 865. Ophthalmoplegia, 811. acute nuclear, 834. basal, Sll. chronic nuclear, 835. com])lete unilateral, 839. Ophthalmoplegic migraine, 873. Ophthalmospasm, 811. Optic atrophy, postneuritic, 789. primary, 787. 788. secondary, 791. disk, anemia of, 779. nerve, 746. GENERAL INDEX. 1049 Optic nerve a part of the central nervous sys- tem, 746. atrophy of, 786. connections with nidi of ocular mus- cles, 798. disease of, 746. fasciculi, 750. general course and connections, 749. neuritis, 779. diagnosis, prognosis, and treatment, 781. etiology, 780. in encephalic tumors, 510, 528. treatment, 528. in leptomeningitis, 293. nature of, 780. symptomatology, 779. projection system, 330. pupillary pathway, lesions of, 823. radiations, 755. reflexes, basal centres for, 753. tracts, course and connections of, 749. decussation of, 752. fasciculi of, 750. Orbital lesions, 840. Origanum liniment, compound, 252. Orthopnea, 970. Osteomata, 501. Otitis labyrinthica, 739. Overlapping areas in cortex, 340. Oxycephalic head, 149. Pacchionian granulations, 98, 261, 262. Pachy meningeal hyperemia, 263. Pachymeningitis, 126, 262. acute symptoms, 263. etiological varieties, 262. external, 263. hemorrhagic, internal, 264. clinical history, 264. definition, 264. diagnosis, 266. etiology, 265. formation of new membrane in, 267. pathology and morbid anatomy, 266. prognosis, 267. reflexes in, 265. situation of lesions in, 266, symptoms, 265. treatment, 267. purulent internal, 268. serous internal, 262, 269. Pain in hemiplegia, 580. treatment by faradic currents, 203. Pala, 52. Palatal muscles, disorders of, 951. paralyses, 953. spasm, 953. Pallidum, 56. Pallium, 406. Palpitations, nervous, 976. Pantomime, definition, 651. diagnostic points regarding, 654. disorders of, among aphasics, 651. Pantomimic disorders, varieties of, 651. Papillee foliatse, 683. Papillitis, diagnosis, prognosis, and treat- ment, 781. etiology of, 780. Papillitis in encephalic abscess, 544. in encephalic tumors, 510. symptomatology, 779. Parachromatism, 758. Paracoeles, 31, 32. Paracusia, 715. acris, 715. duplicata, 716. Willisii, 716, 722. Paradoxic deafness, 716. Parageusia, 698. Paragraphia, 641. Paraldehyde, 243. Paralexia, 641. Paralysis and paralyses, accessorius, 979. and insufficiencies of ocular muscles, 810. bulbar, 1006. cerebral, of children, 604. congenital ocular, 844. cricothyroid, 958. electrodiagnosis of, 193, electroprognosis of, 198. examinations for, 166. facial, 904. in hemiplegia, 569. glossopharyngeal, 944. hypoglossal, 993. infectious and postinfectious, 621. laryngeal, 954, 955, 956, 957, 958. masticatory, 889. muscular electrization for, 200. ocular, due to gross lesions at base of brain, 839. due to orbital lesions, 840. oculomotor, radicular, or fascicular, 836. with hemianesthesia, 838. of azygos uvulae, 952. of esophagus, 976. of faucial muscles, 952, of fourth nerve, 826. double, 827. of iritic reflex in thrombosis, 487, of levator palati, 953, 953. of near vision, 826. of sixth nerve, 827. of sphincters in hemiplegia, 587. of third nerve, 815. of thyroarytenoids, 958. peripheral obstetrical, 622. pharyngeal, 952. pseudobulbar, 353. Paralyzing vertigo, 738. Paramimia, 641. 652. Paraplegia, 165, 604. spastic, 620. Parasinoidal spaces, 261, 262. Parasites of the brain, 504. Paresthesia, 152. pneumogastric, 950. Paresthesias in hemiplegia, 580. Paroxysmal headache, 872. Pars intermedia of Wrisberg, 688, 691, 693, 899. Patellar reflex, 171, 172, 174. Pathetic nerve. {See Fourth nerve.) Pathology, general, 125. Pedodynamometers, 168. Peduncles, cerebellar, fibres of, 72. pineal, 63. Peduncular sulcus, 68. Percussion hammer and esthesiometer, 174. Periarteritis, aneurismal, 442. nodose, 442. 1050 GENERAL INDEX. Periarteritis, syphilitic, 443. PerieneephalitiSj 531. Perimeter, 160. Periosteal nodes in hemiplegia, 580. Periotic noises, 717. Peripheral nerves, 22. Perivascular sheaths, 260. spaces, 260. Perlia's central nucleus, 801. Petrous sinus, 304. Phagocytosis, 141, Pharyngeal muscles, disorders of, 951. paralysis, 952. representation, 337. spasm, 953. Phenacctine, 246, 247. Phenocoll hydrochloride, 245. Phonation centres, 117, 337. Phosphorus, 239, 249. Photisms, 153. alphabetical, 153. sound, 717. taste, 700. Photophobia, 792. Physostigma, 244. Pia, description of, 95, 260. functions of, 260. spinal, 96. Pia-arachnoid, 261. Piesmeter, 158. Pineal body, 5, 64. gland, lesions of, 368. peduncles, 63. Piperazin, 250. Pitres-Blackburn's method of brain section, 400. Pituitary body, 65. gland, enlargement of, in myxoedema, 368. lesions of, 367. Plagiocephalic head, 149. Plexuses, brachial, lumbar, and sacral, 7. special, of the gangliated system, 7. Pneumogastric disorders, visceral, 978. lesions and pulmonary consumption, 971. nerve, anatomy of, 935. branches of distribution of, 941, central neurons of, 939. communicating branches of, 940. diseases of, 935, 946. ganglia of, 940. nuclei, centres in, 116. peripheral course of, 939. physiology of, 935, roots. 796. treatment of sensory diseases of, 950. neuralgias, 948. paresthesia, 950. sensory disease, 948. Poisons, metallic and gaseous, 137, Pole changer, 187. Polioencephalitis, 126, 531, 835. Poliomyelitis, 126. improved by galvanism, 204. Polyesthesia, 152. Polymorphic layer of cortex, 329. Polyopia, 793. Polypnea, 369. Pons, 4, 72. arcuate tracts of, 85. arteries of, 421. centres in, 115. Pons, lesions of pyramidal tract in, 930. nerve tracts in, 83. segmental localization in, 932. small gross lesions of, 926. special ganglia and nuclei in, 83. structures of, 79, 926, 929. transections of, 929. transverse fibres of, functions and lesions of, 930. ventral, lateral, and dorsal views of, 926. Ponticulus, 74. Pontile lesions, 357. causing conjugate deviation, 831, 832. trigeminal anesthesia, 883. gustatory symptoms in, 702. Porencephalus (porencephaly), 314, 598, 601. Porta, 31. Postcisterna, 99. Postcommissure, 5, 58, 366. Postcornu, 33. Posterior longitudinal bundle, 76, 79, 84, 929. subarachnoid spaces, 99. Posterovesicular column of Clarke, 89. Postfovea, 76. Postgeminum, functions of, 370. Postgeniculum, 5, 63, 358. Posthemiplegic pains, 580. Postmortem examination of brain, 395. Postneuritic atrophy, 789. Postoblongata, 2. abscess of, 1005. .and oblongata-spinal transition, lesions of, 997. lesions of, 997, 998. topographical subdivisions of, 998. tumors of, 1003. Postparaplegic disorders in diplegia, 609. Postpeduncle, 5, 380. Postpyramids, 5, 74. Posture sense, tests for, 158. Postvermis, 67, 69. Potassium nitrite, 257. Potential, electrical, 179. Precommissure, 58, 366. Precornu, 33. Predisposition, 132. Prefovea, 76. Prefrontal abscess, 547. lobe, 332. level of nervous system in, 115. method of outlining, 392. result of destruction of, 334.' Pregeminum, functions of, 370. a reflex optic centre, 754. Pregeniculum, 63, 358. lesions of, causing hemianopsia, 768. causing motor troubles of the eye, 754. terminus of macular fibres, 756. Prehemiplegic pains, 580. Preoblongata, 2, 926. segmental localization in, 932. small gross lesions of, 926. structure of, 920, 929. Prepeduncle, 5. Prest^ure sense, tests for, 157. Prevermis, 67. Primary cortical auditory centres, 628. labioglossopharyngeal paralysis, 1006. marantic thrombosis, 306. ventricular hemorrhage, 457. Progressive apoplexy, 458. GENERAL, INDEX. 1051 Projection cell, 13. system, 113. Prosocoele, 31. Prosopalgia, 868. clinical history, 868. definition and synonyms, 868. diagnosis, 871. etiology, 869. pathogenesis, 870. pathological anatomy, 870. prognosis, 871. treatment, 871. Prosoplexus, 52. Prosthion, 147. Psalterium, 60. Psammomata, 500. Pseudencephalus, 313. Pseudesthesias, 153. Pseudobulbar paralysis from lesions of the lenticula, 353. Pseudochromesthesla, 153. Pseudocoele, 32, Pseudocontractures, 575. Pseudogeusesthesia, 153. Paeudohydrophobia, 1005. Pseudoparalytic rigidity, diagnosis of, 621. Pseudoparaplegia, rachitic, 621. Pseudoptosis, 830. Psychic blindness, 635. cells, 15. therapeutics, 224. Psychical deafness, 661. Pterion, 147. Ptomaines, 138. Ptosis due to cortical lesions, 830. from lesions of the striatum, 830. spasmodic, 812. Pulmonary consumption and pneumogaatrie lesions, 971. Pulse and arterial pressure, 178. in encephalic hemorrhage, 454. in encephalic tumors, 513. Pulvinar, 63. part played in vision, 754. Punktsubstanz, 14. Pupillary movements, centre for, 801, nuclei, 370. phenomena in encephalic hemorrhage, 455. in lesions of fifth nerve, 824. reflex, cutaneous, 824. symptoms, in nervous disease, 162. Purkinje cells, 374, 376. Purulent internal pachymeningitis, 262, 268. Putamen, 56. Pyramid, anterior, 106. posterior, 5, 74. Pyramidal cells, layer of, 329. tracts, 84, 86, 106, 107, 930, 1000. Q- Quadrant anopsia, 766. Quadrigeminum (quadrigeminal body), 5, 67. electrical stimulation of, 371. functions and lesions of, .370. R. Kaoe in relation to nervous diseases, 134. Kaohischisis, 313. Reaction, myotonic, 197. of degeneration, 194. Recurrent laryngeal paralysis, 9S5, 966. oculomotor paralysis, 845. Red blindness, 768. nucleus, 67. Reflex or reflexes, anal, 176. ankle, 171. arcs. 111, 112. auditory neuroses, 721. biceps, 171. bulbocavernous, 175. chin, 171. cough, trigeminal, 882. cremasteric, 175. cutaneous, 169. deep, 171. dural spasms, 260. elbow, 171. extensor, 171. Genu's binaural, 163. Haab's cortical pupillary, 824. in hemiplegia, 579. jaw, 172. motor path, central, 112. muscle, 171. neuroses, trigeminal, 881. patellar, 171, 174. pupillary, 824. sensory path, central, 112. toe, 171. triceps, 171. vertigo, 735. virile, 176. wrist, 171. Reil, island of (insula), 36, 350. Relapsing oculomotor paralysis, 845. Residual encephalic lesions, 656. Resistance, electrical, 179. Resorcin for lavage, 263. Respiration in encephalic hemorrhage, 454. in encephalic tumors, 513. nervous mechanism of, 969. Respiratory arhythmia, 969. centres, 116. disturbances due to vagal disease, 969. neui'oses, 969. Rest treatment, diet in, 221, full, 220, 221, partial, 220, 222, schedules, 221, 222, Restiform body (restis), 5, 74. Reticular field, 79. Retina, anemia of, 779. anesthesia of, 792. central artery of, 776. hyperemia of, 777. layers of, 748. structure of, 747. Retinal representation, 343. Retrobulbnr neuritis, 786. Retroinsular convolutions, 360. Revulsor, 226. Rheostats, 186. Rheotome, 186. Rhinocoele, 31. Rhizoneures, 13. Rhombocoele, 32. Rigidity, 166, 573, 575. in cerebral paralyses of children, 609. in encephalic hemorrhage, 456, initial, 575. structural, 675. Rimulse, 52. Risus sardonicus, 895. 1052 GENERAL IXDEX. Kolandic fissure, determination of, 386, 388. or motor cortex, subdivisions of, 334. Rolando, subst.intia gelatinosa of, 89. tubercle of, 74, 1002. Roller's nucleus, 990. Romberg's sign, 170. Roof nucleus, 71. Rotation of heail in encephalic hemorrhage, 455. Salaam convulsion, 985, Salicylates, 246, Salipyrin, 247. Salol, 247, 253. Salophen, 246. Sand tumor, 500. Sarcomata, 497, 500. Scaphocephalic head, 149. Scarpa, ganglion of, 81, 729, 730. Sclerosis, 130. arterial, 445. of the brain, 541, 597, 600. tuberous, 503, 600. Seasonal influences on nervous diseases, 136. Secondary degeneration after cerebellar le- sions, 564. after focal lesions, 556. ascending, 564. descending, 128. initiation of, 557. progress of, 557. optic atrophy, noninflammatory, 791. sinus thrombosis, 306. Secretory phenomena in hemiplegia, 582. symptoms, 176. Semicircular canals, functions of, 728. in relation to sensations of motion, 158. Senility, 131. Sensation, metamorphosis of, 152. of motion, 158. testing for, 153. Sense organs, nervous structures of, 21. Sensorial nerves, ganglia of, 103. Sensory and motor cranial nerves compared, 796. localization, separate, 331. areas in the cortex, 340. cells, 19, 104. centres, 104, 332. cranial nerves, ascending and descending roots of, 80. decussation, 101. lesions of, 1001. disorders in hemiplegia, 580. terminology of, 152. expanse, cortical, 152. investigations, 153. localization, 331. nerve roots, development of, 26. path, 101. projection system, cortical termini of, 330. in centrum ovale, lesions of, 361. roots of the trigeminus, 854. tetanus, 152. tracts and their homologues, comparative table of, 105. Septum, 36. Serial galvanic changes, 194. Serous internal pachymeningitis, 262, 269. meningitis, 278. Serum therapy, 229. Sex in relation to nervous diseases, 134. Shoulder movements, cortical representation of, 336. Sick headache, 872, Sight, afl'ections of, 746. disorders of, in hemiplegia, 582. Sigmoid sinus, 303. thrombosis, 308, Signal symptom, 352. Silver nitrate, 249. Simulated deafness, 724. Sinus and sinuses, cavernous, 304. cerebral, 97. dural, 303. of the brain, diseases of, 259. petrous, 304. thrombosis of, 303. abdominal, 306. associations and complications of, 259. cavernous, 307. clinical history, 306. definitions and varieties, 305. diagnosis, 309, 311. from encephalic abscess, 551. etiology, 308. infective, prophylaxis of, 312. in leptomeningitis, 290. lateral, 308. longitudinal, 307. marasmic, 306. meningeal, 306. pathology, 309. primary, 309. prognosis, 311. pulmonary, 306. secondary, 306. sigmoid, 308. treatment, 311. with encephalic abscess, 545. Sinusoidal current, 191. Sitophobia, 227, Sixth nerve, 806, 807. nucleus, 806. paralysis, 827, 828. Skull landmarks, 147, 388. measurements, 148. table of, 149. methods of measuring. 146, planes of projection of, 148. varieties of, 149. Smell, afTections of, 667. clinical history, 674. diagnosis, 681. hysterical, 679. pathological anatomy, 681. prognosis, 6^2. treatment, 682. disorders of, in hemiplegia, 582. hallucinations of, 675. tests for, 164. Sodium and gold chloride, 249. arsenate, 255. bicarbonnte, 250, 253. nitrite, 257. salicylate, 247. Softening from embolism, 476. from thrombosis, 483. Somatic nerves, 8. Sumnal, 243, Sound photisms. 717. Space centre, 1 17. Spanopnea, 970. GENEEAL INDEX. 1053 Sparteine, 248, 249. Spasm, accessorius, 983. ciliary, 812, 825, clonic, 166, esophageal, 977. hypoglossal, 994. in convergence, 826. laryngeal, 965. lingual, 994. nictitating, 922. of accommodation, 825, of the splenius capitis, 987. palatal, 953. pharyngeal, 953. reflex, dural, 260. tonic, 166. Spasmodic torticollis, 983, congenital, 984. diagnosis, 986. etiology, 985. pathogenesis, 985, prognosis, 987. treatment, 988. Special senses, disorders of, in hemiplegia, 582. paths of, 104. reflexes of, 667. Speech centres, 348. defects due to disease of cerebrum, 628. disturbances and mental disease, 655, associated with hemianopsia, 769. tract, subcortical, 349. Sphincter pupillge, centre for, 802. Sphincters, paralysis of, in hemiplegia, 587. Sphygmographic studies of the pulse, 178. Spider cells, 16. Spina biflda, 313. Spinal accessory nerve, 795. anatomy of, 935. diseases of, 935, 979. peripheral course of, 943, physiology of, 935. spasm, 983. and cranial nerves, homologies of, 795. canal, length of, 5. centres, 115. cord, anterior ground bundle of, 89. columns and tracts of, 89, 90. development of, 28. envelopes of, 95. intermediate gray substance of, 89, lateral horn, 89. length of, 5. nerves of, 5. posterior horn of, 90. relation to different systems of nerves, 7. structural elements of, 91. subdivisions of, 88. ventral bundle of, 89. degeneration, vascular origin of, 129. meningocele, 313. nerves, general description of, 7. tracts, vertical extensions of, 91. Spine, method of stretching, 223. movements, cortical centres for, 335. Spitzka's bundle, 799. Splanchnic nerves, 8. Splenium, 59, Splenius capitis, spasm of, 987. Spongioblasts, 24. Spongiocyte, 13. Springs, thermal, 214. Static electricity, 206. Static electricity, diseases in which useful, 210. methods of applying, 208. Station and sway, 170. Stephanion, 147. Sternocleidomastoid and trapezius muscles, paralysis of, 981. muscle, isolated paralysis of, 979. spasm, 983. Stigmata, somatic, 144. Stomach, washing out of, 227. Strabismus, spasmodic, 812. Stratum intermedium, 66. lacunosum, 328. molecular, 328. radiatum, 328. zonale, 63, 111. Striae, acoustic or medullary, 75. Striata, 55. connections of, 109. Striatum, functions and lesions of, 352, 830. Strontium bromide, 241. Strychnine, 247. nitrate, 257. sulphate, 257. used.hypodermatically, 258. Subarachnoid lymph spaces, 99. Subdural hemorrhage, 269, 270. Subgeminal lesions, 371. Subjective noises, 719. symptoms of nervous disease, 143. Subnasal point (subnasion), 147. Substantia ferruginea, 76. gelatinosa, 80, 87. innominata, 66. nigra, 65, 87, 372. Substituted movements, 576. Subthalamic lesions, 371. region, 65. Subthalamus, 65, 67. Sulci, primitive, 39. Sulcus, mesal, 75. peduncular, 68. Sulphonal, 243, 244. Sumbul, 248. Superior olive, 79. functions and lesions of, 931. stephanion, 147. Supracommissure, 58. Supradural hemorrhage, 269. Supramaxillary neuralgia, painful spots, 865. Surface thermometry, 176. Surgical treatment of nervous affections, 224. Suspension treatment, 222. Sway, normal, 170. Swedish movements in hemiplegia, 593. Sylvian fissure, 39. determination of, 386, 388. Symbols, electrical, 194. Sympathetic nervous system, 7. Symptomatology, general, 142. Syphilis as a cause of nervous disease, 140. Syphilitic endarteritis, 443. thrombosis, 481. Syringocoele, 32. Tabes and laryngeal paralyses, 960, atrophy of cochlear nerve in, 719. gastric crises of, 977. gustatory affections in, 703. olfactory atrophy in, 678. optic atrophy in, 787. 1054 GENERAL INDEX. Tabetic atrophy of the vestibular nerve, 734. Tachycardia, 972. Tachypnea, 970. Taste, affecticms of, 683. clinical history, 698, diagnosis, 705. etiology, 704. hysterical, 704. pathological anatomy, 704, prognosis, 706, treatment, 706. areas, 684. buds, 683. delicacy of, 685. disorders of, in hemiplegia, 582. electrical, 1)85. essential and accessory nerves of, 683. hallucinations of, 699. in facial paralysis, 908. loss of, from encephalic lesions, 703, nerves of, 683. normal, 699. photisms, 700. secondary sensations of, 700. tests for, 165. Tautomeral cells of the- spinal cord, 92. Technique, electrodiagnostic, 197. Tegmental radiation, 104. Tegmentum, 86. Tela, 52. Temperature or temperatures, cranial, sta- tions for taking, 177. elevation due to thalamic hemorrhage, 357. in encephalic hemorrhage, 454, 471. in encephalic tumors, 513. sense, tests for, 156. surface, in hemiplegia, 583. Temporal lobe, method of outlining, 393. Tendon phenomena, 171. in hemiplegia, 579. Tenia echinococcus, 506. semicircularis, 33. solium, 504, Teniola clnerea, 76. Terma, 31. Terminology, anatomical, 12, 47, 51. Testicular therapy, 228. Tetanus, cephalic, S98. hydrophobicus, 898. Tetany, 621. Tetronal, 244. Thalamencephalon, 63. Thalamic disease, 355. Thalamus, 5, 63. connections, 110, 354. facial nerve connections with, 899. functions of, 353. Theine, 255. Therapeutic alternator, 191. Therapeutics, electrical neurological, 201. general, 125, 211. psychic, 224. vibratory, 219. Thermoanesthesia, 152. Thermometry, surface, 176. Thermopolypnca, 369. Third nerve affections in migraine, 844. bilateral paralysis of, 820. eonneeting structures of, 804. general cnurse of, 803. nuclei, 799, paralysis of extraocular muscles, 817. Third nerve paralysis, symptomatology of, 815. syphilitic, 816. total, 815. Thomsen's disease, electrical response in, 197. Thrombosis, clinical history, 484. complications, 487. course, 487. diagnosis, 488, 489. from hemorrhage and embolism, 489. duration, 487. etiology, 487. focal symptoms, 487. of intracranial sinuses, 303. pathological anatomy, 488. simple, 484. softening from, 483. treatment, 490. varieties, 484. Thrombus, 483. Thymacetine, 245. Thymus treatment, 228. Thyreoid treatment, 227. Thyroarytenoid muscles, paralysis of, 958, Tic douloureux, 868. painless, 920. rotatoire, 987. Time relations of mental phenomena, 143. Tinnitus, 716. Tobacco amblyopia, 783, 785, 786. heart, 976. Toe reflex, 171. Toes, centres of representation for, 335. Tongue, atrophy of, 995. electrical applications to, 201. nerves of, 683. Tonics, alterative, 238. metallic, 238. Toxemias diagnosed from encephalic hemor- rhage, 467. Toxic agents causing amblyopia, 782. chemical effects of, 139. amblyopias, 782. origin of ocular disorders, 844. Tracts concerned in speech, 628. of the brain, 54. of the spinal cord, 89, Transections of pons and preoblongata, 929, Transverse fibres of the pons, functions and lesions of, 930. Trapezium, 68, 79, 85. Trapezius muscle, isolated paralysis of, 980. spasm, 783. Trapezoid iDody, 68. nucleus, 713. Traumatic degeneration, 557. intracranial lesions, 429. Traumatisms of the brain, 427. Tremor, 166. in hemiplegia, 578. Trephining points, 393, Triceps jerk, 171. Trifacial neuralgia, 868. Trigeminal anesthesia, 863. due to focal lesions, 882. from pontile and oblongatal lesions, 883. in chronic degenerative diseases, 885. rules for diagnosis of site of lesion, 884. apparatus, motor portion of, 860. cutaneous areas, 857. GENERAL INDEX. 1055 TrigemiDal headaches, 881. neuralgia, diagnosis, 867. due to states of the blood, 866. epileptiform, 867. prognosis, 867. symptomatic forms of, 864. treatment, 867. neuritis, 864. pain, significance of, 864. reflex cough, 882. neuroses, 881. sensory apparatus, irritative focal lesions of, 864. disease, varieties of, 863. spasm, 892. clinical history, 892. diagnosis and prognosis, 896. etiology, 896. treatment, 896. Trigeminus, or trigeminal nerve, accessory nucleus of, 861. anatomy and physiology of, 852. cerebral root of, 861. descending root of, 861. diseases of, 852. motor portion, 8S9. sensory portion, 863, experiments on ascending spinal root, 858. general description, 852. mesencephalic root, 861. muscles supplied by motor portion of, 861. nucleus of, 83, 852. paralysis of, associated with spasm, 889. of motor portion of, 889. peripheral course of motor portion of, 861. of sensory portion of, 855. physiological observations on, 858. roots of, 796. sensory portion of, 854. spasm of, 892. and associated paralysis of, 894. trophic functions of, 858. Trigonocephalic head, 149. Trigonum babenulge, 63. Trional, 244. Trismus, 893. Trochlear nerve. {See Fourth nerve.) Trophic functions of the trigeminus, 858. phenomena in hemiplegia, 586, phenomena independent of paralytic phenomena, 195. symptoms, 176, Trunk and spine movements, centres of representation of, 335. Tuber, 4, 51, 61. lesions of, 369. Tubercle, anterior, 63. cuneate, 77. external, 63. gracile, 77. lateral, 63. of Rolando, 75, 1002. posterior, 63. Tubercular cerebrospinal meningitis, 281. meningitis, 280, 523. diagnosis from encephalic tumor, 523. tumors, 495. Tuberculum acusticum, 76, Tuberous sclerosis of the brain, 503, 600. Tumors, cerebral and spinal, Vol. cortical, 517. dural, 272, 273. encephalic, 493. causing vertigo, 737. clinical history, 506. diagnosis from encephalic abscess, 551, 552. duration, 519. etiology, 494. focal symptoms, 516. general course and stages, 520. diagnosis, 521. symptoms, 508. medical treatment, 528. multiple, 519. pathological diagnosis, 527. varieties, 494. actinomyces, 496. angioniata, 499. angiosarcomata, 500. carcinomata, 501. cholesteatomata, 503. enchondromata, 501. fibrogliomata, 500. fibromata, 501. gliomata, 500. gliosarcomata, 500. gummata, 496. lipomata, 501. myxogliomata, 500. myxomata, 499. myxosarcomata, 499. neuromata, 501. osteoenchondromata, 501. osteomata, 501. psammotoata, 500. sarcomata, 497. tubercular, 495. tuberous sclerosis, 503. prognosis, 527. surgical treatment, 529. in infantile cerebral paralysis, 622. of oblongata-spinal transition, 1003. of pons causing conjugate deviation, 832. of special regions below the cortex, 518. Turpentine, 249. Twitchings in hemiplegia, 578. U. Uncinate gyre, electrical irritation of, 348. Unilateral representation in cortex, 339. Upper extremity, cortical centres for, 336. Upward and downward rotation of eyeballs, affections of, 832. Uralium, 244. Utterance centre, 349. Vagal disease causing cardiac disturbances, 972. causing digestive disturbances, 976. causing respiratory disturbances, 969. neuritis, 947. treatment, 950. Vagus nerve {see Pneumogastric), 935. Valerianates, 248. Valgus in diplegia, 609. Vascular diseases and disturbances, 131, Vasomotor phenomena in hemiplegia, 582, 1056 GENBEAL, INDEX. Vasomotor symptoms, 176. Veins and sinuses, interrelations of, 304. intracranial, diseases of, 312. of the brain, 424. diseases of, 259. Venous lakes, 97. Ventral nucleus, 81. Ventricle or ventricles, fourth, 4. floor of, 74, 75. lesions of, 366. tapping of, 394. Ventricular hemorrhage, 457, 469. diagnosis from intracerebral hemor- rhage, 470. from meningeal hemorrhage, 470. secondary, 458. Ventrolateral nucleus, 711. Veratrine ointment, 251. Verbal amnesia with hemianopsia, 770. blindness, 634, 666. deafness, 632. Vertex, 147. Vertigo, 716, 733. and ocular disturbances, 736. classification of, 735. due to brain tumor, 737. to diseases of the heart, 737- to states of the blood, 738. in encephalic tumors, 510. mechanical, 739. of functional origin, 738. of mixed origin, 738. paralyzing, 738. paroxysmal, 882. reflex, 735. Vesicles, cerebral, 29. Vestibular disease, etiology and pathology, 742. symptoms, 732. end organs, 729. nerve, 81. cerebral terminus of, 731. diseases of, 728. nuclei of, 730. tabetic atrophy of, 734. pathway, focal lesions in, 734. root, 796. Vetter carbon current controller, 186. current adapter, 185. Vicq d'Azyr, bundle of, 63, 111. Vieussens, valve of, 67. Violet blindness, 758. Virchow's method of brain section, 400. Virile reflex, 176. Visceral pneumogastric disorders, 978. Visual affections, miscellaneous, 792. and ocular disturbances, 159. anesthesia, 792. apparatus, diffuse diseases of, 774. asthenopia, 792. disturbances caused by drugs, 783. fields in cerebral paralysis of children, 613. hallucinations, 794. hyperesthesia, 792. localization, 342. pathway, focal lesions of, 757. spectra in migraine, 874. tracts, cortical termini of, 755. Volt, 180. Voltaic alternatives, 204. Voltolini's labyrinthitis, 739. Vomiting in encephalic tumors, 509, W. Weather in relation to neuralgia, 136. Weight of brain, 408. Wernicke's fissure, 45. hemiopic pupillary reaction, 160, 769, 772. White matter of the brain, analysis of, 122. Willms's unalterable current controller, 186. Word blindness, 755, 769. pure, 634. deafness, 345. pure, 632. Wrisberg, pars intermedia of, 691, 899. Wrist jerk, 171. Writer's cramp, electrical treatment of, 205. Z. Zona incerta, 66. Zone of language, cerebral, 643. THE END. ;! ■ > : : Jttttt ' v.'tv!