\4..:3 I Library of Congress.^! Shelf. iJ__-__i gfejUNITED STATES OF AMERICA.^ NERVOUS DISEASES WITH HOMEOPATHIC TREATMENT. JOSEPH T. O'CONNOR, M. D., Ph. D., PROFESSOR OF NERVOUS DISEASES IN THE NEW YORK HOMOEOPATHIC MEDICAL COLLEGE AMI HOSPITAL; PROFESSOR OF MENTAL AND NERVOUS DISEASES IN THE NEW YORK MEDICAL COLLEGE AND HOSPITAL FOR WOMEN; NEUROLOGIST TO THE LAURA FRANKLIN FREE HOSPITAL FOR CHILDREN, TO THE FLOWER HOSPITAL, AND TO THE METROPOLITAN HOSPITAL (BLACKWELL's ISLAND); CONSULTING NEUROLOGIST TO THE NEW YORK OPHTHALMIC HOSPITAL ; MEMBER OF AMERICAN INSTITUTE OF HOMCEOPATHY, ETC., ETC. ILLUSTRATED. NEW YORK. BOERICKE, RUNYON & ERNESTY. 1898. SECOND OOP*. v\ 51663 Copyright, 1898. Ey Boericke, Runyon & Ernesty. TO THE MEMORY OF THE LATE PROFESSOR A. R. THOMAS, M. D. of PHILADELPHIA, AT WHOSE SKILLED HANDS I RECEIVED MY FIRST KNOWLEDGE OF THE BENEFICENT POWER OF HOMOZOPATHV I THESE PAGES ARE AFFECTIONATELY INSCRIBED. JOSEPH T. O'CONNOR. PREFACE. FOR a number of years past successive classes of students have urged the writer to issue in book form his own notes of lectures upon the diseases of the nervous system, given at the two homoeopathic medical colleges in New York. It is in response to these requests that the following pages have been put into book form. They are an amplification of the descriptive part of the lectures and a condensation of the anatomical details introductory to them. The office of lecturer in a medical college is not only to give to his hearers a digest of the accepted text books on his subject, but also to note the advances made in his subject by investigators and clinicians the world over, and to select from these such results as seem worthy of acceptance for the advancement of the student. Matters of purely academic or speculative interest have been omitted from the following pages except when their presentation would seem to conduce to a readier apprehension of related principles or to assist the better in memorizing important facts. As the lectures are for students and practitioners of 8 PREFACE. homoeopathy, other methods of treatment are not given except as allusions in cases not amenable to homoeopa- thic medication as laid down in the Organon of Hahne- mann. Hence the importance of diagnosis and a knowledge of the underlying pathological changes in any given case form a prerequisite to any attempt at cure. To apply homoeopathic therapeutics from the symptoms of a disease admittedly incurable (except experimentally) is to do homoeopathy a grievous harm. Within its limitations Homoeopathy is invincible; to enlarge its domain in even a slight degree is, it is hoped, not a visionary conceit, but in the writer's opinion is possible with accurate records of cases giving unassailable proofs of correct diagnosis and the use of corroborated clinical as well as pathogenetic indications for the use of our remedies. TABLE OF CONTENTS. Introductory. The Examination ........ 17 Electro-Diagnosis -------- 27 Peripheral Nerves -------- 39 Anatomy of Nerve Fibre - - - - - - 39 Degeneration of Nerve Fibre ------ 39 Neuritis ----- ... 42 Multiple Neuritis - - - - 55 Neuralgia -_...--- G8 Trigeminal Neuralgia ------- 68 Tic Douloureux ------- 70 Sciatica --------- 77 The Spinal Cord -------- 86 The Reflexes ----- 95 Diseases of the Spinal Cord - - - - - - 101 Spinal Meningitis - - - 105 Myelitis ... - - - 111 Syphilis of the Spinal Cord - - - - - - 114 Compression Myelitis ------ 116 System Diseases of the Spinal Cord ----- 122 Poliomyelitis anterior acuta ------ 122 Primary Degeneration of the Motor Path - 127 Spinal Progressive Muscular Atrophy ... - 129 Amyotrophic Lateral Sclerosis - - 131 Locomotor Ataxia - - - - - - - 134 Ataxic Paraplegia - - - - - - - 149 Hereditary Ataxia ------- 151 Spastic Paraplegia ------- 153 Non-Systemic Diseases of the Spinal Cord ... - 156 Multiple Sclerosis ------- 156 Acute Ascending Spinal Paralysis ----- 160 Caisson Disease -------- 161 Tumor of the Spinal Cord - - - ... - 165 Syringomyelia .-__.-.- 168 Hydromyelia - ... . . - - 171 Spinal Irritation - - - - - - - - 173 IO TABLE OF CONTENTS. The Cranial Nerves - - - - - - - 176 The Ophthalmoplegias - - - - - - J 96 The Pupil ... - - 192 Oculo-motor Paralysis ._..--. 202 Progressive Facial Hemiatrophy - 207 Peripheral Facial Paralysis ------ 209 Meniere's Disease ------- 219 The Brain 226 Progressive Bulbar Paralysis ------ 237 The Cerebral Cortex — Cortical Areas - - - - - 247 Anaemia of the Brain - - - - - - 262 Hyperemia of the Brain .___-. 263 Cerebral Meningitis -------- 265 Cerebro- Spinal Meningitis ...--- 272 Chronic Hydrocephalus - - - - - - - 275 Abscess of the Brain ..._-_ 277 Apoplexy -------- 280 Apoplexy from Vascular Occlusion ----- 288 Brain Tumor --------- 295 Brain Syphilis ------- 306 Cerebral Infantile Paralyses ------- 308 Acromegaly - .-..-.- 315 The Cerebellum -------- 317 Cephalalgia — Headache ------- 319 Vertigo --------- 322 Tropho-Neuroses -------- 325 Progressive Muscular Dystrophy - 325 Progressive Neurotic Muscular Atrophy » - - - 330 Neuroses - • -..._-. 332 Facial Spasm - - - - - - 332 Torticollis -------- 334 Habit Spasm -...-.. 33^ Epilepsy - .... . ■ . . 337 Migraine -------- 350 Chorea --------- 355 Paralysis Agitans ------- 361 Tetany --------- 364 Myotonia Congenita - - - - - - 368 Hysteria - - _.-.... 371 Hystero-Epilepsy ------- 383 Neurasthenia --------- 387 Traumatic Neurose3 - - - - - - - 396 NERVOUS DISEASES WITH HOMOEOPATHIC TREATMENT. INTRODUCTORY. npO medical students and indeed to many medical practitioners the term Nervous System carries the idea of infinite depth, of inextricable complexity and of insurmountable difficulty. While these terms are perhaps truly applicable to certain parts and functions of the nervous system, yet so much is known of other parts and functions that the student of the nervous system is only hampered and discouraged in his work by having too prominently in mind the difficulties and complexities mentioned. The nervous system is made up of parts morpho- logically alike in type and which perform functions of similar character, that is, to produce, to carry and to receive nervous impulses. Such statement, however true literally, only con- tinues the difficulty in studying the nervous system in health and disease. In illustration it may be said that all secretory organs have one function, that of secreting from the materials presented to them certain substances for certain definite purposes, yet no one would attempt the study of all the secretory organs as 1 2 INTRODUCTORY. members of one system merely because they all have the one common function of secretion. Just as one secretion differs from another in com- position and physiochemical activity, so nervous im- pulses differ among themselves, motor voluntary impulses being widely different from sensory involuntary ones and the latter differing again among themselves, so that an olfactory sense impulse may be utilized by the chemist as an aid in his analysis or an auditory sense impulse by the physicist in his investigations — yet all are manifestations of nerve-force. Our knowledge of the specialized nervous functions of different nerve tracts and masses of nerve cells has been obtained largely by experimental methods on low r er animals (atrophy method, method of develop- ment, method of secondary degeneration) but the results so obtained could not be applied to the human nervous system without the corroborative and confirm- ing facts of pathological investigation in man, when accurately recorded symptoms and their progress during life were thus explained. Notwithstanding such remarkable results, it may be said that the essential nature of disease is, except in cases of microbic or of toxic origin, still a mystery. Many diseases of the central nervous system are impro- perly so designated, as in invasion of the brain structure by a growth from without. The neurone theory has given to the nerve cell and its neuraxone (axis cylinder process) and its dendrites (protoplasma processes) a quasi independence that has IXTRODUCTOEY. 1 3 long been foreshadowed. The mode of transmission of nerve impulses from a central neurone to a peripheral one is still a matter of discussion, yet the opinion most generally held is that there is actual contact of the end- branchings of the neuraxone of the first with the dendrites of the latter. In actual practice the mattter may not be one of importance, yet any conception of the inter-relation of nerve units forming part of one system may offer at least a working hypothesis for the explanation of the ready action of correctly chosen highly attenuated remedies. The independence of the nerve cell as an organ, while explaining many conditions observed in the course of certain nervous diseases, does not fully meet the question raised regarding the action of our attenu- ations, but the theory of the continuity of protoplasm throughout the whole organism, as elaborated by C. Heitzmann, and later by Biitschli, has been more re- cently advanced by a recent observer,* whose con- clusions are summed up as follows: " The facts seem to warrant present belief that the living sub- stance of all organisms is one physiologically con- tinuous, living, plasma, homogeneous throughout in its intrinsic powers and properties, but having varied local and temporary habits of self-expression, which are largely and inextricably correlated with physical and chemical conditionings of its form and composition." * The Living Substance as such : and as Organism. By Gwendolen Foulke Andrews. Supplement to Journal of Morphology, Vol. XII, No. 2. 14 INTRODUCTORY. Through the agency of the continuous living sub- stance we can at least picture to ourselves the un- doubted action, often within a few moments, of highly attenuated drugs, but just as in the case of the higher vertebrates a limb or member when removed cannot be reproduced, so we must consider the nerve cell as an organ which, when destroyed, cannot be renewed. Hence the necessity to the homoeopath of an abso- lute diagnosis in order to determine just what part of the nervous system has undergone destructive change (as discovered by pathological investigation), and the limitations thereby set for restorative action through the influence of drugs. The Halmemannian view of the patient as a sick individual, and not merely as the bearer of some one ill-acting organ, is well set forth by the same in- vestigator, who says that the u true organism is the invisible vesicular substance [continuous protoplasm], whose mass limits coincide of necessity with those of the living being; that all of the multiple parts and powers, functions and organs of living units are, and primarily were, of and for the substance as such, and only partially and incidentally for the animal or plant." From the foregoing we can readily deduce the scientific reasonableness of Hahnemann's dictum to select the remedy according to the totality of the symptoms, and especially those of remarkable or pe- culiar qualities, the conditions of amelioration and aggravation of symptoms or other modalities, which INTRODUCTORY. 1 5 are the manifestations of the living, underlying con- tinuous vesicular substance. To select a remedy, especially in chronic dis- seases, the prescriber must have at his command something more than a Compendium or Condensa- tion of our Materia Medica. The Encyclopedia and its Index or Symptom Register make the storehouse of our knowledge in this direction, with such ad- ditional provings as have since its publication appeared in our journals or in Transactions of the National and State Societies. The homoeopathic remedies recommended in the following pages (in italics) are in the potencies from 6th to 30th, except where otherwise specially desig- nated. To the writer the question of attenuation, as such, is of far less importance in curing disease than the Hahnemannian injunction to not repeat the dose as long as the previous dose is still acting. But in waiving discussion of the question of potency, the writer does not wish to be considered as justifying doses of tincture or of Ix trituration of powerful drugs, in amounts equalling the usual doses of the old school. All adjuvants to medicinal treatment, included under the general term hygienic, should be employed. Their presentation and method of use do not fall within the scope of this book. But in this con- nection it may not be amiss to urge the physician to inquire concerning the use of tooth powders and 1 6 INTRODUCTORY. washes, toilet articles, mineral waters, etc., many of which contain medicinal substances in amounts far beyond those existing in our 3d attenuation, and which cannot fail to introduce activities antidotal to a remedy in use, or productive of new symptoms, which, if not traced to their cause, must be mis- leading to the strict prescriber. The dosage and method of employing antipathic or palliative remedies in cases confessedly incurable are not given in the following pages; they will be found in the allopathic works. The systematic employment of electricity (in its different modes), as subsidiary to homoeopathic treat- ment, must be studied in the text books of that branch of medical science. Its use as a method of diagnosis has, however, been given in condensed form in the cases where such method is necessary. For a more thorough knowledge of the anatomy of the Nervous System than is given within the limits of these pages, the student is urged to study Prof. Edinger's Lectures on the Structure of the Nervous Central Organs, or Prof. Obersteiner's Guide to the Study of the Structure of the Nervous Central Or- gans. Of both of these, American translations have been published. The Examination. The functions of the nervous structures are so many and so various that a general outline of the methods to be followed in examining a case, to deter- mine the presence or absence of a nervous affection, must be given in some detail. Affections of the nervous system may be manifested by changes in sensation, whether of the peripheral sensibility or of the special senses ; by changes in the motor functions of different parts of the body ; by changes in the calibre of the blood vessels of a part, with consequent pallor in one case or redness in an- other ; by alteration of glandular activity; by changes in the conditions of nutrition of the tissues and con- sequent atrophy or hypertrophy of a part ; and in alterations in the psyclie, that is to say, in the mental and emotional parts of our being. Change in sensation may be a loss, complete or partial, or it may be an exaggeration of sensory im- pressions. Loss of sensation is termed anaesthesia ; when the strongest impressions are not perceived, the anaes- thesia is complete, when they are but dimly per- ceived, so to say, it is incomplete : total and partial anaesthesia mean respectively that all, or a part only, of the body or of a limb is anaesthetic. "When used without qualification and in relation to 1 8 THE EXAMINATION. the periphery, the word anaesthesia refers to the ordinary sense of touch. But we have other peripheral sen- sations than those of touch. We can recognize cold and warmth, and we know what pain is. Whether a distinct set of nerve fibres and end organs exist in connection with the sense of pain or not, is a disputed point, yet it is known that pain sensations pass up the cord by a different pathway from that taken by the ordinary tactile sensation ; in disease the former may be lost while the latter is retained. There is no real hyperesthesia as a real exagger- ation of ordinary tactile sensibility. When we read of hyperesthesia we know that algesia or pain sen- sation is meant — a touch is perceived as pain. Analgesia means loss of the power of perceiving pain as such. In such cases the skin may be cut or pierced through without any painful sensation follow- ing, while the sense of touch is retained. When the power of perceiving painful stimuli is not lost, but is only lessened, we use the term hypalgesia. Loss of the temperature sense, or thermansesthesia, means loss of the power of recognizing differences of feeling produced by the application of a cold body and a hot one to the periphery. There is anaesthesia to cold alone or to heat alone in some cases, and there may be dysesthesia of the temperature sense in which cold is felt as hot or vice versa or either may give rise to some different pain sensation. The sensations of the parts beneath the skin have been greatly studied, yet with but little addition to THE EXAMINATION. 1 9 our knowledge. The peripheral mixed nerve fibres pass between muscles and through them and the cellular tissue, so that they must be affected in all tests such as that of estimating the amount of pres- sure made by a weight placed upon the hand lying on a table. Estimating the weight of an object held at arm's length may be by the effect on the nerves of the coverings of the joints, or by the amount of contraction of muscles needed to overcome the pull of gravity. So the sense of position of our limbs (without looking at them) tells us just where they are, whether straight or bent, etc. An experimenter can place one arm of his subject behind the back, fix the fingers and hand in some definite arrangement, and if the subject have the proper sensibility of the deep parts with no interruption of conduction to the brain, he can of his own volition move his other hand and fingers (still without the aid of the eyes) into the same relative position. This sense is called the mus- cular sense, and although the term has been attacked as being inappropriate and misleading, yet it gives a definite idea, and no better term has been proposed. Loss of muscular sense is shown by ataxia, the latter word meaning absence of co-ordination. No voluntary action can be done by one muscle alone, several enter into producing a movement, and their shares in the extent of activity vary. To initiate a voluntary movement, or even such as has become automatic, the higher centres must know in just what amount of relaxation or contraction the required 20 THE EXAMINATION. muscles are, as well as the similar states in the oppo- nents ; then the proper impulse to contraction in the one direction, and to relaxation in the other, being made, the movement is accomplished not by stages or by jerks of the separate muscles, but co-ordinately. When, as in the ataxic, the information mentioned above is not in possession of the higher centres, the movement may be made, indeed, but it is done awkwardly and with evident irregularity. Ataxia may be of three kinds — spinal, cerebellar and peripheral — the latter being as much due to weakness of the muscles as to interference with sen- sory nerve impulses. Spinal and cerebellar ataxia will be considered in the sections on the spinal cord and cerebellum respectively. The prefixes hyper-, meaning excessive ; hypo- or hyp-, meaning diminution; ana-, meaning complete loss and dys-, meaning perversion or falsity, may be used with all the qualities of changed sensation. At times in disease one touch may be felt as if repeated — the prefix poly- is here used ; at times a touch made upon one side is felt as if made on the other — this condition is termed allocheiria. In testing sensation no special apparatus is needed. A bit of absorbent cotton rolled into a loose wisp may be lightly drawn upon the skin, the patient's eyes being covered. He is then required to answer if he has felt it and to say where. If anaesthesia appears to exist, the examiner's finger may be drawn lightly over the spots or territory, and if still no sen- THE EXAMINATION. 21 sation is felt, then the touch may be made heavier. Anaesthesia to the cotton but not to the finger would be classed as hypsesthesia. Next, the pain sensation is to be tested. A needle is used to lightly prick the skin ; if no painful sen- sation is felt the needle may be passed deeper or finally through the skin. If sensation is felt at the first light pricking, of course no loss of the pain sense exists. For testing the temperature sense two test tubes are used, one containing hot water, the other pieces of ice or, in the absence of ice, water as cold as can be obtained. Both test tubes should be dry on the outside. They are to be applied in irregular al- ternation and the subject is required to' say in each case whether the hot or the cold tube has touched him. The hot water soon becomes cool in the test tube and requires renewal. In all cases when testing sensation the eyes of the patient should be covered, so that he may not be misled into believing that he feels when he does not. When using the cotton or finger let him state first that he feels it, as the examiner should not ask "did you feel that!" To poorly educated persons the word foot means often anywhere from the toes up to the knees ; in such cases the subject may be required to point out the spot where the touch was made. Areas of anaesthesia should be marked on the skin with ink or an aniline pencil and figured in the re- 22 THE EXAMINATION. cord. All variations from normal sensation should be recorded. Paresthesias are sensations that are entirely sub- jective, that is, they are not the result of external influences. They are sensations of burning, prickling, "pins and needles", freezing, etc. They may be as- sociated with other forms of abnormal sensation and often precede the occurrence of anaesthesia. The sen- sation may be actual pain of the kind described. Like everything wholly subjective there are no tests for paresthesia. Alteration in motility of any part of the body does not require an elaborate system of testing. When paralysis exists it is shown by inability of the patient to move the paralyzed part. The paralysis may be complete or partial, the latter condition being indi- cated by the word paresis. Testing the strength of a limb or part is best done by the examiner's own muscles. For the upper limb, the patient is told to grasp the examiner's first three fingers and then to squeeze as hard as pos- sible. The same procedure is to be done with the other hand. Difference between the two will be recognized by the examiner at once. Even if both sides are paretic the examiner can after a little experience recognize the fact. Next, the flexor power of the arm is to be tested. If the patient flexes the arm as completely as he can, the examiner putting his left hand on the shoul- der in front, pulls down or extends the flexed arm THE EXAMINATION. 23 with his right. The amount of force requisite for this is inversely proportional to the amount of par- alysis. Of course if there is total and complete paralysis the patient cannot flex the arm or can only make a feeble effort at doing so. Weakness of the flexors or extensors of the wrist is tested by over- coming the patient's effort to put the muscles in action. The extension of the arm is tested by having the patient extend the arm fully, the examiner then trying to overcome it by doubling up the arm, if pos- sible. The fingers may be tested in a similar manner, but more information will be obtained by requiring the patient to open the fingers, to separate them widely, to touch with the thumb successively the tips of the fingers of the same hand. Testing the subdivisions of the lower limb may be carried out in a similar manner. Testing the muscular strength is of . greater value to the examiner in cases of paresis than in those of complete paralysis, the latter being self-evident on the patient's attempting a movement. Hypertonicity of muscles is shown by rigidity of the limb, and the rigidity is difficult to overcome by the examiner at first ; it does yield after some effort, and then the limb is easily bent. On straightening it again the weakness is evident until nearly in full extension, when extension is completed suddenly. Tremor is a condition of alternate contraction and relaxation of opposing muscles of hand and arm, neck 24 THE EXAMINATION. and head, or leg and foot. The extent of motion is small, and the recurrences from 4 or 5 to 10 or 12 in the second. If no tremor is evident, it may be elicited by having the patient hold the hand out with the fingers widely spread. The procedure will usually bring out a tremor if it exist at all. Test the patient further by telling him to hold the hand still; if the tremor increases thereby, he should now be tested by directing him to take from a table a glass of water and taste it. If tremor begins with his taking up the glass, and it increases in the extent of the oscillations as it nears his mouth, he has what is called inten- tional tremor. The motions of chorea, athetosis and in general convulsions need no test ; in the latter, however, the pupils should be examined, when possible, for the reaction to light. Contracture may be tested by endeavoring to over- come it. In . hysterical cases the examiner generally finds a perceptible increase of the spasm acting against his efforts. In organic contractures pain is produced in the endeavor to overcome them. Con- tractures due to anatomical shortening of unopposed muscles cannot be overcome except by forcible rup- ture of the muscle, or similar injury. Paralysis, with atrophy, requires the employment of electrical tests ; these will be found described in the section on electro-diagnosis. Atrophy is indicated by evident loss of tissue, and alteration or sinking at a part that normally is full. The relative part of THE EXAMINATION. 25 the other side may be used for comparison, unless it too has been similarly affected. Loss of symmetry of the two sides of the face may be evident at first sight, or if slight, may require tests. Here, the patient is directed to separate the lips and show the teeth, to blow as if blowing out a candle, to close the eyes, to raise and then contract the eyebrows. Hemiplegia, peripheral paralysis of the facial nerve, hemiatrophy of the face, hysterical spasm of one side of the face, give different results with the above tests, which will be described under the proper headings. Testing the special senses requires different tests. For taste, the four qualities, salt, sour, bitter and sweet, are employed, solutions being applied to the edge of the tongue on its anterior two-thirds. The substances used are simple syrup, a solution of com- mon salt, extract of gentian, and very dilute hydro- chloric acid. Application of each solution is to be made by a separate camel's hair pencil to the tongue, which is kept protruded until the taste sensation de- velops (or a reasonable time if it does not). The acid solution should be applied last, as it dulls the power of tasting. The patient is warned not to talk during the whole experiment, lest the solutions spread over the tongue, and when he notices a taste sen- sation, he selects from a card on which are written or printed the words sweet, bitter, salt, sour, the one that he has perceived. Each half of the tongue is to be tested by itself. (Groldscheider.) 26 THE EXAMINATION. Testing the olfactory nerve is done by holding a small vial containing some well-known odorous material, such as oil of peppermint or oil of lemon, before one nostril, the other being closed. On drawing in a whiff of it the odor will be perceived if the olfactory nerve is intact. Disease of the mem- brane may reduce or abolish the olfactory power. (Groldscheider.) Tests in connection with eye and ear will be con- sidered in treating of the respective nerves. Electro-Diagnosis. Although the subject of electricity in neurology in general is not within the plan of this book, yet the use of the electrical current in the diagnosis of nervous disease must be described with its methods. When a current of electricity is passed through a motor nerve or muscle the related muscle contracts, as soon as the circuit is completed, if the current be of sufficient strength. A difference in results is noted when the current strength is increased and change of poles made. Normally, using galvanism, the negative pole or cathode being on the muscle, (the positive or anode on some indifferent part of the body) there will result contraction with less strength of cur- rent when the circuit is completed than when the poles are made to change places or when breaking the circuit. With increasing strength of current the fol- lowing is the succession of contractions produced under the differences of arrangement just named. Cathodal closure contraction ; anodal closure contrac- tion ; anodal opening contraction ; cathodal closure tetanus. This series is expressed in tabular form and abbreviated as follows : I. CaCC. II. AnCC. III. AnOC. IV. CaCT. 28 ELECTRO-DIAGNOSIS. The last term means cathodal tetanus contraction, because with increasing current strength the contrac- tions become more powerful and tend to prolong, until finally they are here continuous or tetanic. The strength of current causing a contraction should be determined by a proper meter in the circuit. As the unit of current strength is the am- pere, and as only small fractions of an ampere are used in medical electricity, the meter is arranged to show thousandths of an ampere and hence is termed milliamp er emet er . The electrode placed on some indifferent part of the body when testing, should be of definite surface; Erb's normal electrode has a surface of 10 square centimeters. The differentiating electrode should be small, Erb's being a series of three, spherical in shape and graduated in size, the largest being about the size of an average pea. The electrodes, well wetted in warm water, being placed in position and the negative on the nerve or on the part of the muscle at which its nerve is nearest the surface, (the handle of the differentiating elec- trode should be provided with an interrupting arrange- ment, so that the current can be made or broken at the will of the examiner) a weak current is turned on. As the current increases, contraction will be noted in the muscles supplied by the nerve if the differentiating electrode be over the nerve trunk; or in a muscle if its motor point should have been selected. Using the strength of current that brings the first ELECTKO-DIAGNOSIS. 29 appearance of contraction, then by changing the pole by means of the pole changer the small electrode becomes positive and again the current is made and broken. If no contraction is observed it is clear that the negative closure contraction is greater than the positive, either closing or opening, which, as has been shown, is normal. If on the other hand, with the same current strength the positive give better con- tractions than did the negative closure, it is equally clear that the influence of the latter is less than that of the former — which is abnormal. The faradic current, so-called, is in no wise dif- ferent in nature from the galvanic. The secondary coil being generally used, the current is an induced one, and as it is only present when some change of current strength takes place in the original galvanic current derived from the cell which "runs" the far- adic battery, a mechanism (the so-called vibrator or hammer) to produce very rapidly alternating makes and breaks is introduced. Contraction is caused by the secondary current just as in the case of the current from an ordinary galvanic battery, but before the muscle has time to relax a new flow of current conies and the contraction remains as long as the vibrator is acting. Negative and positive, although existing in the far- adic current, are not diffentiated in diagnostic use ; but a better contraction is produced by the negative than by the positive. When a motor nerve is severed the portion distal 30 ELECTRO-DIAGNOSIS. from the point of section begins to degenerate, which process, according to Erb's investigations, is complete at the end of two weeks and in some cases earlier. The electrical reactions have in that time altered in different ways. From the nerve, both faradic and galvanic contractility gradually lessen, until at the end of the second week they have disappeared. In the muscles supplied by the nerve, faradic contractility follows a parallel course, but often (not always) the galvanic contractility gradually lowers until near the end of the second week and then becomes increased and increasing reaches its apex at about the end of the third week ; it then slowly falls, but still keeps above the normal, till about the end of the tenth week in cases that rapidly recover, to the end of the twentieth week in case of moderate severity, and in those that are not to recover it does not reach the normal level until the end of the fiftieth week. After these dates, respectively, the fall continues in the first until the end of the fifteenth week, when it begins to rise again ; in the second it falls to the end of the fiftieth week and then slowly rises. While in the case not to recover it ascends to the end of the tenth week and then descends to finally disappear by the end of two years. The accompanying figures from Erb show graphic- ally the changes just described ; in addition they show that recovery of a nerve after complete separa- tion (or degeneration) takes at least six weeks from the beginning. ELECTRO-DIAGNOSIS. 31 Motility. Galv. Farad. Degener- Atrophy and nuclear g ation of proliferation of W>*j nerve. muscle. p£ Cirrhosis. 3 4 9. 10 11. 12 WEEKS. z S Ga ! v - S3 { anQ Z ( Farad. r^ 1 fjs <> ? * iJuu i^S^I The first ordinate shows occurrence of the lesion and cessation of motility ; the star indicates the Fig. 1. return of the latter, the waved line indicates qualitative change. Degener- ation of Atrophy, etc. Regeneration. 1. 2. 3. 6. 10. 18. 20. 25. 30. 35. 40. 45. 50. 55. Fig. 2. Paralysis with late return of motility. Degener- ,r • • u • Complete dis- ation of Atrophy, nuclear proliferation, cirrhosis. appearance. nerve. Motility. i s Galv - § \ Farad. g> ( Galv. S3 I and £ ( Farad. 2. 10. 20. 30. 40. 50. 60. 70. 80. 90. 100. J iUi ^ / Incurable paralysis ; no return Fig. 3. or motility. Nerve? Degeneration and atrophy R eration . 1 c of muscle fibre. & Motility. £ (Galv. § (Farad. « f Galv. u S an< l £; ( Farad. 000 1 > f p^ ._t 1 |ttUiU iau 'wuwuaa Fig. 4. Partial ED ; probably no de- generation of nerve. $2 ELECTKO-DIAGNOSIS. Degeneration of a nerve is shown by alterations in the contraction of its related muscle when the former is tested by either current; the contractions become weak and finally cease even with strong currents, re- action to the galvanic current continuing for a while after that to the faradic current has ceased. This loss of reaction through the nerve is termed an in- direct quantitative change. When the differentiating electrode is placed on a muscle supplied by a degenerated nerve it is found that instead of the negative pole giving the better response the positive often does so or at least may cause an equally good contraction. This is called serial or qualitative change. Another typical change in the contraction of degen- erated muscles is the absence of the quick, sharp, momentary character of the normal muscle's contrac- tion, it being now slow and lagging. This is called a modal change and, if present, occurs with galvanic current only. The reaction of degeneration (expressed by the let- ters RD) is therefore known by the existence of the changes just mentioned or, to recapitulate them: the muscle contracts slowly and sluggishly ; it responds bet- ter to the positive than to the negative pole (or at least as well) and, indeed, at times in the earlier stages of the process, more readily to small amounts of current ; and finally the faradic reaction of both nerve and muscle is lost. A partial reaction of degeneration is said to be ELECTKO-DIAGNOSIS. 33 present when, without any alteration of the normal polar succession, the contraction is weaker than normal and for both currents, and is slow and dragging. It is found in slight cases of peripheral motor nerve degeneration. The motor points accessible on the surface have been marked on the body by Erb, Ziemssen and others. Because of their importance the figures and explanations are given on this and following pages. M. frontalis. First branch of facial nerve. M. corrug. supercil. M. orbic. palp. Nasal muscles. ( ' M. zygomatici. M. orbic. oris. | Second branch of facial nerve. M. masseter. M. levat. menti. M. quadr. menti. M. triang. menti. Nerv. hypogloss. Third branch of facial. M. platysma. Hyoid muscles. | M. omohyoid Nerv. ant. thorac. (M. pectcralis). M. temporalis. First branch of facial n. Trunk of facial nerve. N. auric, post. Second branch of facial n. Lower branch of facial n. M. splenius. M. sterno-mastoid. N. accessorius. M. levat. ang. scap. M. trapezius. N. post, thoracic. N. circumflex. N. thorac. long. (M. serratus magn). o Supra-clavicular 'c point— Erb's point. £ (M. deltoid., •5 biceps, brachialis anticus and su- ^ pinator longus). Fig. 5. MOTOR POINTS OF FACE. 34 ELECTRO-DIAGNOSIS. M. brachialis ant M. biceps. N. muse, cutan. M. deltoideus ant. M. lumbricales M. adductor brev M. flexor brev. M. opponens M. abductor brev, N M. flexor long M. flexor digit, sublimis M. flexor carpi radial M. flexor digit, profund. M. pronator radii N. median. M. lubricales. M. opponens minimi digit. M. flexor minimi digit. M. abductor minimi digit. M. palmaris brevis. ulnaris. M. flexor carpi ulnar. UPPER EXTREMITY.— ANTERIOR ASPECT. ELECTRO-DIAGNOSIS. 35 M. inteross. I, 2, 3,4. ) (N. ulnaris.) f M. abduct minimi digiti. extensor long, pollicis. M. extensor brevis pollicis. M. abductor long, pollicis. M. extensor indicis. M. extensor minimi digiti. M. extensor communis digitor. M. extensor radialis brevis. M. supinator longus. M. extensor carpi ulnaris. M. extensor radial, longior. M. supinator longus. M. brachialis. N. radialis (musculo-spiral). ' M. tricps. M. deltoid. ' X. circumflo Fig. 7. UPPER EXTREMITY.— POSTERIOR ASPECT. tf ELECTRO-DIAGNOSIS. N. obturator. M. pectineus. M. adductor magnus M. adductor longus N. peroneal. M. tibialis anticus. M. extensor commun. digitor. M. peroneus long. M. peroneus brevis. M. extensor prop, pollicis M. extensor digit, brevis communis M. tensor vagin. femoris. | M. quadriceps'femoris. M. rectus femoris. M. crureus. M. vastus externus. M. vastus internus. M. gastrocnemius. M. soleus. M. peroneus brevis. M. abductor minimi digit. M. interossei. Fig. 8. LOWER EXTREMITY.— ANTERIOR ASPECT. ELECTRO-DIAGNOSIS. 37 M. gluteus. maximus. N. ischiadicus (great sciatic). M. adductor magnus. M. semitendinosus. M. semimembranosus. N. tibialis. M. gastrocnemius (external). M. gastrocnemius (internal). M. flexor commun. digit. M. flexor longus pollicis. N. tibial. Fig. 9. LOWER EXTREMITY.— POSTERIOR ASPECT. Since degeneration of the central neurone does not pass on to the peripheral neurone, it follows that the reaction of degeneration excludes central disease, as it also does functional trouble. The site of the lesion may be the anterior gray horns of the cord (ganglion cells), the motor nerve roots or the nerve fibres. It is not present in primary disease of the muscles (mus- cular dystrophies) except late in the disorder. It is found in neuritis of all kinds, unless when very slight in degree ; in poliomyelitis anterior acuta, in 38 ELECTRO-DIAGNOSIS. myelitis transversa if the anterior gray horns are much affected ; in bulbar paralysis, and amyotrophic lateral sclerosis, in affections implicating, by pressure or otherwise, the cells of the anterior gray horns or those of the motor nerve nuclei in the medulla; in syringomyelia, and after traumatic heematomyelia, and in progressive muscular atrophy of spinal type. In the progressive forms mentioned the reaction is usually PRD rather than complete RD. In prognosis the electro-responses of nerve and muscle are of some importance. " Under like con- ditions — i. e., in one and the same disease from the same cause, the lesion is more severe, the duration of the affection will be the longer, the outlook for complete restoration will be the poorer the more com- plete and typical the RD is and the more advanced its stage. Thus, partial reaction of degeneration is more favorable than the complete RD, and the later stages of RD more unfavorable than the earlier ones." — Erb. Special reactions to electrical stimulation are found in myotonia congenita and tetany. They will be de- scribed in treating of those affections. Peripheral Nerves. Anatomy of Nerve Fibre.— Degeneration of Nerve. Every nerve fibre originates in a nerve cell, and is, in fact, the extension of the axis cylinder process of the cell. Whether the prolonged axis cylinder ever divides in its course into two or more fibrils, although such view has been advanced, is not yet positively decided. In any event, the fibril soon after it leaves the cell receives a covering termed the myeline sheath, which covering is continued to the termination of the fibre. Outside the myeline sheath there is on the peripheral nerve fibre another termed the connective tissue sheath, or sheath of Schwann. It is a delicate, yet dense, connective tissue envelope, which, at some- what regular intervals in its length, undergoes con- striction, thrusting away, as it were, in two directions the myeline, and pressing itself closely to the axis cy finder. At such points (constrictions or nodes of Ranvier) the axis cylinder can be seen, in a properly prepared specimen, uncovered by myeline. Between every two such constrictions is found a flattened, somewhat elongated, nucleus on the inner surface of the membrane. The sheath and its nuclei appear to be of the highest importance in determining the re- 40 ANATOMY OF NERVE FIBRE. -DEGENERATION OF NERVE. generation of a peripheral nerve after injury or other lesion; the absence of this sheath and its nuclei in the nerve fibres of the central nervous system thus explains the irreparability of destructive changes in such fibres. The myeline sheath, after being pre- pared for microscopical examination, shows certain incisures, placed at an angle of about 45° to the long axis of the fibre. These are termed incisures of Schmidt-Lantermann, and are believed to be non-existent in the living nerve, but their occurrence at somewhat regu- lar intervals, and in definite direction, leads to the view that there is normally some structural differentiation at their sites. 18 The nutrition of a nerve fibre n 9 e f at t n h^ n iatTer a ; kept up through trophic influence, or Fig. 10. Fig. io (from Gowers) exhibits the structure of nerve fibre. I. and II. medullated, III. non- medullated fibres. Ac is the axis cylinder or neu- raxon ; M is the myeline sheath ; S is connective tissue sheath nucleus IS an Schmidt ; N a node of • 1 "I 1 1' 1 1 O O j_ ' j_ Ranvier.' The myeiine possibly by direct transfer ol nutrient sheath appears black, x * * Itain. ec smic acid material from its originating cell. When a peripheral nerve fibre is cut across, the distal, or cut-off part, undergoes degeneration, most rapid in the interannular segment suffering the lesion, and next, in point of time, at the peripheral endings. The process of degeneration is a breaking down of the axis cylinder and the myeline sheath, the former disappearing, the latter being transformed into masses ANATOMY OF NERVE FIBRE. -DEGENERATION OF NERVE. 41 or globules resembling oil, with granular debris, all finally disappearing. The nuclei of the connective tissue sheath increase in number, this increase, however, ceasing when the myeline within has been trans- formed into small droplets. There then remains only the collapsed connective tissue sheath. Regeneration of the nerve occurs from the proximal cut end, the axis cylinder advancing along the course of the sheath of Schwann, the addition of the myeline envelope being slightly behind the pro- gressing end of the axis cylinder. The process can be materially hastened in cases where a gap exists between the cut ends by suturing the ends together. Consideration of the nerve cells and nerve endings is reserved for the section on diseases of the central nervous sys- tem. Fig. 11. Fig. 11 shows the de- generation of nerve fibre (from Gowers). At A the protoplasm and nu- clei are increased, the myeline is breaking up, the process being more advanced near the nu- cleus n. In B the break- ing up has gone on to the formation of glob- ules. In C the latter are much smaller, and man)' have been re- moved, so that the fibre is narrow. In D all the products of degenera- tion have been removed from considerable tracts of the sheath. Neuritis. As the terminology of the word indicates, this means inflammation of a nerve. Theoretically, at least, any nerve may be the subject of the inflammatory pro- cess, but practically, certain peripheral nerves and plexuses are especially prone to inflammation. The causes of such inflammation may be arranged in three groups, i. e., toxic, from without the body; auto-toxic, from within, and traumatic. Traumatism, most commonly excessive or prolonged pressure, causes a localized neuritis, that is to say, in one or more nerves that have been thus subjected to the injury ; the toxic, from without the body, and the auto-toxic, from within, may and usually do, in- volve in the neuritic process the nerves of more than one member ; and when the toxic effect is not great or the resistance of the nerve to the morbid influence is great, a slight trauma may be sufficient to determine a neuritis limited to the part of the body so sub- jected to the latter influence. The term peripheral nerve is often used indifferently for the nerve trunk and for the ultimate nerve fibres of which the latter is made up. And if the process of inflammation attack first the connective tissue about the nerve fibrils and the bundles of the same, the term interstitial neuritis is used ; when the pro- cess is limited to the nerve fibrils themselves it is NEURITIS. 43 said to be a parenchymatous neuritis. Clinically, no distinction between these two forms is practicable. When a nerve becomes inflamed it begins to under- go a softening and alteration of structure both in its myeline sheath and in its axis cylinder; the in- flamed spot thus undergoes degeneration so that here no nerve structure is discernible under the microscope. The portion of the nerve distal from this point undergoes degeneration even without exten- sion of inflammation, according to the law of second- ary degeneration, which tells us that any part of a nerve fibre if separated from its origin goes into degeneration. As the motor fibres of a peripheral spinal nerve take their origin in the large ganglion cells in the anterior gray horns of the cord, they degenerate outward from the point of the lesion. The sensory fibres of the same nerves arise from the posterior spinal ganglia and hence degenerate upward and downward. The older view that secondary de- generation goes in the direction in which the affected fibre carries its nervous impulses would thus seem to be not true of the peripheral sensory fibres. As the cylinder axis of a nerve fibre is but the outgrowth and continuation of the cylinder axis process of the originating cell, the cell and its outrunning fibre being looked upon as a unit and termed neurone, it is evident that destruction of the cell is at once followed by destruction of the fibre. The effort has been recently made to prove that destruction of any part of a nerve unit or neurone is followed by de- 44 NEURITIS. structive changes throughout the rest of the neurone and thus is explained an ascending neuritis even in motor fibres. Not only is the nerve fibre proper dependent upon its originating cell, but also the muscle fibre to which the motor nerve fibre is sent and in which it ends, undergoes degeneration with the nerve. There is therefore when complete degeneration of a peripheral spinal nerve trunk or a great portion of it has occurred, loss of function of all the affected fibres, that is to say, no impulses can be carried in either direction and paralysis of motion and of sensa- tion results on the part of the affected nerve. Since the nutrition of a muscle fibre is dependent upon the integrity of the nerve fibre ending in it, it follows that degeneration of the nerve fibre will be followed by a similar condition in the muscle cell. The latter becomes shorter and thinner, its striations more indistinct and closer together than normally ; it takes on a peculiar glassy appearance (vitreous de- generation) and if regeneration of the nerve fibre does not occur the muscle fibre disappears. Meanwhile increase of the nuclei of the sarcolemma and connec- tive tissue proliferation begin and in advanced cases the remains of a few muscle fibres in a mass of con- nective tissue are all that are left. The atrophy is usually evident to the eye in the case of superficial muscles. In many cases of neuritis the lesion does not affect all the fibres or the process of degeneration is not NEURITIS. 45 so rapid as that of regeneration ; hence the paralysis may be slight in degree (paresis) for motion and sensation (hypaesthesia) or in the latter case there may be not destruction but irritation, so that parse sthe- sias occur in the distribution of the nerve fibres so affected. From the foregoing considerations the diagnosis of a neuritis may be readily deduced. The paralysis or paresis, the anaesthesia, hypaesthesia or paresthesia, or a combination of these, limited to the territory supplied by a mixed peripheral nerve, are sufficient to direct attention to that nerve as the organ whose functions have been interfered with or lost. Anaesthesia is, however, often surprisingly little in amount or limited in extent even after severe trauma, or lasts but a relatively short time. The explanation must be in the existence of other sensory nerve fibres for the same territory or a nerve anastomosis. In an inflamed nerve whose continuity has not yet been destroyed pain and tenderness are common manifestations. The pain is constant, with variations in intensity, and in mild cases or those of moderate severity is described as a "dead aching", which by its persistence becomes torturing to the patient. It is increased by anything that causes pressure upon the affected nerve, such as muscular action in the part, passive motion, direct pressure, etc. In severe cases the quality of the subjective pain may be boring, tearing, burning, etc. Tenderness to pressure along the nerve trunk is a 46 NEURITIS. marked feature of neuritis, and even when in slight cases the pressure does not give rise to objective tenderness an increase of the subjective pain is often produced lasting for many minutes. Paralysis is, as has been stated, one of the results of interruption in the continuity of a nerve, so that neuritis in all but the slightest forms gives rise to paralysis of the muscles supplied by the nerve af- fected. Thus neuritis of the musculo-spiral nerve is readily determined by the knowledge that the ex- tensors of the forearm and the supinator longus are paralyzed. Examination of a patient should always include testing the different muscles as to their power of action under the direction of the patient's will. A list of the muscles supplied by the peripheral (spinal) nerves, as well as statements of the action of those muscles, will spare the reader the trouble of studying out this information from his Anatomy should his memory of the facts be faulty. Nerves of the Upper Extremity. Circumflex nerve. Supplies the deltoid, teres minor and the skin over the deltoid. In paralysis the upper arm cannot be raised, some slight amount of abduction is present from the action of the supra-spinatus. From the atrophy that occurs there is loss of the rounded con- tour of the shoulder by the prominence of the bony structures, and as the nerve supplies the structures of the joint the ligaments are relaxed. There is also to be seen and felt a gap between the head of the humerus and the acromion. Paralysis is to be differ- NEURITIS. 47 entiated from anchylosis of the joint by the fact that in the latter, if passive motion be made of the upper arm the scapula moves also, not in paralysis. Musculo-spiral nerve supplies the triceps, both sup- inators, the muscles at the back of the forearm (ex- tensors, abductors and adductors), extensors of wrist and of first phalanges of the fingers, extensors and abductors of the thumb. In the majority of cases of paralysis of this nerve the lesion is near the middle of the humerus, and hence commonly the triceps is not affected. Because of the extensor palsy there is inability to extend the hand upon the forearm (the so-called wrist drop) and also a projection at the back of the hand (synovial sacs, bone) appears, and the first phalanges cannot be extended. If the arm be straightened out the forearm cannot be supinated. Paralysis of the supinator longus is best shown by causing the patient to flex the arm against an opposing force, when the normal bellying of the supinator just below the bend of the elbow will be found to be absent. Because of the loss of the opposing action of the extensors the flexors can- not act fully, and hence the grasp is weakened. Median nerve supplies the pronator teres and pro- nator quadratus, the radial flexor of the wrist, both sets of flexors of the fingers, except the ulnar half of the deep flexor, the long flexor of the thumb, the muscles of the ball of the thumb except the ad- ductor, the first two lumbricales and at times the third. Flexion of the hand on the wrist is impeded, 48 NEURITIS. and even only possible with a strong inclination to the ulnar side ; pronation of the forearm is impos- sible beyond the mid-position to which it is brought by the supinator longus. Flexion of second and third phalanges of the fingers is lost but not completely in the ring and little fingers. The thumb cannot be flexed nor brought into apposition with the tips of the fingers. The unopposed action of the interossei on the last two phalanges causes hyperextension and subluxation of them. Ulnar nerve supplies the flexor carpi ulnaris, the ulnar half of the deep flexor of the fingers, palmaris brevis, muscles of the hypothenar eminence, the in- terossei, the fourth lumbricalis and commonly the third, and the adductor pollicis. In paralysis of this nerve the power of flexion of the hand on the forearm is greatly weakened, the little finger can scarcely be moved, flexion of the first phalanges and extension of the second and third are lost from paralysis of the interossei, but not completely in the index and middle fingers since these receive innervation from the median nerve. Lateral movement of the fingers is impaired and adduction of the thumb is lost. The musculocutaneous nerve supplies the coraco- brachialis, biceps and brachialis anticus muscles, the chief flexors of the elbow. Paralysis of the nerve prevents flexion of the forearm when in position of supination, but flexion can be done when the arm is pronated, by flexing the supinator longus. Combined palsies of the nerves of the arm are NEURITIS. 49 frequently seen and arise from various causes. Disease or injury above the brachial plexus, or affecting the plexus in part or entirely, or affecting more than one nerve trunk below the plexus, can readily produce varied combinations of paralysis. Severe pressure above the clavicle readily affects the fifth and sixth cervical nerves, as they begin to enter the formation of the brachial plexus. Electrical stimulation at a point two fingers' breadth above the clavicle and one finger's breadth behind the sterno-cleido-mastoid muscle causes contraction together of the deltoid, brachialis anticus, biceps and supinator longus (Erb's point: supraclavic- ular point). A not uncommon form of paralysis of the upper part of the brachial plexus occurs from pressure made above the clavicle by the accoucheur in extracting the delayed head or by prolonged pressure during parturition on the shoulder girdle, thus approximating the clavicle and spinal column. This is known as Erb's paralysis. At birth the peripheral nerve fibres are poor in resisting power and the effect of a severe lesion then is long lasting and may be irremediable.* The power of the * In the new born child and for several weeks after birth the resistance to both faradism and galvanism is very high as compared to that of the adult, varying from 7,000 to 10, ('00 ohms during the first week of extra-uterine life. In addition to this, the very young individual shows but little sensitiveness to currents, both faradic and galvanic, that cannot be borne by the adult. The contractions caused in the muscles by either current, whether direct or indirect, differ from those in the adult in being slow and dragging instead of being quick and sharp. The anatomical explanation of these long known facts is found by A. Westphal to be due to the imperfect development of the nerve fibre at birth and during the first few weeks, the myeline sheath being absent in spots and sometimes over long stretches of nerve axis, and when present being thin and evidently but poorly elaborated. The inutility of employing electricity as an aid to diagnosis in cases of Erb's paralysis during the first few weeks of life is thus apparent Microscopical examination shows in the peripheral nerve in the very young, appearances very similar to those seen in the adult nerve degenerated after separation from its cell. The subject matter of this note is treated very thoroughlv by A. Westphal, in Archiv f. Psychiatric u. Nervcnkranlcheitcn, Bd. XXVI., Hft.'l. 50 NEURITIS. muscles of the hand and lower arm is not lost, but the upper arm is motionless and the humerus is ro- tated inward, so that the forearm hangs with its ex- tensor side facing forwards. This inward rotation is stated by Goldscheider to be in the majority of cases not due to paralysis of the external rotator, but to separation of the epiphysis since the inward rotator is inserted lower down than the outward rotator. Another form of lesion of the brachial plexus is seen when the injury occurs from below, in the axilla, involving the eighth cervical and the first dorsal nerve as they enter the plexus. The muscles of the hand are paralyzed, the flexors in the forearm, and when the seventh cervical nerve is affected, the extensors of the hand are also involved. Intermediate forms may occur or the plexus as a whole be affected. Besides the motor paralysis, oculo-pupillary symp- toms may be observed when the roots are affected before the giving off of the rami communicantes. Dislocations, fractures, in the region of the shoulder joint, forced retraction of the shoulders, the arms being raised, during operations, direct pressure from a badly fitting crutch in the axilla, violent muscular activity as in throwing, etc., can produce injury to the plexus, and a primary neuritis of the plexus has been observed. Sensory disturbances may be slight in degree, or on the other hand quite marked after traumatic neuritis. Nerves of the lower limb. Affections of the lum- NEURITIS. 5 1 bar and sacral plexuses are far less frequent than those of the brachial, chiefly because of their pro- tected situation, yet occasionally they, or some of the nerves from them, are the subject of special injury during prolonged parturition, by pressure of the for- ceps, or by tumors, etc. Anterior crural nerve paralysis renders the patient unable to flex the leg at the hip joint except partly by the action of the psoas muscle, which is not sup- plied by this nerve ; the extensors have no power, so that the leg cannot be extended upon the thigh. Hence standing and running are greatly impeded, if not prevented. Paralysis of the obturator nerve causes inability to adduct the thighs ; hence the legs cannot be crossed, nor the knees pressed together. Paralysis of the superior gluteal nerve, a rare oc- currence by itself, causes loss of power of internal rotation, abduction and extension of the thigh. Paralysis of the sciatic nerve causes loss of power in all the muscles of the leg and foot, and the power of flexion of the leg upon the thigh is gone. The peroneal or external popliteal nerve supplies the peroneus longus and brevis, tibialis anticus, ex- tensor communis digitorum, longus and brevis, ex- tensor hallucis longus. Its paralysis results in what is known as "drop foot", the foot hanging lax when the leg is lifted; the toes catch on the ground when the patient attempts to walk and the outer toes cannot be extended, the foot cannot be abducted nor dorsally 52 NEURITIS. flexed and the outer edge of the foot cannot be raised. When the paralysis is of long standing the unopposed action of the calf muscles produces short- ening and consequently pes equinus. The internal popliteal nerve innervates the flexors r both long and short, of the toes, the calf muscles,, tibialis posticus, adductor and abductor of the great toe, the abductor of the little toe, the interossei and lumbricales. In paralysis of the plantar nerve flexion of foot and toes is lost; adduction is lessened; the patient cannot extend the foot nor raise himself upon his toes. II the paralysis be of long standing the unopposed action of mucles innervated by the peroneal nerve causes talipes calcaneus with hyperextension of first phalanges of the toes and flexion of second and third. The areas of sensory distribution ot the peripheral nerves will be more readily understood by reference to the accompanying illustrations than by any description. NEURITIS. 53 Fig. 12. From Hesse. The small curves mark the places of exit oi nerve branches through the fascia. N. axillaris ^circumflex. 54 NEURITIS. H . / ■ / n.cur. FEM.INT. N.CLUNIUM SUP. LUMB 6 Fig. 13. From Hesse. The small curves mark the places of exit of nerve branches through the fascia. N. clunium sup. lumb.= gluteal distribution from lumbar nerves ; N. dun. int. sacrales=gluteal distribution from sacral nerves. Multiple Neuritis. The distinction between neuritis arising from injury and a neuritis of toxic origin can usually be made out by eliciting the history of the case. Yet the writer has seen cases in which the history of traumatism was obtained only after repeated questioning. All the non-traumatic forms may be safely called toxic, either endogenous or exogenous, the exception being possibly where the local- ized influence of cold is the only assignable cause. In one instance a ride on a hot day in the open air pro- duced a neuritis of the brachial plexus, and also of the dorsal nerves supplying the trapezius of the same side. General exposure to cold may cause suppression of cutaneous activity and consequent accumulation of toxic (rheumatic?) material within the body and thus in predisposed cases neuritis may result. The infectious diseases, typhoid fever, diphtheria, tuberculosis, syphilis, etc., can cause wide-spread neu- ritis, as also can septic conditions (puerperium, etc.). The poison of gout, of rheumatism and of diabetes may cause a general neuritis — but with diabetes, syph- ilis and diphtheria, the neuritis may be localized. In Japan a form of multiple neuritis has existed for centuries; it is there known as u kak-ke". Since the rice ration of the Japanese army has been sup- planted by wheat flour and an addition of meat the disease has in great part disappeared from the army. 56 MULTIPLE NEURITIS. The natural inference would be that the disease is due directly or indirectly to faulty diet, but Dr. Albert A. Ashmead, of New York, who spent many years in Japan and who has investigated the disease, is firm- ly convinced that it is due to poisoning by car- bonic oxide, and he reports a remarkable instance of the outbreak of the disease on board a ship sailing from the Philippine Islands bound for New York, and plentifully supplied with good food. Bad weather caused exposure and fatigue, and the cargo of un- refined sugar began to ferment giving off C0 2 , so that the crew were evidently poisoned and the most virulent form of multiple neuritis attacked the ship's company causing several , deaths. Dr. Ashmead's views have led the writer to insist in every case of neuritis upon a most abundant supply of fresh air. In tropical South America, and also in India, a similar type of the disease is known under the name beri-beri. In these regions the affection occurs during the hot season, and the effort has been made to discover a special microbe as its originator. The most frequent cause of multiple neuritis in the temperate zones is undoubtedly the use of alcohol, and in every case in which the evidences of the disease are present no effort should be spared to trace it to that cause. The writer has been so often surprised to find, on questioning servants and other attendants, that a continuous use of alcoholic beverages had ex- isted unsuspected by the family physician, that he is now not satisfied in such a case to exclude alcohol as MULTIPLE NEURITIS. 57 the cause, unless the testimony against such view is overwhelming. Other poisons introduced from without have un- doubtedly caused multiple neuritis. In such cases the history, usually connected with some trade or occupa- tion (mercury, bisulphide of carbon), or a "course" of drugging (arsenic, mercury,) point out the causal in- fluence. Symptoms. — Injury to a nerve trunk, as by pres- sure, affects first the perineurium (perineuritis) then involves the epi- and endoneurium and intermediate connective tissue (interstitial neuritis) the usual evi- dences of inflammation, such as hyperaemia and cell proliferation being found on microscopical examination. From pressure the axis cylinder is injured and may be destroyed and then occurs secondary degeneration of the nerve fibre. Primary or degenerative (parenchymatous) neuritis is of frequent occurrence, the neuritis beginning by degenerative changes in the axis cylinder, but the interstitial connective tissue' soon becomes involved. The most prominent symptom of an acute neuritis is pain, subjective, of the character already described and, objective, by pressure upon the nerve trunk and its ramifications. Paresthesia and hyperesthesia are common symptoms, while occasionally motor irritative phenomena, such as fibrillary contractions and cramps in the muscles supplied by the affected nerves are observed. Vaso-motor and trophic changes may be present ; these are redness and swelling (cedematous), 58 MULTIPLE NEURITIS. herpes, " glossy" skin, bedsores, gangrene, pemphigus, etc., all in the distribution of the nerves inflamed. When the nerve is severely affected or the degenera- tion has advanced, hyperesthesia gives place to anaes- thesia or hypsesthesia, while paralysis and atrophy are to be expected. The most common form of multiple neuritis seen in this country is that due to the long continued use of alcohol in even moderate doses. Hence it is more frequently seen in women than in men, since the latter seem more inclined to get intoxicated and then cease for a time the use of strong drink or else have de- lirium tremens. In my experience, however, I have seen multiple neuritis so often associated with de- lirium tremens in the very poor half-vagrant class having the alcohol habit that I am inclined to think that the distinction holds good only for those who are well nourished. The onset of the trouble is really slow, although the outbreak of positive symptoms may be quite sudden. Vague pains and paresthesias may exist for weeks with some weakness in the legs and many digestive troubles that mislead the family physician in the absence of any knowledge of the real cause. Then some morning on getting up and walking to her toilet table or bath-room the patient sinks to the floor rather than falls, and she is found to be paralyzed in the lower limbs. The muscles and nerve trunks are tender to pressure, the pains in the lower limbs increase and soon the upper extremities are involved, MULTIPLE NEURITIS. 59 although not to the same degree usually. The extensor muscles of leg and forearm are especially affected and the so-called foot-drop and wrist-drop are present. Examination may show areas of anaesthesia and les- sened volume of the affected parts, while the reaction of degeneration determines the character of the atrophy when it is present. The anterior crural nerve being affected the knee jerk is of course gone and tremor of hands, lips, tongue and face may appear. The functions of bladder and rectum are not much interfered with, but in my experience the stomach always or nearly always shows disturbance evidenced by thickly coated tongue and foul breath. In estimating the influence of the infectious diseases in the production of a subsequent multiple neuritis, place should be given to the possible toxic effects of alcohol prescribed during the course of the former disorder, and this is especially true in typhoid fever and tuberculosis. Whether the division of multiple neuritis into a motor, sensory and ataxic form is justified, is to the writer a doubtful point, since the predominantly ataxic or sensory forms are not at all frequent. The metallic poisons, lead, arsenic, silver and mercury can cause multiple neuritis, and of these the first two more frequently than the others. In such cases the arms are affected first, usually, and more than the legs, the reverse being true of alcoholic neuritis. Lead seems to have a selective power in affecting the mus- culo-spiral nerve after the branch to the supinator 60 MULTIPLE NEURITIS. longus has been given off; but it also has a wide- spread influence upon the structures of the central nervous system, so that degenerative changes, especi- ally in the anterior gray horns of the spinal cord and also in the brain cortex, have been observed post- mortem. The local paralysis caused by the poison of diph- theria is seen in the muscles of the palate, oesophagus and larynx and even in the cardiac innervation. Just how the paralysis of accommodation occurring frequently after diphtheria, or of some of the external ocular muscles, is produced, is difficult to say. In one case the writer has seen a typical bulbar paralysis follow- ing a severe sore throat which he believes to have been diphtheritic. In another case a severe and rapidly advancing multiple neuritis followed immedi- ately the disappearance of paralysis of the palate mus- cles occurring from diphtheria. It is to be kept in mind that loss of the knee jerk is a common symptom after diphtheria. The association of neuritic (neuralgic?) symptoms with loss of the knee jerk in diabetes is not as yet understood. On the other hand the insufficiency of Trommer's or Fehling's test for sugar in the urine is now recognized and must formerly have led to errors in diagnosis* * Sugar. The sub-oxide of copper is precipitated by other substances than sugar in the urine (uric acid, kreatin, kreatinin, etc.) and lately Salkowski has called attention to the existence of a body termed pentose that occurs in the urine in certain cases, which precipitates the sub-oxide from Fehling's solution without boiling. The urine, so tested, shows in such cases fluorescence. Such urine does not undergo fermentation by the addition of yeast ; hence the fermentation test should always be employed as a control test in all cases of suspected diabetes or glycosuria. MULTIPLE NEURITIS. 6 1 The diagnosis of a neuritis in a peripheral spinal nerve is readily made out by recognition of pain, sub- jective and objective, in the affected nerve, by the loss or impairment of function, such as anaesthesia, paresthesia, hypaesthesia, paralysis or paresis in the distribution of the nerve, and by the history of previ- ous injury, exposure to cold, previous poisoning, al- coholic, metallic, etc., rheumatic (?), or of antecedent infectious or septic disease, etc. Erb's paralysis has been mistaken for poliomyelitis. Multiple neuritis will be recognized by the paralytic and sensory symptoms in the extremities and limited chiefly to the distal half of each. Where there is a considerable degree of ataxia and anaesthesia it may be mistaken for locomotor ataxia, especially when the onset has been slow. The ab- sence, however, of bladder or rectal implication and of pupillary inaction and of a girdle sensation are against the existence of the latter, while the tender- ness of nerve trunks and muscles, the paralysis or paresis of the limbs and the abnormal electrical re- action do not belong to tabes. Lightning pains as seen in locomotor ataxia do not belong to an ordinary neuritis, yet I have seen in more than one case the most frightful paroxysms of pain radiating from the back down the arms or around the trunk, these being evidently due to severe irritation of the nerve roots. From poliomyelitis anterior the pains would be sufficient to differentiate a neuritis even in the presence of considerable atrophy, while the atrophy 62 MULTIPLE NEURITIS. itself is, in the two diseases, different in distribution ; in the former less in the distribution of nerve trunks than in the muscles associated in some one definite action. In myelitis transversa there are no spontaneous pains unless the nerve roots are implicated; there is no tenderness of nerve trunks, no atrophy of muscles, while there is exaggeration of deep re- flexes, a thing not present in neuritis except in the very earliest stage. In myelitis lumbalis, leading to atrophic paralysis and loss of knee-jerk, paralysis or paresis of bladder and rectum is to be expected. The prognosis in multiple neuritis is good, pro- vided the cause has been removed, or in cases of paralysis following the severing of a nerve if the cut ends be in apposition, the connective tissue sheath of the cut ends serving as a guide or pathway for the new growth from the proximal uninjured part. Multiple neuritis has a tendency to recover, except in the pernicious forms, in which there is some im- plication of the cardiac nerve supply. In the alco- holic form when delirium tremens is present the prognosis is grave as long as the latter condition remains, or if pneumonia develop. Cases of multiple neuritis without the complications recover in a few months, or after many, according to the degree of severity and consequent amount of degeneration. Concerning the homeopathic treatment of neuritis, the general considerations as to treatment already ^iven should be borne in mind. The causal indi- MULTIPLE NEURITIS. 63 cation is always of the first importance in select- ing a remedy. Hence, in cases in which trauma (pressure, etc.) has produced a neuritis, Arnica is, in the writer's experience, the remedy first to be thought of, and should be given in a moderate po- tency aud not frequently repeated. Hypericum has received great praise for its influence in restoring a nerve after traumatic influences, but, in the writer's opinion, it has less influence than Arnica, possibly because it seems to have a selective in- fluence upon either the terminal organs of the sens- ory fibres, or on the posterior nerve roots as they enter the spinal cord. Iu several instances, where the only clinical presumption possible was special implication of the posterior nerve-roots, the remedy in third dilution acted admirably in relieving pain and bringing about a rapid cure, and in at least one case in which an ascending neuritis of the arm followed a punctured wound of a finger-tip this remedy in 200th seemed to be the only one that made the patient comfortable, even after mor- phine had been used in vain for this purpose. Other remedies, such as Rata graveolens, Rhus toxi- codendron, Dulcamara, Ledum palustre, or Apis melli- fica will be thought of should their special causal indications be present. When the use of alcohol can be fairly charged as the cause of a neuritis, even of severe type, there is no oue remedy (unless special contra-indications are pres- ent) so valuable as Cimicifuga racemosa given in 3d or 64 MULTIPLE NEURITIS. 6th ; in a local neuritis whose immediate cause is trauma, while the predisposing cause has been the use of alcohol, Arnica had better be given first, to be fol- lowed later by Cimicifuga racemosa. Next in rank to Cimicifuga racemosa are Banuncuhis bidbosus, China officinalis and Bryonia alba, and in more chronic cases Arsenicum and Lacliesis. Ledum palustre ought to be a valuable remedy in alcoholic neuritis, but the writer has not used it in the multiple affection, owing pos- sibly to the limitations of the direction of the pains produced by it. In other forms (non-alcoholic) of neuritis remedies must be chosen by the symptoms, but here again some cause, such as exposure to cold or wet, will lead the prescriber by a short-cut to the selection of the remedy. Rhus toxicodendron, Rata graveolens, Calcarea carbonica, Didcamara, Natrum sulphur icum, Bellis perennis and many others are to be studied for this purpose. A slight trauma may set up a neuritis in a patient whose nutrition is below par from causes other than the use of alcohol. Quite recently a patient called on the writer suffering from neuritis of the median and ulnar nerves of the left arm, caused directly by a woman in confinement having grasped the arm with great force during one of her pains. There was intense subjective pain, with paresis of the flexors of the forearm and hand. A remedy was given with some slight relief, and on the next visit the doctor- patient stated, as an odd fact, that for several years MULTIPLE NEURITIS. 65 previous there had been a chronic diarrhoea which no remedy seemed to reach and that it had ceased since the existence of the neuritis. Further investigation showed that the diarrhoea had been caused by plung- ing into the sea while overheated, the water being very cold at the time. The diarrhoea, which had stopped during the neuritic attack, returned as soon as the neuritis was lessened by the remedy. Acting upon this hint, Bellis perennis was given in the belief that the diarrhoea must be cured first before the neuritis would go. The result more than justified this opinion, for both diarrhoea and neuritis disap- peared, the latter, however, not at once, for a relapse was caused by clapping the hands at a public en- tertainment. Two doses of Arnica radix, followed by a few of Bellis perennis, restored the patient, whose arm, however, had to be humored for several weeks. At times the location of a neuritis will enable the physician to select the remedy. For instance, any neuritis in the distribution of the nerves from the lumbar and sacral plexuses seems readily influenced by Berber-is vulgaris. If it is limited to the lesser sciatic, 2Esculus hippocastanum seems to be better indicated, and if in the anterior crural, Pdreira brava. The rectal symptoms of 2Esculus hippocastanum, or the bladder symptoms of Berber is vulgaris or of Pareira brava, are strong indications, even though they them- selves have long preceded the neuritis. So a deltoid paralysis (circumflex nerve) of months' standing, occurring in a farmer, and presumably from 66 MULTIPLE NEURITIS. cold, has been relieved in a few days by Sanguinaria Canadensis. For a root neuritis, or trouble simulating this in the upper dorsal roots, Anantherum muricatum 30 has acted in a marvellous manner in several cases. Of the large number of substances already men- tioned as causing multiple neuritis Arsenic, Mercury, Lead, Bisulphide of carbon, and Copper are also well- proven homeopathic remedies. Carbon monoxide has a place in the homeopathic materia medica under the title Carboneum oxygenisatum, but there are many drugs whose provings show symptoms similar to those of multiple neuritis. But we are not limited to remedies known to cause inflammation of peripheral nerves, and should hold in mind the characteristic symptoms, modalities, and especially the causal ones as our guides. The writer has known Phosphorus 6 to make a rapid cure of post-diphtheritic multiple neuritis, the selection of the remedy being made on the ascend- ing of sensory and motor paralysis from the ends of fingers and toes. The diphtheria toxine* (not anti-toxine), in the 200th potency, rapidly cured a hospital case unable to walk from post-diphtheritic polyneuritis. As to the care of a case of multiple neuritis, the cause, if found, having been removed, warmth and good nourishing food, with an addition of assimilable fat, are the chief things. In applying ^Obtained through the kindness of Dr. Paul Gibier, Director of the Pasteur Institute, New York, and potentized for the writer by Dr. Martin Deschere. MULTIPLE NEURITIS. 67 hot bottles or hot-water bags to the affected limbs, the danger of burning must be kept in mind, for the anaesthesia or hypaesthesia may prevent the pa- tient from appreciating the degree of heat used, and the tissues during the existence of the disease have a much lowered vitality. Troublesome ulcers may thus be caused. Motion must be avoided if it produce much sub- jective pain. Massage is, in the writer's opinion, injurious in any stage of the affection. Galvanism is often (not always) of marked value, but should not be employed, as a rule, until the acute pains have somewhat subsided; occasionally the anode to the site of great pain, the cathode in some indif- ferent part of the body gives great temporary re- lief, but at times this is for a short while only, and may be followed by marked and long-continued aggravation. The benefit from the use of galvanism is most in the later stages, when spontaneous pain has greatly lessened; the application should be cathode stabile at an indifferent part, anode labile along the affected nerve trunk, small currents of 2 or 3 m-a for 2 or 3 minutes to each limb. In old cases where atrophy is markedly present, the same electrical treatment as that followed in poliomyelitis anterior should be used. When contractures exist, manipulation and extension of the contractured muscles will often overcome the deformity and bring about restoration of structure and function. Neuralgia. The word neuralgia means nerve-pain, but it is ap- plied only to pain existing in a nerve without any anatomical change in the latter. The pain in neuralgia is of different qualities; it may be boring, tearing, crushing, lancinating, etc. It gen- erally comes in a succession of outbreaks, each lasting a few minutes or, at times, much longer. At the end of the paroxysm there may be entire relief until a new one begins, but often there is during the interval a considerable substratum, so to say, of pain that is continuous. When all pain ceases, not to re- turn, the attack is over. An attack of neuralgia may be brought on by dif- ferent causes, exposure to cold being the chief one ; but mental excitement, excessive fatigue, error in diet, etc., are, at times, provocative. The subjects of neuralgia are neurotic or debilitated, or have gouty or rheumatic constitution. The affection first appears, in the majority of cases, in early adult life ; it rarely occurs before the period of puberty. Neuralgias may be divided into idiopathic, reflex and symptomatic forms, according to causation. When due to irritation of the nerve directly, as by a tumor within the skull, irritation set up by a decayed tooth, etc., it is symptomatic; when caused by disease of some distant organ it is reflex, and when no cause is assign- NEURALGIA. 69 able other than a general state of the system affecting the nerve, it is idiopathic. The pathology of the affection is in donbt. It is easy to assume that the affection must specially in- volve the nervi nervorum, but the irradiation or stream- ing out of the pain apparently to other nerve trunks is best explained by locating the real seat of the trouble in either the posterior spinal ganglia or in the cells of the posterior gray horns of the cord, and ex- tension of irritation to other cells will send up to the cortex impulses of pain felt as coining from the related peripheral nerve. Reflex neuralgias are produced in a similar way and muscular spasm in the part may be aroused by irritation sent to the anterior motor cells. Growers gives an illustration showing a focus of softening in the pons, involving part of the sensory nucleus of the fifth nerve ; during life it had caused severe neuralgic pain in the face. Hyperalgesia (to a light touch) of the skin cover- ing the affected region is observed in many cases, but often firm pressure will ameliorate the pain. Tender points may be found in the course of the affected nerve, at its emergence from a bony foramen or in its course over a bone or where it passes through fascia. The diagnosis of neuralgia is made from the location of the pain in one nerve which changes place from moment to moment, and from the absence of evident organic change in the nerve (paralysis in a mixed nerve, anaesthesia); in neuritis pressure anywhere along JO NEUKALOIA. the affected nerve is painful, while in neuralgia if firm pressure be made it often suppresses the pain, as above stated. The occurrence of pain in paroxysms, with free- dom in the intervals between the attacks, points to idiopathic neuralgia rather than to organic disease affecting the nerve. In reflex neuralgia the distant cause may be difficult to discover. Long continuance of neuralgia may result in setting up some amount of organic change in the nerve. Eruptions such as herpes, pemphigus, etc., in con- nection with pain in a nerve are evidence of organic change in the nerve itself or its spinal ganglion, or, in case of the fifth nerve, in the Grasserian ganglion. Neuralgia of the Fifth Nerve. — Trigeminal Neuralgia. — Prosopalgia. — Tic Douloureux. This is the most common form of neuralgia, indeed it is more common than all other forms taken to- gether. It is the most typical in the characteristics of pain, paroxysms, free intervals, etc. It may attack any one of the divisions of the nerve or two of them or all three. When the first division is the seat ot the trouble the pain is generally over the eyebrow ; it may extend down the side of the nose or be felt in the eye. Painful pressure points are just above the supra- orbital foramen, on the nose near the inner canthus and on the bone just above the outer canthus. When the second division of the nerve is affected, NEUKALGIA. 7 1 pressure points may be found at the infraorbital fora- men, at the side of the nose and on the malar bone. When the third division is involved, the points are in front of the tragus or somewhat above this, at the parietal eminence and at the site of the mental fora- men. The eyeball itself may be a pressure point when its supply from the first branch of the fifth, is involved ; or an ocular neuralgia may exist alone. In elderly persons neuralgia alveolaris in the tooth- less gums has been described by several observers ; the writer has seen loosening of a tooth (from absorp- tion of the alveolar process) follow an attack of facial neuralgia, not once, but many times in the same indi- vidual. The loosened tooth, if treated and kept, seemed to receive the brunt of such trophic change in subsequent attacks, but when it had finally to be drawn, another attack would find a fresh victim in a hitherto firm tooth. The pain in an attack of trigeminal neuralgia varies greatly, but in the paroxysms there is a "shooting" character with a "cutting" quality. At times it is a crushing of the most intense kind ; at others as if the tissues were rapidly torn through as one might tear a strip of cotton cloth. The peculiarity of the affection is its irradiation from one branch of the nerve to another; the supraorbital region may be intensely painful, but in a few moments there may be a streak of pain in the lower jaw or a long stab beside the nose or just in front of the ear. 72 NEURALGIA. Or the pain may play along the face as the so- called "heat" lightning plays across the nocturnal sky — here the lancinating quality of the pain is not marked, but is replaced by a feeling as if the nerve were rapidly crushed. When this lambent character- istic is present the writer has observed a chilled or cold sensation in the nerves, and as a very severe attack with these peculiarities was accompanied in part of its course by an outbreak of herpes, he is of the opinion that such attacks show irritative or even inflammatory changes in the Gasserian ganglion. During a paroxysm of pain the sufferer can bear no external irritation — every thing is unbearable — to move the head or body, to open the mouth, to be touched near the areas of pain, all give increase of agony. A draft of air, an increase of light, a sudden noise, is intolerable, hence the myriad of suggestions to use hot applications or cold ones, to do this or that, have perhaps some beneficial effect in distracting the attention of the now irritable brain, become so from the intensity of the suffering. The attack may last hours or days and then gradu- ally disappear; or, happily, it may be cut short under the influence of a well-chosen remedy. One form of trigeminal neuralgia termed by Trousseau epileptiform neuralgia (a most unsuitable title) deserves attention. In these cases the sufferer is attacked with a suddenness that is appalling by an outbreak of pain in one of the branches of the fifth nerve. The suffering is of the most intense character NEURALGIA. 73 and it may last a minute or two. In the agony of it the patient's face is drawn up, his hand goes in- voluntarily to the seat of pain and he remains bent over and immovable until it ceases. Or, unable to control himself, he literally runs about the room, as if out of his senses, or presses the painful part with his hand or against any object. The paroxysm being over, the patient is himself again, but a sudden motion > even in answering a question, may bring on a return of the pain — and indeed such patients are always in terror. The writer has studied out remedy after remedy for this trouble, but so far has failed to affect it. The patients having this affliction are usually in the latter half of life, but apart from their special trouble appear to be in good health. Among the old- school physicians the disease is considered incurable. The treatment of prosopalgia by homoeopathic rem- edies is one of the most satisfactory experiences in the whole domain of neurology. Of course any rem- edy that is specially indicated must under the circum- stances be prescribed, yet it so frequently happens that certain drugs especially influence certain nerves that they may almost be considered specifics. The side affected, the branch of the nerve, the causal conditions, the conditions of aggravation or amelioration, the underlying reflex causes, must always be taken into account and a study made thereon. Spigelia, Kalmia, Gelsemium, Magnesia phosphorica, Belladonna, Bryonia, Elms toxicodendron, Coloeyntli, Xatrum murla- ticum, and Nux vomica, have in the writer's hands been 74 NEURALGIA. of remarkable efficacy. Natrum sulphuricum 6, (given because of the special yellow-green coating of the tongue, which led to further study of the case and brought out the history that the trouble began while living in a very damp house) cured a case that had lasted for years, and which came to the writer for opinion as to the advisability of neurectomy. Mer- curius has often been of service, and more than one case has been cured by removal of amalgam fillings in the teeth, or by changing a red-rubber dental plate (colored with cinnabar) to a gold one. The dentists refuse to believe that amalgam fill- ings or red rubber plates can give to the saliva any amount of mercury, forgetting or not knowing that the saliva at times contains sulpho-cyanide of potassium, which can readily decompose in the presence of mercury, and form a mercurial sulpho- cyanide. The sulpho-cyanide is not always present, indeed may only appear in morbid conditions ; vide Hoppe-Seyler's Physiologische Chemie. Cervico-occipital neuralgia. A not common form. The pain is as in pure neuralgia, is in the four upper cervical nerves, and is chiefly in the distri- bution of the great occipital nerve, in which region it is not infrequently bi-lateral. It is less par- oxysmal, and the exacerbations are less severe than in trigeminal neuralgia. It may extend down the neck from the jaw, involving the small occipital nerve. Cervico-brachial neuralgia is a rare form. The pain is in the nerve supply from the four lower NEURALGIA. 75 cervical and the first dorsal nerves. It may affect any part of hand or lower arm and posterior part of the neck ; it is greatest in the axilla and in the ulnar nerve. Painful pressure points may be found in the axilla, at the posterior border of the deltoid and on the ulnar nerve behind the elbow, and on the front of the wrist. There is more or less constant pain, with very acute paroxysms, often brought on by moving the arm, or by exposure to cold. It is stated to result from injury, but such a history ought to lead to examination for inde- pendent or associated neuritis of the plexus. The dorsal nerves are mixed nerves ; each di- vides into a large anterior branch and a small pos- terior one, the first dorsal contributing largely to the brachial plexus, its anterior or intercostal portion being small. The first six of the anterior branches are intercostal nerves, and are exclusively distributed to the chest and its coverings ; the last six supply the walls of the chest and abdomen. Intercostal neuralgia is an affection frequently seen, generally in women who are debilitated or neur- asthenic. The nerves oftenest affected by neuralgia are from the fourth to the eighth. Painful pressure points are at the side of the related vertebral foramina, in the axillary line and near the sternum. The pain is more or less continuous, but has severe exacerbations, sharp or stabbing in character, felt in the course of the nerves. The left side is most frequently affected, but both sides at times are 76 NEURALGIA. involved. Exposure to cold is a common ex- citing cause ; the neuralgia may be produced symp- tomatically by disease of the vertebrae or ribs, by growths within the spinal canal, etc., and by ex- ternal injury to the chest wall. It is to be distinguished from pleurodynia, which is a pain located in one spot, and not following the course of an intercostal nerve ; there is great tenderness on pressure. The pain in pleurodynia is aggravated by respiratory movements of the chest, and is probably due to a neuralgia of the pleural nerves (Gowers). Neuralgia mammalis. Mastodynia. Pain in the breast may be idiopathic or symptomatic (tumor). It occurs mostly in women, but has been observed in the male. It affects one gland only, but may involve the lateral as well as the anterior branches of the re- lated intercostal nerves. Terrillon has observed it in women, either stout or slender, whose dependent breasts have not been supported, thus by interference with the local circulation directly causing the affec- tion. The same writer considers ill-fitting corsets to be a cause of the trouble. The paroxysm of pain may last but a few minutes, or may extend over hours ; it may spread to the back, the axilla, the in- ner side of the arm, or even to the fingers ; at times it is of great intensity. A painful pressure point has been observed below and to the inside of the nipple or at the upper outer edge of the gland. The nipple itself may be extremely tender to touch. Mastodynia NEURALGIA. J J occurs after puberty, during pregnancy, or during lac- tation, and may give rise to much apprehension through fear of cancer. Liumbo-abdominal neuralgia involves the lumbar nerves or their derivatives. It is seen in women chiefly, and in the middle period of life. Little is known of its etiology, but cold, exposure and in- trapelvic disorders irritating the cords of the lumbar plexus, are among the causes ascribed. The pains, dull and continuous, become sharp in the paroxysms, are located in the lower back, and stream down the buttock or on the upper edge of the pelvis, or to the hypogastrium, inguinal region and the genitals, on one side. They may involve the inner or outer side of the thigh. Painful pressure points may be found outside of the first lumbar vertebra, above the crest of the ilium, over the middle of Poupart's ligament, or even at the lower surface of the labium majus (or scrotum). Anterior crural pain is not a rarity ; it has been observed in connection with bladder troubles and in conditions of so-called lithaemia. Of neuralgias in the nerves of the sacral plexus the chief one is sciatica. It is nearly as frequent as trigeminal neuralgia, occurs in men four times as often as in women, and in the majority of cases be- gins between the ages of 30 and 50. It rarely be- gins before 20. The predominance of males among the sufferers from sciatica is ascribed to their special conditions yS NEURALGIA. of life, such as exposure to cold, wet, over-exertion, etc. Living in damp habitations, sleeping in wet clothing or on damp ground, working in water, sudden cooling while over-heated, have repeatedly caused an outbreak of the disease. Traumatism plays also a role. Falls upon the but- tocks, pressure of a tumor within the pelvis, of the gravid uterus, of the forceps during labor, even large accumulation of faeces in the rectum, have been assigned as causes. Direct pressure, long con- tinued, as in sitting on a hard bench, has been a cause. Sciatica may be symptomatic of vertebral disease, tumors within the spinal canal, meningitis, etc., but in such cases it is more apt to appear bi-laterally. It is not infrequently an accompaniment of diabetes and often the condition of pain varies directly with the increase or decrease of sugar in the urine. The pain may begin suddenly, but often for a day or two preceding there is discomfort about the hip and thigh on movement. It is an aching with parox- ysms of lancinating or tearing, extending at times downward to the foot or upward to the sacral region ; in most cases the pain is in the back of the thigh and in the calf, but it may be chiefly in the anterior part of the leg or in the foot. Painful pressure points may be found at the sciatic notch, between the trochanter major and tuber ischii, in the middle of the thigh, in the popliteal space, along the fibula, in the middle of the calf, behind the external malleolus and on the back of the foot. NEURALGIA. 79 The lesser sciatic may be involved and then there will be superficial tenderness on the back of the thigh and extension of the pain to the sacral region. The pain is usually increased by motion and by pressure and often the patients assume peculiar posi- tions when sitting or standing. At times the pelvis is raised on the affected side and the spine curved toward the well side ; at times both conditions are reversed. Various explanations of the scoliosis thus produced have been made, paresis of the erectores spinse, spasm of the same, and implication of the nerves of the lumbar plexus, being among the latest. The disease may last a few weeks or may continue, with periods of remission, during many months. Pathology. Gowers considers that most cases of primary sciatica are cases of neuritis. Some wasting of muscles occurs and changes in their electrical re- actions are found at times — conditions belonging to neuritis and not to neuralgia. Changes in the nerve sheath, at times extending to the interstitial tissue, have been found in most of the cases examined. The neuritis is thus a perineuritis. The diagnosis of sciatica consists chiefly in exclud- ing any distant cause of the pain. Such causes have been mentioned on a preceding page. Between a sciatic neuritis and a pure neuralgia of the nerve, the tenderness of the nerve trunk, the subjective pain in it and the wasting of muscle are in favor of the former; the pain in branches of the nerve rather 80 NEUKALGIA. than its trunk and a history of previous attacks of neuralgia elsewhere, are in favor of the latter. The prognosis is good as to cure in cases of sciatica not due to symptomatic causes mentioned on page 78. In such cases the sciatica is only curable by removal of the cause. Homoeopathy has had many and brilliant successes in the treatment of the disease. Coccygodynia is a neuralgia of the last sacral and the coccygeal nerve, the pain being chiefly felt at the tip and on the posterior aspect of the coccyx. It occurs oftenest in women and results from dislocation of the coccyx during labor, from a fall on the buttocks or similar injury, and from disease in the region itself. It is seen chiefly in hysterical or neu- rasthenic persons. It is said to arise spontaneously, but this is rare. Treatment of neuralgia is a matter of studying out the remedy. Some of the remedies for trigeminal neuralgia have been mentioned on page 73 ; to men- tion all the possible remedies would be to recapitulate the names of a majority of our drugs. Experience, however, has shown that many cases present repe- titions of indications for certain drugs, so that the list of those most often found serviceable in trigeminal neuralgia becomes short relatively. In recent cases Aconite is indicated when its special symptoms are present, especially restlessness and anguish, and when exposure to sharp cold has been the cause. Bella- donna; the pain shoots to different parts, there is redness of the face and aggravations from light, NEURALGIA. 8 1 noise, touch (but hard pressure may relieve), a jar, or draft of air. Other remedies that have brought rapid relief at the writer's hands are Kalmia, Spigelia, Plantago major (pains sharp and "play" chiefly be- tween the teeth and the ear), Magnesia phosphorica, Nux vomica, Menyanthes (relief by hard pressure with the hand), Mercurius and Cimicifuga. In patients who are subject to trigeminal neuralgia Arsenicum, Argentum nitricum, Phosphorus, Platinum, Stannum or Staphisagria will frequently be found in- dicated. Malarial cases may require Natrum miiria- ticum, especially after abuse of Quinine, while Cedron and Quinia sulphate among their symptoms have marked periodicity in the return of pain. In ciliary or ocular neuralgia Allium cepa, Paris quadrifolia, Croton tiglium have repeatedly been of value, while Gelsemium, Belladonna, Nux vomica and Mezcreum are highly recommended. In occipital neuralgia Cimicifuga, Picric acid, Am- monium picricum and Carbolic acid; in brachial and intercostal neuralgia Aconite, Spigelia, Anantherum muri- catum 30, Chclidonium (right side) and Ranunculus bulbosus (region of upper ribs), Bryonia, Kali carhonicum and Bumex crispus (region of lower ribs, left side) have been efficacious. In mastodyiiia Belladonna, Chamomilla, Conium, Croton tiglium, Ilelonias, Cimicifuga and Phytolacca have been recommended. Under the heading "sciatica," Knerr in the repertory to Hering's Guiding Symptoms gives seventy-three 82 NEURALGIA. remedies, most of which are marked with the sign of cure. They embrace practically all the remedies al- ready mentioned as indicated in neuralgia. In the writer's hands Gnaphalium has acted curatively in a remarkable way more than once, and if unable to obtain satisfactory indications for some other drug, he would choose, as the remedy for sciatica, Gnaphalium. Good results have followed the use of Colocynth, Rhus toxicodendron and Ammonium muriaticum, Repetitions of sciatica wear upon the patient's strength and gradually bring about gastric, intestinal and circulatory disturbances, which in turn react un- favorably upon the affected nerves. In severe cases of this kind the great constitutional remedies will do more in the direction of giving lasting improvement than remedies chosen simply on the local symptoms. Coccygodynia is so often associated with other pains in nervous or hysterical women that its symptoms must be taken with others in prescribing. When the trouble is alone, the causal indication of trauma (bruise or dislocation) will call for Arnica, or Rhus, or Ruta. Kali bichromicum, Cistus, Antimonium tartaricum, Paris quadrifolia and Petroleum have with other remedies been reported as valuable in the treatment of the affection. In case of failure of remedies to help, manipu- lation of the coccyx through the rectum or vagina may undo a displacement, or removal of the bone may be resorted to, a procedure that has been fol- lowed in some cases by success, in others by failure. XEUKALGIA. 83 Morton's neuralgia, or metatarsal neuralgia, is located at the metatarso-phalangeal joint of the fourth toe, usually. It is of traumatic origin. Lat- eral pressure upon the joint structures by a narrow shoe, and consequent forcing the end of the fifth metatarsal bone against the fourth, compressing an intercurrent branch of the plantar nerve, or treacling through a thin sole upon a stone, with direct in- jury to the part, are common causes. Some amount of dislocation of the metatarsal bone undoubtedly exists in many cases. Cure is to be obtained by removal of the cause — that is, by wearing thick-soled, roomy and well-fit- ting shoes ; roomy and well-fitting stockings are equally essential. During an attack relief will be found by manipu- lating the last three toes by drawing them for- ward and downward and reversing the procedure : the patient will soon find out which brings the de- sired relief. When at home the patient should wear as much as possible roomy slippers having felt insoles. When once well-established, the affection is, even after disappearance by removal of the cause, liable to return from too long standing, or taking too long a walk. Remedies for recent cases are Arnica, Hypericum. Rhus toxicodendron and Ruta; for cases of long existence, besides these, Sabadilla and Cannabis Indica. Erythromelalgia is the name given to a special affection of the extremities, usually the feet, in which 8 4 NEURALGIA. the feet (especially the soles) are red, somewhat swollen and extremely painful, both when at rest and in motion. In the cases seen by the writer there was a history of an excessively long walk under conditions of fatigue or of other depressing influences. At first the trouble may appear in attacks, but soon it be- comes more or less continuous, is often worse at night and on walking, and is better in cold weather. Lewin and Benda, after a study of all the cases reported, have come to the conclusion that it is not a disease sui generis, but that in some of the cases it is a special form of neuritis, in others it is part of a general neurosis, and in still others it is an accom- paniment of brain or cord affection. The cases seen by the writer have been apparently neuritic. One case was cured by Sabadilla; the others did not remain under treatment. The most promising remedies are Sabadilla, Phosphorus and Can- nabis Indica. Squilla has the symptom " soles red and sore when . walking." Acroparesthesia. This term Schultze, of Bonn, applies to an affection long known to neurologists and described commonly as "numb fingers." The trouble seems to be a distinct disorder and is seen most often in those whose work compels them to have the hands in water frequently. It is seen in washerwomen, in dishwashers in hotels, and one case of the writer's was a man who handled ice con- stantly. There is undoubtedly impaired nutrition as an underlying condition in all cases, and in many NEURALGIA. 85 the use of beer. The symptoms are usually prickling or "pins and needles" sensation, affecting the ends of the fingers, sometimes extending up into the hand and sometimes limited to the ulnar or the median distribution. A similar condition has been described as affecting the feet. The symptoms are worse at night and from exposure to cold. The disease is very intractable in many instances. There is no known pathology, the disorder being held by different observers as a neurosis, an acro- neuritis or as a vaso-motor affection, the latter because in some instances there is either shrivelling of the ends of the fingers or slight alteration in color. Treatment should be directed by the general symp- toms, the special symptoms not often leading to the selection of any efficient drug. Electricity, especially faradism, is helpful in lessening the annoying prickling, but galvanism seems to be more potent in the direc- tion of cure. Among our remedies, however, a not inconsiderable number have caused numbness of the fingers ; chief among these are Phosphorus especially, Kali carbonicum, Lachesis, Staphisagria, Crocus saliva, Nux vomica and Silicea. The Spinal Cord. The spinal cord is that portion of the central nervous system placed within the spinal canal. It extends from the level of the upper border of the axis to that of the lower border of the first lumbar vertebra in the adult; in the new-born infant it reaches to the lower border of the third lumbar. Around the central canal, which is all that remains of the cavity of the original neural tube, the gray matter of the cord is located in such manner that its cross-section has something of the appearance of the letter H. The white matter is outside the gray and is composed of medullated nerve fibres. The cord is incompletely divided into two lateral halves by an anterior fissure and a posterior septum of glia tissue. By reference to the illustration the location of the different fibre-tracts, cells, etc., can be readily seen. In the anterior limbs of the gray matter are placed several groups of large ganglion cells whose axis cylinders gathering together at successive levels form the anterior or motor nerve roots. Similarly, from the cells of the posterior spinal ganglia, the nerve fibres form at successive levels the posterior or sensory nerve roots, which enter the cord at the extremity of the posterior horn, or in the column of Burdach ; the latter divide into ascending branches which pass upward, THE SPINAL CORD. 87 Fig. 14. Fig. 14, from Edinger, giving general idea of the structure of the spinal cord. A segment of the spinal cord is shown, the posterior spinal nerve roots of the segment represented (diagrammatically) as arising from single cells (of the posterior spinal ganglion), the centrally directed ones enter the cord, some directly into the column of Burdach, some into the gray posterior horn. The fibres or collaterals that end at or near the level of entrance are seen to do so, as a brush-work surrounding cells in the gray matter from which new fibres arise ; fibres which are to ascend higher than the level of entrance appear as if cut off. The anterior spinal nerve roots are seen to arise from the ganglion cells in the anterior gray horns ; near one motor cell, a fibre from the posterior root is seen, ending as a brush work, thus completing the reflex arc or reflex mechanism. In the gray matter the anterior, lateral and posterior cornua or horns are sufficiently well desig- nated ; Col. ves.= vesicular column of Clarke. In the right half of the picture a fibre from the posterior root is seen ending in a brush work about a cell of Clarke's column, from which a new fibre arises and passes to the extreme lateral edge of the cord, there to turn upwards as part of the direct cerebellar column of white matter. The gelatinous substance of Rolando, the zona spongiosa and the zona terminalis are plainly indicated. In the white matter Pyramid, vord. St. B. and Pyramiden Seitenstr. B.=the anterior or direct and the lateral or crossed pyramidal tracts, respectively. Kleinhirn-Seitenstrang-Bahn=direct cerebellar column ; Fascic. ant. lat.= anterolateral or Gow- ers' column; Seitenstr. and Vorderstr.= lateral tract and anterior tract respectively ; Grund-Bundel = ground bundle or basis bundle, and Grenzschicht=limiting layer, both of short fibres probably ; the columns or fasciculi of Burdach and Goll are indicated by their names. giving off on the way collaterals, and end in a brush work in the neighborhood of cells at the top of the cord, and de- scending branches which passing forward at the level of entrance descend some distance and end in bushlike expansions near the cells of the anterior gray horn THE SPINAL CORD. of one or both halves (forming a segment of a reflex arc) or about the cells of the column of Clarke. The fibres of the column of Burdach are displaced toward the median line by new fibres entering at higher levels, thus forming the column of Groll. Fig. 15. Fig. 15. — Course of some fibres and their collaterals. From an antero-posterior longi- tudinal section of the spinal cord of a human embryo 20 centimetres in length. a=fibres from the median division of a posterior root ; b= their bifurcations in the most anterior part of the gelatinous substance of Rolando ; c= longitudinal fibres of Burdach's column ; d= collaterals. From Lenhossek. The fibres entering the gray matter have a short course ; they end in brush-work near cells in the gray, from which new fibres arise and pass upward in the columns indicated in the illustration. The long fibres (primary neurones) of the columns THE SPINAL CORD. 89 of Goll and Burdach respectively, are for the trans- mission of muscular sense impulses ; those of the direct cerebellar tract are possibly for transmission of similar impulses, but may have to do with impulses from the organs of vegetative function, since the vesi- cular column of Clarke begins (and consequently the direct cerebellar tract) at the level of the lowest pair of sympathetic ganglia ; the fibres of the antero- lateral column carry up, probably, the sensory im- pulses of pain and temperature. The exact route of the impulses of ordinary tactile sensibility may be by a part of the postero-external column, but may be in part through the anterior ground bundles. The paths for voluntary motor impulses from the cerebrum are in the pyramidal tracts, the anterior or direct pyramidal tract coming from the cerebral hemis- phere of its own side, the lateral or crossed pyramidal tract from that of the opposite cerebral hemisphere. The fibres in each case on reaching the destined level, turn into the anterior gray horn of the same side and end in brush work about the large ganglion cells there, from which the fibres of the anterior (motor) nerve roots arise. The view that the fibres of the direct pyramidal tracts cross to the opposite anterior horn through the anterior commissure is now denied. (Lenhossek.) The existence of collaterals from the fibres of the column of Goll has not been observed by Lenhossek. Short fibre tracts occupy the white areas of the cord as yet unmentioned, i. c, the residues of the 90 THE SPINAL CORD. anterior and lateral columns. These, in part, carry fibres connecting different segments of the cord or op- posite halves of the cord (via anterior commissure). The mechanisms in the cord for reflex actions of different kinds are centres with afferent and efferent connections. Their positions are given on page 100. The nerve cells in the spinal cord are many, and can be divided into groups. They are in the gray. The large ganglion cells of the anterior gray, horns have a very peculiar structure, as shown in Figure 16a. They are star-shaped or multipolar. Their processes divide and subdivide at a little distance ■vSN Ml /^ Fig. 16 a. Fig. )6a. — Large motor ganglion cells from anterior gray horn of an ox. The axis cylinder process or neuraxon is downward. The other processes are dendrites. Only the beginnings of the processes are shown. The complicated details of the cell body are shown here ; in Fig. 16b the processes are shown at great length, but the Golgi stain there used leaves the details of the cell body undistinguished. Highly magnified. THE SPINAL CORD. 91 Fig. 16 b. Fig. 16b. — Motor or ganglion cell from the anterior gray horn of the spinal cord of a human foetus, 30 centimetres in length. A collateral branch (Golgi) from the axis cylinder or neuraxon is seen ; near the latter the star is placed. From Lenhossek. Highly magnified. from the cell and end in arborization. Their axis cylinder process passes forward as an anterior or motor nerve root. The cells are in groups, each group being in re- lation to a special muscular function or class of muscles. In the middle and lateral areas of the gray matter are placed many cells, which give rise to fibres that pass outward and turn up in the lateral and antero- lateral white columns. At the junction of the posterior horn with the middle portion of the gray is a column of cells known as the vesicular column of Clarke. The cells 92 THE SPINAL CORD. send out fibres that pass laterally to the edge of the cord, and passing up form the direct cerebellar tract, posterior to the antero-lateral tract. Many of the cells are sensory and are parts of new neurones taking and carrying the sensory impulses brought in by sensory peripheral nerve fibres. At the head of the posterior gray horn is seen, under the microscope, a different appearance from the rest of the gray. It is called the gelatinous sub- stance of Rolando, and contains many small cells and a very fine "felt work" of fibres, some of which appear to get into the posterior and lateral columns. In the region anterior to the gelatinous substance and near the cells of Clarke's column are found most plentifully the so-called Golgi type of cell. (Figure 17.) It is noted for the branching of its processes Fig. 17. Fig. 17. — A Golgi's cell from the posterior horn of the spinal cord of a human foetus, 35 centi- metres in length. The star is placed near the axis cylinder or neuraxon. From Lenhossek. Highly- magnified. THE SPIXAL COED. 93 immediately on their leaving the cell's body, and often showing a remarkable prickly or varicose ap- pearance. The nenraxon soon after leaving the cell body divides dichotomonsly at right angles, and after suffering one or more further subdivisions terminates in very fine free ends. Lenhossek says that these cells are not found in the spinal cord of reptiles, amphibia and fishes ; they are found in the larger mammalians and are most perfect in man. Fig. 18 Fig. 18. — A glia cell from the spinal cord of a child aged 9 months. Lenhossek. Highly magnified. The supporting tissue of the nervous structures of cord and brain is made up of cells which are small in body with a relatively large nucleus and with many fine processes or outrunners. These exist in great numbers in all parts of the central nervous system. and the interlacing or felting of the processes forms a delicate yet tough support for the nervous elements. They are known as glia cells, or ''spider" cells, or Deiters cells. Thev are not transformed connective 94 THE SPINAL CORD. tissue cells, since they are derived from the ectoderm, and they form the septa, even the posterior central septum being made up of them. According to Len- hossek there is no connective tissue within the central nervous system, except such as may accompany the bloodvessels as adventitia. The blood supply of the cord may be considered as coming from three great plexuses ; the first being the so-called anterior spinal artery, derived as two branches from the vertebrals and soon uniting to a common trunk, continuing downward in the anterior sulcus and receiving reinforcements from the ascending cervical, intercostal, lumbar and lumbo-sacral arteries. The other two are derived above from the vertebrals and are similarly reinforced from the posterior branches of the arteries named. These two plexuses course one on each postero-lateral aspect of the cord. The branches from the three plexuses supply the interior of the cord, those from the anterior artery being distributed chiefly to the gray matter, those from a postero-lateral plexus being considerably smaller and supplying the white matter and part of posterior horn of its own side. All of the arteries of the cord are end-arteries. The veins of the cord at their beginnings bear no relation to the arteries either in size, distribution or number. The greater part of the blood supply goes through the anterior artery, but the veins for the return flow are larger than the anterior arteries and are situated posteriorly. The Reflexes. The reflexes, whose centres are in the spinal cord, are the visceral and peripheral ; of the latter there are two kinds, the superficial or skin re- flexes, and the deep or tendon reflexes. In all cases a muscular contraction is set up by the oc- currence of the related sensory stimulus. It fol- lows that for the production of a reflex the re- flex loop or arc, consisting of a sensory nerve fibre, the connections of the same either directly or indi- rectly with the motor ganglion cell in the cord, the nerve fibre from the same and the muscle itself, must be intact and in physiological order. Of the deep reflexes, the most important is the patella tendon reflex or " knee-jerk." The mode of obtaining it is as follows : The subject being seated and with one knee crossed upon the other, the patella tendon is struck sharply with the ulnar edge of the examiner's hand, or with a j^ercussion ham- mer. The sensory impulse thereby aroused is sent to the cord, is passed forward, and arouses in the related ganglion cells of the anterior gray horn a motor impulse which being then sent out produces contraction of the quadriceps extensor muscle, causing the leg and foot to "kick." This reflex is believed to exist in all individuals in a state of health, excepting very young infants, and in some cases in old age. It is absent when any interruption of conducting power 9 6 THE REFLEXES. exists iii any division of the reflex loop, and when the muscle is atrophic, and thus unable to respond. It is prevented by abnormal conditions of the knee joint (anchylosis, etc.). Fig% 19. Fig. 19. — Schematic representation of the origin, course and ending of a motor and a sensory fibre, as also the relation of the sensory collaterals to the originating cells of the anterior nerve roots. The cord appears transparent. From the motor cell in the anterior horn a, arises the anterior root fibre b, whose ending as a small brush work on a striated muscle fibre is shown at c. In the posterior spinal gang- lion d (disproportionately enlarged) is seen a single unipolar cell, whose centrally directed process enters the cord as a posterior nerve root, divides at e into (f, an ascending, and g, a descending) main fibres, which above and below turn into the gray and end free, giving off on the way collaterals at h. The peripheral process of the posterior spinal ganglion cells passes as the sensory fibre to the periphery, where it ends in a naked arborization as at /, or in a complicated structure in a Meissner's corpuscle at k. From Lenhossek. THE EEFLEXES. 97 The mechanism in the cord is, however, not inde- pendent. It is held in check by what is termed in- hibitory influence from the cortex passing downward in the pyramidal tracts continually. Hence, when from degeneration in the lateral tracts, or from brain disease, the inhibitory influence is obstructed in its downward passage or is absent, the knee jerk is characterized by excess in both the amplitude and rapidity of its motion ; it is then said to be exaggerated. Conditions causing exaggeration may exist with those for its failure, and then the knee jerk does not occur. Since in disease of the cerebellum and also in total transverse lesions in the upper dorsal region of the cord or higher, the knee jerk has been repeatedly ob- served to be lost, it has been argued that the vivifying influence, so to say, passes from the cerebellum to the centre for the knee jerk. This view has not received full acceptance by neurologists. Next to the knee jerk in importance, is the Achil- les tendon reflex. It is obtained by slightly pressing the anterior part of the foot in dorsal flexion and then with a percussion hammer or similar object tap- ping the Achilles tendon. Contraction of the calf muscles follows and extension of the foot upon the leg occurs. This reflex is believed to exist in most individuals, but its absence cannot be construed as necessarily meaning the existence of disease ; its ex- aggeration, however, is of the highest importance. When degeneration of the lateral columns has con- siderably advanced, the examiner finds that upon dors- 98 THE REFLEXES. ally flexing the patient's foot somewhat sharply, the calf muscles at once contract and then yield to the continued extension only to immediately contract again, and so on as long as the pressure is kept up or until the muscles become fatigued. The result is a strong planto-dorsal oscillation of the foot at the ankle joint; the phenomenon is termed " ankle clonus." Other deep reflexes are those of the elbow and wrist. When the back of the radius or the back of the ulna is tapped near the wrist, the result is in many cases a reflex movement of the forearm laterally in the direction of the bone so tapped. Similarly, if the tendon of the triceps at the back of the elbow is tapped the partly flexed arm becomes extended. The absence of the arm reflexes is of no importance, since they cannot be elicited in all persons; their ex- aggeration has the same meaning as has that of the patella and Achilles tendon reflexes. Of the skin reflexes the most important is the cremaster reflex. It is obtained by stroking some- what sharply (using the back of the finger end, or the dull end of a paper cutter, etc.,) the inner aspect of the thigh. Then follows contraction of the cre- master of the same side, plainly drawing upward the testicle. The reaction is very lively in the young, but it may be normally absent in the old. The inhibitory influence is increased by the patient's attention being directed to the procedure. Hence, when the knee jerk does not appear or is very weak, by directing the patient to hook together the fingers THE REFLEXES. 99 of the two hands and to pull hard without letting them part, the knee jerk will he produced if it had been previously over-inhibited. There is a false ankle clonus observed in hysterical conditions. It differs from the real one by the evi- dent existence of voluntary or intentional quality instead of the automatic machine-like movement characteristic of the real clonus. Other superficial reflexes are: the abdominal reflex, in which, when the abdomen is stroked along the outer edge of the rectus muscle, the muscle contracts; the gluteal reflex, causing distinct movement in the gluteal mass when the skin of one buttock is stroked; the pectoral or breast reflex, and the scapular reflex, whose names indicate their location. The plantar reflex is of some importance, but it has not been sufficiently studied. When the sole of the foot is tickled lightly, the foot is dorsally flexed: when the stimulation is strong, the leg is flexed upon the thigh and often the thigh upon the abdomen. Absence of this reflex, with exaggeration of the knee jerk, is taken by Dr. Buzzard as strong presumptive evidence of a functional disorder. The illustration, Fig. 20 (from Growers), shows the topographical relation between the spines of the ver- tebrae, the different emerging spinal nerve roots, and the location within the spinal canal of each theoretical segment of the cord with its nerve roots, and the table (from Starr and applied thus by Goldscheider) gives the location of the different centres, reflex, vis- IOO THE REFLEXES. ceral, etc., in the cord, as well as the relation of different levels of the cord to peripheral sensory and motor functions. Stern, mastoid. Trapezius i Diaphragm Serratus Shoulder "1 Hand J ' Ulnar and below. Intercostal Muscles Abdominal Muscles Flexors, hip Extensors, knee Abductors J Extensors? of hip Flexors of knee? Leg muscles for foot Perineal and anal muscles Sensory. Integument Neck and head Neckandshoulder Arm Hand Anterior side of thorax Pit of stomach Abdomen (Umbilicus) Posterior part : upper half Pubes and scrotum anterior part f Outer 1 .t£ ) Anterior ( u * ! ii \< M Leg, inner pos- terior lower half Back of leg Limb and foot, ex- cept inner side Perineum and anus Integ bet. coccyx and anus Scapular refle> 1 Epigast. reflex Abdominal reflex Cremaster reflex S-Knee jerk Gluteal reflex Foot or ankle clonus Plantar reflex Fiff. 20. Diseases of the Spinal Cord. The diagnosis of disease of the spinal cord is based upon a knowledge of its anatomical structure and of the functions of its constituent parts. Vari- ations from the normal in the latter, involve the as- sumption of changes in the former, changes that may he too fine for discovery by our present methods of research or gross enough to be thus observed. For these two types of disease the terms functional and organic are employed, as in affections of other parts of the nervous system. An affection of the cord may be limited to a small part of it or may be diffusely spread through a large part ; hence the terms focal and diffuse. Disease may limit itself to certain definite structures of the cord, such as the posterior columns or the cells of the anterior gray horns ; such manifestations are termed system diseases. Disease of the cord may occur secondarily to dis- ease in some other portion of the nervous system, the disease-process simply progressing in one direction or the other until it finally reaches and enters the cord. In this manner locomotor ataxia or degeneration of the posterior columns has been explained as simply the continuation of degeneration of the posterior spinal nerve roots. Injury to the vertebrae, growths within the bony spinal canal, or haemorrhages acting by pres- 102 DISEASES OF THE SPINAL CORD. sure, may destroy parts of the cord and give rise to extensive secondary degeneration, both upwards and downwards. The microbes (or their toxines) may be carried to the cord by the blood-vessels and give rise to inflam- matory-degenerative changes. So with many inorganic and organic poisons, when carried by the blood- vessels they exercise a specially pernicious effect on the cord (so-called selective action of poisons). Disease of the blood-vessels themselves (as in arterio- sclerosis, chronic alcoholism, syphilitic end-arteritis and peri-arteritis) by decrease of blood supply and by local irritation from them, can cause inflammatory-degenera- tive changes in the cord. Diagnosis of spinal cord disease is first by exclusion of disease of peripheral nerves on the one hand and of the brain on the other; secondly, determining the segments of the cord involved ; thirdly, determining the extent in cross section of the cord structures implicated, and finally determining the character of the # lesion or disease process. The nerve fibres forming the white matter of the cord have each an axis cylinder, which in turn is clothed with a sheath of medullary substance, but there is no connective tissue sheath. Herein is the difference between a peripheral nerve fibre and a spinal cord fibre. Upon the existence of the con- nective tissue sheath and its nuclei depend the possi- bility of and tendency to regeneration of the peripheral nerve fibre after destructive change has occurred. The DISEASES OF THE SPINAL CORD. I03 spinal cord fibre destroyed at any part, not having a connective tissue sheath, cannot be regenerated, and the portion of the fibre not in connection with its originating cell undergoes secondary degeneration, which is permanent. The direction in which degeneration ad- vances is that of the impulses normally carried by the fibre. Ascending degen- eration, therefore, is found only in the posterior columns, the direct cerebellar tract and the antero-lateral tract ; de- scending degeneration is found in the part of the anterior column occupied by the direct pyramid tract and in that of the lateral column occupied by the crossed pyramid tract. The evidences of degeneration, as veS^on^si^own^n shown in properly stained and hardened the middle section ; below with s d h e° s ^end'ng SneT- sections of the cord at successive levels, ation in the lateral col- . , ^ t^'^rJc^rnllt lessen as the section is further away generation limited to the . . . posterior columns and to f r0m file Site 01 tllC OlTgllial leSlOll, the ascending tracts at the o " Fig. '21. lateral edge of the cord (direct cerebellar a tero-lateral tracts). '- owing to the turning inward into the gray of fibres at different levels. There is also a retrograde degeneration that is to- wards the originating cell; it is very slow in its pro- gress. As the fibre is already out of function it has no clinical bearing. Spinal Haemorrhage. May be outside the cord or within its substance. The former is divisible into extrameniiigeal and intrameningeal, according to the 104 DISEASES OF THE SPINAL COED. position of the effusion, and most often results from trauma (in the new-born from injury during extraction), during convulsive attacks, poisoning by strychnia, during infectious disease. Symptoms resemble those of meningitis ; painful stiffness of the spine, radiating pains from the back into limbs, hyperalgesia, paresthesias, muscular rigidity. Later, paraplegia with anaesthesia. Small hemorrhages may give no symptoms, large ones are characterized by the sudden onset of symptoms with evidences of shock, the patient perhaps falling to the ground without loss of consciousness. The symptoms advance rapidly to their full height and amelioration is slow. Chronic meningitis may be a sequel. Haem atomy elia or haemorrhage within the substance of the cord may occur primarily from disease of the blood vessels or from tumors, myelitis, etc., or, second- arily, from trauma, excessive muscular exertion, or convulsions. The symptoms are paralysis of sudden onset, usually paraplegia, but if the lesion is high up the arms are paralyzed. Sensory disturbances, except some anaesthesia, are slight, if at all, but paralysis of the bladder and rectum are to be expected. Patel- lar reflex may be lost at first, to return later and become exaggerated, except when the lumbar cord is the seat of the haemorrhage, in which case it is permanently absent. The haemorrhage may set up a myelitis (or may be the result of it). The prognosis in both forms is serious in cases at all severe ; in haematomyelia the chances of restored integrity to the cord are but few. Spinal Meningitis. Within the spinal canal, yet ontside the proper structures of the cord, lesions of different kinds can occur. Haemorrhage may be extrameningeal or intramenin- geal ; the former is rare and occurs chiefly through trauma; the latter through trauma or in the course of spinal leptomeningitis. The symptoms in either case are those of meningitis, the diagnosis, when not evident from traumatic influence, being made from the suddenness of onset of the symptoms. Meningitis of the cord, like the meningitis of the brain, is divisible into pachymeningitis and leptomenin- gitis, according as the dura mater or the pia mater is the membrane chiefly or solely affected. Since the roots of the spinal nerves pass through the meninges in their course to or from the cord, it is evident that inflammation of the membranes must inevitably affect by irritation and pressure those struc- tures ; hence all forms of meningitis are characterized by certain symptoms in common, viz., eccentric or radiating pains from the spine, hypertonicity of muscles, especially those connected with the vertebras, hyper- algesia, paraesthesias and muscular twitchings in the limbs. Increasing exudation or thickening of the membrane may be great enough to cause paralysis with atrophy in one or more limbs. Pachymeningitis spinalis externa does not occur 106 SPINAL MENINGITIS. primarily, but only from external injury or more com- monly from extension of disease of the vertebrae, etc. The symptoms already mentioned prove the involve- ment of the membrane, while the site of , the primary disease determines the course of the new symptoms. Pachymeningitis cervicalis hypertrophica. A special form of inflammation of the dura, of slow course, occurring in adult life and chiefly in males, in the cervi- cal region of the cord and usually in its lower portion. The causes assigned are alcoholism, injury, exposure to cold, and syphilis. Beginning as a pachymeningitis interna haemorrhagica, the effused blood organizes, new haemorrhages occur from the weak vessels of the new tissue, and this process being repeated from time to time, a succession of layers unites the dura and pia together, forming a dense structure constricting nerve roots and compress- ing the cord structures. The disease is divisible into three stages. First : the irritation of nerve roots causes pain and stiffness of the neck, with violent pain radiating to the occiput and down the spine and the arms, aggravated by motion and pressure ; in some instances the pains (and paraes- thesias) are limited to one side or nearly so. Second: after several months the stage of paralysis with atrophy begins. When the affection is in the lower part of the cervical cord, its manifestations are in the ulnar and median distribution in the arms. The unaffected extensors retract the hand, the fingers being flexed. If the meningeal thickening does not extend below SPINAL MENINGITIS. IO7 the origin of the seventh cervical nerve, the ulnar and median distributions escape in great part, while the radial distribution being more greatly affected, the long extensors are paralyzed and there is a condition similar to wrist-drop. (Ross.) Third: the stage of spastic phenomena begins when the compression of the cord above has become great enough to affect the lateral columns. Hence the usual symptoms of spastic paraplegia. The disease may last for years, at times with periods of remission. The prognosis is always serious, but a few cures have been reported. The diagnosis, where the site of the disease is in the cervical enlargement, is not difficult, since the distribution and character of the pains will exclude progressive muscular atrophy, amyotrophic lateral sclerosis and myelitis. The his- tory of the case will exclude Pott's disease. When the symptoms are predominantly uni-lateral it may be difficult to exclude tumor, but in such case the lesion is to all intents a tumor. Leptomeningitis spinalis. Inflammation of the pia mater, as an acute disease, exists only secondarily to some other affection, as by extension of similar trouble in the membranes of the brain or by transmission of infectious material as in pyaemia, tuberculosis, the infectious diseases, of which the epidemic form of cerebro-spinal meningitis is one ; in the latter, in- stances have been reported in which only the spinal membrane was apparently involved. The disease may begin after some exposure, with 108 SPINAL MENINGITIS. a chill followed by fever, pains in the back and radi- ating pains in the limbs, with painful stillness of the back and neck, rigidity of the muscles of the back or even opisthotonus. The pains are aggravated by even passive movements of the limbs, and besides ten- derness of the skin to touch, any pressure on the deeper parts is provocative of great pain. The tendon reflexes are exaggerated in the early stage. The muscles of the abdomen may be hard and contracted from spasm, and in some cases tightness of the chest amounts to dyspnoea. Similarly, from spasm, the urine may be retained and obstinate constipation exist. The disease progressing, the amount of exudation acts more by pressure, and paralytic symptoms ensue, commonly paraplegia with anaesthesia and paralytic symptoms on the part of bladder and rectum. The disease may last a few days or some weeks ; death may be preceded by a considerable rise in tem- perature and may occur from the effects of bedsores (sepsis) or from those of cystitis ( py elo-nephritis) or from exhaustion. The exudation is commonly purulent or sero-puru- lent, the membranes being bathed in it. If absorption take place, the membranes may be united to one another and to the cord, while increase of connective tissue with subsequent contraction may give rise to secondary changes in the nerve roots and the cord, thus producing a chronic meningo-myelitis, or menin- gitis alone may follow. The diagnosis is to be made from that of myelitis, SPINAL MENINGITIS. IO9 rheumatism, tetanus and meningeal haemorrhage. In a pure myelitis there is little or no pain and the para- lytic symptoms predominate ; in rheumatism there are no radiating pains and no spasm of distant muscles ; in tetanus the early appearance and prominence of trismus, as well as the absence of increased temper- ature, are decisive ; with meningeal haemorrhage there are radiating pains, but they appear with great sudden- ness and violence. The prognosis in internal spinal meningitis is always grave ; the higher the fever, the earlier paralysis sets in ; and the more severe the pains, the worse is the outlook. So in tubercular cases the prognosis is worse than in rheumatic ones and better in traumatic cases than in those arising without known cause. Treatment. Absolute rest in bed must be enjoined with freedom from external irritation of all kinds, even including light and noise. In traumatic cases the well- known remedies, Arnica, Hypericum perforatum, Rhus toxicodendron; in cases following exposure to cold or wet, Rhus toxicodendron, Dulcamara, Bell is perennis, will be thought of, the selection to be made according to the special symptoms in any one case. Belladonna, Bryonia alba, Cicuta virosa, Xux vomica, Mercurius, Physostigma venenosa and Iodoformum should be studied. Iodoform has repeatedly caused cerebral meningitis when absorbed from wounds, and its use in the 6th dilution by the writer has more than once been re- markably helpful in that form ; hence it is advised in the spinal form. 110 SPINAL MENINGITIS. Chronic Spinal Meningitis. A chronic idiopathic leptomeningitis spinalis is an extreme rarity, if it exist at all. As the final stage of acnte spinal meningitis, or as secondary to syphilis or alcoholism or injury it is not unknown. Its symptoms are those of the acute form, but in less severity, and the anatomico- pathological changes in the membranes are increased connective tissue proliferation, causing adhesion of pia and arachnoid, with thickening and opacity. There may be adhesion to the cord causing compression and inflammation of its circumferential edge. When the affection is the result of the syphilitic processes, the more characteristic signs are stages of advance and regression of the symptoms ; the in- completeness of the phenomena and the extensive- ness of the manifestations would give strong pre- sumptive evidence of such cause even without satis- factory history. Treatment. If the case is believed to be syph- ilitic, Sypliilinum, high, may be given, or Mercurius, Auram muriaticum natronatum or Nitric acid, all low, may be used. In non-syphilitic cases the great an- tipsorics, Sulphur, Calcarea carbonica, Lycopodium clav- atum and Silicea ought to be held in mind. Iodo- form 6 has been of such signal value in meningitis that even in old cases, where it has not been used, its employment should not be omitted. Myelitis. The word myelitis means an inflammation of the spinal cord, and, strictly speaking, might be applied to any inflammation of any part of that structure. Its use, however, without any qualifying word, is commonly held to apply to inflammatory processes ex- tending diffusely through the cord transversely. It may include the whole cross-area of the cord, or only a part; it may extend longitudinally through many segments of the cord, or include only one. More than one focus of inflammation may exist at the same time. The anatomical changes resulting from the myelitic process are softened consistency of the cord, loss of difference in tint between the white and gray matter, while under the microscope are seen in- creased vascularity, the vessels being surrounded by leucocytes, swelling of the axis cylinders and of the myeline, and swollen and deformed nerve cells. In a late stage there are evidences of degeneration of the myeline, aggregations of granular corpuscles and of fat granules, and still later, proliferation of the neuroglia, leading to a final stage of connective tissue formation, with disappearance in great part of all nervous elements. At present the process is held to be dependent upon infection, at least in the majority of cases, but exposure to cold and wet, traumatism, etc., I I 2 MYELITIS. cannot be denied as occasional causes. The infec- tious diseases, syphilis, gonorrhoea and septic pro- cesses are the chief excitants. The symptoms of myelitis are those of interference with, or loss of function in, the different structures of the cord and vary with the varying height and ex- tension of the inflammatory process, and its varying intensity in the cross section of the cord. The typical form is a transverse myelitis, and the most common site is the dorsal cord. Symptoms. A prodromal period of some sensory disturbance, limited to slight paraesthesia or pain in the related limbs, is followed by weakness or heavi- ness in the legs that soon becomes paralysis, and anaesthesia for all kinds of sensation, the sensory loss extending upon the trunk as high as the nerve dis- tribution from the upper limit of the disease in the cord. Just above this limit there is irritation and consequent hyperaesthesia upon the trunk, and at its junction with the anaesthesia is felt the very com- mon girdle sensation. With the paraplegia are associated stiffness of the legs and increase of the tendon reflexes, while later, spasms or more prolonged flexor contractions in the lower limbs may occur. If the disease is intense in quality and involves the whole cross section of the cord in the upper dorsal region or higher, the tendon reflexes are abolished in many cases (Bastian, Bruns). Paralysis of bladder and rectum are partly due to anaesthesia, partly to interference with the voluntary MYELITIS. 1 1 3 control. In the early stage the bladder requires the use of the catheter ; later there is incontinence for both viscera. Trophic changes may be found even early, due to the influence of uncleanliness and the lessened resisting power of the skin; bed-sores result at points most under pressure, such as the sacrum, trochanters or heels, and carry with them the danger of septic infection. Cervical myelitis. The symptoms already described are present, with the difference that the higher site of the trouble in the cord causes a higher limit (on the periphery) to the anaesthesia and the girdle sen- sation, and gives rise to paralysis in the arms, usually with some amount of degenerative atrophy. Dyspnoeic conditions may be present from implication of the respiratory muscles. Lumbar myelitis. When the lumbar enlargement of the cord is the site of the lesion the symptoms are different. The paralysis of the lower limbs is degenerative, the tendon reflexes are weakened or lost, anaesthesia may not extend higher than the in- guinal regions, and paralysis of bladder and rectum are very pronounced. The skin reflexes are lessened or absent. In myelitis of any region of the cord vaso-motor changes may occur; cyanosis and oedema of the paralyzed limbs are not infrequent. The course of an acute myelitis is rather rapid, so that in a few days, or perhaps a week, the 114 MYELITIS. symptoms have fully developed, witli some increase of temperature ; then follows a stationary period last- ing some weeks or some months, and from this the disease may regress to cure or to improvement only, or advance to a fatal ending, or to a stage of chronic myelitis, with more or less permanent reten- tion of many of the foregoing symptoms. The prognosis is always doubtful, but is more favor- able when the disease follows one of the acute infectious diseases ; when occurring during the puerperal state, or during tuberculosis, or from sepsis the prognosis is bad. The presence of radiating pains is considered by Oppenheim of good augury, in doubtful cases, while the early appearance of bed sores, or of com- plete paralysis of bladder and rectum are evil omens. Chronic myelitis, except as the outcome of the acute form of the disease, is uncommon. The diag- nosis must be made by the symptoms already de- scribed appearing slowly and with less intensity. Syphilis of the Spinal Cord. That syphilis is often a prominent factor in the etiology of myelitis cannot at present be doubted, but as the disease process only affects the cord by way of the pia and arach- noid, the result is more properly a meningo-myelitis syphilitica. The anatomical changes seen in the meninges at the autopsy may, indeed, be slight, while the cord structures are severely affected and present the appearances of a diffuse or disseminated myelitis ; in other cases the cord is involved only at its periphery (in cross section). MYELITIS. I I 5 The blood vessels are both starting points and channels for extending the disease process, and not only endarteritis, but even obliterating phlebitis may be present. The manifestation of the disease may occur within a year after infection, oftener within the first six years. The symptoms vary, as in all diseases of the cord or meninges, according to the height of the diseased segments, and the extent of the process in cross section. Symptoms of irritation and compression of the nerve roots are radiating neuralgic pains in back and extremities, girdle pain, anaesthesia and parses- thesia and, if the cervical or lumbar enlargement is specially affected, atrophic paralysis in arms or legs, limited to single muscles or groups of muscles, may be expected. From the implication of the cord struc- tures paraplegia occurs, often with predominance of the paretic state in one limb, or a Brown-Sequard's pa- ralysis, with loss of control of the sj^hincters. More characteristic of the syphilitic process is the variability of the symptoms from time to time, or at times from day to day, even the tendon reflexes par- taking of this. In some cases there is a marked spastic gait, with exaggeration of the knee jerks, yet without great in- crease of muscular tonus. As sensation is in these cases (called by Erb syphilitic spinal paralysis) but slightly impaired, it may be assumed that the brunt of the attack is borne by the cord itself. I 1 6 MYELITIS. Compression Myelitis. Compression of the cord can occur as a result of meningeal thickening (q. v.), haemorrhage within the spinal canal (q. v.) of tumors, in the ordinary sense, growing within the vertebral canal and of deformity of the spinal column, most often as a result of tuberculosis or caries of some of the vertebrae (Pott's disease). In the process the bodies of some of the vertebrae are changed, softened and disappear, with consequent falling together of the less affected vertebrae above and below, causing angular projection of the spinous processes of the diseased vertebrae. The in- cluded cord is of course bent and stretched and also exposed to pressure. Additional pressure will follow if the disease involve the periosteum, or cheesy pus accumulate beneath the latter (sometimes for several inches). In other cases formation of pus may be ex- tensive upon the dura mater, causing additional com- pression. The symptoms are of two kinds : those of the vertebral disease and those of the spinal cord and nerve roots. The former are stiffness of the spine, pain on movement, tenderness of certain vertebrae to pressure (a symptom to be accepted with great caution, as it is found in neurasthenia) and protrusion of some of the spinous processes. Even the latter is not to be taken as evidence of vertebral disease, for Charcot has shown (Iconographie de la Salpe'triere, Vol. I.) photographs of the ancient Greek statues of athletes having marked projection of the vertebral spines in MYELITIS. I I 7 the lumbo-dorsal region. The writer holds this to be due to slight displacement backward of the pro- jecting vertebrae, and has seen it after severe work and in some cases of neurasthenia. An angular protrusion is different, and may be ac- cepted as diagnostic of disease of the bodies of the affected vertebrae. The vertebral symptoms may exist for a long time without attracting much attention. The first spinal symptoms are usually painful sen- sations radiating along the course of certain spinal nerves, whose roots are in the extent of the lesion, and they vary according to its site. If the cervical vertebrae be affected the pains are in the shoulders and arms ; if in the dorsal vertebrae there is a girdle pain. The pains are mostly neuralgic in character, but at times are dull, drawing. The tendon reflexes whose reflex loops are below the site of the disease process are always increased. Next, weakness and stiffness of the lower limbs appear, the weakness gradually increasing until com- plete paralysis results. These symptoms may begin in one leg, to appear later in the other, or may pre- dominate in one. The seat of the affection is in the majority of cases in the dorsal vertebrae; when in the cervical vertebrae the arms are affected first and the lower limbs only later in the course of the disease. In many cases the spastic paraplegia, with rigidity of legs, ankle clonus, etc., are present, due to the interference by compression with the passage of in- I I 8 MYELITIS. hibitory impulses down the cord. In some cases the paralysis of the lower limbs is a lax one. Sensory disturbances, besides the pains already mentioned, are limited to some anaesthesia and pares- thesia. Bladder and rectum are affected in nearly all severe cases of compression of the cord, in the early stages retention of urine appearing, in the later stages incontinence. In the few cases in which the lumbar vertebrae are the seat of the disease there will be atrophy of the related muscles with reaction of degeneration. The disease is almost always chronic in its course, and the vertebral affection may exist for months and even for years before the spinal symptoms appear. Sometimes the spinal symptoms give the first clue to the existence of disease of the vertebrae ; often both sets of symptoms appear about the same time and in some cases the deformity of the spinal column is absent. The further course of the disease is protracted, often with periods of apparent cessation or even of temporary relief of the paralysis. The majority of cases die, bedsores, cystitis and pyelonephritis, septicaemia or general tuberculosis being agents in the fatal ending. The prognosis is much more unfavorable when the bone affection includes either the lumbar or cervical enlargement of the cord, or when it appears in the adult, or when evidences of general tuberculosis are present. Diagnosis. First, from the symptoms already given, MYELITIS. I 1 1 diagnosis of pressure upon the cord in some definite portion must be made. Next in order is the diagnosis of the character of the latter. Pott's disease appears in young life, although it may come at any age. Car- cinoma of the vertebrae appears for the most part after the 40th year. In the one case there often are signs of tuberculosis, in the other the existence of carcinoma elsewhere would be a guiding point. In Pott's disease the kyphosis is as a rule angular; in carcinoma the deformity is a protuberance not angular and less in size than in the other condition. In carcinoma of the vertebrae the initial sensory symptoms are of great intensity, so that the term paraplegia dolorosa is used to designate the extremely painful condition found in compression of the cord, due to this cause. Pathological anatomy. Post mortem, the cord when taken out is noticed to be softer than normal in the compressed portion, is smaller and sometimes even appears constricted. There is no real inflammation, so that the term myelitis is incorrectly applied to the condition present. Microscopically, a number of the nerve fibres are destroyed, many are in the process of degeneration, with swollen axis cylinders already deprived of their myelin e sheath. Later comes pro- liferation of glia tissue, and subsequently a sclerosed area. The diagnosis of myelitis will depend upon the existence of paraplegia, stiffness of the limbs, exag- geration of the tendon reflexes (occasional loss of knee jerks in a total transverse myelitis high up in 120 MYELITIS. the cord), anaesthesia in the paralyzed parts, girdle sensation at the npper limit of anaesthesia, paralysis or paresis of bladder and rectum, the occurrence ot bed-sores. Meningitis is characterized by pain and superficial tenderness of limbs without bladder symp- toms; multiple neuritis, by pain along the nerve trunks and no bladder trouble. Landry's paralysis of central type is a rapidly ascending disease of the cord. The hygienic treatment of myelitis consists of measures to prevent, if possible, the formation of bed-sores, or the occurrence of cystitis. For the first the patient should be often examined in the parts exposed to pressure, and these should be bathed in alcohol and water, while the bed clothing should be scrupulously clean. If there is paralytic retention of urine, the catheter must be used only after extreme aseptic precautions; if there is incontinence, a suitable urinal should be kept always in place. The bowels should be relieved by the aid of plain enemata. Of the remedies to be prescribed, those having causal indications should be used first. For traumatic cases, Arnica, Bellis perennis and Bhus toxicodendron; for cases following exposure to dampness or wet cold, Dulcamara, Bhus toxicodendron, Bellis perennis. A cause should always be looked for. . When none of the foregoing is found, the existence of some in- fectious disease (or a wound) may give a clue to an effective remedy. If syphilis has existed, and no other cause is assignable, Mercurius iodatus flavus, or solubilis, may be prescribed, or the isopathic prin- MYELITIS. I 2 1 ciple may be employed by prescribing Syphilinum 200th or higher. Similarly, if gonorrhoea has pre- ceded the disease. Many substances, metallic, vege- table or animal in origin, have caused experimentally, myelitis (Bruns) in the lower animals, but our prov- ings have not been carried to such extent on the human subject. Nevertheless many of our drugs have among their symptoms those strongly characteristic of the disease. The symptoms that are diagnostic are not, as we learn from Hahnemann, the ones lead- ing to the selection of a remedy, but rather those that are striking and peculiar, together with the ag- gravations and ameliorations. In the early stage, Aconite, Belladonna, Gelsemium, Veratrum viricle ; when any fever has lessened, Arsen- icum, the metals, especially Mercurius, Cadmium and Plumbum. Oxalic acid, Secale and Phosphorus may be studied. In the chronic condition, besides the remedies men- tioned, Beroeris vulgaris when the bladder symptoms are marked, JEscidus hippocastanum when rectal, sacral or perineal symptoms are prominent, Picricum acidum when the genito-spinal centre is irritated. In old cases, with marked spastic symptoms, Lathyrus sativus has been of great service. Cases of myelitis uncomplicated with meningeal in- volvement are not common, and the reader is referred for additional remedies to the section on spinal men- ingitis. System Diseases of the Spinal Cord. Certain systems of fibres, or of cells, may be at- tacked by certain degenerative disease processes to the exclusion, or nearly so, of all other parts of the cord. The term does not include processes of de- generation following and resulting from a lesion in some part of a system, such, for instance, as the secondary degeneration of a lateral column after haemorrhage in the cerebral motor tract. Poliomyelitis anterior acuta. This disease is pre- dominantly one of early childhood, most of the cases appearing during the first, second and third years, while after the fifth year cases are few, although the disease may occur in the adult. It is an infectious disease, appearing sometimes as an epidemic in small areas of country, but its special microbe is as yet unknown. It also occurs after other infectious diseases, such as scarlatina, measles and whooping cough. Symptoms. The outbreak of the affection is like that of any acute infectious disease. The patient is taken, usually while in good health, with high fever, headache, some pains in the limbs, vomiting at times, and may become delirious or stupid, and in some in- stances will have general convulsions. These acute symptoms last from a few hours to a day or two, but occasionally may continue a week or so. SYSTEM DISEASES OF THE SPINAL COED. I 23 At the end of the acute stage it is noticed that the child is paralyzed, the paralysis being wide- spread and, perhaps, involving all four extremities, the trunk muscles and the bladder. A slowly progressive improvement soon sets in, and whole limbs may be restored to full power and activity, or many groups of muscles regain their function. This process may continue for several weeks, or for some months, and then it stops, and the patient is left with paralysis of certain groups of muscles, most frequently in one leg, very often in both, less often in an arm, or in an arm and leg. The paralysis is a lax one, with loss of the tendon reflexes of the muscles involved, and with atrophy and reaction of degeneration. The muscles most commonly left in this state are, in the leg, those on the extensor side, the anterior tibial, the common extensors and the external peroneal; any one of these or any two or all three may be affected. In the thigh, the quadriceps extensor and the inward rotators are often the ones chiefly paralyzed; in the forearm, the extensors ; in the arm, the deltoid and flexors. I have seen one case in which the calf muscles were completely atrophied. Sensibility is at no time altered, nor is any pain present, except some tenderness of muscles during the process of atrophy. Owing to the unopposed action of unaffected muscles, various deformities arise, talipes equino-varus, talipes valgus, flexor contraction at the knee, and some lateral I 24 SYSTEM DISEASES OF THE SPINAL CORD. curvature of the spine being those most frequently seen. Pathologically, the disease is a myelitis limited to the anterior gray horns of the cord, with destruction of some of the motor cells. As a cell once destroyed cannot be reproduced, it follows from the regression of the paralysis that many of the cells have not lost their integrity ; and cases of paralysis, from the disease under consideration, existing for some years, have shown very great improvement as soon as treatment was begun, which continued until the limb or limbs were practically restored to usefulness. The nutrition of a limb severely affected is lowered and its rate of growth retarded. Hence, in cases of long standing, the bones are smaller than normal in all directions and the member is shorter, while the skin is cyanotic and cooler than that of its healthy fellow. The diagnosis in the acute stage cannot be made, except in the presence of an epidemic of the disease. When the paralysis is first observed, if convulsions have preceded it, the physician may think of cerebral infantile paralysis ; but in poliomyelitis the loss of the tendon reflexes would resolve all doubt. From multiple neuritis the absence of pain or of tenderness along the nerve trunks, and the fact that multiple neuritis is extremely rare in children, would be sufficient for differentiation. The chronic form of poliomyelitis anterior is a rarely observed disease. It begins with weakness of SYSTEM DISEASES OF THE SPINAL CORD. I 25 one limb, which gradually increases until the use of the member is seriously impaired. Xext, the fellow mem- ber is attacked, and still later, the other limbs ; and in the course of several months there may be incomplete paralysis of all. The paralysis is a lax one, and upon testing there will be found degenerative atrophy of certain groups of muscles, just as in the acute form. Sensation is not impaired, but there may be slight rheumatic pains. Fibrillary contractions in the degen- erating muscles are almost always present. The sphincters are not affected. The disease process, after having gone on for several months, may stop and a process of restoration set in that at times becomes complete. In other cases there is a steady advance of the trouble until all the muscles of the limbs, as well as some of the trunk, are wasted, and the patient is bed-ridden. Death occurs in from one to three years, usually from implication of the respiratory muscles, when pneumonia (from the inva- sion of the larynx and bronchi by food) or even a slight bronchitis, is sufficient to cause a lethal ending. Diagnosis. From progressive muscular atrophy of spinal origin the disease is differentiated by the fact that weakness and paralysis precede the atrophy, and that the progress of the disorder is here rapid. The treatment of poliomyelitis anterior in the acute stage must be purely systematic, as in the case of any infectious fever of childhood; but when the acute symptoms have passed off and the paralyzed condition of the limbs is recognized, Plumbum should I 26 SYSTEM DISEASES OF THE SPINAL COED. be given in a moderate dilution. This metal has caused degeneration of the cells in the anterior gray horns of the cord, and the earlier the diagnosis the sooner the remedy can be prescribed. After the active process has ceased in the cord, restoration of cells not destroyed takes place to a considerable degree, and it is fair to assume that an early use of so homoeopathic a remedy as lead is, will be of great value. This remedy is of undoubted service in cases of old standing paralyses from a previous poliomyelitis. The writer gives it in 30th potency, a dose every night for a week, intermits for a week and resumes— and so on. If other remedies are in- dicated, they should be given from time to time. Goldscheider has shown that the trophic influences governing the peripheral parts are kept active by the stimulus of centripetal impulses from the per- iphery. Hence, the undoubted value of massage, of " salt rubbings," etc., in this paralysis. But greatest of all is the systematic use of galvanism to the af- fected muscles. The anode is to be used with an interrupting handle, and a current strong enough to cause contraction in the muscle is to be passed and then broken, making interruptions and contractions of the muscles about twice in a second, twenty-five or thirty times. Another muscle or set of muscles is then treated, and so on until all the paralyzed muscles have been thus exercised. The other pole, cathode, is to be kept on some indifferent part, and possibly with advantage over the spine above the SYSTEM DISEASES OF THE SPINAL CORD. I 27 site of the cord lesion. This should be a large flat electrode. The current required to cause contraction may be so great that the pain cannot be borne, in which case by employing a non-interrupting handle the anode may be used labile, up and down the af- fected muscles for three or four minutes each, the current strength to be moderate, 6 to 8 m-a. The treatment should be given every other day for a period of 5 or 6 weeks, and then intermitted for a week or two, to be resumed for another period of 5 or 6 weeks. Contractures and deformities may, in the young, be prevented or lessened by orthopaedic mechanical devices. Primary Degeneration of the Motor Path Under this term Mobius makes a bold generalization and includes the diseases known as spinal progressive muscular atrophy, progressive bulbar paralysis, and amyotrophic lateral sclerosis. Charcot had given to the latter form its place as a distinct type of disease, while Growers in his consideration of chronic muscular atrophy (text book) says he has not yet met with a single case of progressive muscular atrophy in which the pyramidal tracts were not affected, and in another part of the same chapter he states: " Atonic muscular atrophy is, at least in many cases, the visible expression of a tendency to decay of the whole motor path, from the cortex of the brain to the muscles.' 1 Since in both of these forms of disease the symp- toms of progressive bulbar paralysis often appear, and since the cranial nerve nuclei in the medulla are con- 128 SYSTEM DISEASES OF THE SPINAL CORD. sidered as the analogues of the groups of ganglion cells in the anterior gray horns of the cord, the gener- alization of Mobius need not be considered strained, and it is of value in giving a readier insight into the features of the three forms. Mobius says that a primary degeneration of the motor tract may exist throughout its whole extent, from its beginning in the cells of the central convolu- tions of the cortex to its ending at the ganglion cells in the anterior gray horn of the cord ; that it may involve only the fibres of the tract in their spinal extent and the anterior horns ; and, finally, that it may affect the anterior horns alone. Destruction of the cells here of course involves destruction of the rest of the peripheral neurones and the muscle fibres to which they are distributed. The same author doubts the existence of a primary degeneration limited to the lateral columns, that is to say, without implication of the cells of the anterior horns. The anatomical changes are always the same : the cells become shriveled in appearance, they break up and disappear, as do the axis cylinders, the medullary sheaths being seen in all stages of degeneration ; slight secondary proliferation of the glia, slight changes in the blood-vessels, shrinking of the muscle fibres, with fatty or waxy degeneration and fissuration in them, and increase of connective tissue or of fat amid them, and increase of the muscle nuclei, are later changes. The cause of the disease is unknown, but Mobius thinks that congenital weakness in the neuro-muscular SYSTEM DISEASES OF THE SPINAL CORD. 1 29 apparatus is a fair presumption ; it begins in the adult as a rule while in good health and is not found in several members of a family. Spinal progressive muscular atrophy begins usually in one upper limb, more often the right. In the majority of cases, weakness and wasting are noted first in the muscles of the ball of the thumb, in some instances preceded by slight rheumatic pains or numb- ness. Soon other muscles become affected and the eminence at the ulnar side of the palm or the inter- ossei and lumbricales gradually disappear. Next, in most cases, the muscles of the forearm are involved, but in some instances they escape for a time, the deltoid and other muscles about the shoulder being attacked instead. Occasionally, the atrophy begins in the shoulder muscles. After the disease has progressed to some extent, the other side is affected, but not necessarily in the same order. When the wasting in the interossei and lumbricales is pronounced, and the extensors and flexors of the forearm are still intact, the hand assumes the much pictured "claw hand" type; in other cases the un- opposed action of the long extensor of the metacarpal bone of the thumb brings that member up to the level of the other metacarpal bones and gives rise to what is known as the "ape hand." After the deltoid, the triceps and biceps and supra and infra- spinat us are involved in varying order, fol- lowed by the trapezius, rhomboid, pectoral, serratus I30 SYSTEM DISEASES OF THE SPINAL CORD. and other deep muscles of back. The muscles of back of the neck may be affected so that it is difficult to erect the head upon the spine. The intercostals suffer in some cases ; in others the diaphragm — in either case respiration is abnormally performed. The lower limbs are not affected until late in the disease, and usually not so severely as the upper ones. During the process of wasting the muscles show certain symptoms, not, however, characteristic of the disease, but rather of atrophic degeneration. Fibrillary contractions or " flickering," to use Gowers' term, in parts of a muscle, are quite common. The electrical reactions vary according to the rapidity of the wasting as well as its degree, so that the electrical con- tractility may be only lessened or it may be extin- guished ; where there is some amount of paralysis preceding atrophy, as occurs in some parts (Gowers) there may be the typical reaction of degeneration ; in other parts there may be partial reaction of degen- eration. The tendon reflexes disappear as soon as the related muscles become even slightly affected. Bladder and rectum are not involved, but sexual power is often lost. The progress of the disease is usually a steady one, at times with apparent cessation, and Gowers holds that when once actually arrested, it does not usually again become active. Its duration may be a few years or many. Death occurs, commonly, from some inter- current pulmonary disorder or from the invasion of the medulla by the disease process, which, indeed, is SYSTEM DISEASES OF THE SPINAL CORD. I 3 I the most frequent "complication," and will be described under diseases of the brain-axis. Amyotrophic Lateral Sclerosis. It may be accepted that in the great majority of cases of spinal progressive muscular atrophy, the lateral pyramidal tracts in the cord are also degenerated, and that the usual clinical evidence of the latter process is not present, because in all cases the ganglion cells are so extensively in- volved that the resulting widespread atrophy of muscle renders spastic symptoms with exaggeration of the tendon reflexes impossible. In some cases, the damage to the ganglion cells not being so extensive, the symp- toms cine to disease of the lateral columns do appear, and then to the syndrome the term amyotrophic lateral sclerosis is applied. The symptoms begin in the same way as in the previously described form, by gradual spread of atrophy in the small muscles of one hand, but in the muscles not affected there is hypertonicity with active tendon reflexes, the knee-jerks even at this early period often being exaggerated. Alter several months the patient complains of weakness in the legs, and soon the typical spastic gait with weakness of legs and marked increase of the knee jerk and often ankle clonus, with absence of pain or sensory disturbance and of bladder or rectal trouble, prove plainly enough the existence of degeneration of the lateral columns. The patient can walk until a late period in the disease, but the weakness and stiifness of the legs make walking an effort. The last stage of the disease is the appearance 132 SYSTEM DISEASES OF THE SPINAL COED. of bulbar symptoms. Death occurs from some inter- current affection, mostly of the respiratory organs, or from cardiac or respiratory paralysis, due to the bulbar involvement. The diagnosis of spinal progressive muscular atrophy is not difficult. By the inexperienced it may be con- founded with one of the muscular dystrophies. But the beginning of the trouble usually in the small muscles of one hand, the age of the patient at the time of its first observed symptoms, the absence of similar cases in the same family, the presence of fibrillary contractions and in some muscles of the re- action of degeneration, give the stamp of authenticity to the diagnosis. Chronic poliomyelitis anterior attacks several limbs, the atrophy is preceded by paralysis, the reaction of degeneration is present in the affected muscles, the progress is relatively rapid up to a certain point, when it ceases and improvement results, or else it advances in a way not to be distinguished from progressive mus- cular atrophy. The absence of pain or of other sensory disturbances will distinguish progressive muscular atrophy from syringomyelia, pachymeningitis cervicalis hypertrophica and caries of the lower cervical vertebrae. In the atrophy following lead poisoning there is no advance in progress after the cause has been removed, while the history and concomitant symptoms will de- cide before- such cessation occurs. Amyotrophic lateral sclerosis is readily recognized by its symptoms already SYSTEM DISEASES OF THE SPINAL CORD. I 33 described, and the differential diagnoses just given will apply here. In both forms the occurrence of bulbar degenerative changes are to be expected, and this may lead to confounding the disease with disseminated sclerosis. If the views of Mbbius that progressive muscular atrophy and amyotrophic lateral sclerosis are but the manifestation of congenital fault in the structures of the motor paths, be correct, the problem of treatment becomes more complicated. Goldscheider's view that trophic influence is aroused and kept active by peri- pheral sensory impressions is widely accepted, but if the cells themselves (motor neurones) are imperfect, increased peripheral stimulation ought to wear them out the sooner. Nevertheless, the writer has seen the most remarkable results, amounting to arrest of the atrophy, in more than one case under the use of taradism to the affected region and of Phosphorus 6 internally, continued for some months ; and that method is here recommended in the spinal type of progres- sive muscular atrophy. Other remedies, such as Plumbum metallicum, Cuprum metatticum and Zincum metallicum may be better indicated in individual cases, and different observers have used Arsenicum, Picrkum aeidum, Argentum nitrieum, Physostigma vene- nosa, Belladonna and Xux vomica. The value of the deep acting antipsoric remedies in constitutional con- ditions mav be tested here. 134 SYSTEM DISEASES, ETC. LOCOMOTOR ATAXIA. Locomotor Ataxia. Tabes Dorsalis. This disease, of frequent occur- rence, is, except in a few atypical cases, the easiest of diagnosis among all the organic affections of the nervous system. Its appearance depends upon the existence of a previous syphilitic infection, or at least Erb's statistics show that in but five per cent, of his cases could a 23receding syphilis be fairly excluded. As the anatomical changes occurring in the progress of the disorder entirely differ from those of the syphil- itic process, it is assumed that the latter leaves behind it a toxine having a specially injurious affinity, under certain exciting causes, for certain nervous structures. The exciting causes are physical overexertion, ex- posure to wet and cold, an immediately preceding attack of some acute infectious disease, "fast" living and other weakening influences. From a series of 600 cases of the disorder in Erb's private practice, Leimbach (Deutsche Zeitsch. f. X'h'kunde, Bd. 7, Hft. 5 u. 6) has selected 400 in which the records were exceptionally complete in de- tails. The first symptom most frequently observed was the lightning pains which occurred as such in 277 cases in the legs, in 5 in the back, and in 1 in the SYSTEM DISEASES, ETC. LOCOMOTOR ATAXIA. I 35 arms. In 62 cases the lightning pains did not appear as the first symptom, and in 11 cases only as the third, while in 47 cases they did not occur throughout the whole course of the disease, but 100 of the ob- served cases were examined in the early stage of the disorder. A feeling of weakness in the legs and of too readily occurring fatigue as noted as the first symptom in 78 cases, as the second symptom in 113, as third in 44, and as fourth in 11. Leimbach considers this, although appearing in many nervous affections, as of great diagnostic value, especially as an early or initial symptom. Loss of the knee jerk and of the Achilles tendon reflex is the most constant symptom in tabes, yet in 3.75 per cent, of the 400 cases the reflexes in the lower limbs were normal, but the percentage of such exceptions will undoubtedly be lessened as time ad- vances in the 100 cases in the early stage. Paresthesias in legs and feet have a high rank as the initial symptom ; they occurred as such in 74 cases, as the second symptom in 110, and as third in 55. The disease is predominantly one of middle life, being most common from 30 to 50, and this because the syphilitic infection occurs most frequently between the 20th and 40th years, the interval elapsing between infection and the appearance of the disease being usually something less than ten years, although it has followed within two years and been delayed 15 or 20. 136 SYSTEM DISEASES, ETC. LOCOMOTOR ATAXIA. Its occurrence in childhood is denied by Oppenheim, but it may develop as late as the sixtieth year.* Men are much more frequently affected than women. The disease is divisible into three stages : the pre- ataxic, the ataxic, and the paralytic. The first is manifested most commonly as sensory disturbances, consisting of severe sharp pains, lancinating and light- ning-like, shooting down the lower limbs, or limited to small areas, and often mistaken for rheumatic pains. In some cases these are boring or constricting or burning. They appear in attacks lasting from a few hours to a day or two, and are often intolerable in severity ; the intervals of freedom from pain are in- definite in length. A symptom of great diagnostic importance and which appears early in the great majority of cases, is loss of the reflex contraction of the pupil to light, while the associated contraction in convergence is re- tained. This manifestation is known as the Argyll- Robertson pupil. In testing the response of the pupil under the retinal stimulus by light, it is important that the patient keep his gaze fixed on a distant object, for contraction will occur upon converging for a near object, such as the examiner's face. In a few cases the associated action in convergence may also be lost. Inequality of pupils may be present with or * Mendel lias reported some cases of children with undoubted typical symp- toms of tabes, the first appearing at the ages ten and eleven. In both in- stances there was undoubted syphilitic heredity and in one a vesicular eruption appearing after birth was treated with mercurial baths. It is now held that early appearing tabes is due to hereditary syphilis. SYSTEM DISEASES, ETC. — LOCOMOTOR ATAXIA. 1 37 without the foregoing Argyll-Robertson character, or the latter may be unilateral only. An early symptom, when it occurs at all, (100 out of 400 cases) is temporary diplopia due to paresis or paralysis of some of the exterior muscles of the eyeball. It comes suddenly without any exciting cause, lasts an indefinite time and disappears ; it may return later and then become permanent. The di- plopia is often very annoying to the patient, but it may be so slight as not to be noticed except under tests. Ptosis may be present with such ocular palsies or independently; it may be bilateral. Optic nerve atrophy occurs in about 10 per cent, of the cases (Leimbach's statistics give 6.75 per cent.). It is an early symptom and, indeed, may precede all others. It has been noted in many cases that the disease seems to spend its force upon the optic nerve, for the early appearance of the atrophy is not followed by farther development of the disorder, or this is retarded or postponed for years. The atrophy is the so-called primary atrophy, of bluish-gray or muddy tint when seen in ophthalmoscopic examination. It goes on to blindness. Disturbance in the functions of the bladder is very common in the disease, being found in more than 80 per cent, of the cases, while as first symptom it occurred in 90 out of 400 cases, as second symptom in 119, and as third in 74. The disturbance may be a leakage if the desire to urinate is not at once yielded to, or it may be inability to pass urine 138 SYSTEM DISEASES, ETC. — LOCOMOTOR ATAXIA. except by the aid of the diaphragm and abdominal muscles. A paralytic state of the rectum occurs, but much less often than the trouble with the bladder. Weakening of sexual power and desire, often to complete extinction, was found in 58 per cent,, and as a symptom belongs mostly to the early stage of the disease. The paresthesias already mentioned as early symp- toms of locomotor ataxia are most commonly felt in the feet or legs, especially in the soles and edges of the feet, less frequently but not rarely in the region of anus, perineum, scrotum and penis. More fre- quent than, the latter are paresthesias in hands and arms, while a special paresthesia in the ulnar distribu- tion has been observed often enough to give it a diagnostic value. The paresthesias vary in character. Some patients feel as if a layer of felt were under the soles or as if cushions were there, others feel a numbness or prickling or crawling ; sometimes a sensation of cold is complained of, and in one case the patient felt as if the sacral, anal, perineal and genital regions were closely packed in ice. Burning or "raw" sensation is not infrequently felt. Hypesthesia or even anesthesia (often with anal- gesia), retardation of pain sensation (pin-prick not felt for sometimes two or three seconds), allocheiria (pin- prick in one part felt in the analogous part of the other limb), often precede the occurrence of ataxia. The ataxia itself is but one form of anesthesia. LOCOMOTOR ATAXIA. I 39 The so-called muscular sense fibres cannot carry the sensory impulse originating in the end organs in the muscles (or in the joints!). Hence the information to the brain of the position of a limb or any portion of it is insufficient and misleading, so that for the successful voluntary motion of any part the needed information must be obtained through the sense of vision. The patient, with eyes closed or in the dark, cannot co- ordinate his muscular actions, cannot stand with feet together without swaying (Romberg's symptom), cannot walk a straight line, and after the ataxic stage has well advanced cannot do these acts even with the aid of the sense of vision. For a time, however, he can walk by keeping the feet widely separated, so as to get a broad base of support, and by throwing the foot, as it were, forcibly, the heel reaching the ground first, thus making sure of each succeeding step. His greatest difficulties are going up and down stairs, and turning around while standing. When the ataxia reaches the upper limbs it is first observed in the finer movements of the hands, so that buttoning the clothing, writing, or playing a musical instrument becomes difficult, and the latter at last impossible. Ataxia of the arms is relatively infrequent, Leimbach's statistics showing its occurrence in only 17 cases out of 400, and all but two of the cases were those in which the disease was of long standing when the symptom appeared, or else of very rapid progress. The tests for ataxia are simple enough, and limited 140 in number only by the ingenuity of the examiner. To have the patient stand with feet close together, eyes being closed, and observe the swaying of the body in different directions; to have him lie down and with one heel endeavor to touch the knee of the other leg, or to put one heel on top of the toes of the other foot ; with the foot to describe a circle in the air ; to tell him to simply cross one leg over the other — all these are but a few of many possible tests, and in all even slight amounts of ataxia will be discovered by a mere novice. So with the arms. To direct the patient (eyes being closed) to bring the two forefingers together from a distance ; to have him touch with one forefinger successively, and each time from a distance, the tip of the nose, the middle of the forehead, the chin, the lobule of the opposite ear, _ are well-known methods. If ataxia exist, the movements, instead of being done grace- fully, as under normal conditions of co-ordination, are made unsteadily, doubtfully, and usually go wide of the mark. The simple test of crossing the legs when the patient lies with eyes closed will often tell the whole story. Although ataxia is due to impairment of co-ordina- tion, and is not a manifestation of muscular weakness, yet its increase means an excessive amount of mus- cular exertion when walking, so that, as it increases, the patient becomes more and more unable to make such exertion, and finally, perhaps after years, he becomes bed-ridden, and is in the so-called SYSTEM DISEASES, ETC. LOCOMOTOR ATAXIA. 141 paralytic stage. Meanwhile there are other symptoms present. The girdle sensation, as if a band or girdle were tightly constricting the waist or lower abdomen, oc- curred in 31 per cent, of 400 cases and even appeared as the initial symptom in 34 of these ; it is not diag- nostic of this disease, since it occurs in other forms of spinal cord trouble, nor is it continuous, but when present it is extremely trying to the patient. The so-called "crises" are of great importance diagnostic ally, but they do not appear to be frequent. Leimbach reports 17 cases of gastric crises (in 10 of these the crises were the first evidence of the disease), 1 case of rectal crises and 3 of laryngeal crises, out of 400 cases of tabes. The crises are suddenly occurring attacks of disturbance in some organ without any recognizable adequate cause. Thus attacks of gastric pain with or without vomiting, sometimes nausea and vomiting with- out pain ; attacks of spasmodic coughing, simulating whooping cough ; and attacks of severe diarrhoea, often choleraic in character, are some of the crises. They may last a few hours or many, or even some days, and usually cease as suddenly as they came. Renal crises, consisting of severe pain in the region of the kidneys, accompanied by apparent suppression of renal activity; and clitoris crises or sexual orgasm in the female, have been noted by authors. Mobius classes with the crises attacks of paraesthesia in the rectum, the sensation being that of a thick stick or 142 similar body being thrust upward. In a case under the notice of the writer this sensation was an almost continuous one for months. Trophic disturbances occur during the course of the disease in a very small percentage of the cases, and arc confined to the bones and joint structures. The bones become fragile, the ends eroded or crumbling, the cartilage may disappear and spontaneous luxation occur, with deformity, due in great part to effusion and swelling, often of the whole segment of the limb, yet without evidences of inflammation. This latter manifestation is known as Charcot's arthropathie tabetique and is probably seen more often in hospital cases than in private practice. It affects the knee-joint most often, but other joints may be attacked. Trophic changes in the skin, such as eruptions of various kinds, may be looked upon as complications, but an intractable form of ulceration occurs at times on the sole of the foot as a result of slight injury, such as a trifling cut. Neuritis, of degenerative type, in the peripheral spinal nerves, occurs occasionally in advanced stages of the disease ; it may lead to atrophy of muscle, most often seen in the legs. The diagnosis of locomotor ataxia in any well de- veloped case is comparatively easy, the large number of the chief symptoms permitting variation, yet assur- ing such positiveness in the grouping of them into sets that error is practically impossible. Thus, any one of the following groups makes the diagnosis absolute : M3 Lancinating pains in legs, Argyll-Robertson pupil and loss of knee jerk. Loss of knee jerk, optic nerve atrophy, and pares- thesias of feet. Paresis of eyeball muscles, weakness of bladder, lancinating pains. Similar groupings of the foregoing symptoms or of others may be made by the examiner, and if in ad- dition there is found Romberg's symptom or ataxia under tests, the diagnosis is beyond doubt. The crises may direct attention to the possible existence of the disease when they occur in the early stage. Multiple neuritis, after the acute symptoms have passed away, might be mistaken for tabes, since there are often present distinct ataxia, loss of knee jerks. Romberg's symptom, and in some cases optic nerve atrophy as sequel to a preceding optic neuritis. But the history of acute onset, rapid progress, tender- ness of nerve trunks, and presence of degenerative atrophy of muscles in the affected limbs, suffice for differentiation. It must be remembered, however, that peripheral neuritis does occur in a few cases of locomotor ataxia. Post-diphtheritic paralysis (neuritis) may involve the limbs and cause ataxia, loss of knee jerks, paraes- thesias, or paralysis of eyeball muscles, but the his- tory, and especially the paralytic symptoms of palate, pharynx and oesophagus as early secpiels of the throat affection will prevent confounding the later manifes- tations with tabes. 144 SYSTEM DISEASES, ETC. — LOCOMOTOR ATAXIA. Not a few cases have been observed that began apparently as locomotor ataxia, and finally developed into dementia paralytica ; sometimes the reverse has been the case. In both, the eye symptoms may be common, and loss of the knee jerks is found in a not inconsiderable fraction of cases of general paresis of the insane. In doubtful cases time will be needed for determining the diagnosis. The anatomical changes found post-mortem in lo- comotor ataxia are first, because most conspicuous (even to the naked eye in most cases), a gray de- generation of the posterior columns, with the excep- tion of a small field anteriorly adjoining the gray at the posterior commissure, and extending laterally somewhat on each side. Next, Lissauer's zone at the end of the posterior gray horn, and the vesicular column of Clarke, show loss of fibres and cells, while the posterior nerve roots show marked atrophy of their constituent fibres. Just where the pathological process begins has been a fruitful cause of discussion. It has been maintained that a leptomeningitis exists with consequent constric- tion of the posterior nerve roots as they pass through the membrane and necessarily with neuritis and atrophy. It has been maintained that degeneration of the nerve roots is the starting point without any necessary meningitis. And finally it is held by many that the initial point is degeneration of the cells of the posterior spinal ganglia with extension of the process upward in the cord and downward in the peripheral H5 fibres. The process attacks at times the spinal root of the fifth cranial nerve and the respiratory bundle in the medulla. The fibres of the tenth nerve or its posterior nucleus and the twelfth nerve nucleus are sometimes attacked. The Gasserian ganglion, which is analogous to the posterior spinal ganglia since its cells give rise to the spinal root (so called) of the fifth nerve, in some cases showed atrophy of its cells and fibres ; the optic nerve atrophy begins in the ganglion cell layer of the retina and extends backward. The motor nerves of the eye- ball, especially their nuclei and rootlets, may be af- fected ; the exact cause of the Argyll-Robertson symp- tom is, however, not yet definitely established, but it is presumed that some degenerative change exists in the central gray beneath the corpora quadrigemina. The changes in the cord first appear in the upper lumbar segments, except in those cases in which the disease affects first the arms, when the cervical seg- ments of the cord are first attacked. Prognosis. The outlook for cure of locomotor ataxia is practically hopeless, but in the first and second stages there is hope of lessening the pains and other trials of the patient. Even after the so-called para- lytic stage has set in there is a possibility of amelior- ating annoying symptoms. The disease lasts for many years, unless when blad- der trouble with its consequences occurs early. Death results from some intercurrent affection. The treatment of locomotor ataxia must be in the I46 SYSTEM DISEASES, ETC. — LOCOMOTOR ATAXIA. largest degree hygienic. Severe physical exertion must be avoided, but very moderate exercise in the open air is to be insisted upon. The food should be nour- ishing and easily digested. Stimulants and tobacco are to be forbidden, or allowed only in the smallest amounts. The ataxia and also (in some cases) the paresthesias and pains are lessened by the use of Frenkel's muscle drill or re-education of the muscles. This method consists in the carrying out of definitely ordered co- ordinated muscular actions in which the patient must use the will in directing the muscles. The* exercises are as varied as the directions in which his muscular co-ordination is lost, and are meant to utilize to the highest degree the few remaining sensory nerve fibres. It is not applicable when locomotion or the power of balancing is lost, nor when optic nerve atrophy has far advanced, as the eyes must be used to help correct faulty action. The exercises are in no sense gymnas- tics, strength as such not being sought. The use of galvanism alone (or combined with faradism) along the spine and limbs is recommended by some observers as serviceable in relieving many of the annoying symptoms; the current should be rather strong, 15 to 25 or 30 m-a. The writer has used it, but has seen no special results. Treatment by suspension in Sayre's apparatus, modi- fied so that the suspension is from the elbows (arms being flexed) as well as from the head, has in some cases been helpful, especially in relieving the bladder SYSTEM DISEASES, ETC. LOCOMOTOR ATAXIA. 1 47 symptoms. It should be gradual in beginning and ending, should be given every other day, two or three minutes at a time, during six or seven weeks. It is not admissible if arterio-sclerosis or bulbar symptoms are present, nor in the so-called paralytic stage. A mild form of suspension may be given by having the patient seated, so that the suspension shall use only the weight of the body above the hips at first. The employment of hydrotherapy is recommended by many ; the matter is one to be decided only after knowledge of the patient's susceptibility in this direction. Believing with Erb and Mobius that tabes is a post- or para-syphilitic disease, the writer has during the past few years used the principle of isopatlry in treating it, and has given Syphilinum, 200 or higher. Marked improvement has been seen in some cases, but this may have been due to the patient's ceasing to use powerful drugs. Ergot has caused sclerosis of the posterior columns, as shown by post-mortem evidence, but Secale in different po- tencies, has not in the writer's hands influenced the disease in the least, undoubtedly because Secale was homoeopathic only in a gross way; in addition, the cases of poisoning by Ergot showed no progression in the affection produced. JEscidus Mppocastanum is said to have caused the disease; "whole flocks of sheep, having been fed dur- ing the winter on horse chestnuts, have been afflicted with Tabes Dorsalis, and many have died of it." * *Ad. Lippe, M. D., Homoeopathic Quarterly, April, 1870. The constriction in the rectum, which has been observed by the pro vers of ^Esctrfus, is often present in this disease. I48 SYSTEM DISEASES, ETC. LOCOMOTOR ATAXIA. Four cases of cure are recorded by Bonninghausen under the use of Aluminum metallicum. Other observers have used with asserted benefit Argentum nitricum, Phosphorus, Plumbum metallicum and Picricum acidum. Physostigma, Lachesis, Nitric acid, Rhus toxicodendron, Silicea and Graphites have been credited with benefit- ing patients suffering from this disease. In the writer's hands Angustura vera materially helped in one case where the lightning pains were of great intensity. Carboneum sulphuratum ought to be of signal service in restraining at least the advance of the disease, while Zincum metallicum and Cadmium metallicum (vide Erb's statement quoted in article on Syringomyelia), should be borne in mind. Duboisia and Physostigma both cause unsteadiness on standing or walking with eyes shut, but in the former it would appear from other symptoms to be vertiginous in origin, in the latter probably neuritic. Lippe (Repertory) gives Nux moschata the first rank as a remedy for tabes dorsalis, and the next and only remedy, Phosphorus. From the foregoing it will be seen that in any case a close study of symptoms and especially of the ameliorations must be made ; if we are to increase our therapeutic resources in the treatment of loco- motor ataxia it must now be by recording all the symptoms and by collating the results of our prescrip- tions, and thus ascertain just in what respect and to what degree different remedies influence the course of the disease The various crises, including the lightning pains, arc ATAXIC PARAPLEGIA. 1 49 treated according to the symptoms of each case, especial- ly the aggravations and ameliorations. At the present writing the pain crises, in a case in which the only relief is obtained while the painful part is immersed in water as hot as can be borne, have been evidently influenced by Strontiana carbonica 30, at frequent intervals during an attack. Ataxic Paraplegia. Whether the clinical picture seen in a case of ataxic paraplegia is due to a distinct pathological entity, or represents the results of separate disease- processes in the lateral and posterior columns re- spectively, cannot yet be decided. Certain it is, that cases having many of the distinctive symptoms of spastic paraplegia, and many of those of locomotor ataxia, do exist. It is plain, however, that a com- bination of the two diseases per se does not exist, and, indeed, cannot exist, for some symptoms of each are missing. The disease is described as beginning usually be- tween the thirtieth and fortieth years, but it has developed as early as the fifteenth and as late as the sixtieth year. It is considered by Gowers to be an isolated form of hereditary ataxia, but the writer has under observation the case of a boy aged twelve, unable to walk from the amount of paraparesis, the trouble having begun at least as far back as his eighth year, while he has double optic nerve atrophy (of the gray or primary variety) with exaggeration of the knee I50 SYSTEM DISEASES, ETC. — ATAXIC PARAPLEGIA. jerks, slight ankle clonus and hypertonicity of the paretic lower limbs — symptoms that exclude Fried- reich's disease absolutely. The early symptoms are those of spastic paraparesis with the addition of some ataxia. In the case men- tioned above, the first symptom of ataxia was noticed in the arms, the patient when trying to clap his hands failing to succeed. Weakness of the legs, with too ready fatigue, is seen, but the ataxia, present under the usual tests and conditions, has more the quality of reeling (when walking or standing) than that of locomotor ataxia. Lightning pains and the girdle sen- sation are present in rare cases and impairment of sensation is likewise rare. The knee jerks are exag- gerated, and usually ankle clonus can be elicited. The bladder may be affected (retention paralysis) while sexual power is frequently lost. Loss of the reflex mobility of the pupil has been observed in some cases, while optic nerve atrophy occurs at times. The disease advances chiefly in the direction of increasing weakness of the lower limbs, with spas- tic symptoms, when, of course, the ataxia is gradually overshadowed, the patient, it may be, after a lapse of years, becoming bed-ridden. Some cases appear to be predominantly locomotor ataxia, with an affection of the lateral columns super- added. The course of the disease is extremely slow, death occurring after many years, and then usually SYSTEM DISEASES, ETC. HEREDITARY ATAXIA. I 5 I from some intercurrent affection, pyaemia from septic- infection (bed-sores), or from nephritis, the result of long-lasting bladder trouble. In the causation of the disease syphilis seems to have no part, while suppression of perspiration, ex- cessive physical exertion, sexual excesses, etc., have been ascribed as immediate causes. A similar clinical picture has followed the use of Lathi/rus deer a (and sativus), and also the use of diseased corn (in Italy, under the name pellagra). The treatment of ataxic paraplegia should be that of chronic myelitis, but from the facts named in the preceding paragraph, Latliyrus cicera or sativus ought to be of decided service ; the writer lias used it in diffuse myelitis with secondary degeneration with great benefit. Ustilago may be tried in view of a possible relation to pellagra, although our prov- ings have shown its influence in the sexual sphere of women chiefly. Hereditary Ataxia-Friedreich's Disease. This affection is one of the so-called " family" diseases, and appears in several members of the same generation. It is believed to be due to con- genital fault, as often shown by the smallness of the cord, seen in autopsies of its victims. The symptoms of the disease appear first about the time of puberty in most cases, although there has been reported as occurring as early as the sixth or seventh year a distinct ataxia of the lower limbs, 152 SYSTEM DISEASES, ETC. HEREDITARY ATAXIA. accompanied by some amount of muscular weakness. The gait is a modification of that of locomotor ataxia, since the weakness produces something of a "reeling" quality. Sensory disturbances are absent, lancinating pains having been only rarely noted, while hypsesthesia when observed has been only in the later stages. The knee jerk is lost early, as a rule. Choreiform movements occur in many cases, especially in the muscles of the neck, and then causing irregular oscillation of the head. The course of the disease is very slow, and several years may elapse before ataxia of the arms appears. Contrac- ture in different muscles causes at times scoliosis, or talipes, or hyperextension of the toes, etc. Dif- ficulty in speaking, the words being imperfectly enunciated, and nystagmus, are common features of the disease when it has well advanced. Paralysis of eyeball muscles, or loss of pupillary reflex, has been occasionally noted, but most observers insist that the eye fundus is always normal. Vesical troubles are extremely rare, and no " crises " occur in the disease. As the disorder progresses, increasing weakness of the lower extremities eventually confines the patient to bed. It may extend over a period of thirty or forty years, but death comes from some intercurrent disorder, and, of course, at any time. The prog- nosis for cure is hopeless, but with care and proper hygienic regimen, life will be prolonged. The anatomical changes, as shown by microsco- 153 pica! examination are confined to the spinal cord and medulla chiefly, and the smalm ess of the cord seen in all cases examined is taken as evidence of imperfect development. The disease is really a com- bined system degeneration of the column of Goll entirely, the column of Burdach in part, the crossed pyramidal tract, the direct cerebellar tract, and in some instances the ascending antero-lateral tract. Changes in the medulla have not as yet been suf- ficiently well studied to deduce positive conclusions therefrom. Spastic Paraplegia. — Spastic Spinal Paralysis. This disease-manifestation was formerly called pri- mary lateral sclerosis because of its clinical likeness to secondary degeneration (sclerosis) of the pyramidal tracts. Its existence as an independent primary disease is now so stoutly contested that it must be a rare affection if it exist at all. It is gradual in onset, weariness in the legs being first noted, advancing to paresis and later to paralysis, without sensory disturbance or trophic change, without implication of the bladder or rectum. A sense of stiffness is felt in the affected limbs, or a feeling as if the muscles were too short. The existing hypertonicity is shown by the markedly exaggerated knee jerks and, in well advanced cases, 154 ankle clonus or even a patellar clonus (on pulling on the quadriceps femoris by means of the patella) may be observed. The affected limbs undergo contraction at times, from fatigue or in attempting a movement. The contractions are temporary at first, but in course of time a condition of rigidity comes on mostly of the extensor and adductor muscles. In consequence, the gait becomes the well-known spastic gait, the knees nearly together, the legs slightly bent at the knee ; the steps taken are short and the balls of the feet scrape the ground, the heels not reaching it. At each step the weight of the body causes an ankle clonus, thus giving a quivering quality to the gait. The upper limbs may be affected in course of time with stiffness, impaired activity and increased deep reflexes. The affection is slow in its progress usually ; it may continue for years or may cease to advance. Sections made from the cords of those who had the affection during life have not shown an isolated primary disease of the pyramidal tracts, but have shown other diseases or secondary degenerations with implication of the lateral columns. The trouble is now believed to be in most cases a result of syphilitic myelitis, diffuse myelitis, multiple sclerosis, tumor of the cord or brain, syringomyelia or even hydrocephalus. Nevertheless, Oppenheim maintains the possibility of the existence of the independent primary affection, but in every case with these symptoms endeavor should be made to discover some cause such as those mentioned. SYSTEM DISEASES, ETC. SPASTIC PARAPLEGIA. I 55 Hysteria is said to simulate the condition. The diagnosis is made chiefly by determining the presence or absence of any primary affection. In hysteria there may be a deceptive false clonus, but the onset of the symptoms is sudden and usually after some psychical excitement, while the rigidity has the peculiarity of hysterical contracture. The symptoms of spastic paraplegia in the adult appear between the 20th and 40th years, as a rule. The cause assigned is at times trauma or exposure to cold ; a preceding syphilitic infection or an acute in- fectious disorder or even lead poisoning, is stated by Oppenheim to be capable of developing the disease. The treatment should be that laid down in the section on chronic myelitis ; Lathyrus sativus or cicera has produced the symptoms. Non-Systemic Diseases of Spinal Cord. Multiple Sclerosis. — Disseminated or Insular Sclerosis. A condition in which numerous small foci of sclerotic change are distributed widely and irregularly through the brain and spinal cord. In size these foci vary from that of a pin's head to that of a large bean, and, while they occur in the gray matter, are in greater numbers in the white. In accordance with their pre- dominance in any special area or tract will the result- ing symptoms differ, so that theoretically a case may occur which cannot be diagnosticated during life. Cer- tain groups of symptoms, however, are so closely associated in the disease that most cases, as far as we can judge, can be diagnosticated. It is a disease seen mostly in early adult life, but cases have been reported in which it has appeared as late as the forty- fifth and as early as the fifteenth year. The writer has seen a case in which the tremor did not come on until the forty-seventh year, but the speech diffi- culty dated from early childhood. The etiology of the affection is unknown, but its manifestations frequently follow the cessation of some infectious disease, such as smallpox, scarlatina, measles, etc., or appear as the effect of trauma or of violent emotion. Striimpell has lately advanced the hypothesis MULTIPLE SCLEROSIS. I 57 that the disease is primarily a multiple gliomatosis, due to inborn conditions. In a typical case the patient sliows a certain inter- ference with voluntary motion of the hands and arms, of the eye-balls and of the laryngeal muscles. The arms and hands, when the patient attempts any move- ment with them, are seized by a tremor, of small amplitude at first, but increasing in extent as the motion is continued. If told to take up a glass of water and drink from it, he shows a simple tremor on taking hold and the tremor becomes so wide in its increasing excursions that the contents of the glass may be violently thrown out. All the tremor ceases when the patient is at rest; but as the head and trunk muscles may be implicated they may continue in tremor when the patient is sitting or standing, because they are then in action. The eye-balls, when the gaze is directed to one side, show oscillation, known as nys- tagmus ; often the nystagmus is present when the patient simply looks* ahead. The speech difficulty has not been analyzed as to its muscular components, but is made up of somewhat jerky breaks in the emission of speech sounds, so that words are dissected into syllables and there is absence of the usual tailing and rising inflection commonly heard in ordinary conver- sation. From these peculiarities the speech of insular sclerosis is termed " scanning" speech or syllabic utter- ance. Besides the foregoing characteristic symptoms there are others of scarcely less diagnostic value. The 158 NON-SYSTEMIC DISEASES OF SPINAL CORD. symptoms of spastic paraplegia are present in greater or less degree ; weakness, with stiffness of the legs, spastic gait, exaggeration of the knee jerks. Optic nerve atrophy is frequently seen in the course of the disease, more frequently than was for- merly supposed. (Buzzard.) It appears first as pale- ness of the temporal half of the disk, but eventually involves the other half, yet not with such loss of visual power as might be supposed from the ophthalmoscopic appearances. The mental state of the patient is altered; he is usually in a pleased or contented frame of mind, and fits of irrepressible laughter without cause, either ob- jective or subjective, are not infrequent in the early stage ; they have no relation to mental decay. (Oppen- heim.) Disturbances of sensibility, mostly paresthesias of fingers and toes, appear in some patients, but are only temporary. Attacks of vertigo are found in the ma- jority of the cases. During the course of the disease in some instances, apoplectiform attacks with perhaps complete loss of consciousness appear and are at times followed by a hemiplegia that soon disappears ; such attacks materially injure the patient. Occasionally paresis of the extrusor or of the detrusor of the bladder occurs, but does not become permanent. Aggregation of the islets of sclerosis or their in- creased size in some definite region will give rise to corresponding symptoms, such as atrophy, paralysis of bulbar nerves, or tabetic symptoms with loss of MULTIPLE SCLEROSIS. I 59 the knee jerk (Growers); but the Argyll-Robertson pupil does not occur, although inequality of pupils has been reported; lightning pains have been observed. Paralyses of some of the muscles of the eve-ball are not uncommon, and optic neuritis has been noted. The disease may present a picture of transverse myelitis or of primary spastic paraplegia ; the cerebral symptoms already mentioned will place the affection nosologically, even when the typical symptoms are ab- sent; but dementia paralytica must be excluded. Pathologically, the islets show increase of con- nective tissue with loss of the medullary sheaths of the nerve fibres, while the majority of the axis cylin- ders remain for a long time. The development of the disease is slow, its course is very gradual ; it may last ten or fifteen years, but it may remain stationary for long periods and actual remissions occur. A neurosis has been described with many of the symptoms of multiple sclerosis, and hysteria has re- peatedly exhibited intentional tremor. Nystagmus is present in other affections of the brain and also in independent ocular troubles, and intentional tremor has been observed in connection with cerebellar lesion. The prognosis is absolutely bad as regards cure, but the possibility of cessation of advance or remission in the disease gives a certain hopefulness to the outlook in cases without threatening bulbar symptoms, or in those in which the apoplectic manifestations have not appeared. l60 NON-SYSTEMIC DISEASES OF SPINAL CORD. Treatment. Claims have been made that the dis- ease has been been benefited by the use of Physostigma venenosa, Argentum nitricum, Plumbum, Nux vomica and Phosphorus, but the writer has not been able to influence its course by any remedy. If Strtimpell's hypothesis of the essential nature of the disease be well founded, it might be possible to retard its pro- gress by our deep acting constitutional remedies such as Sulphur, Calcarea, Lycopodium, Silicea, Thuja occi- dentalis, etc. Acute Ascending Spinal Paralysis. Under this term Landry described a special form of disease in which, after some prodromal symptoms, general in character, a lax paralysis ensues, first in the legs and more in one than in the other in the beginning, with fever, and, in many cases, intestinal symptoms. The patient is compelled to remain in bed and the weakness attacks the muscles of the abdomen and then those of the arms. Next follow bulbar symptoms, consisting of difficulty in swallowing and in the use of the organs of speech. Attacks of dyspnoea, culminating in paralysis of respiration as the final term of the series, if continued, end the scene within a few days. The ordinary sensibility is not disturbed, the tendon reflexes are at first not changed, but later become extinguished, and the functions of the bladder and rectum are, as a rule, not affected. The electrical excitability of the muscles remains ACUTE ASCENDING SPINAL PARALYSIS. l6l undisturbed and there is no atrophy. There are also no mental symptoms. Profuse sweating is generally present, and some oedema may be observed. The fever may continue during the whole course of the disease. Enlargement of the spleen has been repeat- edly noted. The progress of the disease is rapid, in some cases the fatal end occurring within two or three days, or it may be delayed for a week or two. Cures do occur, but the convalescence is very slow. From the foregoing it will be seen that the prog- nosis is serious, and as all the cases reported do not seem to be of one character, it is difficult to assign any given case to a definite place in classification. Some are undoubtedly instances of multiple neuritis, and some appear to be cases of myelitis, but perhaps the real character of the affection is that of acute ascending infectious neuritis, with final implication of the structures of the medulla and possibly of the cere- brum. From the symptoms, PJiosjrfiorus, Oxalic acid, Lathyrus sativus, Ledum pdlustre and Aluminium metal - Ileum would appear to be indicated. The Caisson Disease.— Diver's Paralysis. In laying the foundations of bridges or in other work done at considerable depths below the surface of the water, the workmen are in an atmosphere whose pressure is two, three or, in some instances, five times that of the ordinary atmosphere. Under the pressure mentioned the men suffer but 162 NON-SYSTEMIC DISEASES OF SPINAL CORD. little, if at all ; indeed, there is a sense of stimulation, but if the pressure be rapidly lowered there come on in a short time some serious or even dangerous symptoms which are relieved if the patient can be returned to the pressure chamber. If the pressure be gradually reduced to that of the ordinary atmos- phere no ill effects follow, and an arrangement of chambers with successively decreasing pressure has been in use, through which the worknen pass into the outside air, staying for a time in each ; or, lately, one intermediate chamber only, with a means of slow escape from it of the compressed air, serves even better the desired end. When through the recklessness of the workman or insufficiency in the method of lowering the pressure, the change from the working pressure to that of the outside air is made too rapidly, the symptoms of the disorder come on. Under the influence of increased atmospheric pressure there is taken up through the lungs a proportionally increased amount of the constituents of the inspired air, in accordance with the physical law of absorption of gases by liquids. If the pres- sure is gradually lessened the absorbed gases are gradually released from the circulation, through the lungs and without damage ; if the pressure is rapidly lessened, the absorbed gases appear as bub- Ides within the containing liquid. In the case of the larger blood vessels, these are passed along in the circulation, but in the case of small vessels, THE CAISSON DISEASE. 1 63 and especially the terminal arteries, the minute bubbles act as emboli, occlude such vessels, and cut off the blood supply to the area of tissue supplied by them. According to Kadyi, the arteries supply- ing the lateral and posterior aspects of the cord are smaller than those of the anterior and central portions, and in the whole dorsal extent of the cord the vessels are especially small. Consequently this part becomes the site by predilection for the gas emboli, with consequent spinal symptoms and secondary degenerative changes in the cord. The liberation of the gas in minute bubbles outside of the blood vessels, or through them and the pos- sible production thereby of minute fissures in the cord, are of much less importance than the areas of necrosis, softening and reactionarv inflammation set up in the cord in the manner stated. A full discussion of the subject is given in a paper by Dr. A. Hoche, of Strasburg, in Berliner kliuische Wochenschrift, 22, 1897. The symptoms are felt in from two to thirty minutes after leaving the pressure chamber too rapidly, some time being required for the evolution of gas bubbles. Nitrogen is the chief constituent of the gas bub- bles, it not being so readily held by the blood as oxygen or CO 2. The symptoms are evidently of spinal . and cere- bral origin : vertigo, pain and noises in the ears, nausea, and even vomiting, with weakness in the 164 NON-SYSTEMIC DISEASES OF SPINAL COED. legs. Intense neuralgic pains in the muscles and joints of back and lower limbs, with anaesthesia of the surface of the legs, and often with retention of urine. Slight cases recover in a few days or a few weeks ; severe ones may die early, or after lingering for some months. Permanent damage to the cord, with secondary degeneration, is often the sequel, as shown by paraplegia, paresis of bladder, etc. The greater the pressure and the longer the time the worker remains in the working chamber, the greater is the amount of gas taken up by the blood; hence the need of gradually lessening the pressure as the workman passes out into the ordi- nary atmosphere. As soon as symptoms appear, the patient should be returned to the pressure chamber until relieved, and then slowly emerge into the open air through the graded pressure chambers. Even up to the third day this should be done, for P. Bert in his experi- ments on the effects of increased atmospheric pressure on animals, found on the fourth day after symp- toms had developed, gas emboli and blood coagula within the vessels of the spinal cord. Otherwise the treatment by internal remedies should be symptomatic. Arnica and Rhus toxico- dendron would appear to be the best suited to the early symptoms ; later, the case may be treated as one of chronic myelitis. TUMORS OF THE SPINAL CORD. 1 65 Tumors of the Spinal Cord. In the section on Compression Myelitis, tumor within the spinal canal is mentioned as a cause of the symptoms, yet the subject of tumor within the canal needs separate consideration. Tumor affecting the spinal cord is most often meningeal in origin, less frequently it arises within the cord itself, and rarely from the vertebrae. It may, therefore, be between the dura and the bony wall of the spinal canal, or enclosed within the mem- branes, or between the membrane and the cord itself, or wholly within the latter. In the first three cases the eifect of a tumor is to produce compression of the cord, often with great irritation of the nerve roots, with symptoms resulting therefrom ; in the fourth case the symptoms will be those of diffuse myelitis, at times with peculiar dis- sociation in the qualities of peripheral sensibility, as in syringomyelia (q. v.). Tumors arising from the meninges are sarcomata, myxomata, enchondromata and lipomata; those occur- ring in the cord itself are gliomata, sarcomata, gum- mata and tubercle. Tumor of the cord is generally small, but glioma and sarcoma may involve many segments of the cord. Solitary tubercle may be as large as a hazel-nut. The symptoms of tumor of the spinal cord already mentioned become peculiar in their distribution when only one lateral half of the cord is affected. The result then is Brown-Sequard's paralysis, in which 1 66 NON-SYSTEMIC DISEASES OF SPINAL CORD. there is motor paralysis and absence of the muscular sense below the site of the tumor and on the same side, while sensory paralyses, chiefly of the pain and temperature senses, are found in the corresponding* parts of the opposite side. At the level of the lesion a band of anaesthesia on the side of the lesion, and one of hypersesthesia in the corresponding part of the opposite side exists. With meningeal tumors the irritation of the nerve roots causes severe pain in the distribution of the nerves so irritated, and such pain may long precede the symptoms of compression of the cord. From irritation of the nerve roots, spasmodic con- tractures of the limbs are observed; they may be very severe. The reflexes are increased when the lateral columns are affected, except when the lesion is situated in the lumbar enlargement of the cord, and then the knee jerks are absent. Paresthesias, hypeesthesia, or anaesthesia may exist. Paralysis comes on in the course of time ; it may be of one or of all four extremities, according to the site and lateral extension of the tumor ; some atrophy may be present. Death follows from exhaustion, or sepsis, preceded by paresis of bladder and rectum and formation of bed-sores in a considerable proportion of cases. The pathological changes resulting from tumor of the cord are flattening, and decrease in its size in cross-section, with marked softening, studded with TUMQRS OF THE SPINAL CORD. 1 67 small haemorrhages. Secondary degeneration and re- active inflammation serve to complicate the symptoms of the case. The diagnosis is to be made from Pott's disease, transverse myelitis and pachymeningitis cervicalis hypertrophica. In the first, the age of the patient, the presence of tuberculous trouble elsewhere, and the marked stiffness and painfullness of the vertebral column, together with angular projection of some of the spines, are decisive. In the case of myelitis there is not the gradual increase of the symptoms, nor the succession of them found in tumor of the cord. At the same time it must be held in mind that a tumor wholly within the cord will usually not give rise to the severe neuralgic pains found when the neoplasm is outside of it. Pachymeningitis is to all intents and purposes an extra-myelonic tumor. The character of the tumor may be inferred if in any other part of the body a tumor exist; gumma may be inferred from antecedent history of syphilitic infection. Tumors arising from the membranes show but little tendency to invade the structures of the cord, and the latter exhibit a remarkable resisting power to the increasing pressure (A. Westphal). The prognosis of tumor within the spinal canal is absolutely bad, but surgical interference has occasion- ally rescued the patient from his threatening fate. In a study of 123 cases, of which 100 were described in detail, by M. Allen Starr, 22 cases were operated on, yet in only 6 were the patients relieved of the 1 68 NON-SYSTEMIC DISEASES OP SPINAL CORD. paralytic symptoms, probably because surgical inter- ference was at too late a period. Starr states that most intraspinal tumors are malignant, and that al- though this darkens the prognosis, still operation should not be refused, provided the tumor is extra- myelonic, which fact is difficult of ascertainment. He considers as evidences of intra-myelonic tumor, Brown- Sequard paralysis, early degenerative atrophy, trophic changes and bedsores, and the appearance of analgesia before anaesthesia. The medicinal treatment of intraspinal tumor can- not be on the diagnostic indications, for the tumor is simply a foreign body within the spinal canal, irritating and compressing nerve roots and cord structures. The symptoms thus produced are not those of the disease itself. Hence, if prescribing our remedies is to be of service they must be chosen according to the symptoms of the patient's person- ality, the aggravations, ameliorations, etc. If the diag- nosis of tubercle or of syphiloma can be fairly as- sumed, the isopathic method may be of value, and in the latter instance the use of the remedies sug- gested in the section on syphilis of the spinal cord is recommended. Syringomyelia. Proliferation of glia cells and fibres in the central gray of the cord results in the formation of a tumor, a glioma. Increasing growth compresses the blood supply at its periphery and the centre breaks down, SYRINGOMYELIA . 1 69 forming a cavity more or less tubular, and to this condition the term syringomyelia is applied. As the central gray is invaded and in part destroyed the symptoms are peculiar. The cause of the trouble is primarily an inborn defect or morbidity of the affected region itself, but often some exciting cause (trauma) is needed to start the process into activity. The symptoms of the disease manifest themselves most often in late youth or early middle life. In one or both hands a slowly progressive muscular atrophy appears, perhaps preceded by some pain, vague in character. The atrophy is similar to that observed in progressive muscular atrophy of spinal type and, like it, it may first appear in the muscles above the elbow or around the shoulder. Fibrillary contractions may be noticed in the atrophying muscles, whose electrical contractility is lessened or changed at times to the reaction of degeneration. The grouping of the muscles affected depends upon the direction in which the gliosis advances in the cord. Most frequently it involves the cervical enlargement, often implicates the dorsal segments, rarely the lumbar portion. The special and characteristic clinical feature of the disease is the peculiar anaesthesia for certain qualities of sensation. In the affected member and over a larger area than that of the atrophy, there is loss, often complete, of sensation for pain and for temperature, so that a needle prick or the faradic current is not appreciated as such, and hot or cold I 70 NON-SYSTEMIC DISEASES OF SPINAL CORD. bodies when applied to the anaesthetic region cannot be differentiated from simple touch, tactile sensation being retained. The muscular sense is not impaired. Paresthesias, a feeling of cold or of heat or a mix- ture of the two, are present # in most cases, but sub- jective pain is rare. Trophic and vaso-inotor disturbances are frequent. Blebs and bullae may form upon the skin of the affected parts and, bursting, leave ulcers often difficult to heal. Eruptions, eczematous or herpetic, are not infrequent, while bluish-redness or oedema of hands or arms has been observed. Panaritia with anaesthesia and analgesia (Morvan's disease) has been so often associated with syringomyelia that it is held by many to be a manifestation of the disease ; others, however, maintain that it is due to associated neuritis. Scoli- osis and kypho-scoliosis may appear in the course of the affection. From pressure on the lateral pyramidal tracts there may follow at a somewhat advanced period spastic paraparesis. The gliosis may predominate in one-half of the cord, when the symptoms will be practically unilateral ; it may extend in more than one direction or have more than one cavity; it may extend upward, involv- ing the medulla, and so give rise to bulbar symptoms; if it extend low down in the cord, the legs will be affected in the same way as the arms. Inequality of pupils is not rare, and concentric narrowing of the visual fields often exists. (Gold- scheider.) SYRINGOMYELIA. I/I Diagnosis. In a typical case the peculiar sensory disturbance with the associated atrophy will be suf- ficient for the diagnosis. But not all cases are typical and when the sensory symptoms are absent it will be impossible to decide between this disease and pro- gressive muscular atrophy of spinal type or amyo- trophic lateral sclerosis. Hydromyelia. By this term is meant a congenital condition analogous to and at times associated with hydrocephalus, in which the central canal is widened tor a greater or less extent, usually more posteriorly than anteriorly, and at times irregularly. Unless path- ological changes occur in its walls and adjoining tissues, it has no clinical importance. The treatment of syringomyelia can only be symp- tomatic and then not guided so much by the diagnostic symptoms as by those that characterize the patient, such as his aggravations and ameliorations or peculiar symptoms not part of the special trouble. It is interesting to note a report of two case- having all the symptoms of syringomyelia which appeared alter ''running" a chip or shaving of zinc into a finger and a thumb, respectively, reported by Dr. Joseph Mies of Cologne (Munch, med. Woeh- enschrift, 19, 1896). The men were both healthy at the time of the injury, one aged 40, the other 33. The symptoms were gradual in development ; in one case the diagnosis of progressive (spinal) muscular atrophy was made after some four years, the temper- ature and the pain sense not being then affected. 172 NON-SYSTEMIC DISEASES OF SPINAL COED. After eight or nine years the temperature and pain senses were found affected. The other case was more rapid in its progress, but the results were the same. The reporter considered the symptoms to be the re- sult of slow poisoning by zinc, and compares the cases to those reported by Schlockow as cases of peculiar spinal cord affections in workers in zinc. Eulenburg, in commenting on Mies' cases, rejects the theory of chronic poisoning by zinc, and con- siders an ascending neuritis to be the middle link between the peripheral injury and the consecutive spinal cord affection. (Deutsche med. Wochenschrift, 29, 1896.) He further considered that Schlockow's cases of various troubles, due to inhaling the vapors of zinc, were chargeable to impurities present, es- pecially arsenic, cadmium and lead. It may be worth noting that in both of Mies' cases the splinter or shaving of zinc had been touched with ordinary hydrochloric acid, which may have made in the wound zinc chloride, a soluble poisonous compound. Treatment. Since the affection is an invasion of the cord by the proliferation of glia cells, the symp- toms will vary according to the parts of the cord affected either destructively or by pressure. To pre- scribe on such indications cannot be expected to in- fluence the advance of the real disease. Hence, the diagnostic symptoms should not be taken into ac- count in searching for a remedy, but reliance placed on the symptoms of the patient that are constitu- SPINAL IRRITATION. 1 73 tional, the times and conditions of aggravation, ameli- oration, etc. The possibility of special influence of the metals mentioned in causing organic change within the cord should be held in mind in prescribing for the disease. The manifestation termed Morvan's disease, whatever be its cause, would lead us to use remedies known to be of especial service in panaritia, such as Dioscorea vittosa, Natrum sulphur icum, Silicea, Sulphur , Hepar sulphuris calc, etc., but analgesic panaritium is a special manifestation not as yet noted in the provings. Spinal Irritation. Under this name a set of symptoms referable to the posterior or sensory spinal nerve roots, is fre- quently found in hysteria, neurasthenia, or may exist alone. The symptoms are pain in the back with tender- ness to pressure or at times even to touch and often with a subjective sensation of burning. The patients complain of tiredness on exertion and the exertion is apt to increase the painful sensations in the spine. Painful pressure points may be found at the sides of the vertebrae, about the lower cervical and upper dorsal and in the lower dorsal and upper lumbar regions. Pressure may result in simple increase of the already existing pain, in the production of an added sensation of soreness in situ, or in causing pain or other annoying sensation in the limbs or other distant parts. 1 74 NON-SYSTEMIC DISEASES OF SPINAL CORD. When the seat of the trouble is in the lower cer- vical or upper dorsal region, the use of the arms, as in holding a book, in sewing, or in doing up the hair (in women) aggravates the condition. In one case the midcervical region seemed most affected, and then the pressure of the coat collar was intolerable. If the dorsal region is affected, the patient may be unable to sit with the back resting against the back of a chair. Symptoms of neurasthenia or hysteria are often pres- ent, and are given under those heads. The affection appears in adolescence and in early adult life, and, as it is often slow in onset, adequate cause may not be discoverable ; the general terms overwork, worry, overstudy, etc., may mean much or little in this connection. The writer has seen the affection in a number of cases follow an attack of grippe. As cases have been cured by relieving uncor- rected errors of refraction or other ocular troubles, intrapelvic disorders, etc., it has been assumed that such conditions are etiological factors in producing the affection. Sexual over-indulgence, whether in a normal or abnormal manner, is a causal factor in many cases. The lowered vascular tonus, as evidenced by relaxed blood-vessels of face and hands in many cases, is prob- ably existing within and will account for the spinal .symptoms ; engorgement, especially of the veins with- in the spinal canal, results in pressure and irritation of the nerve roots, particularly of the posterior or sensory ones ; and most of the associated symptoms, SPINAL IRRITATION. I 75 such as weak digestive power, constipation or diar- rhoea, palpitations, etc., may be thus accounted for, either directly or indirectly. The knee jerks are generally exaggerated. The diagnosis is to be made between this affection and an organic disease, such as compression myelitis, spinal meningitis or meningo-myelitis. In organic af- fections there is motor weakness, often with rigidity, the weakness may amount to paresis or paralysis, or the pains radiate from the spine instead of being limited to it. The history, the continuance of the symptoms for long periods without much change, the absence of paralysis of bladder or rectum, are in favor of spinal irritation. The prognosis for cure is good. Treatment should be both medicinal and hygienic ; it will be given in the section on neurasthenia. The Cranial Nerves. During the last few years the effort has been made (and with a large measure of success) to ap- ply the rule of uniformity to the origin of both the cranial and the spinal nerves. The latter, as has been stated in the section on the spinal cord, arise in two ways : the motor nerve fibres from large ganglion cells in the anterior gray horns, the sen- sory fibres from the posterior spinal ganglia, whose cells give off fibres that at a short distance divide, one part going to the periphery and ending there in free division or in a specially developed end organ, the other part passing into the region of the posterior gray horn of the cord. Of the cranial nerves, those having motor function arise from large cells aggregated in masses within the brain structure, such masses being analogues of the cell-groups in the anterior gray horns of the cord. Similarly, some of the cranial nerves subserving sen- sation, notably the auditory, and part of the fifth, arise from ganglion cells outside the brain structures proper. In the case of the olfactory and visual functions the analogy is not so close. On the base of the brain is seen anteriorly on each side, lying in a groove or sulcus at the bottom of the frontal lobe, the so-called olfactory nerve, whose anterior end is somewhat enlarged into the olfactory THE CRANIAL NERVES. 1 77 bulb, which is the residue of an enormous develop- ment of brain structure in animals endowed with the olfactory sense in a high degree. The olfactory bulb contains specialized globular structures known as glomeruli, granular cells and star cells and giant ganglion or "mitral" cells. Buried in the mucous membrane of the upper and inner nasal cavities, besides the epithelial cells proper, are specialized olfactory cells from which there pass backwards fibres through the cribriform plate which then almost immediately end in a brush work that half surrounds a glomerulus in each case on entering the olfactory bulb. The opposite half of the glomerulus is enclosed by the brushy endings of the dendrites of a mitral cell. It would therefore appear that the peripheral neu- rones of the fila olfactoria form the real olfactory nerve and that the fibres going brainwards from the mitral cells (secondary neurones) form an intermediate tract which at the anterior perforated space divides into three so-called roots. The outermost is the largest and its fibres end in the cortex of the hippocampus; the middle division is poorly developed in man; the fibres of the internal division pass through the anterior commissure to the cortical area of the other side. Loss of the power of smell is most frequently due to disease of the mucous membrane affecting the in- cluded olfactory cells and nerve fibres, to nasal poly- pus, to dryness of the nasal mucous membrane due to trophic changes following paralysis of the fifth nerve, 178 THE CRANIAL NEEVES. or to obstruction in the lachrymal canaliculi. Falls and blows upon the head may cause laceration and separation of the filaments of the nerve proper from their connection with the cells of the olfactory bulb. Disease in the anterior fossa, such as tumor, menin- gitis, bone affection, may cause compression of the olfactory bulb and tract. Excessive olfactory stimula- tion has caused loss of the faculty (Growers) and senile atrophy of the bulbs has occurred in old age. With the loss of the sense of smell, the sense of taste is usually lost for "flavors," the latter being appreciated via the posterior nares. Loss of the former with retention of the latter is due to disease of the mucous membrane in the upper part of the nasal passages. Anosmia, due to cortical disease or to disease back of the internal capsule, cannot be diagnosticated by the olfactory symptoms alone. The combination of aphasia and right-sided hemiplegia with left-sided anosmia has been observed several times ; it is prob- ably due to implication of the external olfactory root, near the island of Eeil. Functional anosmia is seen at times in hysteria and neurasthenia ; in the former it may be part of the hysterical anaesthesia. Congenital absence of the olfactory tracts and bulbs has been met with. Hyperosmia or increased sensitiveness of the olfac- tory nerves is seen at times in the hysterical and the insane. THE CRANIAL NERVES. 1 79 Hallucinations of smell occur at times in the in- sane, and occasionally as the aura preceding an epi- leptic spasm. Parosmia, or perversion of the sense of smell, is a rare condition, in which every impression made upon the olfactory nerve is translated, so to say, as a disagreeable odor, always the same. The con- dition is probably cortical. Treatment must be influenced by the diagnosis of the underlying condition, and hence examination of the nasal passages, as well as a knowledge of the history, is imperative. If local conditions, past or present, place the affection in the category of purely nervous trouble, the matter of treatment becomes that of the cause. In the absence of such condition other symptoms must be relied on for making a diagnosis of causes within the cranium ; if neither these nor intra-nasal disease be present, the treat- ment must be purely symptomatic. The prognosis in the nervous forms, whether of the bull), tract or cortex, is not encoura^ino:. The optic nerve is similar in its beginning to the olfactory. The rods and cones of the retina are the specialized sensory end organs of vision. The former terminate in prolongations, with knobbed ends, the latter divide each, and then give off short branchings. So-called horizontal cells connect func- tionally the endings of the neighboring groups of rods, while another set of cells carry impulses from 180 THE CRANIAL NERVES. rods and cones to large ganglion cells, from which arise the long nerve fibres that pass brainward. If we push our analogy, we may say that the rods and cones, with their endings, form the real optic nerve. All the fibres of what has hitherto been under- stood as the optic nerve are not centripetal in their course. There are centrifugal ones, probably from cells of the anterior corpora quadrigemina. The optic nerve, as we must continue to desig- nate the long nerve fibres, passes backward and toward the middle line, where a partial decussation with the nerve of the other side takes place, and in such manner that the fibres from the inner halves of the two retinas cross, those from the outer half of each retina continuing on their own side. Behind the crossing, or chiasm, the mass of fibres is termed the optic tract. It winds around the cms of its own side and passes upward, giving most of its fibres to the external geniculate body, a few only to the anterior corpus quadrigeminum of the same side. From cells of the external geniculate body new fibres arise, which pass backward as the optic radiations of Gratiolet, and end in the cortex of the cuneus and its continuation on the posterior aspect of the first occipital convolution. In the cortex of the occipital lobe both retinas are represented, the light-impulses from the outer half of the retina of its own side, and those from the inner half of the opposite retina being brought together. Fig. 22, from Bechterew, gives a diagram- HE CBAXIAL XEBVES. 181 matic representation of the course of the fibres, and explains also the production of hemianopsia by a le- sion affecting the fibres anywhere behind the chiasm. Fig. 22. From Bechterew. The course of the light-im- pulses from their starting point in the retina to their arrival in the cortex (cuneus) is shown. The fibres, from the inner half of each retina, are seen to cross at the chiasm ell ; the optic tract ends in the exter- nal geniculate body iiyc, and the anterior corpus quadrige- minum of the same side, qa ; some fibres may end in the posterior mass of the optic thalamus, p, tit. New fibres arising from these structures form the optic radiations t)'V, and end in the cuneus C- The commisure of Meynert,CJ/,and that of Gudden, eg, have no- thing to do with carrying light impulses, but connect the large basal ganglia of the two hemi- spheres, probably. The retina is designated by the part marked /'. The pupil is not represented, but it is readily understood that rays of light from the right must im- pinge on the left half of the retina. A lesion at no is seen to affect all the fibres from the retina of the left eye ; hence no light impulses can pass back, and that eye is totally blind. A lesion in the optic tract, at tro or at I, is seen to affect only the fibres coming from the left half of each re- tina. Hence each eye is half- blind and in the same-named half of each retina. This hemi- anopsia takes its qualifying word not from the half of each retina, but from the absent half of the visual field. In the case assumed the lesion is in the left optic tiact or in the left optic radiations, and there must exist loss of vision in the Tight half of the field — that is, a right hemianopsia. A lesion at ch will affect the decussating fibres only, and there will result a bitemporal hemi- anopsia ; while to produce a bi-nasal hemianopsia there must be two lesions one on each side of the chiasm. The optic nerve is the only nerve that is access- ible to inspection ; here, by the aid of the ophthalmo- scope, the retinal expansion of the nerve can be studied in health and disease, and alteration of func- tion or structure is, speaking generally, as much the subject of neurology as of ophthalmology. Strictly speaking, diseases of the retina itself, such as retin- itis albuminurica, retinitis pigmentosa, or choroido- 182 THE CRANIAL NERVES. retinitis syphilitica belong to the latter department of medicine, yet they must be recognizable by the student of the former. On the other hand, the atrophies seen in the disk, whether primary (in association with degenerative disease of the spinal cord or brain), secondary (re- sulting from injury to the nerve at or in front of the chiasm) or consecutive (to optic neuritis), are of the highest interest to the student of nervous diseases. Testing the visual acuteness, the color sense and the visual field is often a necessary part of the ex- amination in nervous disease, since the results thus obtained may be decisively diagnostic or of high cor- roborative value. Fig. -i-6. Fig. 23 From Baas. Outlines of the visual field of the right eye, lessening of whose outline is abnormal (Forster's minimal visual field). The fields for colors are indicated by the different methods of outlining, the key to which is at the lower right of the figure. The lines gathering together in the centre indicate the coming to- gether of fibres from different parts of the retina and meeting to form the optic nerve at the disk, beneath which they assume their medullary sheaths. The pupillary reflex must be tested both directly and consensually. In the former, if no light-impulses THE CRANIAL NERVES. 1 83 are sent back to the primary optic centre, no reflex contraction of the pupil can occur, but if light enter- ing the other eye affects the pupil of the first one, we know that the third nerve of the first is not at fault and that the trouble is loss of conduction in the optic nerve of that eye. So in hemianopsia we may obtain valuable information by the hemiopic pupillary test as to the site of the le- sion. If by means of a plane mirror light be thrown on the half of the retina now rendered useless by the lesion, when the lesion is not further back than the corpora quadrigemina, the pupil will not respond; if the lesion is in the occipital cortex, or in the optic radiations between the cortex and the corpora quad- rigemina (and external geniculate body, optic thal- amus), the pupil will respond. The test is, however, difficult ot application, but, theoretically, its value is great. Loss or lessening of visual power often bears no relation to the evident change in the disk or head of the nerve. In papillitis, or so-called choked disk, the swelling may be very great, yet loss of vision be slight, and vice versa {vide section on brain tumor). On the other hand, loss of visual power may be due to error of refraction, and disappear as soon as the error is corrected by proper lenses. Hence the stu- dent of this branch of medicine should possess and be able to use a case of trial lenses. Mapping the field of vision often tells a great deal. Central scotoma means loss of conduction of the 1 84 THE CRANIAL NERVES. fibres occupying the middle of the nerve trunk be- hind the orbit ; loss in the periphery of the field Fig. 24. Fig. 24. From Baas. The visual fields of a case of left homonymous hemianopsia. The dividing line between the seeing and non-seeing halves, is seen to be perpendicular, but without curving around the centre or fixation point, as it usually does. In this instance, however, the field for green is seen to extend beyond the centre. may mean an affection of the fibres at the outside of the nerve trunk, or simply a lessening of con- duction in all the fibres, normal vision being less acute at the periphery of the field. Changes in the color sense are to be expected THE CRANIAL NERVES. I8 5 in optic nerve atrophy, and often precede ophthal- moscopic evidences, or even material contraction of the field for white. Congenital absence of the color sense (by no means a rare occurrence) will render nugatory the tests with candle and colored glass in diplopia. ; in such cases the test must be by the use of prisms. For details in the method of examination in the foregoing the student is referred to works on oph- thalmology. Optic neuritis or papillitis is an inflammation of the head of the optic nerve or disk. It is char- acterized by swelling, oedematous and inflammatory, lessened transparency of the tissues, with extension of the swelling to some distance beyond the limits of the disk. The edge of the disk loses its sharp- ness, becomes softened or " woolly" in outline, and V Fig. 25. Ophthalmoscopic appearance of choked disk. From Gowers. 1 86 THE CRANIAL NERVES. over the steep edge the vessels can be seen to de- scend. The veins are swollen and tortuous, the ar- teries narrow, and both disappear in places, being covered by the swelling. The general tint of the swollen papilla is reddish and striated. The term " choked disk" is given to the condition, but the term is misleading as implying a definite mode of origin, which, indeed, is now admitted to be not due to constriction or to pressure of fluid within the sheath of the nerve. Neuro-retinitis (descendens) is believed to origi- nate in the nerve or centres behind, but its ophthal- moscopic appearances differ from those of papillitis in being without any considerable swelling of the disk, and the uniform redness of the disk passing un- changed into that of the retina. Papillitis has swell- ing of at least § mm. equalling 2 dioptres of re- fraction. The most frequent cause of papillitis is brain tumor ; it also occurs with meningitis, abscess of the brain, sinus thrombosis, and occasionally in hydro- cephalus internus, after acute infections diseases, and rarely during amenorrhcea and anaemia. The trouble is generally bilateral, but occasion- ally it is unilateral even when of central origin; unilateral optic neuritis is most frequently due to dis- ease of the nerve at the back of the orbit, or at the optic foramen. Prognosis of papillitis is largely a matter of diag- nosis of its cause. When due to anaemia or amenor- THE CRANIAL NERVES. I 87 rhoea, the chances of cure are fair, especially as in these cases it advances rapidly and is apparently not accompanied by the destructive changes in the nerve which occur in the slowly advancing degeneration set up by brain disease. In any case, remedies must be addressed to the whole condition. Papillitis, if unchecked, advances to consecutive atrophy of the nerve. This consecutive atrophy does not differ in appearance from that known as secondary atrophy, due to compression of the nerve behind the bulbus. In both cases the disks are usually of the brilliant whiteness of tendon ; with the former, how- ever, there may be white spots outside the disk in the region of the macula. Primary atrophy of the optic nerve is seen in asso- ciation with central degenerative disease of the nervous system, such as locomotor ataxia or dementia paralytica. Here the disk is generally of a bluish-gray or at times of a light muddy tinge. The atrophy accompanying multiple sclerosis is most marked in the temporal halves of the disks and is generally white. Toxic influences, such as alcohol, tobacco, lead, bi- sulphide of carbon, mercury and (recently reported) Filix mas have caused atrophy of the nerve, in some instances preceded by papillitis. Such cases be- long to the ophthalmologist, but are mentioned here as offering suggestions in the selection of remedies. The writer has used Carboneum sulphuratum 6, and fluid extract of Filix mas in 6th dilution in the nope ot arresting the primary atrophy seen in lo- I 88 THE CRANIAL NERVES. comotor ataxia and dementia paralytica, but without result. Functional amblyopia occurs in hysteria and in at- tacks of migraine, with concussion of the brain and after profuse haemorrhage. Temporary hemianopsia may be present in migraine. Irritable retina is found in neurasthenia, hysteria, from excessive use of tobacco ; it may follow exposure to very bright light or the reverse. The use of smoked glasses to protect the eyes is unadvisable under ordinary circumstances, the retinal hyperes- thesia being thereby increased. The treatment of functional amaurosis or amblyopia must be largely that of the underlying neurasthenic or hysterical condition, or according to the cause, if any can be found. At the New York Ophthalmic Hospital the reme- dies most used for neuro-retinitis are Belladonna, Kalmia, Macrotin, Nux vomica. Phosphorus, Plumbum metallicum and Pulsatilla — all in low dilution, gene- rally 3x. Duboisia, Mercurius corrosivus and Veratrum album have been used less often. Pulsatilla has been found to be especially valuable in choked disk. In Dr. Rounds' Clinic at the above named institution a case of optic nerve atrophy from abuse of tobacco and alcohol, without perception of light, has been so far improved under the action of Agaricus — 15 drops of the tincture three times a day — in 18 months that he is now able to walk the streets alone. A nephew and a son of this patient had the THE CRANIAL NERVES. 1 89 same trouble, but refusing or being unable to stop using alcohol and tobacco have not improved. In all three cases the disk was brilliantly white. The third nerve. This nerve, unfortunately termed oculo-motorius, arises from groups of cells placed be- neath the floor and somewhat to the side of the aqueduct of Sylvius. The fibres pass downward and coming together emerge from the inner face of the crus in front of the pons. From the occurrence of isolated palsies of eyeball muscles, experiments on animals and post-mortem examination (microscopical), it is held that each eye- ball muscle is innervated by fibres from a definite group of cells. The arrangement of the groups as given by M. Allen Starr is the following : Sphincter iridis Ciliary muscle g Levator palpebral Internal rectus "^ Superior rectus Inferior rectus ^ Inferior oblique g In the middle line beneath the aqueduct is a cen- tral group of cells, while from the so-called posterior nucleus fibres are given off that pass into the nerve of the opposite side. This decussation is believed to concern the internal recti, whose action in convergence is distinct from the isolated action of one internal rectus. The fourth nerve arises from a group of cells pos- terior to the third nerve nucleus. The fibres pass backward and upward to emerge as a nerve trunk behind the posterior quadrigemina and cross over the 190 THE CRANIAL NERVES. middle line to wind around the opposite cms and appear at the base. The sixth nerve which, for convenience sake, had better be considered here, arises from the cells of its nucleus situated beneath the floor of the fourth ventricle. The fibres pass downward and emerge next to the middle line and behind the posterior border of the pons. The muscles supplied by the third nerve are already given in the table. The fourth nerve supplies the superior oblique, the sixth the external rectus. The actions of the eyeball muscles are indicated in most of them by their names ; the internal rectus turns the eyeball inward or toward the nose, the external rectus turns it outward or towards the tem- ple, the superior rectus turns it upward; the inferior rectus turns it downward; the oblique muscles act similarly to their opposite named recti — thus the superior oblique turns the eyeball downward, the in- ferior oblique turns it upward, while both obliques turn it somewhat outward, and both superior and inferior recti turn it somewhat inward. In turning both eyes to the right or to the left there must be an associated action of the internal rectus of one eye with the external rectus of the other. Cases occur in which with a paresis of the external rectus of one side the internal rectus of the other side is inactive in binocular vision, but if the first be covered the internal rectus of the second acts perfectly. From this it is inferred that the sixth Q^ % t " ♦ * -%. ♦ ♦ ♦ ♦ | ♦' •^ _J&- — ♦ ♦ ♦ ♦ Nervus oculomotoruLS ♦ 1 ♦ ♦ ♦«; ♦* Muse oblu/wis infei wr V^ ♦'♦ * 4 ♦ 4 ♦ sAbducens. / "V / # # ♦♦1 ♦ MuscAreetus superior y ^^ tfntcrmis. ^_ ♦ • ^ ^ W + * / ^% -> ♦ 4 ♦# Muse troc7deeiris . • 4 4 * 4 -/ / / ^J/zZ.?C^ rectus inferior. ♦ ♦ * V V" * ♦ * ♦ t Nervus oculomotor -ius . g 40 I •* Fig. 26. Fig. 26. From Roth. In the illustration of diplopias resulting from paralysis ot different muscles of one eye, each large square represents the binocular visual held, subdividedas tollows : UPPER OUTER UPPER UPPER INNER OUTER DIRECTLY IN FRONT INNER LOWER OUTER LOWER LOWER INNER The reader sees the double images in the drawing as if his own left eye were affected. To make the drawing represent paralysis of a muscle of the right eye he must represent himself as being in front of the patient and mentally view the double images from that position. The perpendicular meridian of the cornea is indicated by a thick black line. The arrows indicate the direction of action of the different muscles, their insertions at the cornea showing also the rotatory action of the muscles. The arrows marked OCUlomotoriUS point to the resulta influence of the action of all the muscles supplied by the third nerve. The components are separated by the pinterolated drawing showing the diplopia from isolated paralysis cf the internal rectus. The figures in black represent the true images, those with cross-lines the so-called false images of the affected eye. The dotted lines within the larger squares are lines of separation between single vision with both eyes and double vision. To compare the statements of a patient (looking at a lighted candle with both eyes, a red glass being held before one), the examiner should be behind the patient if the left eye is affected, but in front of him if the right eye. On mapping out the double images as stated by the patient these double images will agree in either case with those as given by Roth. 192 THE CRANIAL NERVES. nerve nucleus is connected with the sub-nucleus of the third for the internal rectus of the other side. The sixth nerve nucleus thus acts as the centre for the conjoined action of both eyes in lateral movements of the eyes, and the connection be- tween the two nuclei is held to be via the pos- terior longitudinal bundle or fasciculus, a bundle of nerve fibres passing down from the region of the third nerve nucleus to the lower part of the medulla. Conjugate deviation of the eyes to one side is a symptom of high value if correctly interpreted. It may be due to a cortical or sub-cortical lesion, or to a pontine one ; in either case it may be para- lytic or irritative. A paralyzing lesion in the cere- brum may cause besides hemiplegia paralysis of the opposite sixth nerve with associated inaction of the internal rectus on the side of lesion. Hence there then will be conjugate deviation of the eyes to the side of the lesion. If the lesion be an irritative one the opposite sixth nerve nucleus overacts, and with it the internal rectus of the side of the lesion. There is then conjugate deviation from the side of the le- sion. "The patient looks towards the convulsed mem- bers if there is irritation ; he looks towards the le- sion if it is a paralyzing one." (Landouzy, Grasset.) The rule is reversed in the case of a pons lesion causing conjugate deviation of the eyes. The Pupil. The pupil is the circular aperture in the iris. The iris is a muscular curtain separating the anterior from the posterior eye-chamber. It is com- PUPIL. 193 posed of circular fibres termed collectively the sphincter pupillse, which are innervated by a branch of the third nerve, and radiating fibres forming the dilator pupillse under control of the sympathetic. The two sets of fibres are antagonistic and their combined action is to regulate the size of the pupil and hence to regulate the amount of light entering the eye. When an increase of light falls upon the retina, besides the sensation transmitted to the occipital cortex an impulse is also sent through the optic nerve to the anterior pair of the corpora quadrigemina, each corpus receiving such impulse from both eyes. From the cells of the anterior corpus a new impulse is sent to the anterior part of the third nerve nucleus below, from which in turn a motor impulse is sent to the sphincter pupillae, with consequent contraction of the circular fibres, and hence diminution of the size of the pupil. Lessening of the amount of light entering the eye acts negatively by lessening the demand on the third nerve nuclei, and then the tonus of the dilator fibres antago- nizes the now passive sphincter, and the pupil dilates. The fibres or connections between the anterior corpora bigemina and the third nerve nuclei have not as yet been anatomically demonstrated. Since both an- terior corpora receive the light-impulses for pupillary action from each eye, it can readily be understood why both pupils must normally be of the same size, even if light be admitted to one eye only. When the visual axes are made to converge, as in 194 THE CRANIAL NERVES. accommodating for near objects, the pupil contracts in associated action ; when accommodation is relaxed the visual axes become more nearly parallel and the asso- ciated action of the sphincter pupillse ceases, and the pupil dilates. Hence in testing pupillary activity under the stimulus of light, the subject must be made to look at a distant object, 10 feet away, if possible. From the foregoing it is plain that alteration in the actions of the pupil, apart from adhesions of the iris, etc., must be due either to an affection of the third nerve or its nucleus or its cortical area, or a le- sion involving the connection between the anterior corpus and the third nerve nucleus, or else to the sympathetic. Irritation of the sympathetic fibres for the iris causes dilatation of the pupil ; paralysis of these fibres causes contraction through the now unopposed action of the sphincter. Test for the unimpaired action of the sym- pathetic supply to the iris is made by stroking sharply or pricking or faradizing the skin at the side of the neck ; dilatation of the pupil of the same side then occurs if the sympathetic supply is unaffected. The reflex is known as the pupillary skin reflex. In facial neuralgia, in migraine, in some forms of headache, with chronic disorders of the teeth, etc., the pupil of the affected side may be altered as to size. Even affections in distant parts (mediastinal tumor) may so affect the sympathetic nerves as to alter the size of the pupil of the same side. When the radiating fibres are contracted (irritation of the sympathetic) to a high degree, the pupil is PUPIL. I95 dilated, but some contraction is possible under the in- fluence of light and in accommodation. When the radiating fibres are paralyzed (paralysis of the sympathetic) the pupil is moderately contracted, but can contract still further under the influence of light and accommodation. When the sphincter is paralyzed (third nerve) the pupil is dilated, but contraction under the influence of light and accommodation does not occur. The skin reflex is, of course, not affected, and the action of atropine, which besides paralyzing the sphincter also irritates the radiating fibres, increases the dilata- tion ad maximum. Duboisine, hyoscyamhie and many other mydriatics act in the same way. Spasm of the sphincter causes marked narrowing of the pupil, which is immobile under the influence of light and accommodation or even the skin reflex, the sphincter fibres being more powerful than the dilator ones. E serine increases in such cases the myosis by irritating the sphincter and paralyzing the radiating fibres. Pilocarpine, muscarine and nicotine act simi- larly. When only one set of fibres is paralyzed, the un- opposed action of the other set results in its contrac- tion, which increases by continuance, so that in course of time the dilatation from third nerve paralysis, for instance, becomes greater than at first. Paralysis of both sphincter and dilator fibres causes moderate dilatation, with immobility of the pupil (ca- daveric position). I96 THE CRANIAL NERVES. The reaction of the pupil under the influence of light upon the retina may be lost, while the asso- ciated action in accommodation and convergence is retained. This is known as the Argyll- Robert son pupil, and is found in disease affecting the central gray below the aqueduct of Sylvius, the sub-nucleu& for accommodation and convergence escaping. The condition is often present in locomotor ataxia. Spinal myosis is the term given to loss of the sympathetic influence in the same disease ; when present, the pupil is contracted often to the size of a pin-head, and may or may not have the character of the Argyll-Robertson pupil. It must be remembered that in elderly persons the pupil becomes small, and its reactions slow or nearly disappear; the skin reflex shows the loss first. Dilated pupils in the old are pathological, whether from local ocular trouble or from nervous disease. On the other hand, contracted pupils in persons under fifty must be interpreted in a similar way. The Ophthalmoplegias. The word ophthalmoplegia is used to indicate paralysis of the eye muscles. When only the external muscles of the eye are affected it is called ophthalmoplegia externa, when only the muscles within the eye are involved it is o. interna ; o. partialis and o. totalis indicate respectively paralysis of some of the muscles and of all. The source of paralysis of an eye muscle may be a lesion of the related nerve within the orbit or in OPHTHALMOPLEGIAS. 1 97 its course after emerging from the brain, or between the latter point and its nuclear origin, or finally in the nucleus itself. In any case the affection may be acute or chronic. When a muscle whose function is to turn the eye- ball is paralyzed, the eyeball can no longer be directed as formerly by the normal activity of the muscle, and the eye lags behind its fellow when the attempt is made to view an object lying in such direction. As a result the rays of light from the object do not fall upon the yellow spot of the affected eye, as in the normal eye, and two images are seen, because for the production of one image in binocular vision the visual axes must be so directed that rays from the object fall upon the same parts of the two retinas. If, for instance, the affected eye be unable to turn outward, then in any effort to look in that direction the eyes are crossed, but the image seen by the affected eye is apparently still further in the direction in which the vision has been directed. For, as the rays of light cross in entering the eye it is plain that objects situated higher than the pupil must affect the lower segments of the retina. The brain has learned by experience to associate impulses received by the lower portion of the retina with objects situ- ated above the eye ; similarly, impulses received from the upper portions of the retina are recognized as being made by rays from objects below the pupil, those from the left half of the retina and those from the right half representing objects in the opposite lialf of the visual field in each case. I98 THE CRANIAL NERVES. The importance of correctly determining the position of the image seen by the affected eye both absolutely and in relation to that seen by the unaffected one, is so great in the examination of certain forms of nervous disease that study of the figure reproduced from A. Roth is urged upon the reader. When only one of the ocular motor nerves is para- lyzed, the inability of the affected eye to follow the examiner's finger to the normal limit in some one direction will permit of a ready diagnosis. When two nerves are affected the same method will apply ; when all three nerves are paralyzed the im- mobility of the eyeball will make the fact plain; a paretic state of the muscle or muscles may not show when tested as above directed, but yet may give double images under the test with candle and colored glass. The causes of ocular palsies are chiefly rheumatic influences (cold) and syphilis directly affecting the nerve or indirectly causing pressure from gummy meningitis at the base. Diphtheria not infrequently is followed by paralysis of one or more eye muscles, usually the iris and ciliary muscle, more rarely the internal recti as well. In locomotor ataxia, abnormal- ities in the action of the muscles of the eye are quite frequently seen ; in the early stages these paralyses are usually temporary. Complete paralysis of the third nerve results in loss of power in the internal, superior and inferior recti, inferior oblique, the ciliary muscle, the circular fibres OPHTHALMOPLEGIAS. 1 99 of the iris and the levator palpebral When the fallen upper lid is raised, it is seen that the eyeball cannot move except outwardly and also downward and out- ward. The pupil is dilated but not ad maximum; it does not react reflexly to light nor in the effort at accommodation, the latter faculty being of course absent. The eyes are divergent, but the diplopia is crossed. Only a part of the third nerve supply may be affected; hence at times a single muscle only is paralyzed. A slight ptosis may be caused by paralysis of the sym- pathetic, the fibres of Mtiller's muscle thereby be- coming paralyzed; at the same time the dilator fibres of the iris being paralyzed, the unopposed action of the sphincter causes contracted pupil. Hysterical ptosis occurs, usually with associated spasm of the orbicularis ; and a functional ptosis noticed on waking in the morning is sometimes ob- served, which soon passes off. Paralysis of the fourth nerve is not often seen. The resulting diplopia is in the lower and outer half of the field and is especially annoying in walking, de- scending stairs or when at work. Downward move- ment of the eye can be made, but then the eye turns somewhat inwards so that the visual axes cross and the diplopia is therefore homonymous. Paralysis of the sixth nerve occurs next in frequency to that of the third. The visual axes are crossed and the diplopia is homonymous. Nuclear Ophthalmoplegia. Under the title polio- encephalitis superior acuta (in contrast to p. inferior, 200 THE CRANIAL NERVES. one of the bulbar affections) Wernicke has described a disease, acute in onset and rapid in course. Be- ginning with headache, vertigo and vomiting, delirium or it may be somnolence, occurs, and at this time paralysis of the muscles of the eye appears; in some instances almost total ophthalmoplegia was finally mani- fest, the sphincter iridis and levator palpebrae being unaffected. Neuritis optica occurred in some cases and ataxic gait, similar to that of cerebellar disease, was noted. No increase of temperature was recorded, but the pulse was usually rapid. Most of the cases have ended fatally within a week or two. Post-mortem examination revealed an acute hsemor- rhagic encephalitis of the central gray at the floor of the third ventricle and beneath the aqueduct of Sylvius. The cause assigned in the early cases is chronic alcoholism ; later, cases have occurred after infectious diseases, especially influenza, from poisoning by spoiled sausage, by carbon monoxide and by nicotine. Progressive nuclear ophthalmoplegia as an inde- pendent affection is rare; as an accompaniment or part of some organic disease of the nervous system it is not infrequent, especially in bulbar paralysis, locomotor ataxia, dementia paralytica and progressive muscular atrophy; it has also been observed in multiple sclerosis and in combined system-disease of the spinal cord. The disease is gradual in its onset, in most 'cases a slight ptosis with some diplopia being the earliest NUCLEAR OPHTHALMOPLEGIA. 201 symptoms. With the progress of the disorder, other muscles are involved gradually. The interior muscles of the eyes escape in most cases, so that the af- fection is generally an ophthalmoplegia exterior bi- lateralis. The prognosis is unfavorable for cure ; the disease process may extend over many years, but it may cease to advance. The danger to life becomes greater when the process seizes the motor nerve nuclei in the medulla, or when it is a part of pro- gressive muscular atrophy. Anatomically, the disease is a chronic inflamma- tory or degenerative process in and about the ocular nerve nuclei beneath the floor of the aqueduct of Sylvius, the anterior sub-groups for the innervation of the ciliary muscles and the sphincters of the irides ap- parently escaping in most of the cases. The syphil- itic process can affect the same region ; such cases may improve under treatment. In multiple sclerosis the nuclei are not affected, as a rule, but the nerve roots are the seat of the trouble (Oppenheim). Treatment should be that of the associated dis- ease, but as the latter is frequently initiated by the former, the treatment then must be symptomatic. At the New York Ophthalmic Hospital, Agaricus, Gehemium and Physostigma are favorite remedies in paralysis of eyeball muscles. Causticum and Conium are especially indicated in isolated ptosis and in paralysis of the ciliary muscle. When the affection is even probably nuclear, Sypli- 202 THE CRANIAL NERVES. ilinum high, Plumbum and Carboneum sulphur atum should be studied, while if the trouble be part of a more extensive degenerative process, the remedies applicable in the latter may find place here. Cases undoubtedly syphilitic will require Merc. jod. flav. y low, and if gumma be suspected it must be removed by the solvent action of iodide of potassium in ma- terial doses. Other remedies that have proven valuable in treat- ing paralytic eye muscles are Bhus tox. and Arnica, prescribed on rheumatic or traumatic indications, Jaborancli, Natrum mur., Nux vomica, Senega and Sul- phur. Euphrasia and Phosphorus have cured when indicated by accompanying special symptoms or condi- tions. In all cases the remedy should be sought for by studying the known indications of the different drugs. Recurrent or periodical oculo-motor paralysis is a somewhat rare affection with some peculiar features that led Charcot to give it the name ophthalmo- plegic migraine. It usually begins in youth or early childhood, in one case at the age of 11 months. The attack may be divided into two parts. First, severe pain in, around and. behind the eye of one side with headache of the same side and vomiting. These symptoms continue for a day or two, a week, or even three or four weeks (Mobius), and they cease with the occurrence of the paralysis, which may affect all the muscles sirpplied by the third nerve. Occasion- ally the external rectus has been affected. The pa- RECURRENT OCULO-MOTOR PARALYSIS. 203 ralysis lasts perhaps a few days, perhaps many months, but seems to be in direct relation to the length of the sensory part of the attack. The attacks return at definite intervals, in some cases a week, in others a month, in others six months, in some patients always at a menstrual period, and so on. In those having frequently recurring attacks, these are shorter. In the intervening time most of the paralytic symptoms slowly dis- appear, but partial ptosis or weakness of the pupillary reflex may remain after all other symp- toms have gone. The intervals become less as years go on and the paralytic symptoms more permanent. The disease seems to be related to migraine, yet has positive differences from it. Migraine is at times accompanied by ocular palsies, but these are seen in the beginning of the attack, not after cessation of pain. With migraine there is in most cases in- heritance, in the present disease none. Yet the pres- ent trouble is migrainous in its sensory manifesta- tions. No satisfactory hypothesis of its origin has as yet appeared. The treatment ought to be, in the first part of the attack, that for migraine ; in the second part, that for paralysis of the third nerve. But the best results will be obtained by placing the patient under treat- ment during the interval and using, as they may be indicated, our great antipsorics. 204 THE CRANIAL NERVES. Insufficiencies and other abnormalities of the ocular muscles have been assigned as causes of certain ner- vous affections, such as epilepsy, migraine, headache, chorea, facial and other spasm, vertigo and even organic nervous disease. Discussion of the subject has been extensive during more than a decade and repetition of it is out of place in this book. That an inborn insufficiency of some muscle of the eye can, in course of time, set up in a neurotic person many symptoms of nervous trouble may not now be doubted, but that post hoc means propter hoc in all cases in which graduated or other tenotomies were followed by relief, is not the writer's opinion. Uncorrected errors of refraction may undoubtedly give rise to headache and other nervous trouble. In either case of eye strain the concomitant nervous disorder may not be amenable to remedies until the ocular defect is removed or corrected. Special treatment for the ocular conditions just men- tioned belong properly to the ophthalmologist. The fifth cranial nerve or trigeminus apparently emerges by two roots from the side of the pons. Its origin is analogous to that of a spinal nerve for the posterior or sensory root originates, in the Grasserian ganglion, the cells of which give rise to the peripheral fibres and to the post ganglionic, afferent or sensory root. The fibres of the latter enter the pons and turn downward, ending each in a brush-work around the cells of the gelatinous substance in the medulla and upper cervical cord. In cross sections of the medulla THE CRANIAL NERVES. 205 and upper cervical cord the fibres can be seen as a compact mass, a mere fringe outside the substantia gelatin osa at the level of the decussation of the pyra- mids, but as a large kidney-shaped bundle in the pons. Until recently it was termed the ascending root of the fifth. The motor root ot the fifth cranial nerve is divisible into a larger, the motor root proper, and a smaller root considered by Kolliker to be also motor, by others to be trophic in function. The latter arises from cells not aggregated into a nucleus, and placed at the outer limit of the gray matter around the aqueduct. The fibres from them can be seen in all sections as far down as their place of exit from the pons. They are called the descending root of the fifth. The dis- tribution of the fibres is not known. The motor root proper arises from the motor nucleus situated within the pons. Its fibres pass forward be- neath the sensory fibres and their ganglion and are distributed to the masseter, the two pterygoids, mylo- hyoid, anterior belly of the digastric, the temporal muscles and tensor tympani. The motor root receives some fibres from the nucleus of the opposite side. The trigeminus is the sensory nerve of the face as far back as the ear and as low as the lower outline of the lower jaw, of the scalp as far back as the crown, of the mouth and its contents, including the teeth, soft palate and uvula (but not the extreme base of the tongue); the antrum and the frontal sinus, part of the external auditory canal and the greater part of the 206 THE CRANIAL NERVES. membrana tympani. The dura mater, which is the only sensitive membrane, is supplied by this nerve, except in the occipital region and the posterior fossa, and the tentorium and the falx are innervated by it. The four ganglia situated on different divisions of the nerve are of some importance in connection with the sympathetic fibres which it receives; they subserve trophic, vasomotor and secretory functions. The cortical area is unknown, but its sensory re- presentation is probably in the parietal cortex, its motor representation being probably in the lower portion of the central convolutions of the opposite hemisphere. Neuralgia of the fifth cranial nerve has been al- ready considered under Neuralgia. Trophic changes, such as herpes, in the distribution of the nerve are seen at times during an attack of trigeminal neuralgia. Herpes may be extensive and may affect the mucous membrane lining the mouth and give rise to additional pain in eating. Its cause is con- sidered to be irritation of the Gasserian ganglion. Paralysis of the nerve may occur from injury or from pressure by a tumor at the base. The result is anaesthesia throughout the distribution of the nerve, with paralysis of the muscles supplied by it. Chew- ing is done by the muscles of the opposite side, whose pterygoids carry the jaw toward the affected side. If irritation of the Gasserian ganglion be present, herpes of the cornea, followed by keratitis neuroparalytica (so- called) may be a result. PROGRESSIVE FACIAL HEMIATROPHY. 207 Treatment of such affections of the fifth nerve must be that of the underlying cause. Progressive Facial Hemiatrophy. A rather rare affection, characterized by wasting of the skin, subcutaneous tissues, bones, and at times the muscles of one side of the face. The affection develops usually between the tenth and twentieth years, and more frequently in girls. No cause is assignable in many cases, but in some, undoubted history of trauma at the affected site or a preceding infectious disease, can be obtained. The disease may show first at some one region, such as the neighborhood of the orbit. The skin becomes thinner and whiter (loss of pigment) or else becomes yellowish or brown (excess of pigment), the hair becomes finer, and later falls out. The sub- cutaneous connective tissue disappears and the skin becomes wrinkled. The disappearance of fatty and connective tissue from the bottom of the orbit permits the eyeball to sink and then the palpebral fissure be- comes narrower — the eye appearing smaller than its fellow of the other side. The disease is slow in pro- gress and when the bones are much involved, the asymmetry of the face becomes very striking. When the affection does not begin until adult age, the bones are but rarely attacked. The masseter muscles usually escape, but the muscles of the tongue are at times wasted. The electrical reactions in the affected mus- cles are not altered. The functions of the skin may be altered, the sebaceous secretion being lessened, while 208 THE CRANIAL NERVES. secretion of sweat may be greater; the power of blushing may be lost on the affected area. Anaesthesia is not present as a rule, but pains in the distribution of the fifth nerve may precede the appearance of the atrophy. The disease progresses to a certain point and then ceases to advance. It has been seen as a complication of other nervous diseases and a similar atrophy in the arm may accompany it. The pathology of the disease as ascertained by Men- del is, that it is due to a neuritis of the fifth nerve with degeneration of its so-called descending root. Treatment of such cases as have apparently followed trauma, has some hope. In one case where the affec- tion began soon after a blow beneath the eye, the trouble was arrested, arnica being given among other remedies, and galvanism used. The current was given stabile, the negative pole, an insulated carbon elec- trode, being placed upon the atrophied masseter muscle inside the cheek. The patient was under treatment several months and now, after the lapse of some years, the asymmetry of the face is hardly noticeable. The facial or seventh cranial nerve is made up of the neuraxones of the cells of the facial nucleus in the pons. The fibres pass, while still within the pons, inward and upward, curving around the nucleus of the sixth nerve to pass downward and outward, finally emerging at the lower edge of the pons between the olivary and restiform bodies of the medulla. It enters a bony canal in the temporal bone, where it is joined by the chorda tympani PERIPHERAL FACIAL PARALYSIS. 20g given off from the lingual branch of the fifth, and finally emerges at the stylo-mastoid foramen. The facial nerve is the motor nerve for the mus- cles of the face, the platysma, the stapedius and the stylo-hyoid muscles. The chorda tympani carries taste fibres,* which after joining the facial probably leave it by the great petrosal to once more become part of the fifth. The facial area in the cortex is in the lower part of the motor area, and chiefly of the anterior cen- tral convolution. The fibres from its cells pass inwards to the internal capsule, and take the most inward position in the motor tract, which position they hold in the pes of the cms. At the beginning of the lower third of the pons they cross and end at the nucleus of the facial nerve. They are the first fibres of the motor tract to decussate, and so furnish means for an important difference in diag- nosis between a cortical lesion and a lower pons lesion. Peripheral Facial Paralysis.— Bell's Palsy. The facial nerve being wholly motor in function (ex- cept that in part of its course it carries taste fibres from the lingual nerve which leave the trunk via the great petrosal nerve), disease or injury to the nerve is shown * There is much reason for holding that the sense of taste is carried by the fifth cranial nerve (lingual branch) chorda tympani, great petrosal and the second di- vision of the fifth (but individual differences exist) from the anterior two-thirds of the tongue, and that the posterior third is subserved by the ninth or glosso- pharyngeal. Both nerves are nerves of common sensation also. 2IO THE CRANIAL NERVES. by paralytic symptoms in the muscles of the face. Such paralysis differs from paralysis of the face of cerebral origin ; in the latter case the upper part of the facial distribution is usually not affected, the nerve supply through the trunk of the facial not arising from the cells of its nucleus, but from some higher source, and not forming part of the motor tract. Hence in a hemiplegia the orbicularis oculi, the temporal and the corrugator muscles are not paralyzed. Peripheral facial paralysis most commonly results from exposure to cold and especially to the local influ- ence of a draught of air upon the face. It also occurs in ear disease, from injuries to the region of the ear and from accidental section of the nerve in operation on the parotid gland. It has been recorded as part of multiple neuritis and in locomotor ataxia and at times in the infant from pressure of the forceps during delivery. The symptoms appear within a few hours or a day or two after exposure, preceded at times by pain in the region of the ear (local implication of the fifth nerve). The most marked objective symptom is the inability to close the eye of the affected side ; even the ordinary winking reflex is gone. The forehead cannot be wrinkled, nor the eyebrow brought to the middle line, as in frowning. The angle of the mouth on the affected side is lower than its fellow of the opposite side ; in blowing, the air escapes from this angle of the mouth instead of the middle. In chew- ing, the food cannot be properly moved and accumu- PERIPHERAL FACIAL PARALYSIS. 211 lates between the teeth and the cheek from loss of power in the muscles of the latter. The dilator muscle of the nostril of the affected side being para- lyzed, that nostril is narrower than its fellow. The lower lid not being in close apposition to the eyeball, the tears do not get into the lachrymal canal and may overran the cheek, giving rise to redness and irritation; the eyeball being always uncovered (even during sleep) it is not kept free from minute particles, which, together with evaporation, tend to set up irritation or even inflammation of the conjunctiva. The course of the nerve, its association for a short distance with the eighth nerve, its own branches (es- pecially the chorda tympani) permit of fine topo- graphical diagnosis as to the site of the lesion, which is valuable for the prognosis. Between the junction of the chorda tympani below and the geniculate gang- lion above, run the taste fibres. A lesion in the lower part of the bony canal or after emergence of the nerve from it, is not accompanied by loss of taste. A lesion higher up in the canal may have temporary loss of taste with lessening of the salivary secretion and hence dryness of the mouth. Rheumatic forms of facial paralysis are generally peripheral and relatively slight in degree. The elec- trical reactions of both nerve and muscles are not changed, and rapid cure (within a few weeks) is to be expected. When the nerve at the end of two weeks shows a lessening but not complete loss of reaction to galvanism, while the muscles give slow 2 1 2 THE CRANIAL NERVES. contraction to direct application, without reversal of the formula, there is partial RD, and favorable prognosis of cure within three or four months may be given. When complete ED of nerve and muscles is shown by the electrical tests, cure may occur in a few months or perhaps not at all. If the lesion is due to ear disease, disease of the bone, etc., cure cannot take place until such disease ceases. If the originating cause was section of the nerve (operation, or other injury) a secondary operation to suture the divided ends together will be necessary before restoration of function can be effected. In severe cases, after some months, secondary con- tractures affect the paralyzed muscles, the mouth being drawn up on the paralyzed side, and, to a casual ob- server, the really unaffected side then appears to be the paralyzed one. Anatomically, Bell's palsy is due to degenerative peripheral neuritis of the facial nerve ; the symptoms may occur in bulbar disease (q. v.). Disease of the nucleus alone will not cause involvement of the muscles surrounding the eye. Gummy exudations at the base may involve the emerging fibres of the facial, but the auditory nerve will then hardly escape, and other and distant cranial nerves may be affected. The writer has reported a case of paralysis of the 3d, 5th and 7th nerves in a syphilitic ; here, while there was inability to close the eye completely, there was also partial ptosis. The homoeopathic treatment of Bell's palsy must PERIPHERAL FACIAL PARALYSIS. 2 I 3 be guided largely by the causal indications. In the writers experience Rhus tox. and Dulcamara have given apparently good results. Causticum in one case and Cimicifuga in another acted similarly. Aconite, Bellis perenniSj Ruta grav. and Belladonna are remedies that ought to be thought of in the rheumatic form of the affection. Since many cases are light in degree and would probably get well of themselves, it will need many such recorded cases to enable us to say definitely just how much our remedies accomplish. In the cases that are symptomatic of some other disease as the cause, treatment for the latter is, of course, of the first importance. The employment of galvanism in facial paralysis is a routine matter with the writer. Patients seem to experience benefit from it. To protect the eye the writer instructs patients to close down the upper lid with the hand many times in the day and to sleep with a well-applied bandage over the closed lid. Further, patients should rub the paralyzed side of the face upward often during the day. In old persons, peripheral facial paralysis may be very intractable. Spasm in the distribution of the facial nerve will be considered with the spasmodic disorders. The eighth cranial nerve is the common trunk of two nerves, distinct in origin and in function. One arises in the ganglion cells of the ganglion spirale of the cochlea, from which fibres can be traced out- 214 THE CRANIAL NERVES. ward to the cells of the organ of Corti and inward to the medulla. This is known as the cochlear nerve and is the real auditory nerve. The other arises from cells in the intumescentia ganglioformis Scarpa? or vestibular ganglion in the superior fossa at the bottom of the internal auditory meatus. Fibres go from the cells in two directions, in one to the vestibule and semi-circular canals, in the other to the medulla. This nerve is known as the vestibular nerve, or space-sense nerve, since it carries impulses from the semi -circular canals in which any change of position of the head results in alteration of the relation between the membranous duplicate of the semi-circular bony canals and the fluid within them. The two nerves while yet within the internal auditory meatus unite into a common trunk, which reaches the medulla and enters it by two divisions, the lateral and posterior one being the cochlear, the inner and anterior being the vestibular nerve. The greater number of the fibres of the cochlear nerve end amid the cells of the ventral or accessory acoustic nucleus, while a portion wind around the inferior peduncle of the cerebellum to reach the chief nucleus and Deiter's nucleus. The fibres of the vestibular root pass to the inner side of the ventral nucleus and reach the chief nu- cleus and Deiter's nucleus, amid the cells of which most of them end. From the ventral nucleus new fibres arise that cross in the raphe, pass into the lateral lemniscus in THE CRANIAL NERVES. 2 I 5 part, in part to the formatio reticularis, arid end about the cells of the posterior corpus quadrigeminum and internal geniculate body, whence a new set of neurones begin, whose long fibres go to the cortex oi the temporal lobe. A part of the fibres do not cross, but pass up on their own side. Fibres from the chief nucleus and Deiters nucleus are sent to the cerebellum to end at the roof nu- cleus, or the emboliform and globose nuclei (Flech- sig) ; a part enter the formatio reticularis, or enter the raphe and get to the formatio reticularis of the other side ; another part crossing, enter the lateral lemnis- cus. The cortical area in relation to the vestibular nerve and its central tracts is unknown, but is placed by Bechterew in the parietal lobe. Irritation of the nervous structures in the coch- lea, or of the cells in the temporal lobes, will give rise to dysacusis, a condition in which ordinary sounds are perceived painfully, as seen during menin- gitis, headache, etc., and at times in hysterical states. Irritation of the same structures may also cause sub- jective sensation of sounds, as ^whistling, buzzing of insects, singing or ringing, etc. Such subjective sen- sation is termed tinnitus aurium. Its most frequent cause is aifection of the middle ear, circulatory dis- turbance, etc. It may be constant, and often is the basis of auditory hallucinations in the insane. Destructive changes in the auditory nerve or its end organs in the cochlea give rise to loss of hear- ing power, either total or partial. Affections of the 2l6 THE CRANIAL NERVES. external and middle ear can give rise to deafness by preventing or interfering with the conduction of sound waves to the cochlea. Such deafness is to be dis- tinguished from nervous deafness by examination with the otoscope and head mirror, and by the use of the tuning fork. When a tuning fork is set in vi- bration and its handle applied to the mastoid process the bone will conduct the sound-waves to the cochlea under normal conditions. Under the same conditions when such perception of sound ceases, if the still vi- brating instrument be removed and held near the external auditory meatus, the sound will be perceived anew. Thus bone and aerial conductions are both present, the latter being, of course, the better. If bone conduction is the better, the defect is in the middle or outer ear. If bone conduction is lessened or lost, the trouble is in the nerve or its endings. When the semi-circular canals or the fibres from them are irritated, false sensations are received from them by the cerebellum and cerebrum ; the patient feels as if turning around, or as if falling in one di- rection or another. Such vertigo is known as aural vertigo if symptoms of auditory character are at the same time present. Meniere's Disease, so called, is an extreme form of aural vertigo, and is characterized by sudden attacks of violent vertigo, so violent at times that the patient feels it as a blow behind the ear, and may be 21/ thrown to the ground. At the same time there is a loud and often shrill noise in one ear. The sufferer becomes pale, the face covered with sweat, and at the end of the attack, which may last in the begin- ning but a few minutes, there is vomiting or nausea. Consciousness is not lost, but in some cases mental confusion, with darkness before the eyes, is present. The symptoms are due to an affection of the labyrinth, such as haemorrhage (injury), inflammation, syphilis, etc. The manifestation of the trouble in at- tacks is difficult to understand as part of a pro- gressive disease, and they have been ascribed to variation of intra-labyrinthine pressure, due to changes of vaso-motor influence. In most of the cases deafness in some degree and tinnitus had been present, but occasionally deaf- ness did not appear for some hours or some days after the first attack. The attacks tend to increase in frequency, and finally the patient may be confined to bed, since the vertigo becomes continuous on movement. When the deafness becomes absolute the vertigo ceases as a rule, because the labyrinthine nerve organs have then been destroyed. That the symptoms can come from affection of the eighth nerve trunk or its so-called roots, is proven by F. Alt's report of a case in which the symptoms came on, and after the attack hearing was nearly lost. Total deafness existed two weeks later, not- withstanding which the patient kept to his bed on 2 1 8 THE CRANIAL NERVES. account of the recurring vertigo. He was found to be suffering from leucocythsemia, and died in three months. The autopsy supported the diagnosis of leucocy- thsemia. Microscopic examination showed the middle ear to be intact, the labyrinth without evident change, but the inner and outer nerve roots showed spots of small-celled lucsemic infiltration and the trunk of the nerve slight degeneration. Here then was a case with well-marked Meniere's symptoms in which the labyrinth was not involved. In another way the case is worthy of note, and, perhaps, makes a point of diagnostic import between affec- tion of the labyrinth and that of the nerve — deaf- ness, even when total, was not accompanied by ces- sation of the vertigo. Diagnosis. In severe cases of Meniere's syndrome, epilepsy may be erroneously diagnosticated. The sudden fall, the partial (even momentarily complete) loss of consciousness would make us suspect the pres- ence of the latter disorder, but deafness is in favor of the former. Dr. v. Frankl-Hochwart maintains that cases of epilepsy occur in which the attack is ushered in with vertigo, tinnitus, nausea and vomit- ing, but without loss of hearing. Cases of epi- lepsy with Meniere's triad as the aura, cannot be differentiated from the genuine Meniere's disease if demonstrable ear affection is present. Treatment of any form of aural vertigo must be largely influenced by discoverable cause, such as 219 middle ear disease, affection of the Eustachian tube, syphilis, etc. Symptomatically, Natrum salicylicum and Chininum sulphuricum are both well indicated and have repeatedly benefited. A typical case, which had been in the hands of several aural specialists, was relieved entirely and rapidly by the writer's prescribing CJieno- podium antJielminticum cum Terebintliina (in 3d dilu- tion), the mixture having been that taken by the involuntary prover. The deafness was intense, the patient only hearing conversation if it was very loud, yet she could distinguish the tinkle of the door bell two stories below ; this symptom is found in Allen's Encyclopedia, Vol. X., under Chenppodium. Other remedies reported as serviceable are Aurum metallicumj Ledum palustre, Tabacum and TJwridion, The glossopharyngeal or ninth cranial nerve is a mixed nerve. Its sensory fibres arise from the cells of the petrosal ganglion in the foramen jugulare and pass outward to subserve with common sensation and the special sense of taste the posterior third of the tongue and with common sensation the root of the tongue, pharynx, soft palate, Eustachian tube, tympanum and upper part of larynx. The centripetal fibres from the same cells pass in- ward and enter the medulla in the postero-lateral groove and reach the sensory nucleus where they end. The second neurone arises from the sensory nucleus and ends near the cells of the temporal lobe. The motor fibres arise from the nucleus ambiguus, dorsal to the olivary body. They pass out in the 220 THE CRANIAL NERVES. same groove with the sensory fibres and form a com- mon trunk. They are finally distributed to the muscles of the palate, pharynx and the middle constrictor of the oesophagus. Isolated disease of the ninth cranial nerve has not been observed, owing to the difficulty of detecting it. Irritation of its fibres would produce the globus sen- sation as seen in hysteria, but this is to be considered as cortical in origin. Paralysis of the nerve would cause loss of taste and tactile sensation in the posterior third of one-half of the tongue and loss of tactile sen- sibility in other parts named above. Its nucleus is affected in bulbar paralysis (q. v.). The tenth cranial or vagus nerve is a mixed nerve having both motor and sensory fibres. The latter arise from cells of the ganglion jugulare (Henle), otherwise called the ganglion of the root (Quain, Gray) within the jugular foramen. They are dis- tributed to the dura mater of the occipital region and posterior fossa, to part of the external auditory meatus, to the oesophagus, pharynx and stomach, to the larynx and whole respiratory tract. The centrally directed fibres from the ganglion pass into the medulla below the glossopharyngeus and reach the sensory vagus nucleus below the floor of the fourth ventricle, practically continuous with that of the glossopharyngeus in front. The motor fibres of vagus arise from the motor nucleus, the nucleus ambiguus (common to the ninth and tenth cranial nerves). The fibres pass out by THE CRAXIAL XERVES. 221 several rootlets, having been joined by some fibres from the nucleus of the spinal accessory nerve just back of the vagus nucleus, and are sent to the mus- cular structures of the pharynx, larynx, oesophagus, stomach and intestines, as well as to the trachea and bronchi. The vagus contains both accelerating and inhibit- ory fibres for the respiratory centre, for the heart, and for the vaso-motor centre. Secretory fibres are sent to the abdominal viscera and to the respiratory tract. The wide distribution of the vagus fibres, the many functions which they subserve, especially in the thoracic and abdominal viscera, make affections of this nerve, for the most part, subjects for the consideration of the general practitioner. Affections of the nerve will be described in con- nection with the eleventh nerve. The spinal accessory or eleventh cranial neive arises in part from the posterior portion of the motor vagus nucleus in the medulla, from which, indeed, as has been stated, fibres join the root of the vagus while yet within the medulla. Some fibres from the nucleus join the vagus after emergence. Another portion of the nerve, the spiual portion, arises from the cells of the lateral and of the outer part of the anterior gray horn of the cord, their lowest origin being about the level of the fifth cervical nerve. The fibres pass outward through the lateral columns by several roots and ascend, successive additions being 222 THE CRANIAL NERVES. made at each higher level. The trunk thus formed passes into the cranium through the foramen magnum and then turns outward to emerge from the cranium by the jugular foramen. Within the skull the fibres of spinal origin are joined by those arising from the nucleus in the medulla, but upon the emergence of the common trunk the latter divides into two branches, an inner and an outer. The former joins the vagus, contains the fibres from the nucleus in the medulla, and innervates the muscles of phonation ; the latter contains the fibres of spinal origin and innervates the sterno-mastoid muscle and the upper part of the trap- ezius. Paralysis of the vagus includes the fibres of the spinal accessory from the medulla. In such paralysis the palate hangs down on the side affected, it is not raised in intoning, the speech becomes nasal and in swallowing liquids a part may escape by the nose. The pharyngeal muscles being affected, swallowing is difficult. The laryngeal muscles show paresis of the abductor of the vocal cord of the affected side, and if paralysis, the cord is in the cadaveric position and immobile. The heart's action may be accelerated, but this is usual only when the nerves of both sides are affected; the breathing then becomes slow and irreg- ular. Defective contraction of the stomach with faulty digestion and loss of the sensation of hunger can result from a paralyzing lesion of the nerve; irritat- ing lesion has caused insatiable appetite. THE CRANIAL NERVES. 223 Lesions of the nerve may be from affections of the base of the skull or of the upper vertebrae, from meningitis, syphilis, etc. Lesion of a division of the nerve can occur from injury, pressure of a tumor or by direct poisoning, as in diphtheria. Spasm in the distribution of the vago-accessorius nerve may affect the pharynx and oesophagus (globus) or the larynx (laryngismus stridulus, larynx "crises" in locomotor ataxia). Treatment of affections of the nerve must be purely symptomatic unless the cause can be traced (meningitis, syphilis, etc.). Reference to the section on Bulbar Paralysis may give some hints. A lesion of the spinal or accessory portion of the eleventh cranial nerve causes paralysis of the sterno- cleido and trapezius muscles. In consequence the head cannot be turned to the opposite side, nor the shoulder of the affected side raised. The full contour of neck and shoulder region is changed and appears sunken. Only the upper portion of the trapezius is com- pletely paralyzed, the other portions being also in- nervated by the cervical nerves. The scapula is more distant from the spinal column than normal and is also rotated, the lower angle being nearer the spine than normal. Atrophy is present. If both nerves are affected both sets of muscles that support the head are affected, and there will be inability to hold the head up, so that the latter falls 224 THE CRANIAL NERVES. forwards or backwards in accordance with the pull of gravity. Lesion of the nerve within the skull or in the for- amen magnum may he by pressure from exudation, meningitis, etc. Below the foramen, disease of the upper vertebrae and injury, etc., can affect it. In progressive muscular atrophy its nuclear origin may become in- volved. Spasm in the distribution of the spinal part of the spinal accessory nerve will be considered in the section on Spasmodic Diseases. Treatment of paralysis of this part of the nerve must be first for any underlying cause or any in- cluding disease (bulbar paralysis, progressive muscular atrophy). The hypoglossal or twelfth cranial nerve arises from the cells of a nucleus beginning in the lower portion of the medulla and placed antero -laterally to the central canal. Towards the rest of the brain the canal is gradually displaced dorsally until it merges into the widening posterior fissure and opens out as the fourth ventricle. The nucleus of the twelfth nerve is placed obliquely, so that it gets nearer to the canal and the opening of the fourth ventricle and its upper part is below the floor of the latter and near the median line. From the long nucleus fibres arise which pass down- ward and outward between the pyramid and the olive to emerge as the twelfth nerve roots. THE CRANIAL NERVES. 225 The nerve supplies the muscles of the tongue, both intrinsic and extrinsic and the genio-hyoid muscle. Paralysis of the nerve after its emergence from the medulla may be by compression from exudation, tumor; in the foramen and lower down by similar conditions or by disease of the bone. Within the medulla it may be affected (and usually bilaterally) in bulbar paralysis. In paralysis of one hypoglossal nerve the affected side of the tongue lies higher at the base than does the other half; when protruded it deviates curved towards the paralyzed side. When moved within the mouth its back part deviates towards the unaffected side. If both nerves are affected the tongue lies motion- less on the floor of the mouth; speech and eating are greatly interfered with. For further description and treatment vide section on Bulbar Paralysis. Fig. 27. The positions of the different nuclei of origin of the cranial nerves will be understood by study of the accompanying fig- ure, which represents the ] structures between the an- terior pair of the corpora quadrigemina and the up- per portion of the spinal cord. The structures of the right half are seen. To the left and below Bad. anter.= anterior nerve root. XI and bracket are at the nucleus of the elev- enth nerve ; fibres pass dorsally and are seen at the side as rootlets. Near them is a line, finely dot- ted, the common ascending root of the eleventh and tenth nerves. They pass under the end of the upper dark mass, which is the nucleus of the tenth nerve posteriorly and of the ninth anteriorly. Above this conjoint nucleus is seen the nucleus of the twelfth. In the middle of the picture, extending lengthwise, is seen a thick dotted mass traceable into the pons, where it turns down and out. It is the so-called ascending root of the fifth nerve. Fs.=sensory root of fifth nerve ; Fm. =motor root, whose fibres can be seen coming from its nucleus, the dark egg-shaped mass above. From the sensory root of the fifth a thick line can be traced upward into the region beneath the corpora quadrigemina ; it is the descending root of the fifth. The long dark mass in the middle beneath the nucleus of the ninth and tenth is the large nucleus of the eighth nerve ; its fibres are entering at VIII, passing under the other nucleus of the eighth nerve. Just above the latter nucleus is seen a scattered nucleus, that of the seventh nerve, whose fibres gather together and course over and around the sixth nerve nucleus. The roots of these two nerves are sufficiently well indicated. IV, near corp. quad., shows both fourth nerves crossing. At III are seen fibres of the third nerve coming from its nucleus. fi ons Var<^ Fig. 27. The Brain. The Brain- Axis. By the term brain-axis is meant the brain structures between the lower end of the medulla and the optic thalami. It therefore embraces the medulla, pons Varolii, crura and the corpora quadrigemina with their included structures. As many special nervous masses and fibre-tracts are mentioned in the present section and have been alluded to in the preceding one it is deemed advisable to consider here briefly the finer anatomy of the brain- axis and chiefly by the description of illustrations. At the level of the first cervical nerve a section of the spinal cord shows some variation from the usual appearance of a lower section. * Fig. 28. Fig. 28. From Henle. Fg, Fuuiculus gracilis or column of Goll ; Fc, funiculus cuneatus or column of Burdach ; Cgp, posterior cornu ; Cga, anterior cornu. THE BRAIX-AXIS. 227 The ascending posterior columns have increased greatly, the posterior gray horns are thrust outward and have become smaller and at the end of each is seen, turned anteriorly, the large mass of gelatinous substance of Rolando. A section in the lower pail of the medulla shows the ending of the decussation of the pyramids, the fibres of which are seen crossing the middle to get into the lateral column of the opposite side. The anterior Fig. 29. Pig. 29. From Henle. Decussation of the pyramids. Kg, nucleus of Goll's column ; (/, gelatinous substance at head of posterior gray horn. gray horns are thus separated from the central gray matter. A spinal rootlet of the eleventh cranial nerve 228 THE BRAIN. is seen emerging at the left. In the column of Goll the nucleus of that column is beginning. Figure 30 shows a section of the medulla a little higher. The decussation of the pyramids is just be- ginning, a few fibres of each crossing. The nucleus of the column of Goll fills nearly all the area formerly Fig. 30. Fig. 30. From Henle. Decussation of the pyramids at the level of the lower roots of 12th cranial nerve. Nc, nucleus cuneatus or nucleus of column of Burdach. Figs. 28, 29 and 30 show the gray matter in light tint, the white matter in dark. occupied by fibres and the nucleus cuneatus or nucleus of the column of Burdach is quite large. THE BRAIX-AXIS. 229 Fig. 31. Fig. 31. From Obersteiner. The structures shown in the right half are explained diagramatically in the left half. iVrt, motor nucleus of ninth and tenth nerves. IX a, ascending root of ninth nerve. Sgl, substantia gelatin- osa. VOL, descending spinal root of fifth. Crst, the restiform body. IlS, direct cerebellar tract. Oi, inferior olive. Lm, lemniscus. Py, pyramid. Figure 31 represents a section of the medulla through the calamus scriptorius. The opening above is the beginning of the fourth ventricle. The pyra- mids are intact. The olivary body, the tenth and eleventh nerves coming from their nuclei, the restiform body and the direct cerebellar tract are to be noted; fibres (at x) coming from the nuclei of the posterior columns are seen to curve to the middle line and cross. The twelfth nerves frame as it were between them the interolivary tract or lemniscus. 230 THE BRAIN. Fig. 32. Fig. 32. From Obersteiner. Cbllm, part of cerebellum. VITI, the eighth cranial nerve. Villi, lateral root. Vlllm, median root. VIII ac, accessory nucleus. VIII Jl, chief nucleus of the eighth. JV VII, nucleus of the seventh. VII a, root fibres ascending from the same. Figure 32 shows a section of the medulla made at the striae acusticae. The floor of the fourth ventricle is wide and flat, the covering cerebellum has been cut away except at the sides of the section. The restiform body is seen surrounded by the roots of the eighth cranial nerve emerging as one trunk below. The seventh nerve nucleus is seen giving off fibres which here pass upwards. THE BRAIN-AXIS. 231 Fig. 33. Fig. 33. From Obersteiner (reduced). N VI, nucleus of sixth cranial nerve giving off fibres which descend (shown as thick lines). VII b, ascending fibres of seventh cut across. VIIc, descending fibres of seventh. Xdt, nucleus dentatus of the cerebellum. Flp, posterior longitudinal fasciculus. Figure 33 shows a section of the pons. The con- nections with the cerebellum have been cut away. The motor tract fibres are not in a compact mass as in the pyramid of the medulla, but are in bundles separated by the cross-fibres of the pons. A portion of the seventh nerve nucleus is seen at this level giving off some fibres which ascend. The fibres from the lower level have already ascended to turn around and over the sixth nerve nucleus, but the turn or knee is at a level a little higher and camiot be seen in this section, but as they turn backward they are again seen in the section, and pass downward. The restiform body has at this level become really the inferior peduncle of the cerebellum. The lem- niscus is in a compact mass and in the field above is the formatio reticularis. 232 THE BRAIN. Fig. 34. Fig. 34. From Obersteiner (reduced). Lng, Lingula ; Vlma, velum medullare anticum. Brcj, superior peduncle of the cerebellum. Vd,'de- scending root of fifth cranial nerve. Flp, posterior longitudinal bundle. Lm, median lemniscus. Lml, lateral lemniscus. Frtg, formatio reticu- laris. Py, pyramidal tract separated into bundles by the cross fibres of the pons. Figure 34 shows a section beyond cerebellar struc- tures. The superior peduncle of the cerebellum is seen coming from its place of origin (?), to be shown in the next figure. The lemniscus has separated into two distinct bundles of fibres — the lateral or lower lemniscus, which goes to the region of the corpora quadrigemina, and the median or upper lemniscus, which terminates in the cortex of the parietal lobe. The formatio reticularis and the posterior longitudinal bundle are indicated. THE BRAIN- AXIS. 233 Fig. 35. Fig. 35- From Obersteiner (greatly reduced). Tho, optic thalamus. Cgm, internal geniculate body. C'/l, external geniculate body. II, optic tract. _Pp, pes or crusta of the crus cerebri. SnS, substantia nigra. Ntg, red nucleus of the tegmentum. 777, fibres of the third cranial nerve. N III, nucleus of the third nerve. Lm, median lemniscus. Aq, aqueduct of Sylvius. Figure 35 shows a section through the anterior pair of the corpora quadrigemina, the crura cerebri, through part of the optic thalami and of the external geniculate bodies. Around the aqueduct is seen the central gray at whose outer limit is the descending root of the 5th cranial nerve ; below the aqueduct and lateral from it is the nucleus of origin of the 3d cranial nerve, from which the nerve fibres are going downward to emerge through the crus. They pass the posterior longitudinal bundle just beneath the central gray and through and around the red nucleus of the tegmentum. The lateral lemniscus has dis- appeared, the median one remains. The large mass of substantia nigra separates the pes or foot of the crus from the parts above, all the latter being in- cluded under the word tegmentum. 234 THE BEAIN. Fig. 36. From Bechterew. A schematic representation of the course of fibres from the nuclei of the posterior columns of the spinal cord to and through both lemnisci and to the cerebellum. C, the cortex ; nl, the lenti- cular nucleus ; th, the optic thalamus ; cL, Luys' body or corpus subthalamicum ; qa and qs, the corpora quadrigemina ; nil, nucleus in the lateral lem- niscus ; OS, the superior olive ; VIII, anterior acoustic nerve nucleus ; oi, the olivary body ; nla, nucleus of antero-lateral column ; nip, nucleus of pos- tero-lateral column ; nfc, nu- cleus cuneatus, at the top of the column of Burdach ; nfg, nucleus gracilis or nucleus of the column of Goll ; cr, resti- form body becoming the inferior peduncle of the cerebellum. The fibres in the latter can be traced in the figure and need no explanation, except to say that fibre 2 represents the di- rect cerebellar column of the spinal cord. The course of fibres from the nucleus of the lateral columns is not given They get into the formatio reticularis 1 vide Figs. 31 and 34) and ultimately reach the parietal cortex. Recent investigations by A. Hoche, of Strasburg, give new light on the course of the column of Growers or antero-lateral tract. His results support the conclusions of H. T. Patrick, THE BRAIN-AXIS. 235 of Chicago, and others, who traced the fibres of this column in lower animals to the region of the corpora quadrigemina, where they turn backward with the superior peduncle of the cerebellum and end in its middle lobe. Hoche's investigations were on man, with the same result. Edinger had already proposed that the antero-lateral tract and the direct cerebellar tract be termed cerebello-spinal tracts, ventral and dorsal, respectively. Gowers' column, in view of these new facts, cannot now be considered as carrying pain- and temperature-sense impulses. Fig. 37. From Edinger. 236 THE BRAIN. Figure 37 gives a side view of the brain axis with the optic thalamus and part of the cerebral cortex. Fibres going to the occipital lobe from the primary optic centre are marked "stabkranz" (corona radi- ata). The left optic tract has been cut across, so that the chiasm with the remaining portions of the optic nerves is hanging to the right, out of its proper place. The word " fuss" is upon the foot or pes of the right eras cerebri. The geniculate bodies are indicated, the external or lateral one and the internal or median one being so designated. Of the corpora quadrigemina the positions of the two on the right side are shown and designated. The arm or brachium from each is seen. The three peduncles of the cerebellum are seen cut across, and their relative positions shown. The word "bindearm" is upon the superior, the word "pons" is on the middle, and the term corpus restiforme is upon the inferior peduncle. Fig. 38. From Edingei. PROGRESSIVE BULBAR PARALYSIS. 237 Figure 38 gives a view of the inferior surface of the brain-axis with the left hemisphere of the cere- bellum attached. At the optic tract in front, the chiasm and attached portions of the optic nerves have been turned backward. Pes pedunculi=pes or foot of the crus cerebri. The places of exit of the cranial nerves are marked by a Roman numeral in each case. Progressive Bulbar Paralysis. — Glosso-labio-phar- yngeal Paralysis. The disease is a progresssive de- generation affecting the motor nuclei existing beneath the floor of the fourth ventricle. Its cause is un- known ; its relation to degeneration of the motor cells in the anterior gray horns of the cord has already been stated. It is seen mostly in the latter half of adult life, the majority of the cases occurring between the ages of 50 and 60. It has been ascribed to ex- posure to cold, to trauma, to over-use of the related muscles, to lead poisoning, syphilis, great emotional strain, and one case appeared after an attack of diph- theria. Its onset is very gradual, the first symptoms being those of the tongue, whose finer movements in articu- late speech become impaired, the sounds represented by the letters 1, t, d, n and r being the first to become indistinct in enunciation. Later, the letters k, g hard and j are imperfectly uttered. The tongue may by this time show some gross changes ; it cannot be freely or fully moved and may show some area of distinct atrophy. Later the lips become affected and the labials p, b, f, v, m, as well as the vowel o, cannot 238 THE BRAIN. be properly sounded. When the muscles of the soft palate become involved, a nasal tone is given to the speech, and from imperfect closure of the posterior nares in attempting to swallow liquids, the latter may come out of the nose. The oesophageal muscles being affected, swallowing becomes a matter of difficulty, and, as there is im- perfect closure of the larynx, there is danger of invasion of the larynx and bronchi by foreign matters and the consequent setting up of pneumonia. When the laryngeal muscles are well involved the voice is weak or veiled or even absent, while coughing is impossible or toneless. The atrophy of the tongue increases so that its movement is eventually impossible, and as it lies at the bottom of the buccal cavity it usually exhibits a peculiar fibrillary tremor to be likened to a fine vermicular motion ; furrows and depressions in the tongue show the atrophy. The lips also become atrophic, are incapable of closure, so that the mouth is always more or less open, and the patient cannot blow or whistle or smile. From the open mouth (the lower lip and chin hanging), the saliva drools con- stantly, while the muscles of the upper part of the face being unopposed, the naso-labial folds are more pronounced than normally and the face takes on an expression of pain. Sensation is not affected, except that a feeling of tension is felt in the muscles of the throat, but the pharyngeal reflex becomes lost. The electrical reactions may show no change from ACUTE BULBAR PARALYSIS. 239 the normal until the disease has well advanced, and then only the partial reaction of degeneration. The disease is slowly progressive, yet most of the cases end fatally within three years or so ; cases have been reported in which the lethal termination occurred within the first year. The fact that the degeneration is only part of a widespread process in the motor nuclei, whether of the anterior gray horns below or of the region of the aqueduct of Sylvius above, must be held in mind in considering the prognosis. The disease is incurable. An acute, apoplectic form of bulbar paralysis, due chiefly to thrombosis or embolism, occasionally to haemorrhage, exists. With this, since other parts in addition to the motor nerve nuclei of the bulbar region are involved, there are usually some additional symp- toms as well as the suddenness or rapidity of onset, to serve as guides in diagnosis. Paralyses in the limbs, rapid pulse, disturbances of respiration and at times implication of the bladder, put the trouble outside the category of degenerative nuclear disease. Tumors affecting pons or medulla may by pressure give rise to many of the symptoms of bulbar paralysis, but the existence of syphilis, of cardiac affection, or of vas- cular disease, will direct the attention aright. Pseudo-bulbar paralysis must be borne in mind as a possibility. It is due to symmetrically placed lesions in the cortex of both cerebral hemispheres or in the basal ganglia on both sides. The symmetry in location on the two sides will not be absolute and the apoplectic 24O THE BRAIN. onset, or the occurrence of stages of advance, will distinguish this form from the slowly progressing trouble due to degenerative disease in pons and me- dulla. A special form of disease having bulbar paralytic (and sometimes atrophic) symptoms, mostly with some ophthalmoplegia, and in many of the reported cases muscular asthenia which may involve all the limbs, has been described by a number of observers. The disease may begin with ptosis (one-sided or bilateral) or some other muscular affection of the eye. Here> as also in all the muscles involved, the special feature is myasthenia, so that a few efforts tire out any muscle for the time being, and this exhaustibility appears under tests by the faradic current, the muscle respond- ing fairly well at first, the response failing after a few contractions have been elicited. The condition worsens, but after a time, it may be months, improve- ment may set in and an apparent restoration occur. This recovery is believed to be deceptive and to mean only remission. Cases have died after return of the disorder following a complete apparent recovery lasting several years. Post-mortem examination has so far revealed nothing to account for the symptoms. The bulbar affection just described has lately at- tracted a great deal of attention. Oppenheim has termed it bulbar paralysis without post-mortem find- ings; Jolly, amyosthenia gravis pseudoparalytica ; and Strlimpell, asthenic bulbar paralysis. As Erb had re- PSEUDO- BULBAR PARALYSIS. 24 1 ported three cases of the affection in 1878, it has been called Erb's disease, but the name asthenic bulbar paralysis is generally accepted. The treatment of bulbar paralysis must be largely guided by the diagnosis in any case. In the pseudo- bulbar paralysis (from cortical lesions) remedies must be addressed to such lesions if possible, and greater weight must be given to the non-bulbar symptoms. In the apoplectic form, while the bulbar symp- toms must be guides in choosing a remedy, never- theless the character of the lesion, when this can be ascertained even as a probability, may make a change in the selection. The true degenerative form will require the reme- dies that are known to produce similar degeneration. Dr. Berridge, of London, reported as a fact that workers in binoxide of manganese are frequently af- fected by bulbar paralysis. The writer has used this drug in one case without result, but in a case of the apoplectic variety, the symptoms having existed with- out material change for two years, the Manganum binoxide given three or four times a day in third tri- turation caused marked improvement in speech, power of swallowing, and other symptoms. Lilienthal in his therapeutics (made up of clinical reports of cure or improvement) gives Plumbum, Caasticum, Cadmium sidph., Phosphorus and Nux vomica as having been serviceable in bulbar pa- ralysis, but without differentiating between types of the disease. 242 THE BRAIN. Two cases of the asthenic form are at present un- der the writer's care. Manganese binoxide 3d trit. was given in both cases without any perceptible ef- fect. Nux vomica 2x seemed to hold the disease in check, but one patient said it stimulated him, yet had no effect on his speech or power of swallowing. Hydrophobinum 200 (given because of the nerve cen- tres affected) brought great relief, and then because of the choking in a dangerous degree that came on when laughing, Stannum 200 was prescribed, and with marked improvement. Meanwhile, the speech has be- come better, its tone less nasal, but some myasthenia is present, so that he has to take a period of rest before any business interview. It is typical of such cases that their symptoms are always better in the morning after a good rest, which brings Phosphorus to mind as a remedy. Prof. Jolly in reporting his cases, mentions the fact that the symptom myasthenia as seen in them was very like that produced by proto-veratrine. In a case of bulbar affection not of the asthenic variety, but due to syphilis and probably gummatous, seen by the writer several times in consultation, the physician had prescribed Veratrum viride, low, on the indica- tions characteristic of that drug, especially those of the tongue. Whenever he withdrew the remedy, the bulbar and paralytic symptoms distinctly worsened. The patient was supported for many weeks by rectal feeding, and received large doses of Potassium iodide in the same way, but notwithstanding the use of the lat- DISEASES OF THE CENTRAL XERVOUS SYSTEM. 243 ter drug, it is more than doubtful that his recovery from the dangerous bulbar symptoms, which resulted after a few months, would have occurred without the special influence of the Veratrum. Diseases of the Central Nervous System. Under the term central nervous system are in- cluded all nerve structures existing from the cerebral cortex down to, but not including, the ganglion cells in the anterior gray horns of the spinal cord and the places of entrance into the posterior part of the spinal cord by the posterior spinal nerve roots. The word brain means all the nerve structures within the skull cavity, and these are divisible into five pairs of organs, three of which are evident on inspection of the brain when removed from the skull ; the remaining two, being buried within the brain mass, are recognizable after section as anatomical entities only by a knowledge of development. The brain developes from five fundamental brain vesicles (originally three primary ones) in such way that the first (beginning at the nasal end) grows at such a rapid rate that it covers in all the others ; the second and third develop to a less extent, re- taining their original relatively central position, while the fourth developes laterally into two large masses; the fifth undergoes but little enlargement. The structures of the fourth and fifth, although covered in from above, are readily seen from below. The first is the cerebral hemisphere; the second 244 THE BRAIN. the thalamus ; the third the corpora quadrigemina anterior and posterior of one side, the fourth is pons and cerebellar hemisphere, while the fifth is a lateral half of the medulla, In each case there is a pair separated or nearly separated, one from the other, except in the third and fifth where the separation is only indicated by a more or less distinct raphe. The functions of the brain structures are the ag- gregations of the functions of their individual neu- rones, and these functions are of two kinds — that is to say, the cell body either sends out or receives impulses. A centrifugal impulse or one from the cortex to the periphery, is a motor impulse; a centripetal one or one from the periphery to the cortex as the final or end station, is a sensory impulse. Motor impulses are of one kind only — that is, they cause contraction of muscle fibre. Hence, it may be assumed that if a motor impulse from cells in a cor- tical area in relation to, say, the right leg, could be switched off, as it were, so as to reach a muscle of the left forearm, that muscle would be put into ac- tion. It is otherwise with sensory impulses. Here the end-organs are highly differentiated, so that quali- ties of heat, cold, simple touch, pain, the degree of flexion of a limb, or the amount of contraction of a muscle, can be in each case correctly appreciated. It is to be assumed that could the cells of the organ of Corti replace the rods and cones of the retina, the former would not be affected by the rays of light falling on the pigment layer — they were not DISEASES OF THE CENTRAL NERVOUS SYSTEM. 245 diner entiated for such purpose. On the other hand, it may be that the end-organs of the skin are not so highly differentiated as has been just suggested, but that they receive different impressions and send inward impulses of a general character, which, in turn, are taken up by intercalated neurones acting as transformers, and passed on as fully differentiated qualities of sensation. In this way may be explained the existence of a chain of several neurones which exist in the pathway of sensory conduction; for the con- duction of centrifugal motor impulses but two neurones are needed, both being long ones, the central neurone beginning as the cell of the motor area of the cortex and ending in the neighborhood of the large gang- lion cell of the anterior gray horn of the cord, which cell is the beginning of the peripheral neurone, whose terminus is in the end plate upon a muscle fibre at the periphery. The neural pathways between the cortex and periphery, both sensory and motor, form the projection system of fibres. The optic thalamus is the fully developed second fundamental brain vesicle. It is in connection ap- parently with all parts of the cerebral cortex of its own hemisphere and sends also fibres downward, some of which join those of the motor tract whose cells act independently of volition. The thalamus is divisible into five large irregular and unequal masses, the larger posterior one being the pulvinar. The third fundamental brain vesicle in developing 246 THE BRAIN. gives rise to the corpora quadrigemina and the struc- tures below them, including the nuclei of origin of the third and fourth cranial nerves. The vesicle develops inwardly instead of outwardly, so that in- stead of large ventricular spaces there is a channel of small lumen known as the aqueduct of Sylvius, and which is all that remains there of the original neural tube. Below are the crura cerebri, not sepa- rable anatomically from tissue above ; yet as they are composed largely of the motor and sensory tracts, together with other fibre tracts, they cannot be considered genetically as derived from the vesicle in question. The fourth vesicle develops laterally into two masses, the cerebellar hemispheres, from each of which fibres pass inwards, decussate in the middle line, and go forward to the frontal lobe of the oppo- site cerebral hemisphere. The mass of fibres on each side and at the cross- ing, form a considerable part of the bulk of the pons Varolii, which also holds the motor and sensory tracts in their passage downward and upward, respectively. Still further increasing the bulk of the pons, are the nuclei of the fifth and sixth cranial nerves. The fifth brain vesicle develops into the medulla oblongata, which contains anteriorly the motor tracts now united into compact masses of fibres, known as the pyramids of the medulla, the continuation upwards of sensory pathways, the nuclei of cranial nerves from the seventh to the twelfth, and specialized structures known as the olivary bodies. THE CEREBRAL CORTEX AND THE CORTICAL AREAS. 247 The Cerebral Cortex and the Cortical Areas. The cerebral cortex is composed so largely of cells that on section it appears gray. It is in folds or con- volutions (also termed gyri); the depths or de- pressions between them are termed fissures (or sulci). The fissures appearing earlier in fcetal life are known as primary fissures and are an inch or more in depth. These are the fissure (so-called) of Sylvius, the fissure of Rolando, the interparietal — all on the outer face of the cerebral hemisphere, and on its inner face the parieto-occipital and the calcarine fissures. Between the cerebral hemispheres at the top is the great longitudinal fissure completely separat- ing the two hemispheres in the frontal and occipital regions, but in the middle only as far below as the corpus callosum. Fig. 39. From Edinger. 248 THE BRAIN. Fig. 40. From Edmger. Figures 39 and 40 show the locations and names of the different convolutions, lobes and fissures. The frontal lobe extends as far backward as the fissure of Rolando and downward to the fissure of Sylvius. It extends over and around to the inner face of the hemisphere as far back as the calloso-marginal fissure and an indeterminate line ascending from the latter to the upper edge of the hemisphere. The parietal lobe is included between the fissure of Rolando in front, the fissure of Sylvius below and a line drawn from the posterior end of the latter to the lower end of the anterior occipital fissure, thence extending to the parieto-occipital notch. On the inner face of the hemisphere the parietal lobe is represented in the precuneus between the ascending part of the calloso-marginal and the parieto-occipital fissures. THE CEREBRAL CORTEX AND THE CORTICAL AREAS. 249 The boundaries of trie occipital lobe are the parieto- occipital notch above, in front the interparietal and anterior occipital fissures and a line from the anterior end of the lateral occipital fissure downward to the lower edge of the hemisphere. On the inner face of the latter the occipital cortex is in the cuneus and the lingual lobule. The temporal lobe includes all of the cortex below the fissure of Sylvius and in front of the imaginary lines already described in bounding the parietal and occipital lobes. Beneath, it is continuous with the occipitotemporal convolution, and on the inner face, with the uncinate gyrus and the gyrus of the hippo- campus. Fig. 41. Fig. 41, from Edinger, shows the convolutions on the under surface of the cerebral hemispheres. The convolutions or gyri are marked on one hemisphere, the fissures or sulci on the other. Their continuance with the inner and outer face of the hemispheres is readily seen. 25O THE BRAIN. The cells of the cerebral cortex are of different kinds and have been depicted as being in several layers, from four to nine in number according to the views and interpretation of the observer. The cells may be classified according to their respective functions and these are to send out to or to receive impulses from the periphery (here meaning any part outside the brain) and to interact among themselves in co- ordinating or integrating separate impulses or in arous- ing to activity cells not directly impressed (reproduc- tion of memories, association of ideas). The neuraxones from the cells of the motor area and the fibres bringing sensory impulses to the sensory areas are called the projection system of fibres; fibres passing from the cells of one convolution to those of another in the same hemisphere make up the as- sociation system of fibres ; and fibres that connect the cells of any cortical part of one hemisphere with the analogous part of the other are known as the com- missural system of fibres. A motor impulse (projection system) is carried by two neurones only, a central and a peripheral one. The sensory path to the cortex from the periphery is over two or more neurones. In the association system there are long tracts as well as very short ones ; thus, the frontal lobe is connected with the temporal and occipital lobes, the extremes of the temporal and occipital lobes are connected by fibre tracts that can be readily demonstrated. The fibres of the commissural system make up the THE CEREBRAL CORTEX AXD THE CORTICAL AREAS. 25 I bulk of the corpus callosum and the anterior white commissure. Experimental investigation on the lower animals and accidental ones on man have shown conclusively that certain definite areas of the cerebral cortex sub- serve certain functions ; that when a certain part is excised or otherwise destroyed there follows loss ot motor power in a definite part of the body and that if in another animal the same cortical area be irritated there appears motion (spasm) in the part analogous to that paralyzed in the previous experiment. Further, the proof from pathology puts the truth of the doctrine of brain localization beyond question. To go more deeply into the methods of these in- vestigations or their history is beyond the scope of this book. Their results as at present accepted are shown in Figure 42. The cortex of the central convolutions of one hemis- phere is the motor area for the opposite half of the body and is divisible into three sub-areas, the upper third for the lower limb, the middle third for the up- per limb and the lower third for the face (including lips, tongue, larynx, and pharynx). Finer subdivisions of these sub-areas has been fig- ured by different authors but have not as yet received full acceptance. The sensory impulses from the periphery are re- ceived by the cells in the posterior central convolution and probably also in the cortex extending a little be- hind the interparietal fissure. It is held by many that 252 THE BRAIN. there are cells with sensory function in the anterior central convolution. The cortical areas for some of the special senses are well known. The visual cortical area is in the occipital lobe and chiefly in the cuneus with some extension to the occipital convolutions on the outer face of the hemisphere. The auditory area occupies the greater part of the superior and middle temporal convolutions. The areas for taste and smell are in the convolution of the hippocampus and in the uncinate gyrus (some writers give just the reverse). Fig. 42. Fig. 42. From Edinger (modified). The motor speech area is indicated by the word Sermo ; the auditory speech area by the word Auditus ; the visual language area by ViSUS lit., and the visual perception memory area by V. percep. In the figure the tip of the temporal lobe is assigned by Edinger as the cortical area for the sense of taste. In the text an alternative location is given. It is axiomatic now that when a cortical cell acts for the first time it undergoes some change, that some permanent alteration is thereby made in it and that when it is called upon to act again the individual THE CEREBRAL CORTEX AND THE CORTICAL AREAS. 253 is conscious that he has had such experience before. This is the explanation of memory. If the first im- pression or change in the cell were made under special intensity, or if the action be sufficiently often repeated the individual can at will call up a mental image of the object seen, or a mental reproduction of the sound heard (in the case of such sensory impressions) or can repeat some intricate muscular action. We possess, therefore, the faculty of memory not only for sensation received but for motor impulses sent out. The child learns to talk by a very slow continuous process lasting during several years. And when it has learned, its faculty of articulate speech is simply the aggregate of all its motor memories of how to arrange its lips, tongue and pharyngeal muscles to produce certain definite sounds. The area for such muscular memories is located in the posterior part of the inferior or third frontal convolution. This is also called Broca's centre, from the name of the physician who first successfully called attention to disease of this area as the cause of loss of the speech faculty without loss of power in the muscles used in speech production. This result is termed motor aphasia ; the subject not only cannot speak, but he also cannot repeat what another has requested him to say, nor can he read aloud. The areas for sensory memories of language are in- cluded in or are near to the sensory areas for hearing and sight. 2 54 TH E BRAIN. The area for auditory speech memories embraces the posterior half of the first temporal convolution and a small part of the second. Destructive lesion of this area causes loss of the memories of the meanings that the individual has learned to attach to certain uttered sounds or words. Hence, a person so affected is, when hearing his own language spoken, as one listening to a foreign tongue. He is not deaf, for sounds other than those of language are heard and appreciated as well as ever. The condition is known as auditory or sensory aphasia. In this case he can speak but is apt to use words wrongly; he cannot speak " after" another, nor read aloud correctly, be- cause he no longer has the regulating influence of the auditory speech centre. Visual memories related to language are those of printed or written words. They are stored up in the cortex of the angular gyrus. Destructive lesion in this area causes loss of the ability to read and the individual is in the position of one who has never learned to read. The condition is known as word blindness or alexia. An infrequent form termed optical aphasia is that in which the individual while recognizing by sight certain objects (watch, stove, etc.,) and knowing their purpose yet cannot "find" their names, but may be able to do so when aided by the sense of touch or of hearing, from whose speech centres the motor speech memory may be aroused. The lesion is believed to be in the cortex between the angular gyrus and the extremity of the auditory speech area. THE CEREBRAL CORTEX AND THE CORTICAL AREAS. 255 The areas for language are marked in Fig. 42, page 252. Writing from a copy or at dictation may be either lost or retained in motor aphasia ; in auditory aphasia the former is retained, the latter lost. As the lesion may not be destructive of a whole area, degrees of loss in the different aphasias must exist and in many cases affected, a complicated symptomatology is pres- ented. As the different speech centres are connected, each with all the others, by association fibres, it is evident that a lesion interfering with conduction along one or more of these pathways must cause disturbance in the inter-relation of those centres among themselves. Finally, lesion in the path way s of conduction of the motor speech centre with the organs of speech, and of the organ of hearing with the auditory speech centre, causes aphasia of a simpler type than in the cortical forms. The making of a schema explanatory of the physio- logical bases for the production of speech and its understanding, brings into the problem elements that are psychological, which must in any case be influenced and varied by the inventor's self-introspection. Paraphasia is the faulty use of words by substitu- tion ; the individual intending to ask for water, for instance, may utter the word " stable " or some other unrelated word. Conversation becomes almost impos- sible when paraphasia exists. It is evidence of loss of conduction between the speech centres or of a lesion in the auditory area; it does not occur in sub- cortical sensory aphasia, and, of course, will not exist in cortical complete motor aphasia. 256 THE BRAIN. The terms just used are, cortical, meaning that the actual cortical area is directly affected; sub-cortical, when the pathway between the peripheral organs and the related areas is injured. The term transcortical, as applied to aphasia, means that the pathway from a supposititious "idea" centre (which in turn is used only to represent concretely the summation of all the memories such as the color, shape, weight, tempera- ature, smoothness or roughness, taste, odor, etc., which, taken together, make up the idea of an object), to the motor speech area or from the sensory speech areas to the assumed "idea" centre, is injured. A "writing centre" in the cortex is not believed to exist. Voluntary writing is initiated in the young, and in the poorly educated adult, primarily from the arbitrarily assumed "idea" centre via the motor speech centre. Thus may be explained the movements of lips and tongue in children when learning to write and also in the adult who rarely writes. In the ordinarily well educated person the writing act is probably dominated by the auditory memories of the words to be written, hence from the auditory speech centre ; in those whose intellectual work is predominantly reading, the act of writing is probably immediately governed from the visual centre for language. The schema, Fig. 43, of Wernicke, and the explan- atory table, apply to pure cases of isolated forms. Such cases are not common, and when two or more forms are associated the results of examination of the THE CEREBRAL CORTEX AND THE CORTICAL AREAS. 257 patient's powers of language may not be susceptible of satisfactory interpretation. a a \ — Ifi Fig. 43. Cortical a. — Loss of understanding uttered language Cannot speak after another " write at dictation " write voluntarily " read aloud Can copy Can speak voluntarily but with paraphasia Cortical b. — Cannot speak voluntarily " speak after another " write from dictation " write voluntarily " read aloud Can understand what is spoken Can copy Subcortical a. — Cannot understand uttered language " speak after another " write from dictation Can write voluntarily " copy " speak voluntarily " read both to one's self and aloud Conduction aphasia, between a-b. — Can speak voluntarily and after another " understand spoken words " copy Cannot read aloud " write at dictation " write voluntarily Transcortical b. — Cannot speak voluntarily " write voluntarily Can speak after another " understand spoken language " read understandingly and aloud. " copy " write from dictation Subcortical b. — Cannot speak voluntarily " speak after another Can copy " understand spoken language " read understandingly " write at dictation " write spontaneously " express number of syllables in a word Transcortical a-.B — Cannot understand words heard " understand what he reads Can speak after another but without understanding read aloud without understanding write voluntarily but with paragraphia write at dictation speak voluntarily but with paraphasia copy 258 THE BRAIN. a represents the auditory cortical speech area; &, the motor cortical speech area. B, the assumed idea centre. The dark lines below a and b are the pathways from the auditory organ, and that to the organs of speech respectively. The arrow - heads show the direction of conduction. The association fibres between the auditory speech area and the motor speech area are represented by the line from a to b. Interruption in it causes con- duction aphasia. Destructive lesion at a causes cortical auditory aphasia. Lesion at b causes cortical motor aphasia. Lesion in the fibres (dark line) below a causes subcortical auditory aphasia. Lesion in the fibres (dark line) below b causes subcortical motor aphasia. Lesion between a and B causes transcortical au- ditory aphasia. Lesion between b and B causes transcortical motor aphasia. Alpha represents the cortical visual language area; beta represents the motor area for right hand. In reading aloud the visual area arouses the auditory area a, and this, in turn, the motor speech area b. Understanding what is read is by continued trans- mission from alpha to a and thence to B. Writing at dictation is via a, alpha, beta. Copying needs only the visual language area and the motor area in left hemisphere for the hand, and association fibres, thus alpha — beta. THE CEREBRAL CORTEX AXD THE CORTICAL AREAS. 259 The visual memories of objects perceived are stored up in the cells of the angular gyrus, but as it is next to the supramarginal gyrus, disease of one area often affects the other. Hence, with loss of the power of reading there is frequent association of loss of the recognition of familiar objects. The latter condition is known as apraxia; in it the patient is unable to recognize by sight objects of every-day life, but may be able to do so through uuinjured areas for other modes of recognition. Thus, a watch being unrecognized by sight may be at once cor- rectly perceived when it is placed near the ear and its ticking heard. Lesion of the fibres beneath the angular gyrus has been oftener noted than lesion in the cortex. The various sensory and motor faculties connected with language are in the left cerebral hemisphere in right-handed persons; in left-handed persons they are in the right hemisphere. In either case after de- struction of an area the corresponding area of the opposite hemisphere soon learns to act as substitute. The visual memories of objects (perception) ap- pear to be represented in the angular gyri of both hemispheres. (See Fig. 42, page 252.) Aphasia must be distinguished from dysarthria or anarthria, in which the muscular activities involved in producing articulate speech are impaired or lost as a result, commonly, of degenerative disease in the medulla (vide bulbar paralysis). Aphasia is only a symptom, most frequently from 260 THE BRAIN. lesion in the affected area, or the many association paths from one area to another. It occurs also as a result of toxic influences (infectious diseases, uraemia, etc.), from trauma (depressed fracture of the skull af- fecting one or more of the areas related). It also may appear in conditions of exhaustion and after fright ; in the latter case if complete motor aphasia exist it may be difficult to distinguish it from hys- terical muteness. Treatment. When an organic affection is the cause of aphasia the treatment must be directed to such disease. When functional only, the symptom aphasia will be taken into account. Our materia medica contains very little of purely aphasic symptoms of any one variety. Motor aphasia is found under Chenopodium antJielminticum ; para- phasic symptoms are given under Natrum mur., Cal- carea carb., and Lycopodium ; alexia, under Lycopo- dium, Hyoscyamus and Plumbum, and optical aphasia under Baryta acetica. Some of the symptoms given are possibly due to general mental weakness and the differentiation of remedies for the varieties of aphasia must be made now from clinical experience. THE CEREBRAL CORTEX AND THE CORTICAL AREAS. 26 1 Fig. 44, from Edinger, shows a perpendicular transverse section of the brain through the optic thalami. The left optic thalamus is shown separated from the right one by the third ventricle. The positions of the nucleus caudatus and nucleus lentiformis and the relation of the three bodies to the internal capsule are evident. To the outer side of the lenticular nucleus is seen the cortex of the island of Reil at the bottom of the so-called fissure of Sylvius. The positions of the corpus cal- losum, fornix and optic nerves, all cut through, are indicated. The drawing is largely schematic. Fig. M. Fig. 45, from Edinger, is a horizontal section of the brain. The various parts are indicated by their names. Balken = corpus callosum. Fig. 45. 262 THE BRAIN. Anaemia of the Brain. As an independent primary condition anaemia of the brain cannot exist, but is found as a secondary state, the result of vascular disease or of cardiac weakness, or as part of a general anaemia. In its acute and usually temporary manifestation the symptoms may be alarming to lay observers. This is termed syncope or a fainting fit, and is com- monly caused by fright or similar emotional shock, which by influencing the heart results in lessening or stopping the flow of blood to the brain. The symptoms are mental confusion, loss of vision, vertigo, nausea, loss of power over the limbs, so that the pa- tient falls and then remains apparently unconscious, or nearly so, for a short time, varying from a minute or a few minutes to a considerable fraction of an hour. In less severe cases the above-mentioned symptoms are less in degree. In cases of chronic cerebral anaemia there are drowsiness, which is replaced by insomnia on lying down (effect of position), mental depression, apathy, with inability or aversion to work, attacks of fainting, weakness of memory, etc. All of the symptoms ex- cept insomnia are relieved by lying down. The prognosis of the acute condition, especially as seen in young persons, is favorable, and there is no danger to life even in a prolonged syncope when it is not dependent upon an excessive loss of blood or pronounced cardiac disease. HYPEREMIA OF THE BKAIN. 263 In chronic cerebral anaemia tlie prognosis is that of the underlying cause. Treatment of an attack of syncope should always include placing the patient in a horizontal position without pillow for the head, and stimulating reflexly the respiratory and cardiac centres by dashing cold water on the face and chest. Hyperemia of the Brain. When, from any cause, the flow of blood into the cranial cavity is in such amount or at such rate that the veins cannot carry it off in equal degree there is present an excess of arterial blood; and when the capacity of the veins is for any reason increased in relation to a normal influx of arterial blood, there will be an excess of venous blood. Both con- ditions are hyperaemias, the former being termed active, the latter passive. Active or arterial hyper- aemia may be produced by strong emotion, such as a fit of anger, by the action of certain drugs, such as alcohol, nitrite of amyl, nitroglycerine, etc., by a cold bath, etc. Passive or venous hyperaemia is usually a continuous state dependent upon some mechanical obstruction to the venous efflux from the brain, such as tumors of the neck pressing upon the jug- ular veins, certain diseases of the heart, emphysema of the lungs, etc., but a passing hyperaemia of this kind follows muscular effort in which the diaphragm assists, as in the case of lifting heavy weights, strain- ing at stool, etc. 264 THE BRAIN. Repetition of the causes of arterial hyperemia re- sults in a more permanent dilatation of the arterioles and this in turn gives rise to retardation of the blood current with consequent lessened rate of metabolism within the brain, an engorgement hypereemia, yet with many of the symptoms seen in states of cerebral anaemia. The symptoms of acute arterial hyperemia of the brain are a rising of heat to the head and face, with a sense of distension, pulsation felt in the carotids and head, headache, at times vertigo or even partial obscuration of consciousness. The symptoms are aggravated by stooping, coughing, lying down, etc. Such acute congestion may be accompanied by a rise of body temperature, and cannot be distinguished from the early stage of a meningitis. Passive hyper- emia from venous obstruction below has similar symp- toms, but usually of less intensity and without the marked pulsation seen in the active arterial type. In continued or chronic states of engorgement hyper- emia due to loss of tonicity of the vessels' walls, there are sleeplessness with more or less drowsiness when up and about, weakness of the mental powers, especially when concentration of mind is required, headache, with emotional depression or even unmotived anxiety or morbid fears. This condition is cerebral neurasthenia. Prognosis in cases of active or arterial congestion is good, except where cardiac disease seems to be the cause ; in the form due to venous obstruction the CEREBRAL MENINGITIS. 265 prognosis is that of the causal condition ; in the form due to vascular dilatation the prognosis for cure will depend on the length of time the condition has existed, upon the underlying cause (alcohol, tobacco, etc.). In cases of recent origin or where reformation in the mode of life can be established, a cure may reasonably be expected. Oppenheim considers that masturbation plays a predominant role in causing dilatation of the cerebral blood vessels. The treatment of cerebral hyperemia must be by remedies chosen with recognition of the causal con- dition if such can be found, and the accompanying symptoms. As a symptom, a congestive cerebral state can be produced by very many drugs; in the Symptom Register to Allen's Encyclopedia 52 drugs are given under the rubric Congestion of the Head. The rem- edies most often indicated in the condition are Bella- donna, Hyoscyamus, Melilotus, Opium, Lachesis, Calcarea carbonica, Ferrum phosphoricum, Nux vomica and Vera- trum viride. JDirca palustris and Fagopyriim esculentum have been eifective in the writer's hands. In pas- sive hyperemia Chloral hydrate 30, Baryta carbonica, China, Silicea, Piper methysticiim and Amyl nitrite in potency have been of great value. In any case the accompanying symptoms should decide the choice of the remedy. Cerebral Meningitis. Inflammations of the meninges of the brain are classi- fied as pachymeningitis and leptomeningitis according 266 THE BRAIN. to the membrane chiefly affected, the dura, or the pia and arachnoid. External pachymeningitis (dura mater) occurs at times as a result of disease in the skull bones. Its symptoms are the general ones, fever, headache, per- haps delirium or even convulsions and its relief or cure depends on removal or lessening of the externally acting cause. Internal pachymeningitis is haemorrhagic in its nature, the haemorrhage occurring in successive out- breaks. The effused blood becomes organized and forms layers of connective tissue which are readily separable on post-mortem examination and are studded, especially the innermost ones, with minute new haemor- rhages. The thickening thus formed acts as an extra-cerebral tumor and upon its location will depend the special symptoms. It occurs in chronic alcoholism, in dementia paralytica or other chronic wasting disease of the cerebral cortex, as well as in chronic kidney disease. It is stated to have been observed in individuals of the hemorrhagic diathesis and during the course of pernicious anaemia, leucaemia, scurvy, etc. Light cases may show only the symptoms of some general affection of the brain, but in a severe case there is marked cerebral excitation similar to that of delirium tremens, or a unilateral epileptiform attack. This may be followed by a comatose state that may last for days or even weeks (Oppenheim). With the usual signs of increased brain pressure the first attack LEPTOMENINGITIS. 267 may end fatally and then cannot be distinguished from an apoplexy, but if recovery occurs it is apt to be complete. The diagnosis is difficult and at first may be impossible ; the chief point is the recurrence of symptoms of cortical irritation in an alcohol habitue , an old person, or alter external injury to the head. Leptomeningitis or inflammation of the pia (and usually the arachnoid) occurs in three or four distinct forms — the purulent, tubercular, syphilitic, and an epidemic form known as cerebro-spinal meningitis. Purulent leptomeningitis is caused by some pyogenic micro-organism; thus the disease is an outgrowth of some infectious process in a part of the organism other than the brain. Thus pyaemia, septicaemia, pneumonia, scarlet fever, and similar diseases may give rise to an infection of the meninges via the blood vessels. Direct invasion, by way of the sheaths, along the out- side of nerve trunks, or of vessels from suppurating neighboring structures is not uncommon. Injuries to the head resulting in an open wound may give access even through unbroken bone to the germs (v. Berg- mann). The disease-process affects chiefly the convexity of the cerebral hemispheres, but in many cases the mem- branes at the base are also involved. Hyperaemia of the pia-arachnoid, then thickening and turbidity and next the appearance of pus, mostly aggregated along the fissures, is the order of succession. The cortex may become involved, small haemorrhages, foci of sup- puration and an interstitial oedema being present ; or 268 THE BKAIN. the ventricles may show inflammation of their lining, often with a sero-purulent fluid within or even a real hydrocephalus. Fever in the beginning and of atypical course, with or without a chill, violent headache, continuous but with times of aggravation, obscured consciousness with delirium or sopor are common symptoms, while during the delirium and even in sopor, evidences of the ex- istence of severe headache are present. The pulse is often irregular, bowels confined, abdominal walls retracted and extreme hyperesthesia both of the periphery and of the special senses is present. Con- vulsions may occur, either general or limited to one side or to a single limb. When the disease-process affects the basal mem- branes the symptoms are those of compression or irritation of the cranial nerves, such as paralyses or spasm of ocular muscles, inequality of pupils, absence of the light-reflex, optic neuritis, facial paralysis or facial spasm, gnashing of the teeth or even trismus. Perhaps the most diagnostic symptom of meningitis of any kind that has invaded the posterior fossa of the skull is the retraction of the head, with rigidity of the neck, often accompanied with rigidity of the limbs. In the later stages coma with loss of the deep reflexes comes on, together with irregular and rapid pulse, rapid and sometimes irregular respiration or respiration of the Cheyne-Stokes variety. Death occurs in the increas- ing coma or in convulsions. The disease is always acute in character and may TUBERCULAR MENINGITIS. 269 end fatally in a few days, but more commonly it lasts from one to two weeks. When coma comes, a fatal ending may be predicted (Oppenheim). Recovery lias been observed, in one case of the writer's with serious damage to the cranial nerves and the mental powers. The prognosis is always grave. The diagnosis will be made from the rapid oc- currence of cerebral symptoms in individuals suffering from septic or suppurative processes in other parts, or from infectious diseases. But these diseases them- selves may begin with cerebral symptoms that later clear up. Tubercular meningitis, like purulent meningitis, is to be considered a secondary disease, but, unlike the latter, is always due to the invasion by the same bacillus or to the effects of its toxine. Its victims are never those in good health, although in some instances it may appear to be the primary disorder, but are pale, weak, ill-nourished, " scrofulous" individuals, already affected with some form of tuberculous de- posit. It is mostly seen in children between the ages of two and twelve, but occasionally in the adult. The disease is characterized by a long prodromal stage, as might be inferred from the kind of bacillus at work. The tubercle bacilli being carried via the blood vessels to the meninges, settle thereon and, as a result of their presence and irritative action, inflam- matory exudative changes in the membrane occur, 27O THE BRAIN. with subsequent changes known as the eruption of miliary tubercles, in which the characteristic bacillus tuberculosis is found. The process is mostly at the base, but usually extends to the spinal membranes. Along the fissure of Sylvius and other large fissures on the convexity, tubercles and exudation are found, but in less amount. The prodromal symptoms are those of general mal- aise. The child becomes languid, refuses to play, becomes irritable or moody, with restless nights or even sleeplessness. Headache comes on, at first light and temporary, later severe and continuous, yet with periods of violent exacerbation, and vomiting without cause and projectile in character, constipation and occasional rises of temperature. Intermittency of these symptoms is to be expected during its early or pro- dromal stage, which may last during three or four weeks or may extend over a much longer period. When the disease has, so to say, settled, and the meningitic process has begun, the headache becomes continuous and intense, delirium appears, with great restlessness, fever of an irregular type, pulse showing the same peculiarity, but more often slow, partial or general convulsions, gnashing of the teeth ; the sleep, such as it is, is interrupted by a sudden pierc- ing scream (cri hydrencephalique), The symptoms due to irritation or pressure at the base are those of interference with the cranial nerves there, especially the ocular nerves. Inequality of the pupils with dilatation (less often contraction), with CHRONIC MENINGITIS. 2J\ loss of the light-reflex, paralytic strabismus, associated deviation of both eyes to one side and even optic neuritis are symptoms to be looked for. Symptoms due to implication of structures in the posterior fossa are retraction of the head, with rigidity of muscles at the back of the neck, with extension to the back, and even the limbs. The delirium passes into sopor and then into coma, deceptive remissions being not infrequent ; the coma becomes more profound, the respiration irregular, as- suming at times the Cheyne-Stokes type, a general paralytic state of the muscles replaces rigidity, and with a rapid rise at times (104° or 105° F.), or lowering of temperature (96° F., or even lower) death ensues. The lateral ventricles generally contain an increase of fluid, turbid or at times sanguinolent in character; this state of hydrocephalus interims may be ex- tensive enough to affect, by pressure, the cortex. Diagnosis is to be made chiefly by the history (tuberculosis elsewhere), the age of the patient, and the early cerebral symptoms coming on in spells either singly or grouped. Prognosis is bad, but cases have been reported in which cure has resulted ; here the question of diag- nosis must be brought forward. Chronic meningitis as a manifestation of chronic alcoholism appears predominantly on the convexity, while when the result of the syphilitic process it affects chiefly the base. The symptoms in either case 272 THE BRAIN. are those of meningitis of the related type, although of less intensity, but the diagnosis of chronic menin- gitis, except when the above-named etiological con- ditions can be shown to exist, is practically impossible during life. Cases are said to have occurred as the sequel or continuation of the acute cerebro- spinal meningitis or of insolation. Epidemic cerebro-spinal meningitis is a disease due to a germ similar to if not identical with the pneumococcus. The disease occurs in the temperate zones, especially during the winter and spring, and in crowded dwellings, and chiefly among children and youthful individuals. It appears epidemically, but its distribution seems to depend in some degree upon climatic or ether similar conditions, since it is a rather common affection in some parts of the United States, while it is rare in other parts in nearly the same latitude. Sporadic cases, of course, can occur. The invasion by the disease is rapid and in some cases almost sudden. The early symptoms are general malaise, chilliness, restlessness, pains in the back and back of head and at times in the extremities, and the evidences of a ssvere illness are apparent. Next, vomiting, hypersensitiveness to noise, light and touch, with delirium and fever, come on. The temperature is variable, rarely goes beyond 104° F.; the pulse is rapid and also variable. Of diagnostic value is the appearance of herpes labialis in the early days of the disease. Retraction of the head, stiffness of the neck muscles, and contraction of the muscles of the back, EPIDEMIC CEREBROSPINAL MENINGITIS. 273 even to the production of opisthotonos, are symptoms that come on within the first few days, in varying degree. In most cases, some form of eruption appears on the skin, such as erythema, urticaria, roseola, purpura, the latter being of great diagnostic value. General convulsions may occur early in the disease and may recur. In unfavorable cases symptoms of paralysis with coma in the course of a few days or by the end of a week, and paralytic phenomena involving some of the cranial as well as the spinal nerves, are to be expected; these are myosis or other alteration of pupils, paralysis of muscles of the eyeballs, nys- tagmus, optic neuritis, partial or complete deafness, monoplegia, hemiplegia, or even paraplegia. In severe cases the disease runs a very rapid course, death occurring within a few days ; in cases of moderate severity the disease may extend over two or three weeks. The mortality varies in dif- ferent epidemics, in some 75 per cent, having been noted, the average being 57 per cent. (Oppenheim) ; towards the end of an epidemic lighter cases are in the majority. Pathologically the disease process is an inflamma- tion with fibro-purulent exudation in the pia extend- ing over the convexity and base of the brain, and also to the membranes of the cord with special ac- tivity around the lumbar enlargement. The cranial nerves, especially the optic, third and eighth are infil- trated or embedded, and the latter nerve may be a 274 THE BKAIN. pathway for extension of the inflammation to the in- ner ear and middle ear. Diagnosis is not difficult in an ordinarily well marked case if similar ones exist in the immediate neighborhood (epidemic), but in sporadic cases the affection has to be differentiated from other forms of meningitis (tubercular) and from other infectious diseases, especially pneumonia, which, indeed, may be associated. An absolute diagnosis may be made by aspiration of the spinal canal in the lumbar region, the aspirated fluid showing the presence of the meningococcus intercellularis, or of the pneumo- coccus, the latter apparently being the more virulent. Herpes labialis does not occur in tubercular menin- gitis. Sequelae are blindness, deafness, chronic headache, chronic spinal meningitis, muscular incoordination, and sometimes paralysis. Blindness and deafness im- prove spontaneously in some cases, but in most re- main. The treatment of any form of cerebral meningitis must at first be largely symptomatic. IF any causal indication exist it should be heeded ; hence, in cases of traumatic origin Arnica will naturally be first thought of; if from exposure to excessive heat, Glonoine. In general, the symptoms in the beginning will call for Belladonna, Bryonia, Gelsemium or Aconite. Later, if symptoms of cerebral irritation are pro- nounced, Cantharis, Hyoscyamus, Cicuta virosa, Cimi- cifuga, Veratrum vir. or Zincum may be required. CHRONIC HYDROCEPHALUS. ~/D If effusion is evident from the signs of increas- ing brain pressure, Apis, Hetteborus, Opium or Digi- talis may be required. Bryonia is highly regarded by different observers when there is excessive pain. Iodoform 6x or higher, has, in the writer's hands, been of signal service in chronic meningitis. Cuprum aceticum, Zincum met., Crotalus horridus, Rhus fox., Calcarea curb., Lycopodium and Sulphur have been reported as curative or beneficial. In all cases the symptoms should be the guide to the remedy. In tubercular meningitis the brain symptoms will not lead to a selection of a remedy for the real disease. The fatality of this form of meningitis will make it advisable to use TubercuVinum in a high dilution. Chronic hydrocephalus is, in the vast majority of the cases, a condition beginning in intra-nterine life. It may have advanced at term to snch degree as to cause difficulty in delivery or at such time it may be latent and only develop within a few weeks or months. The condition is an accumulation of fluid within the ventricles of the brain and is due to occlusion of the openings of communication between the general ventricular cavity and the cavity of the arachnoid, or between the cavities themselves. The development of the latent disorder may not occur until set in action by some accident, trauma, or some trifling intercurrent affection. The manifestation of the disorder is a gradually progressing enlargement of the head. The enlarge- 276 THE BRAIN. ment is in all directions, forwards, backwards, later- ally and even upwards, but here the yielding of the fontanelles and opening of the partly closed sutures allows greater horizontal distension. The face, below the roofs of the orbits, of course, shows no change, and there is a marked contrast of small face and large head, the general outline being triangular when viewed from the front, while from above the outline is more or less round. Increasing pressure of the fluid within, results in a thinning of the skull bones, which in ad- vanced cases can be felt. Cerebral symptoms appear ; impeded development of the brain results in retardation of mental develop- ment as well as of muscular growth and control. The child cannot learn to walk, at times cannot sit up on account of the weight of the head, does not learn to talk. The cranial nerves are affected by the pres- sure, and strabismus and, occasionally, optic nerve atrophy are seen. The general state of the patient shows cerebral irritation ; the child is poorly nourished, generally wretched and unclean. Paresis of the lower limbs, with increased tendon reflexes, is not uncommon. The prognosis is bad, most of the cases dying within two or three years. Lighter cases may grow up, with development of mental and physical powers to a considerable degree, the enlargement of the head remaining. The diagnosis is to be made from rickets, or in later years from acquired hydrocephalus, the result ABSCESS OF THE BRAIN. 277 of pressure by a tumor in the posterior fossa upon the vena magna Galeni, obstruction of the aqueduct of Sylvius, etc. In rickets the shape of the head is box-like, the fontanelles are not prominent, there are other evidences of the disease and cerebral symptoms are absent. The treatment of chronic hydrocephalus should be by the employment of our deeply acting remedies, such as Calcarea carb., Calcarea phos., Sihcea, Sulphur and Baryta carb. Rapid improvement must not be expected. In one case of the writer's after several months' treatment with some of the remedies just mentioned, marked change for the better appeared on giving Helleborus 6. Abscess of the Brain. The suppurative process in the brain requires the presence of a pyogenic mi- crobe. This may be introduced from without via a scalp wound (without any fracture of the underlying bone), or from within by direct invasion from some suppurating process in the neighborhood (chronic purulent otitis media), or by means of the blood ves- sels, from suppurative foci in distant parts (abscess of the lung, empyema, etc.). An acutely occurring abscess is chiefly seen as a result of trauma, and then affects the convexity, the symptoms being, like those of meningitis, mental con- fusion, delirium, fever of irregular type, with severe headache. If the motor area be involved, there will develop hemiplegia or monoplegia, preceded by epi- leptic convulsions. 278 THE BRAIN. Acute symptoms may be the culmination of the chronic process. The other forms of brain abscess are of gradual de- velopment, and may remain latent for months or even years, the period of latency being characterized by irregular outbreaks of cerebral symptoms, with in- crease of temperature ; the acute episodical manifes- tation disappears, and the patient returns to a state of health, which, in turn, is again invaded by a re- currence of the previous symptoms. Headache, often of a severe type, is a frequent symptom; it is not seldom located at or over the site of the abscess. Vomiting is frequently seen; optic neuritis, while not uncommon, is yet less often observed than in brain tumor. The pulse is slow generally, but at times is accelerated. The cerebral hemispheres are much oftener the seat of abscess than the cerebellum, while abscess of the pons or medulla is rare. In the cerebrum the temporal and frontal lobes are more " often the seats of abscess, and if this is very extensive and deep, many of the underlying tracts will be invaded, giving rise to sensory aphasia (often misinterpreted as evi- dence of mental weakness — Oppenheim), injury to the motor tract, hemianopsia ; if in the occipital lobe, hemianopsia is to be expected. Brain abscess, if otitic in origin, will occur in either the temporal lobe or the cerebellar hemisphere, according to the location of the original affection on the anterior or posterior part of the petrous bone. ABSCESS OF THE BRAIN. 279 Abscesses of distant origin (suppurative processes in the lungs, empyema, etc.) are located most often in the region supplied by the Sylvian artery; pyaemia frequently causes multiple brain abscesses. The diagnosis of abscess of the brain will rest upon the existence of some adequate cause, trauma, suppurative ear disease, etc., but tumor may occur after trauma. The recurrence of cerebral symptoms in attacks often ushered in by chills, the wide tem- perature range, the non-implication generally of the basal cranial nerves (except the optic, and occasion- ally the olfactory) are cardinal points. Acute abscess may end fatally before the specially diagnostic symp- toms appear, and then the diagnosis from acute meningitis may be impossible. Meningitis is not in- frequently set up by suppuration within the brain, while sinus phlebitis may occur from extension of the original ear affection. The course of acute abscess, or the terminal at- tack of the chronic affection varies. When trau- matic, the fatal termination is delayed more than when due to ear disease. In general, the time limit is from a few days to a very few weeks. Death occurs from coma and exhaustion, or from the breaking of the abscess into a lateral ventricle or externally, with consequent apoplectic or convulsive symptoms, with coma. The treatment of abscess of the brain is purely surgical. 280 THE BRAIN, Apoplexy. Cerebral haemorrhage. A blood vessel ruptures under the pressure of the blood within it, either because of congenital or acquired weakness of its walls or from abnormal increase of the blood pres- sure, whether from kidney disease or cardiac hyper- trophy or both. The occurrence of intracerebral haemorrhage in the infant during the process of parturition may be considered as mechanical, owing to the prolonged or severe compression to which the yielding skull is exposed. Towards middle life the arteries mani- fest a degenerative change known as arterio-sclerosis, and this increases in degree with advancing years, being greater in some individuals than io others. Such degeneration is hastened by certain diseases, or by long-continued poisoning by certain substances (chronic kidney disease, the long-continued use of alcohol, etc.), while the haemorrhagic diathesis, leu- cocythaemia, pernicious anaemia and syphilitic disease of the blood-vessels within the skull cavity, are more direct causes of haemorrhage. The influence of heredity is seen in the occur- rence of cerebral haemorrhage during several suc- cessive generations, either through inherited weak- ness of the vessels themselves, or tendency to dis- eases causing the weakness. Miliary aneurisms situated on the circle of Willis or the arterial CEREBRAL HEMORRHAGE. 28 I branches arising therefrom, are frequently the sites at which haemorrhages occur. Given weak arteries with spots of advanced de- generation and aneurismal protrusions, any sudden increase of blood pressure, as in physical exertion, strong emotion, after a heavy meal, etc., may deter- mine a break in a blood vessel ; but, without this, the time must come when the vessel will finally yield under the ordinary blood pressure, and it may be, as is not infrequently the case during sleep. Prodromal symptoms are rather rare ; when present they consist of vertigo, pressure in the head, cardiac anxiety, paresthesia of one side, perhaps some mental confusion and difficulty of articulation, but such symp- toms are not necessarily prognostic of an oncoming haemorrhage. The attack comes on suddenly and in most cases during apparent good health, the patient falls to the ground and is at once comatose ; the face is turgid, red or purplish ; all the reflexes are gone, including the pupillary and corneal reflexes ; the pulse is full, strong, and may be slow or normal or accelerated in rate ; the skin is usually moist. The respirations are slow and stertorous and with each expiration the cheeks puff out. Urine and faeces may pass involuntarily ; the former generally contains some albumen. The limbs are entirely relaxed, yet when lifted and let drop a difference may often be observed, those of the paralyzed side drop like lead, 282 THE BRAIN. those of the other side sink rather than drop, owing to some muscular tonicity remaining. The temperature may fall a degree or two during the first half day, then it ascends to the normal and may even rise beyond it, while the surface temper- ature on the paralyzed side is a degree or two higher than on the normal one. Subnormal temperature, if considerable in degree or long continued, is of evil omen. Should the case progress to a fatal termination, there will be generally a rapid rise of temperature, disturbance of respiration, which may take on the Cheyne-Stokes rhythm, rapid pulse ; if the end be delayed beyond a few hours, hypostatic engorgement of the lungs is apt to occur, death following within a day or two. In more prolonged cases the coma may lessen, the corneal and swallowing reflexes return, but the reactive inflammatory process around the effused blood introduces a fresh element of disturb- ance, delirium often coming on and lasting until death, or being replaced by sopor, coma or other symptoms with lethal ending. In favorable cases coma lessens within a few hours, a soporous condition serving as transition stage before even temporary consciousness returns, the deep reflexes appear gradually, movements of the unparalyzed limbs occur, as during restless sleep, and when the patient emerges into consciousness there is found some emotional or mental weakness. The most marked effect of cerebral haemorrhage CEREBRAL HAEMORRHAGE. 283 is hemiplegia, face, arm and leg being affected, but the distribution of the facial nerve to the frontalis, corrugator supercilii and orbicularis palpebrarum muscles are usually not implicated, because the central neurones for them are not in the pyramid tract. The hypo- glossal distribution is involved in the paralysis, hence the unopposed action of the genio-glossus of the sound side causes deviation of the organ to the paralyzed side when the tongue is protruded. Im- plication of the lower face muscles is shown by asymmetry of the angles of the mouth, the cheek of the affected side being lower and that of the sound side being higher, owing to the unopposed tonicity of its muscles. Some degree of anaesthesia is noticed in many cases in the paralyzed parts, and the cremasteric and abdominal reflexes are absent on the paralyzed side. Within a short time the knee-jerk of the af- fected side becomes exaggerated. Later, ankle clonus can often be obtained. With right - sided paralysis some kind of aphasia, motor or auditory, is to be expected; it is often temporary. The symptoms following a stroke of apoplexy are classed as temporary, and permanent ; the former are also called indirect, because they are not from the direct destructive influence of the lesion which causes permanent effects, since a destroyed nerve fibre in the central nervous system cannot be replaced or restored. Many symptoms are thus indirect. Some amount of voluntary control reappears in the af- 284 THE BRAIN. fected limbs ; the face loses most of its asymmetry ; the leg recovers its powers to a large degree ; the arm, while not so helpless as at first, improves in only a slight degree. Rigidity of the muscles of the affected limbs comes on in some cases early ; that is, within a day or two ; it may pass away soon or stay for a week or two. But between two and three weeks after the seizure there occurs the late rigidity with contractures. The latter are characteristic when fully developed, the fingers being flexed, the hand flexed on the arm, the forearm flexed and pronated, the arm adducted. The lower limb is in the extended position and when the patient is able to walk gives rise to the peculiar gait of the hemiplegic, for as the patient is able to flex the limb at the knee but slightly, he must, in order to progress, lift up that side of the pelvis (and with it the whole of the paralyzed limb) by contraction of the trunk muscles of the opposite side, at the same time turning the body on the sound leg. Hence he describes on the ground an arc of a circle with the paralyzed member, or, as the Germans put it, "he mows the ground." If, after three weeks or so, no contractures appear (and no exaggeration of the deep reflexes), complete restoration of voluntary power may be expected, the paralysis in such cases having been owing to indirect influence (pressure) and not to destructive action of the effused blood upon the motor tract. The muscles of the paralyzed parts waste somewhat, CEREBRAL HEMORRHAGE. 285 but generally it is the wasting due to non-use, though in some cases the wasting is too rapid to be thus explained and must be attributed to the cerebral cause ; what part of the brain it is that has such trophic influence is not known (Groldscheider). The electrical reactions are normal or nearly so, the re- action of degeneration never occurring. The muscles that act in association on the two sides are not affected, but the trapezius at times shows some weakness in its upper part. The affected limbs are more or less cyanotic, are often somewhat swollen, while the palm of the contracted hand is moist from retained per- spiration. As late symptoms, secondary to hemiplegia, are seen at times certain associated movements in a para- lyzed limb when its fellow of the opposite side acts, and also posthemiplegic tremor, occasionally of the intentional variety. In children choreiform action, or athetosis (a continuous writhing movement of fingers and hand, or of fingers, hand and arm, occasionally of toes and foot) is present in many cases. When the site of cerebral haemorrhage is in the neighborhood of the large basal ganglia and the motor tract, hemiplegia must result, but haemorrhage may take place in any other part of the brain and then the symptoms will vary accordingly (vide Figs. 44 and 45). Haemorrhages upon the cortex (vessels of the pia) must be very extensive to cause a hemiplegia, since the whole motor area would have to be subjected to 286 THE BKA1N. the effused blood. As a matter of fact, complete hemiplegia from haemorrhage upon the cortex is rare, while a partial hemiplegia, especially of one limb or part, and begun with spasm, points to the cortex as the site of the lesion. The centrum semiovale is the site of haemorrhage less often than the internal capsule and basal ganglia ; the nearer to the cortex it is, the more nearly do the symptoms resemble those of the cortical lesion — and the deeper the haemorrhage, the more closely do they approach those of typical hemiplegia. Haemorrhages into the pons are less frequent than those of the cortex. If in the upper two-thirds, a typical hemiplegia may be caused ; if in the lower third, a crossed hemiplegia will result — i. e., paralysis of the limbs of the side opposite the lesion, the face being paralyzed on the same side as the lesion. When the haemorrhage is from a median branch of the basilar artery, as it most often is (Growers), its location is central, the apoplectic attack is ushered in generally with convulsions that are bilateral mostly, while all four limbs may be paralyzed. In pontine haemorrhages the danger of death is very great. At times haemorrhage in the neighborhood of a lateral ventricle breaks its way into the latter and from it the whole ventricular system may be invaded. The result will be a distinct and alarming aggravation of symptoms already present ; coma deepens or returns, the unaffected side becomes paralyzed and convulsed or even general convulsions may occur, tetanic rigidity CEREBRAL HAEMORRHAGE. 287 being one mode of the latter. The prognosis be- comes absolutely hopeless, death occurring within a day or two. The sensory disturbances during an apoplectic attack already mentioned will, of course, be more marked the greater the invasion of the posterior part of the posterior limb of the internal capsule, and may be permanent ; pain may exist in the paralyzed limbs, either continuously or as painful hyperesthesia on being touched. Conjugate deviation of the eyes and head to one side is of some diagnostic value. If they are directed away from the paralyzed side it means a cerebral paralyzing lesion or a pontine irritative one ; if they are towards the paralyzed side, there are conditions of irritation in a cerebral lesion (cortical or possibly ventricular haemorrhage without irritation), or the lesion is in the pons and is paralyzing. The fate of the blood effused in cerebral haemor- rhage is, first, coagulation ; next, breaking down of the constituents of the clot ; then, absorption. Mean- while, the surrounding brain tissue sets up protective inflammatory changes in proliferation of glia cells and connective tissue, forming a capsule within which further absorption of the broken-up clot goes on, until finally the latter has disappeared and its place is taken by serous fluid, the result being a hemorrhagic cyst. In the case of quite small haemorrhages, the walls approximate and the space is bridged across by con- nective tissue, whose subsequent contraction results 288 THE BEAIN. in the formation of an apoplectic cicatrix. Either process requires considerable time, the formation of a hemorrhagic cyst requiring at least three or four weeks (Oppenheim). Apoplexy from Vascular Occlusion.— Acute Encephalomalacia. When an artery is occluded in the brain, the tis- sues depending on it for their blood supply must die for want of nutrition, there being in the brain but little vascular anastomosis. The occlusion may be either from an embolus or a thrombus. An embolus, being a detached mass of fibrin in the arterial current, gets to a point beyond which in the narrowing vessel (usually where a branch is given off) the blood current cannot carry it. The source of the embolus is in most cases the heart itself, which, when diseased as by endocarditis, or with valvular trouble, has deposits within it of coagulated fibrin. Of the latter a fragment, if de- tached, is sent out in the blood current and is ar- rested as described above, in some small vessel. Emboli are at times carried by the blood-current from a thrombotic deposit in a diseased large blood vessel, or enter the heart from the venous side in cases of pulmonary gangrene, ulcerative bronchitis, etc. Thrombosis, being a deposit chiefly of fibrin in a vessel (excepting the capillaries) is due to alteration in the composition of the blood, or in the structure APOPLEXY FROM VASCULAR OCCLUSION. 289 of the walls of the blood vessels. The latter is the most frequent cause of cerebral thrombosis, and is due to atheroma or to syphilitic endarteritis. Acute infectious diseases, exhausting chronic ones (phthisis, cancer, etc.) alter the blood's composition, and may cause thrombosis. Diagnosis between embolus and thrombosis of a brain artery is largely a matter of age, since an apoplexy in an individual past forty-five and without heart lesion is more likely due to thrombosis than to embolism. Apoplexy in persons under forty and without heart lesion is presumably due to occlusion from syphilitic endarteritis. Embolic occlusion is seen mostly in the young, and is but rarely repeated. The symptoms of apoplexy from embolism are similar to those from cerebral haemorrhage, but are less in intensity. Their onset is sudden and with- out prodromata ; those of thrombosis usually have prodromata, sometimes repeatedly during a long- period precedent to the apoplectic attack. Embo- lism affects most often the branches of the middle cerebral artery, and somewhat more frequently the left one than the right ; thrombosis has the same pre- dilection, but the arteries of the circle of Willis, the basilar and the internal carotid are not infre- quently the site of either form of obstruction, the thrombotic process, however, often extending to neighboring branches not at first affected, thus in- creasing the gravity of the condition. Syphilitic en- darteritis affects particularly the circle of Willis, but 290 THE BRAIN. its larger branches, as well as the vessels leading to it, are often its victims. The brain tissue dependent upon the blood pre- viously supplied by a now occluded vessel dies and undergoes softening, unless there be collateral circu- lation. This is not possible, except on the cortex, and then in limited degree, and in the larger ves- sels leading to the circle of Willis. Softening has been classified as red, yellow and white, but the color in red softening is due to the presence of blood coloring matter, and is found in parts that are vascular in the normal state (such as the cortex) ; by decomposition and absorption of the blood pigment the red tint changes to yellow, and then the term yellow softening applies. In the white matter the softening is nearly white in tint. The consistency of the softened mass is semi-liquid, and after its complete absorption its site is repre- sented by a cicatrix generally, at times by a cyst. While the symptoms of an apoplexy from vas- cular occlusion are, in the main, those of a cerebral haemorrhage, yet there are differences that will suf- fice in most instances to determine to which class the case belongs. In the former the face is generally not turgid, the respiration less disturbed, the initial lowering of temperature seen in cases of haemorrhage is rarely present, while its rise will not be great when it does occur. Embolus occluding a brain artery is more apt to produce convulsive movements at times epileptiform in character, and, if the vessel APOPLEXY FROM VASCULAR OCCLUSION. 29 1 involved be small, there may be no loss of conscious- ness. In thrombosis, even of a large vessel, there may be no loss of consciousness, or the latter may come on only after symptoms of hemiplegia. The symptoms from occlusion of a cerebral blood vessel are direct and indirect, and if collateral circu- lation be established (cortical, internal carotid, etc.), all the symptoms will disappear. Oppenheim holds that a thrombus may break down and be washed away in some cases, and thus explains transitory hemiplegia. The direct symptoms are those that re- main, and they are of the same value in localization as in the case of haemorrhage. Aphasia is more common in occluding lesions of the left hemisphere than in haemorrhage ; hemia- nopsia and hemianaesthesia are the results if the pos- terior cerebral is blocked up and no anastomotic cir- culation is possible (not common). The prognosis, so far as life is concerned, is more favorable in occlusion than in haemorrhage, as a general rule, but when coma is intense the danger is rather in its intensity than in its duration (Gowers), a moderate degree lasting several days being not in- frequently followed by recovery. Thrombosis of the basilar artery is almost always fatal, and next in fa- tality is that of the internal carotid. Danger to life increases with each succeeding attack of thrombotic occlusion, and in the thrombotic process there is great tendency to recurrence ; in embolism there is but little, while in syphilitic vascular disease recur- 292 THE BRAIN. rencc must be expected if the disease be not ar- rested. Inflammatory reaction sets up around the softening tissue, and it is more severe than the corresponding process in cases of haemorrhage, and may give rise to severe cerebral complications, such as delirium, head- ache and convulsions, the latter at times a very un- favorable complication. If the paralytic symptoms, although not so great nor so extensive in acute softening as after haemor- rhage, do not disappear after two or three weeks have passed, they will be permanent. From throm- bosis there is distinct impairment of the mental faculties ; from embolism there is usually but little, or there may be none at all. The treatment of apoplexy consists in first placing the patient in the most advantageous posture. He should be put to bed and laid on the paralyzed side; the respiratory muscles of the sound side have thus the fullest freedom of action and stertor is said to thereby cease. Cold applications may be made to the head and warm ones to the extremities, mustard applications being advised by different authors. Treatment by drugs at this stage must be almost wholly symptomatic. The effect of even a small haemorrhage within the skull cavity is to set up irri- tability of the vaso-motor centres, and our remedies if chosen by the resultant symptoms, will quiet the vascular excitement. Belladonna, Glonoine, Melilotiis alba and Opium will be thought of at once. When the APOPLEXY FROM VASCULAR OCCLUSION. 293 coma is profound, the stertorous breathing marked, the face dusky and the patient covered with sweat, Opium is the chief remedy. When the face is red and hot even if coma or stertor be present Belladonna should be prescribed; Glonoine and Veratrum viride resemble Belladonna very greatly, but the cardiac irregularity of the first and the more powerful pulse of the second may serve as points of difference. Jfelilotus alia ought to be of service in the early active stage. The foregoing remedies have been used by the writer in such cases in the third centesimal dilution, excepting Glonoine which had better be given in the sixth ; in cases of alarming character, the doses may be given every 15 minutes, but the intervals should be lessened as soon as improvement in the pulse or the respiration or the appearance is noted. When consciousness has been even partly restored, Arnica radix should be given in third dilution every two or three hours, a few doses only, after which the symptoms should be studied for special indica- tions and later, when inflammatory reaction has set up, the same method should be followed. In cerebral thrombosis but little can be done at the beginning, since the occlusion already present will extend, or if not absolute will soon become so. If as a result of the shock vascular symptoms set up, the remedies already mentioned will possibly be indicated, but Glonoine or Baryta muriatica will at once be thought of. Lachesis and Crotalus liorridus ought to be of value in combatting the reactionary inflammation 294 THE BRAIN. and in keeping it within limits. Phosphorus and Sepia have been highly commended in this stage. Embolic occlusion, after it has occurred, cannot be remedied. Aconite followed by Arnica radix 3, ought to be of service in preventing too severe a reaction. For the hemiplegia or other paralysis following any form of apoplexy, Causticum, Cocculus, Nux vomica, Graphites, Baryta and Arnica are recommended by a number of observers. The writer has seen apparently remarkable results from Nux vomica, low, 2x, in hos- pital cases ; and in private practice, Baryta carbonica or muriatica. It must not be forgotten that the symptoms due to destructive changes in the motor area or motor tract cannot, according to present views, be relieved, and that the other or indirect symptoms can and do disappear without treatment. Nevertheless, the sec- ondary (indirect) symptoms may not disappear unless under the action of suitable remedies. The use of electricity has been greatly extolled in the treatment of hemiplegia and other paralyses of cerebral origin. As a means of keeping up the nutri- tion of the muscles of the paralyzed part faradism is of high value, and should the paralysis be only an in- direct symptom, its disappearance will then find the muscles ready and able to act. The employment of static electricity in relieving the secondary contractures in hemiplegia has been much vaunted; the writer has used it repeatedly with- out the slightest effect in such cases, although it hap- pened that the patients themselves were at first deceived BRAIN TUMOR. 295 and believed they had received a greater power and free- dom of motion in the paralyzed limbs. Hemiplegics, like other paralytics, learn to use with greater adroit- ness such trifling power as may exist in the affected limbs, and thus may honestly believe that a cure is being effected. Brain Tumor. A growth in or upon the brain may irritate or destroy the parts adjacent to it, or may do both. It may therefore produce localizing symptoms. It also in most cases causes general ones which, taken to- gether, will justify the diagnosis of brain tumor. Such a mass is only a foreign body, the localizing symptoms being those depending upon its location, the general ones being largely due to pressure of the growing mass. The kind of tumor cannot be known from either set of symptoms but may often be determined by other information. The records of the autopsy table show that certain parts of the brain are places of election for certain kinds of tumor. Glioma may affect any part of the brain but selects first the cerebral hemispheres and next the cerebellum ; tubercle affects mostly the cere- bellum and next the pons; syphiloma is found oftenest at the base, next on the cortex in the central and pre-central regions, while it is rare on the cerebellum or in the white matter of the cerebrum. The existence of morbid growths elsewhere in the 296 THE BRAIN. body would make it probable that a tumor of the brain is of the same nature. Age is at times of great help ; a brain tumor in a child is evidence that it is probably tubercular in character, while a tumor in a person of advanced years is more probably glioma (including sarcoma) than syphiloma, the reverse being the case in the young adult. The rate of progress in growth (as shown by in- creasing intensity of the symptoms) may be of cor- roborative value. Glioma grows slowly and being itself liable to haemorrhages may give rise to apoplectic attacks ; carcinoma grows rapidly but it is usually metastatic in origin, while syphiloma grows rapidly in one direction and at the same time breaks down in another, accounting thus for the changeability of its symptoms. The general symptoms of brain tumor usually pre- cede the appearance of the local ones. Headache exists in the great majority of cases ; it is mostly continuous, but has spells of aggravation. Its intensity is often frightful, and its character varies in different cases ; it is aggravated by forced exertion, stooping, coughing, etc. Its subjective location may be frontal, occipital, lateral or diffusely spread, but the subjective location is of no value in localizing the site of the tumor; the head is often sensitive to percussion with the fingers and at times extremely so in the neighbor- hood of the growth. Choked disk is considered by Oppenheim to be BRAIN TUMOR. 297 characteristic of the existence of tumor, nine out of every ten cases of it being so caused. He differen- tiates the swollen choked disk from a simple optic neuritis, which also can exist as a result of brain tumor, but which is to be seen as well in other dis- eases. It has been observed that the vision, during the course of brain tumor, does not fail to the degree expected with such swelling and obliteration of the disk ; the vision does finally disappear if the patient live for a considerable time, the ophthalmoscope then usually revealing consecutive atrophy of the nerve. The mental state suffers generally during the course of a brain tumor, varying from slight loss of power of attention or concentration to an absolutely stupid condition, or apparently as if overcome by an opiate. Conditions of insanity develop quite often, mostly of the type of mania, occurring in paroxysms, or at times of hallucinatory insanity or melancholia, but more often the mental change is evidenced by silly, foolish behavior — in one case the writer has seen marked hysterical manifestations. Growths at the base or distant from the frontal lobes, and tumors of small size, are not so apt to cause psychical change. Vertigo is frequently an accompaniment of brain tumor ; if violent it becomes a localizing symptom. It is not attended by nausea, generally. Vomiting, projectile in character, is noted in the majority of cases ; if associated with headache, as it often is, it may give rise to the erroneous diagnosis of migraine. Slowness of the pulse is observed when intra-cranial 298 THE BRAIN. pressure becomes considerable ; it is not an early symptom unless the structures beneath the floor of the fourth ventricle become implicated, and then it has a localizing value. Attacks of convulsions with or without loss of con- sciousness, or of the latter alone, or of temporary blindness, are among the less frequent general mani- festations. Localizing symptoms vary with the site of the tumor ; they may be irritative in character, or para- lyzing, most often the latter. The symptoms are often indirectly produced, especially when intra-cranial pres- sure is great. Tumors of the frontal lobes are apt to cause marked mental changes already mentioned; if left-sided, motor aphasia will be present when the motor speech area becomes affected ; if riglrt-sided there may be no local- izing symptoms. Tumors involving the central convolutions are apt to cause motor irritative symptoms in the beginning, such as spasm in one definite part of the body; the spasm is repeated at varying intervals, and in time paralysis of the part (monoplegia of face or arm or leg) comes on. General convulsions may result, epi- leptic in character, but beginning in the same definite part (Jacksonian epilepsy). With the growth of the tumor the paralysis spreads until a hemiplegia is pro- duced, with strong tendency to contractures. In most cases there is some hypsesthesia or paresthesia in the paralyzed side. BRAIN TUMOR. 299 Tumors affecting the cortex behind the motor areas must interfere with the muscular sense, and, if in the neighborhood of the supramarginal and angular gyri of left hemisphere, will cause alexia. Tumors in the occipital lobe, if involving the cortex adjoining the calcarine fissure, will produce homony- mous hemianopsia; if affecting the outer face of the occipital lobe, especially the angular gyrus, there may be loss of the memories of the uses of things pre- viously well known, such as the objects seen in everyday life ; this condition is known as psychical blindness. If the tumor involve the anterior area, it may encroach on the angular and supramarginal gyri, with the result of causing alexia, if on the left side. Hemianopsia is also caused when the tumor affects the white matter of the occipital lobe, since the optic radiations will be affected. Tumors of the temporal lobe, if left-sided and in- volving the auditory speech area, cause word-deafness with paraphasia; otherwise such tumors of either side cause no direct symptoms. Tumors of the centrum semiovale are not specially characterized by their symptoms, but the nearer they are to the cortex the more will cortical symptoms appear; hemiplegia of gradual onset is considered to be symptomatic, while, if the corpus callosum be specially implicated, extension of the growth will probably cause paraplegia. Tumors of the corpus callosum are also believed to cause a marked stupidity, apathy or soporous condition. (See Fig. 45, page 261.) 300 THE BRAIN. Tumor at the base can hardly help affecting some of the cranial nerves. If in the anterior fossa it is likely to affect by pressure the olfactory and optic nerves and, by extension of pressure, the third nerve and first branch of the fifth. If upon the sella turcica, the optic chiasm, the hypophysis, the nerves of the orbit and the first branch of the fifth; if in the lateral cavity of the middle fossa, all branches of the fifth may be affected and also the ocular nerves. Tumors of the posterior fossa will by pressure affect the nerves arising from the pons and medulla ob- longata, directly or indirectly, except the twelfth nerve, which by its low point of emergence may escape direct pressure. Tumor affecting one crus cerebri will usually cause hemiplegia of the opposite side, with third nerve paraly- sis of the same side. (See Fig. 38, page 236.) Tumor in the corpora quadrigemina and the struc- tures just below it, causes ataxia and paralyses of the eyeball muscles ; the ataxia is of the cerebellar variety. Tumors of the pons and medulla are infrequent. If limited to one side of the pons, a tumor may cause hemiplegia of the opposite side of the body, when it is above the middle ; if below the middle, it will probably cause alternating hemir>Legia, that is, paralysis of arm and leg of opposite side with paraly- sis of the face on same side, and the latter may show degenerative reaction. If the tumor is low down in the pons, the face escapes. Tumor in the medulla or BRAIN TUMOR. 301 pons, involving the neighborhood of the sixth nerve nucleus, will cause paralysis of that nerve, and there is then often conjugate deviation of the eves to the other side. (See Fig. 38, page 236.) Tumor in the medulla, if on one side, will cause incomplete hemiplegia, arm and leg of opposite side being affected, but with paralysis of the tongue on the side of the lesion. If the growth involve both halves of the medidla, the symptoms will be those of bulbar paralysis with, possibly, paralysis of the four limbs. If it invade the fibres forming the in- ferior peduncle (medulla), or those of the middle peduncle (pons) of the cerebellum, ataxia, cerebellar in character, is to be expected. The direct symptoms of tumor of the cerebellum are occipital headache, extending at times to the nape and even lower, vertigo, and cerebellar ataxia. The ataxia disappears when the patient is lying down ; when up and walking about it is a reeling gait, or if slight, it is as if he were in fear of falling ; the ataxia does not affect the arms. The forced move- ments seen in cerebellar troubles, turning continually to one side when lying, or going to one side when walking, cannot as yet be positively ascribed to disease of any definite part of the cerebellum, although both are cerebellar symptoms ; they have been noticed in con- nection with involvement of the middle peduncle of the cerebellum. Tumors of the middle lobe of the cerebellum, if growing downward, will by pressing upon the floor of the fourth ventricle give rise to 3 From The Homoeopathic Eye, Ear and Throat Journal. ''This work covers a field hitherto unfilled in homoeopathic literature. Its thirty-nine chapters are an able expo- sition of the subject from all standpoints, while the special therapy of the various diseases is very complete and valuable. Dr. Carleton, who has had an extended experience in this special line, has presented a timely book. It also marks the appear- ance of the well-knows firm of Boericke, Runyon and Ernesty as publishers of homoeopathic works. They are to be congratulated upon the excellent appearance of their first venture, which is typographically all that could be desired, and an admirable exposition of the printer's art." From Win. B. Tan Lennep, A. M., M. D., Prof, of Surgery, Hahnemann Medical College of Philadelphia, Pa. " Concise, comprehensive and up to date." From W. A. Dewey, M. D., late Prof of Materia Medica, Hahnemann Hospital College of San Francisco, Cal. " I am much pleased with the work ; it is the latest and best on the subject in the Homoeopathic School ; a special feature is the excellent arrange- ment of the Homoeopathic Remedies, and the careful indications therefor." From Nathaniel Robinson, M. D., Pres. Kings County, N. Y., Homosopalhic Medical Society. "Avery flattering triumph both for author and publishers; it should be in the library of every Homoeopathic physician and surgeon. It is clear, precise, and remarkably well up to date, both medically and surgically. There is nothing in Homoeopathic literature that can compare with it." From E. Guernsey, M. D., Pres. Medical Boards of the Metropolitan Hospital and Hahne- mann Hospital of N. Y. " A model of condensed thought and practical information." DISEASES OF THE EYE. By N. L. MacBride, M. D., O. et A. Chir. Dean of the College of the New York Ophthalmic Hospital; Professor of Ophthalmology in the College of the New York Ophthalmic Hospital, etc., etc. Illustrated. 310 pages. Cloth, $3.00 net; by mail $3.20. Half morocco, $4.00 net; by mail $4.22. From The Medical Century. "There are chapters devoted to the ophthalmic diseases, the diagnosis and correction of anomalies of refraction, operations on the eye and other important topics not heretofore published in any work on this subject by a homoeopathic author. Throughout the text of the book the indication's for the use of the homoeopathic remedies are tersely given and in most instances the potency is also mentioned. The author has in this handy volume about all that is necessary for the busy doctor to know of eye diseases in order to treat them with satisfaction and success." From The Homoeopathic Eye, Ear and Throat Journal. "This work is a model of brevity from the preface to the end, and bears the impress of the author's personality throughout. Within a reasonable compass is given a concise description of the diseases of the eye, optics, errors of refraction, etc. The remedies mentioned in the treatment are those most frequently used by the author, and the potency he has found most efficacious is expressed. In giving the pathology the latest German authorities have been followed. The chapter on the "Use of the Ophthalmoscope" is excellently adapted to teach students and general practitioners the art of using this excellent aid in diagnosis." From The Medical Era. "An examination of the book makes clear the fact that the author has succeeded most admirably in his design. It is eminently a practical work for the general practitioner, and gives instructions by which he may deal with all cases that arise in his practice that must not of necessity go to a specialist. The descriptions of disease are clear, and the instructions for treatment are plain and practical. For the general practitioner it is the best book on the eye and its diseases that we have seen. We wish to congratulate the publishers of Dr. MacBride's work on the very handsome book that they have made; it is on a fine quality of paper, type is large and clear, and the binding handsome and substantial. We earnestly commend the work to the student and the practitioner.'" From The North American Journal of Homoeopathy. "The aim of the author has been to set forth in as concise and useful a manner as possible the results of his long experience. While the illustrations are not numerous those that are used, both of the eye itself and of the instruments employed, convey much useful information to the general practitioner. In mentioning the remedies found to be curative the potency is often given, which is something contrary to the usual custom. Many important subjects are treated, among them being " The Art of Using the Ophthalmoscope," " The Diag- nosis and Correction of Anomalies of Refraction," " Operations," etc." From Dr. C. M. Thomas, Prof. Ophthalmology Hahnemann Medical College, Philadelphia, Pa. "Dr. MacBride's book is much appreciated and you will find it among those recommended to the students in the college announcement." A COMPEND OF THE PRINCIPLES OF HOMCEOPATHY AS TAUGHT BY HAHNEMANN, AND VERIFIED BY A CENT- URY OF CLINICAL APPLICATION. By William Boericke, M. D. Professor of Materia Medica in Hahnemann College of San Francisco, Cal., etc., etc. 1 60 pages. $1.50 net; mailed, postpaid, on receipt of price. From North American Journal of Homoeopathy. "This book covers concisely the whole field of Homoeopathy, with many references to its literature for its further systematic study both as a science and as a practical art. — It is just what it was intended to be — an intelligent elucidation of the salient points so often metaphorically treated by Hahnemann." From The Chironian. "To those who wish to understand, and especially to those who are desirous of defending the principles of our school, the book is well worth perusal.'' From The American Homoeopathist. "The book is divided in thirteen chapters and an appendix. Taking them seriatim the titles are the following: The Therapeutic Field; Principles of Pharmacology ; The Homoeopathic Materia Medica; Drug Proving; Interpretation of Drug Pathogenesis ; Drug Relationship ; The Application of Homoeo- pathy; The Simillimum ; The Second Prescription ; Hahnemann's Nosology ; Posology; The Preparation of Homoeopathic Medicines; Hahnemann's Philosophy; Appendix. MEDICAL BOOKS PUBLISHED BY A ' Compend of the Principles of Homoeopathy ' should be in the hands of every honest homoeopath ; it is not a large book, it is not a costly book: but it is a book that talks out in meeting and is filled with homoeopathic data collected from the original papyrus and put into readable shape. All hail to the Compend." THERAPEUTICS OF THE EYE. By Dr. Charles C. Boyle, M. D., O. et A. Chir. Surgeon to the New York Ophthalmic Hospital; Professor of Ophthalmic and Aural Therapeutics in the College of the New- York Ophthalmic Hospital, etc., etc. 404 pages. Cloth, $3.50 net; by mail $3.72. Half morocco, $4.50 net; by mail $4.72. — A reference work, divided for convenience for consultation into three parts: Part I. Remedies alphabetically arranged with the therapeutics relating to eye symptoms. Part II. Affections of the eye, under which are given the different remedies with their applied therapeutics. Part III. A repertorial index, alphabetically arranged. From Dr. Timothy F. Allen, A. M. ? L. L. D. ? Prof. Mat. Med. and Therapeutics N. Y. Homceo. Med. College. " 'The Therapeutics of the Eye,' by Boyle, is a step in the right direction; namely, an examination of our Materia Medica and its convenient presentation for use in diseases of the eye by a competent specialist, — when every organ shall have been studied by specialists after this fashion, their work tested and the results given to us, homoeopathic therapeutics will be more readily and successfully applied." From Dr. Mai'till Deschere, Prof. Pcediatry N. Y. Homceo. Med. College. "Dr. Boyle's work on Therapeutics of the Eyes will be of invaluable service, not only to the specialist, but to every homoeopathic practitioner. It abounds in reliable indications." From Dr. F. H. Boynton, Prof, of Ophthalmology, N. Y. Med. College; N. Y. Ophthalmic Hospital College, etc. "Prof. Boyle's 'Therapeulics of the Eye' is an admirable com- pilation of verified symptoms, the major portions of which have proved curative in the experience of the author and his associates, the surgeons of the N. Y. Ophthalmic Hospital. The arrangement under anatomical heads and repertorial index will be useful to the careful homoeopathic prescriber in finding the indicated remedy. The section on ' pains in the eyes and head ' will be of great value not only to the ophthal- mologist, but as well to the general practitioner. I gladly welcome the book and shall recommend it to my students." DISEASES OF THE KIDNEYS AND URETERS WITH THEIR HOMCEOPATHIC TREATMENT. By Bukk G. Carleton, M. D. Genito-Urinary Surgeon and Specialist to the Metropolitan Hospital, Blackwells Island, Department of Public Charities of New York City and the Metropolitan Polyclinic, etc , etc. Illustrated. 253 pages. Cloth, $2.75 net; by mail $2.91. — A companion volume to a Carleton's Genito-Urinary and Venereal Diseases" thus completing the subject of the Uropoietic Diseases. From The American Homoeopathic!. "Dr. Carleton gives the profession a valuable book and upon an exceedingly interesting subject. — He handles his subject in a masterful manner; brings his authorities in witness; and presents the matter in such attractive form that it appeals to the general practitioner as a good book to have near at hand. In forty chapters he traverses the whole subject and in every aspect of it, giving many very good photomicrographic plates; while especially good are the homoeo- pathic remedy indications." From The Hahnemaniliau Monthly. "It is a book presenting established facts which have been proven and developed by the author's own personal experience, which has been extensive. The treatment of each disease, medical and surgical, is fully considered, brief drug indications being given under each condition described. The closing chapter is devoted to a complete resume of the symptomatic and clinical indications of the drugs used in these diseases, and it will prove to be of great assistance to all practitioners of medicine. The general make-up of the work is a good specimen of the bookmakers art, the illustrations being exceptionally good." From The Medical Times. "As we turned over one page after another of this book we were fascinated with the clear, terse style of the author, his wonderful faculty of con- densation, and the evidence of logical thought and extensive reading everywhere shown. We know of no work on the subjects discussed which contains so much valuabe in- formation in so short a space. We congratulate the author upon the excellence of his work, and the young publishing house upon the success of their new venture. HINTS AND SUGGESTIONS AS AIDS IN THE CARE AND PRESERVATION OF THE TEETH, AND THE RELATION OF THE DENTAL ORGANS TO OUR HEALTH. By Charles G. Pease, M. D., D. D. S. Professor of Oral Surgery in the Metropolitan Post Graduate School of Medicine of New York City, and Late Lecturer on Materia Medica, Therapeutics and Pathology in the New York Dental School, etc., etc. 98 pages. Cloth, $1.00 net; mailed, postpaid, on receipt of price. — Dr. Pease has given us a book of great value to every one, not alone to the medical profession. THE TREATMENT OF DISEASE WITH THE TWELVE TISSUE REMEDIES, BEING A TREATISE ON BIOCHEMISTRY. By William Boericke, M. D. 189 pages. $0.75 net; by mail $0.81. — This little book is a condensation of our larger works upon the subject, and gives all the sharp, characteristic symptoms of each of the 12 remedies, and is just the work for beginning the use of the Tissue Remedies in treat- ment of disease. NERVOUS DISEASES, AND HOMOEOPATHIC TREATMENT. By Joseph T. O'Connor, M. D., Ph. D. Professor of Nervous Diseases in MEDICAL BOOKS. the New York Homoeopathic Medical College and Hospital; Professor of Mental and Nervous Diseases in the New York Medical College and Hospital. Neurologist to the Laura Franklin Hospital for Children ; Consulting Neurol- ogist to the New York Ophthalmic Hospital; Neurologist to the Metropolitan Hospital BlackwelFs Island, New York. Member American Institute. Il- lustrated. 416 pages. Cloth, $3.75 net; by mail $3.99. Half morocco, $4.75 net; by mail $5.00. This work is based upon the author's lectures at the Colleges in which he is Professor of his specialty, and he has treated the subject comprehensively, yet without omission of necessary detail. The work is divided into sections, each considering some large division of the Nervous System and introduced by description of the finer anatomy assisted by illustrations. The dominant note of the book is Homoeopathy as given by Hahnemann's Organon.