Columbia SInttJem'tp mtljeCitpofllfttigork THE LIBRARIES iHebical Hibrarp Digitized by tine Internet Archive in 2010 witin funding from Open Knowledge Commons http://www.archive.org/details/nervousdiseasestOOhami NERVOUS DISEASES: THEIR DEvSgetption and Treatment. A Manual for Students and Practitioners of Meiiciue. BY ALLAI^ McLAl^E HAMILTOIs^, M.D., FKLI.OW OF THE NEW YOEK ACADEMY OF MEDICINE; ONE OF THE ATTENDING PHYSICIANS AT TH l' HOSPITAL FOE EPILEPTICS AND PARALYTICS, BLACKWELL'S ISLAND, NEW YOPvK CITY; ONE OF THE CONSULTING PHYSICIANS AT THE HUDSON KIVER STATE HOSPITAL FOR THE INSANE, AND MALf; AND FEMALE INSANE ASYLUMS OF NEW YORK CITY, ETC., ETC., BTC. SECOXD EDITION— REVISED AND ENLARGED. With Seventy-two Illustrations. PHILADELPHIA: HEISTEY C. LEA\S SOI^ & CO, 1881. Entered according to Act of Congress, in the year 1881, by HENRY C.LEA'S SON & CO, In the Office of the Librarian of Congress. All rights reserved. fiRANT, F.\IRKS & RODGEBS, KUclroti/pers and Printers, .52 & .54 Nurth Sixth Street. TO MY FRIENDS FOEDYCE BARKER, M. D., JOHN T. METCALFE, M. D MEREDITH CLYMER, M.D., THE PIONEER IN THE FIELD OF MODEKN NEUROLOGICAL LITERATURE IN AMERICA. PREFACE TO THE SECOND EDITION. In presenting a new edition of my l)ook I wish to express to tlie profession my hearty appreciation of the favorable reception accorded to the first, which has been ont of print for several months, I thank my impartial reviewers, and take pleasure in saying that >\dierever possible, I have endeavored to adopt their suggestions, and I trust, have succeeded in remedying tlwi faults, many of whicli are unavoidable in a first edition. The present edition is enlarged l)y nearly one hundred pages and contains many new illUvStrations, in fact this feature of the book has undergone an almost entire change. The enlargement is a matter of necessity, owing to the recent advances in our know- ledge of neurological medicine. I have used certain portions of my essay which received the prize of the American Medical Association, in 1879, in the preparation of a chapter upon diseases of the lateral columns of the spinal cord. Other chapters have been remodeled, and I hope improved, especially in regard to the introduction of matter relative to localization of disease in the brain and spinal (^ord. ALLAN McLANE HAMILTON, New York, 43 East 33d St. Nov. 1st, 1881. PEEFACE TO THE FIRST EDITION. It has been my object to produce a concise, practical book; and should the satisfaction be ever accorded me of knowing that I have made the subjects of Diagnosis and Treatment of Nervous Diseases more simple to my readers than I think they now are, I shall be amply rewarded for the task I have undertaken. I have not considered Insanity, because I believe that this subject deserves much more extended notice than it could possibly receive in a book of this size and kind. I have deemed it advisable to include a short article upon Cerebro- spinal Meningitis, though, by many authorities, it is not regarded, strictly speaking, as a nervous disease. I think, if for no other reason, its interestiug diagnostic relations entitle it to consideration. In conclusion, I wish to thank Drs. Loring, Janeway, Mason, Shakespeare, my resident physicians, Drs. Meyer, Naylor, Eyan, and Baldwin, and Mr. F. O. C. Darley, for valuable assistance in the preparation of this volume. ALLAN McLANE HAMILTON. New York, Mat 1st, 1878. CONTENTS INTRODUCTION. PAGE I. Hints ly regard to Methods of Examination and Study — Examina- tion of the patient, symptomatology, etc. — Aiitopsical and microscopical examinations ........... 17-21 II. Instruments used for the Diagnosis and Treatment of Xervous Diseases — The Thermometer, ^Esthesiometer, Dynamometer, Ophthalmo- scope, The Percussion hammer — Apparatus for the Treatment of Ner- vous Diseases — Electrical, Rubber Muscles, Hypodermic Syringe, Ether- Spray Apparatus, Spinal and Cranial Ice-bags, Cauteries, etc. . . 22-37 CHAPTER 1. diseases of the cerebral 5IENINGES. Cerebral Pachymeningitis — Acute, chronic — Chronic Pachymeningitis with hematoma — Acute Cerebral Meningitis, basal, vertical — Rheumaiic Menin- gitis — Meningitis of the Aged — Acute Granular (Tubercular) Meningitis^ Acute granular meningitis of the convexity — Chronic Cerebral Meningitis 38-75 ' CHAP.TER II. DISEASES OF THE CEREBRXJil AND CEREBELLUM. Symptomatic Cerebral Hypercemia — Cerebral Hemorrhage . . . 76-126 CHAPTER III. DISEASES OF THE CEREBRUM AND CEREBELLUM:"(C0NTINUEd). Symptomatic Cerebral Ancemia (acute, chronic, infantile) — Stomachic Vertigo — Auditory Vertigo 127-144 CHAPTER IV. DISEASES OF THE CEREBRUM AND CEREBELLUM (CONTINUED). Occlusion of Intra-Cranial Vessels — Thrombosis — Embolism — Throm- bosis of the Cerebral Arteries — Thrombosis of Sinuses and Veins — Embol- ism of the Cerebral VesselSf ........ 145-163 xi XU CONTENTS. CHAPTER V. DISEASES OF THE CEREBRUM AND CEREBELLUM (CONTINUED), PAns Cerebral Softening — Acute, chronic — Asemasia (aphasia) — Cerebral Scle- rosis — Diffused Cerebral Sclerosis 163-204 CHAPTER VI. DISEASES OF THE CEREBRUM AND CEREBELLUM (CONCLUDED). Brain Tumors — Cerebellar Hemorrhage — Tumors of the Cerebellum — Soften- ing and Abscess of the Cerebellum 205-23.'> CHAPTER VII. DISEASES OF THE SPINAL MENINGES. Spinal Meningitis (acute pachymeningitis) — Acute and Chronic Spinal Meningitis — Spinal Pachymeningitis — Spinal Tumors — Spinal Hemorrhage. meningeal, central . ... . . . . . . 23(i-2ri4 CHAPTER VIII. DISEASES OP THE SPINAL CORD. Spinal Hypercemia Spinal Congestion, Subacute Spinal Hyperaemia — Spinal Irritation . . ' 255-264 CHAPTER IX. DISEASES OF THE SPINAL CORD (CONTINUED). Inflammation of the Spinal Cord — Myelitis — acute, chronic — Acute Ascend- ing Paralysis — Antero-Spinal Paralysis of Infants — Of Adults . 265-294 CHAPTER X. DISEASES OF THE SPINAL CORD (CONTINUED). Progressive Muscular Atrophy — Partial Facial Atrophy — Pseudo-IIyper- trophic Muscular Paralysis 295-320 CHAPTER XI. DISEASES OF THE SPINAL CORD (CONTINUED). Posterior Spinal Sclerosis (Locomotor Ataxia) — Sclerosis of the columns of GoU — Antero- Lateral Amyotrophic Sclerosis 321-346 CHAPTER XII. DISEASES OF THE SPINAL CORD (CONCLUDED). Infantile Spastic Paralysis — Functional Disease of the Lateral Columns — Hysterical Spasmodic Spinal Paralysis — Primary Degeneration of the Lateral Columns — Tetanus 347-383 PAOB CONTENTS. CHAPTER XIII. BTTLBAH DISEASES. Epilepsy — Bulbar Paralysis 384-420 CHAPTER XIV. CEBEBBO-SPINAX DISEASES. Cerebro- Spinal Meningitis — Cerebro- Spinal Sclerosis — Alcoholism — acute — chronic — Nicotinism — Hydrophobia — Hysteria — Hystero-Epilepsy — Catalepsy^ 421-482 CHAPr,ER XV. CEBEBBO-SPINAL DISEASES (CONCLUDED). Chorea — Paralysis Agitans — Exophthalmic Goitre .... 483-510 CHAPTER XVI. DISEASES OF THE PERIPHERAL NERVES. Neuralgia, facial, cervico-occipital, cervico-brachial, intercostal, or pleuro- dynia — Sciatic — Crural, visceral, ovarian, urethral, renal, etc. . . 511-53Y CHAPTER XVII. DISEASES OF THE PERIPHERAX, NERVES (CONTINUED). Neuritis — Ancesthesia — Tumors of Nerves 538-647 CHAPTER XVIII. DISEASES OF THE PERIPHERAL NERVES (CONTINUED). Local Paralysis — Facial paralysis — Traumatic paralysis — Diphtheritic paralysis , . . 548-565 CHAPTER XIX. DISEASES OF THE PERIPHERAL NERVES (CONCLUDED). Lead Poisoning — Fxinctional Spasm — Tetany — Functional spasm with vol- untary movements — Reflex spasm — Facial spasm without pain — Torticollis — Professional Cramp — Writer's Cramp — Dancer's Cramp — Telegrapher's Cramp, etc., etc. — (Esophagismus 566-587 LIST OF ILLUSTRATIONS. FIG. PAOK 1. Seguin's Surface Thekmometer 22 2. Gbay's System of Head Straps 23 3. Sibveking's ^sthesiometer 26 4. Diagram fob making Records 28 5. Mathieu's Dynamometer 2!^> 6. The Author's Dynamometer 30 7. Loring's Ophthalmoscope 31 8. Percussion Hammer 33 9. Manner of Tssting Tendon-reflex. (Gowers) 34 10. The Author's Gas Cautery 36 11. Osteoma of Dura Mater. {Lancereaux) 43 12. Tuberculous Matter about Vessels. {Cornil- and Eanvier) 66 13. Distended Perivascular Spacbs. {Fothergill) 86 14. 15. Tracings of Patellar Tendon-Reflex. (Brissaud) 101 16. Cortical Centres. {Morel) - 105 17. Charcot's Scheme of Cerebral Motor Tracts 107 18. Internal Cerebral Vascular Supply. {Charcot) 110 19. External Cerebral Vascular Supply. {Charcot) Ill 20. Miliary Aneurisms 113 21. Multiple Lesions with Tongue Atrophy . - . . 117 22. Instrument for Applying Heat and Cold 126 23. Tissue Changes in Softening 175 24. Handwriting of Agraphic Patient. {Boumemlle) 184 25. Handwriting of Patient with Cerebro-Spinal Sclerosis and Agraphia 184 26. Plate Showing Third Frontal Convolution. {Baieman) ....... 186 27. Choked Disk. {After Leibreich) 208 28. Plate Showing Decussation of Optic Nerve Fibres. {Charcot) . . . 209 29. Tubercular Deposit 212 30. Sarcoma of Brain 212 31. Gumma op Brain 213 32. PsAMMOMA OF Brain 213 33. Encephaloid of Brain 213 34. Glioma of Brain 213 34a. Cerebellar Aneurisms. {Bristowe) 229 35. Deformity op Hand in Cervical Pachymeningitis. {Charcot) 238 36. Scheme of Conductors in Cord . . ^ 246 XV Xvi LIST OF ILLUSTRATIONS. via. PAOK 37. Diagram Showing Relation of Motor, Sensory, and Reflex Functions OF Cord. (Gowers) ^'^ 38-41. Muscular Changes in Antero-Spinal Paralysis of Infants. OQ.A (Duchenne) -°^ 42. Antero-Spinal Paralysis. (Seguin) . • -87 43. Main en Griffe. {Duchmne) 296 44. Perimeter of Chest in Progressive Muscular Atrophy. (Duchenne) . 300 45. Atrophy of Left Shoulder "^^ 46. Partial Facial Atrophy 309 47. Pseudo-Hypeetrophic Paralysis. {Gowers} 314 48. Mechanics of Muscular Action in Pseudo-Hyfertrophic Paralysis. (Gowers) 316 49. Appearance of Muscular Tissue in Pseudohypertrophic Paralysis. (Charcot) 319 50. Appearance of Trophic Changes in Locomotor Ataxia. (Charcot) ... 332 51. Course of Posterior Nerve-Root Fibres. (Clarke) 335 52. Sclerosis of Columns of Goll. (Charcot) 341 53. Method of Provoking Dorsal Clonus. (Gowers) 350 54. Contraction of Feet in an Advanced Case of Primary Degenera- tion OF THE Lateral Columns 357 .%. Syringo-Myelia and Hydro-Myelia. (Leyden) 360 56. Scheme of Fibre Connection in Lateral Columns. (Flcchsig) .... 361 57. Sclerosis of Lateral Columns 366 58. Map of Suffolk Co., Long Island, Showing Prevalence of Endemic TETANUS 376 59. Retraction of Head in Cerebro-Spinal Meningitis. (Levns Smith) . . 422 60. The Pathology of Hysteria 467 61-64. Attitudes of Hystero-Epileptic. (Bourneville and Regnard) . .471-475 65. Exophthalmic Goitre ( Yeo) 505 66. Charts Showing Nervous Areas. (After Henle) . . . 532 67. The Author's Percuteur 535 68. Trophic Changes of Skin or Hand in Neuritis 539 69. Sarcomatous Neuroma. (Foucault) 547 70. Wire Hook foe Treating Facial Paralysis 553 7L Reflex Spasm from Genital Irritation 577 72. Instrument Used for Treatment of Torticollis 580 NERVOUS DISEASES. INTRODUCTION. HINTS IN KEGAED TO METHODS OF EXAMINATION AND STUDY. Ik beginning our consideration of the diseases which are to form the subject of the succeeding pages, it is well to start with systematic rules for investigation, and it is of paramount importance that we should pursue some plan which will enable us to avoid confusion, and assist us in making an accurate diagnosis by exclusion. I, therefore, propose a scheme to be used in the examination of patients, and would add a word of caution in regard to the error many of us make in too readily accepting and isolating nervous symptoms as distinct, which, after all, may be expressions of some general disorder. It too often happens that simple digestive disturbances, cholestersemia, or perhaps ursemic poisoning give rise to symptoms that are seized upon as the basis of a distinct nervous disease, and the error is not recognized in time to arrest the true mischief. We are to determine the existence and relation of disorders of motility and sensation, as well as mental symptoms, defects of speech, sight, or hearing, together with the causes which enter into their production. EXAMINATION OF THE PATIENT. Prelimixary Examination. — Sex, age, temperament, appearance, duration of present disease, existence of complicating maladies, previous history, hereditary predisposition, habits. SYIMPTOINIATOLOGY. Motility, degree of, location of loss or increase (one side or one-half of body?), groups of muscles or single muscles, face, trunk, or extremities, lateral or bilateral, symmetrical or unsymmetrical, loss or exaggeration of electro-muscular contractility, fibrillary contractions, muscular power, associated with deformities or contractures ; atrophy or hypertrophy, gen- eral or partial ; spasms, tonic or clonic, attended or unattended by loss of consciousness; condition of reflex excitability. Tremor. — Local or general, increased or controlled by will, "fine" or " coarse;" time of day, continuous or at intervals; subsidence or continu- ance during sleep; whether evoked by jarring limb, or by tapping tendons or muscles; increased or stopped by flexion or extension of foot; accom- panied or not by pain ; associated or not with rigidity of joints when limb is flexed 2 17 18 INTRODUCTION. Incoordination of upper or lower extremities, variety of action in which it occurs; gait; aggravation by closure of eyes; loss of muscular sense; loss of locating power. Sensation. — General or partial anaesthesia ; dyssesthesia or hyperaes- thesia ; susceptibility to painful impressions ; temperature ; tactile sensibili- ty ; sensibility to pressure; pain, localized or general; character of pain, neuralgic, terebrating, dull, or paroxysmal ; time when aggravated ; its associations ; time of transmission of sensation ; appreciation of form. Disorders of Organs .of Special Sense. JEyes. — Nystagmus, strabismus, conjugate deviation (see article Cere- bral Hemorrhage), retinal changes, corneal changes, pupillary changes, ptosis, diplopia, amblyopia, amaurosis. The existence of color blindness. Ear. — Deafness, subjective noises, discharge. Speech. — Aphasia, slow speech, clumsy speech, ataxic speech, loss of speech (mutism). Visual and auditory relations. Vertigo. — Variety ; concomitant phenomena. Psychical Disorders — Illusion, hallucination, delirium, mania, me- lancholia, delusions, and their character, loss of memory, loss of con- sciousness, imbecility, idiocy, excitability, dementia. Miscellaneous. — Character of cutaneous surface, changes in tempera- ture of general surface or localized spots, cranial temperature, variation in salivary secretions, changes in pigmentation and appearance of hair, perspiration, etc. Exciting Causes ; Diagnosis ; Treatment. This list, though imperfect, will, I think, enable the observer to pursue a systematic course in examining his patient. He should, at the same time, take careful notes for future reference, so that variations in the symptoms and changes of treatment may be remembered. Before leaving the subject of examination, I wish to refer to the value of post-mortem examination and microscopical investigation of the morbid anatomical changes. These subjects belong more properly to special works upon pathology and microscopy, but it may not be amiss to add a few hints to those already given in regard to certain important steps to be taken. In removing the ealvarium the thickness of the cranial bones should be noted, as well as the condition of the diploe ; but extreme care should be em ;ployed, in sawing through the bone, not to wound the meninges and brain- .substance beneath; for the saw-teeth may unexpectedly tear through, lacerating and injuring these parts, so that they may be almost useless for subsequent examination. After the skullcap has been removed, the POST-MORTEM EXAMINATION. 19 observer should be on the lookout for Pacehonian bodies, and ready to re- cognize any adventitia that may be attached to the dura mater. The condi- tion of the longitudinal sinus and veins which are contained in the dura ma- ter should be examined as to their fulness, etc. ; the thickness, vascularity, color, and opacity of their tissue should also be carefully noted and then an incision may be made, and this membrane slit up with a pair of blunt- pointed scissors, or it may be cut around at the level of the saw cut. The arachnoid and pia mater are then to be inspected : the existence of effusion, either serous, purulent, or bloody; and the presence of granular deposit or vascular changes noted. The brain should be lifted back, and the cranial nerves carefully cut as near as possible to their points of exit from the skull, the optic first, and then the carotid arteries and posterior nerves ; next the tentorium, and finally the other nerves, vertebral arte- ries, and the spinal cord as low down as possible, taking care not to make pressure by insinuating the finger into the foramen magnum. The brain may then be removed.^ If it is desired to remove the cord, the skin and muscular tissue of the back should be divided and thrown back, and the spinous processes and laminse exposed. These latter should be sawn through on each side and carefully raised by the blade of the chisel^ When the brain is removed, it should be placed with the base downwards, and the appearance of the convolutions noted, the membranes having been removed. Evidences of pressure are to be looked for, and the color is to be noticed, as well as the depth of the sulci and superficial evidences of softening or sclerosis, morbid growths, and infiltration. The organ may be turned over, and the arteries at the base inspected in regard to the existence of anomalies, aneurisms, degeneration, thrombosis, or embolism. The fissure of Sylvius may be next examined, and the middle cerebral artery traced by sections. As to the method of making cuttings of the brain, we may, perhaps, find resort to the horizontal section of Flechsig, espe- cially when the patient has presented before death symptoms indicative of degeneration of the internal capsule. We are enabled to carefully compare by this means the relations of the gray nuclei and the peduncular fibres. The cranial nerve-trunks are to be carefully noticed, and if any suspicious appearance is observed, a section may be removed for micro- scopical examination. The crura and pons are to be examined carefully for softening, secondary degeneration, extravasations and the like, and the appearance of the basal parts of the hemisj)heres next noticed. The brain-substance may be inspected, in other ways by cutting through the cor- pus callosum, and turning each hemisphere gently back, or by slicing oif the brain -substance with a broad sharp knife previously dipped in water or alcohol, so that the white matter may be examined at difierent levels, as recommended above. The condition of the ventricles should be noticed as to the effusion of serum or blood, or the condition of -the lining mem- ^ Removal en masse, of the brain and its membranous coverings should never be attempted ; the result of such a procedure being mechanical injury, which reduces the organ to a pultaceous mass, rendering it unfit for examination. 20 INTRODUCTION. branes. The parts at the floor of the lateral ventricles deserve special study, and the corpora striata should be inspected ver}' attentively, the extra-ventricular and intra-ventricular parts being carefully sliced. A vertical section just posterior to the fissure of Rolando (Pitre's section) may be made. The fulness of the vessels in the deep parts of the brain, the existence of patches of softening or induration, and the pres- sure of cysts, tumors, or morliid growths should be looked for. It is al- ways advisable in cases where aphasia has been a symptom during life, to carefully inspect the anterior convolutions, particularly the third frontal, which is the generally acknowledged seat of the lesion, and we may do this examining at the same time the appearance in the fissure of Sylvius, and carefully slicing that portion of the brain anteriorly, and laterally to the corpus striatum of the left side. It is hardly necessary to allude to the importance of carefully exam- ining the medulla and the roots of the various cranial nerves, the pyrami- dal decussation, and the cerebellum, and for this purpose it is advisable to remove such parts as are Avauted for subsequent microscopical exami- nation. The cord must be examined critically in cases of spinal disease, and the same directions are given for its inspection. Suspected portions may be cut out and laid aside, care being taken to secure as much of the external roots as possible. In special cases nerve trunks or peripheral nerves may be exsected for future examination, and in cases presenting muscular atrophy and degeneration it is well to ascertain the morbid changes in the muscles. If we desire to use the microscope it is gener- ally necessary to harden the tissues, although fresh nervous substance may be teased apart in glycerine or serum by needles prepared for the purpose. If we prefer the first method we may put such masses of the brain or cord as we desire to harden into Miiller's fluid, which is prepared as follows : — R. Pota.ss. bichromat. 50 grammes, Sodic sulphate, 20 grammes. Water, 1600 grammes : Or, what is better, the solution recommended by Prof. J. W. S. Arnold, of the Medical Department of the University of the City of New York: R. Ammon. bichromat. 11 grammes, Methyl alcohol, 320 grammes, Water, 640 grammes. Care should be taken not to secure specimens which are too large, as they do not harden thoroughly, the exterior becoming hard while the in- terior is difiluent and useless. They should be left in the solution for a month or six weeks, but not till they become granular or cheesy, for then it is impossible *to make a good section, as the tissue is apt to crumble under the knife. At the end of this time, or when the tissue is quite firm, it may be removed and placed in a fifty per cent, mixture of alcohol and water. The specimen may be examined to test its hardness by making sections with a razor from time to time. If a verv thin section can be MICROSCOPIC EXAMINATION. 21 made with a moistened razor without parting, adhesion, or crumbling, it may be considered to be in fit condition for removal from the hardening solution. A solution of bichromate of ammonium, 15 grains to the ounce of water, is an excellent hardening solution, in which the specimen may remain until it has been uniformly saturated, and hardening has com- menced, and then it is to be removed and placed in a solution of chromic acid, two grains to the ounce of water, where it is to remain until hard enough for cutting. This is the process recommended by Dieters. The specimens may be taken out and kept for use in dilute alcohol till they are needed. When the hardened tissue is to be examined, it is to be imbedded in pith or paraffine, and either placed in a section cutter, or held in the hand. By practice, this latter procedure becomes quite easy, and very thin sections may be skillfully made. A piece of brain or a length of cord of a convenient size is surrounded by elder pith previously prepared to receive it, and bound in place by a string, or by a piece of fine copper wire. When moistened, the pith swells so that the tissue receives uniform pressure and support. If the paraffine process be that employed, the tissue is to be carefully dried and placed in a small paper mould which is afterwards filled with melted paraffine, this however should not be too hot,^ and care should be taken to exclude air-bubbles. When cool and solid the upper part of the paper may be torn away, and the specimen is ready for cutting. A flat razor is the best instrument of which I know for ordinary work. Its blade should be dipped in a saucer containing alcohol placed conveniently by, and the face of the section should be moistened from time to time. The individual holding the mould firmly between the thumb, forefinger, and second finger of the left hand, cuts away a portion of mould and tissue so that a level surface is left exposed ; then, with moistened razor, he plants the blade, and slowly cuts a thin slice of paraffine and tissue to- gether ; this is removed by a camel's hair brush which has been dipped in alcohol, and next dropped into a small vessel containing dilute alco- hol, and then placed in the staining fluid, which may be the follow- ing:— R. Carmine (pure), gr. xx, Liq. ammonise, q. s. ut dissolv., Glycerin 86, A quae, aa ^ij. — M. After being allowed to soak for several hours or days, the sections are removed and dropped into water slightly acidulated with acetic acid. They are now to be placed in absolute alcohol for a short time, and after- wards in oil of cloves until they become transparent. A perfectly clean slide is procured, upon which one of them is placed and a drop (not too large) of Canada balsam is next applied. It is then covered by a thin ^ I have recently used metallic bottle caps, which may be easily procured. When the paraffine is cool the metal may be stripped off. 22 INTRODUCTION. glass cover, care being taken to exclude air-bubbles. Various prepara- tions are used to stain nervous tissue ; for instance, a solution of chloride of gold will stain the nerve fibres, and render them more distinct ; haima- toxylin and osmic acid are also used, and the black analin process of Herbert Major^ produces the most beautiful results. These manipulations, however, are out of place here, and I would refer the reader to any one of the excellent text-books that have appeared during the past few years for more explicit directions. It is often necessary to make sections in all possible directions and posi- tions, and to do this properly the microscopist must not only have practice but patience and care. It is advisable to procure at least two objectives, one for coarse appearances, and the other for minute changes, and I would suggest that these should be an "inch " and a " quarter inch." INSTRUMENTS USED FOR THE DIAGNOSIS OF NERVOUS DISEASE. It is essential that we should possess certain instruments which shall be more valuable and exact than our unaided senses, so that we may not Fio-. 1. oiily niake reliable investigations, but compare from time to time such variations as may occur in the patient's condition. Those I propose to describe are intended for examinations of tem- perature and sensory changes, and for the detection of altered motility. The Thermometer. — There are several instruments made for the purpose of determining variations in temperature, and though some are of extreme delicacy, I do not think it will be worth while to recommend them, as they are bulky and troublesome, and are better adapted for experimental purposes than actual clinical use, and among these is Lombard's instrument. In Dr. Seguin's surface thermometer we possess an admirable little instrument for testing the surface temperature. It has an expanded base, and may be applied to the surface of the body, taking care to cover the top by a perforated piece of thin rubber or leather. A coat or two of shellac varnish to the upper part of the bulb will answer the same purpose, viz., that of prevent- ing the mercury from being affected by the temperature of the room. For the determination of deep temperature we may avail ourselves of any of the good self-registering instruments. Two surface thermometers should be used, one on the sound, and the other on the affected side of the body, and the deep temperature maybe taken at the same time for comparison. A new form of surface thermometer has recently been made in "^'^^^^ England. The glass tube is spirally coiled upon itself and "^surfti'ce"^ enclosed in a circular box. This form has the merit of being, ^raeter"" Unaffected by other than the body temperature. ^ West Riding Reports, vol. v. CEREBRAL THERMOMETRY. 23 Within the past two or three years a great deal of interest has been excited by the remarkable investigations of Broca, who found that it was possible to detect deep changes of temperature in the cerebral organs by means of surface thermometers applied to the exterior of the cranium ^ Broca's observations were confirmed by those of ^ Dr. Landon Carter Gray, of Brooklyn, N. Y., and by ^Maragliano and Seppilli, two Italian experi- menters. Albers of Bonn was undoubtedly the first person (1861) to suggest cerebral thermometry ; but Broca's work was the first undertaken in a systematic and fruitful manner. By the use of six or more thermometers applied to the head at various points, with every allowance for external disturbing agencies and sources of error, it is found that the central temperature undergoes various modi- fications, amounting sometimes even to several degrees; and Gray was enabled to diagnose and localize the existence of a cerebral tumor by this diagnostic means. The thermometers should be those known as Seguin's, or, better still, of the form modified by Dr. Gray. They should be tempered perfectly, and so constructed that ordinary pressure upon the bulb shall cause no rise in the column of mercury. A proper system of straps (Fig. 2), -p- 2 such as has been devised by Dr. Gray, or a cap of gum-rubber, with perforations, enables us to apply the thermometers upon both sides of the head, over the points we desire to examine. Dr. Gray has adopted the names Frontal, Parietal, and Occipital — stations relating to the positions indicated by the names to designate the places over which the tests are to be made. A ther- Gray's System of Head straps. mometer is to applied (after the index column is shaken down) to these spots for a period at least of twenty minutes, and then the figures are read without remov- ing the instruments. When a spot with increased temperature is found, the other thermometers are to be grouped about the suspected locality. Repeated tests show more or less sameness in the readings, so that it is possible to determine that a very limited portion of the brain is the seat of morbid action. In one case Gray was enabled to diagnose a tumor before death. 1 Progr^s Medical, 1877, quoted by Gray. ^N. Y. Med. Journal, August, 1878, p. 131. ^ Eevista Sperimentale di Freniatria e di Medicina Legale. *Tlie adjustment of these straps should be made so that those passing over the head should go in front and behind the fissure of Eolando which divides the important mo- tor tracts. Gray measures from the fronto-nasal fissure, and fixes the location of the fissure as 6f inches posterior to this point. 24 INTRODUCTION. ^ Dr. Gray thus details the observations he made : — "The patient was a female, aged thirty-four. There was present a typical ' choked disk,' marked pain in the temple and brow, becoming unbearable in paroxysms, nausea, vomiting, ptosis, paralysis of the ocu- lar muscle. The first paroxysm of pain came on January 21st. The bodily temperature ranged near the normal. Upon these symptoms a diagnosis of intra-cranial tumor was made, probably situated at the base. Placing my thermometers upon the head, I ascertained the temperature at the different stations to be as follows: Left. Right. Frontal, 96 75° 98.33° Parietal, 95° 99.75° Occipital, 96.75° 100.50° The average of the two sides, if calculated, will be found to be 96.16° on the left, on the right 99.52°, the average for the whole head being 97.84°. The rise above the normal averages is startlingly apparent. At the Left Frontal Station it was 2.39°; at the Left Parietal, 56.0°; at the Left Occipital, 4.09°; at the Right Frontal, 5.12°; at the Right Parietal, 6.16° ; at the Right Occipital, 8.56° ; while the average of the left side had mounted above the normal 2.33°, the right side 6.QG, and the average of the whole head 4.33° ! This particular observation was taken as I was at the outset of my study of the subject, and was made with my first set of thermometers, which, as I have already stated, were defective. I have satisfied myself, however, that the defect amounted to but a little over one degree. If, therefore, from these figures one and a half degree be deducted, all fear of error may be dismissed; and yet the increase is unmistakable. About this date (March 4th), I wrote Dr. Rockwell : "I shall certainly expect to see inflammatory changes from the base of the fissure of Sylvius back- ward along the occipital lobe, as well as that these changes shall be spread around the base of the fissure." The patient died March 16th. * *****" The meninges were found apparently normal, with the exception of a slight congestion. At the base of the brain the membranes and skull were to all appearances healthy. But a soft, jelly-like tumor, the size of a hazel-nut, was found between the horizontal or posterior branch of the fissure of Sylvius and the first temporal fissure, while the whole of the right occipital lobe was converted into a colloid, extremely vascular mass, which gave way under examination, this degeneration also extending anteriorly to the tumor as far as the fissure of Sylvius. There was no apparent disease except at these points. Upon microscopical examination, I ascertained the tumor to be a typical glioma, thickly strewn with small extravasations of blood." Dr. Chas. K. Mills ^ has reported an interesting case of tumor of the 1 Loc. cit. ^ Phil. Med. Times, Jan. 18, 1879. ^STHESIOMETEK. 25 brain, involving portions of the first and second frontal convolutions, in which he found that the temperature obtained over the middle frontal station averaged 1.50° above that of the other stations. The evidence collected by the few observers already mentioned shows the normal average temperature to be about as follows at the stations designated : K. Frontal . L. E. Parietal . L. " . E,. Occipital L. " 93.71° 94.36° 93.59 , 94.44. 91.94 , 92.66° MARAGLIANO AND SEPPILLI. 97.07 , ,97.16, 97.07 , .97.12. .96.71. . 96.81 . BROCA. 95.39 95.79 92.84 91.49 92.66 N. B. The experiments of Gray and Broca were made during cool weather. Gray found the average temperature on the left side of the head to be 93.83° ; right, 92.92°. The average temperature of the whole head, ex- clusive of the vertex, 93.51°. Average temperature of motor region of vertex, 91.67°. His conclusions may be summed up as follows : " If there be an alteration of temperature at any of the lateral stations of more than one and a half degree above or below the average tempera- ture of such station, this fact will justify a suspicion of abnormal change at that point. "If there be an alteration of temperature at any of the lateral stations of more than two degrees above or below the average of such station, this fact will constitute strong evidence of the existence at this station of ab- normal change. " In proportion as the alteration of temperature at any individual sta- tion is increased or decreased beyond the figures just mentioned, in exact proportion will the strength of the evidence be increased as to the exist- ence of abnormal change at that station, until, the maximum or mini- mum having been passed, the evidence will become almost conclusive. " Should it so happen that such elevation of temperature above the average should be at any lateral station on the right, causing a rise at this point beyond the average temperature at the corresponding station on the left, this would strengthen the suspicion or the evidence." My own observations have been but few in number, though I trust I shall soon be able to add to Dr. Gray's valuable collection of facts. In one case of undoubted cerebral tumor under my charge there is a rise of temperature of three degrees, which does not even vary a degree though I have made over thirty examinations under all sorts of circum- stances. In one case of chronic cerebral meningitis, there was a general rise of cranial temperature, which was highest at the vertex, however. The .^STHESiOMETER was first suggested by Sieveking, and has since been modified by different individuals. We have several different varie- 26 INTRODUCTION. ties to choose from, but no one is better than the original instrument of Sieveking, which is also used and recommended by Brown-Sequard. It is made of brass or steel, and very closely resembles a shoemaker's mea- Fig. 3. Sieveking's ^sthesiometer. sure. The movable slide and permanent arms at the end are sharp- pointed. The bar upon which the free slide moves is ruled in centi- meters. The other sesthesiometers are mostly shaped like dividers, and are open to the objection that the points are liable to be unconsciously approximated when the instrument is removed, so that the result of investigation is somewhat unreliable. Carrol's jesthesiometer has one advantage. The points are bifurcated, one arm ending in a bulb, while the other is sharp, so that analgesia as well as anaesthesia may be tested. ^STHESIOMETER. 27 Dr. E. C. Seguia has made a very decided improvement upon the original instrument of Sieveking. He has had it constructed of alumi- num, and of a smaller size, so that it is light and small, and may be easily carried in the pocket-ease. The principle upon which the sesthesiometer is constructed is the fol- lowing : The normal receptivity of tactile impressions enables the subject to distinguish two points which are brought simultaneously in contact with the skin. This susceptibility varies greatly in different regions in proportion to the delicacy of the tactile sensation located therein. If there be loss of sensation as an accompaniment or result of nervous dis- ease, of course the distance between them will have to be increased be- fore the points will be felt as two. In hypersesthesia they may be much more nearly approximated and distinguished as two than in the anaesthe- tic state. The average distance at which the two points of the instrument can be felt in the normal state are as follows : — Point of tongue ^ line Red surface of lips 2 lines Palmar surface of third finger 1 line Tip of nose 3 lines Metacarpal bone of thumb 4 " Skin of cheek 5 " Mucous membrane of hard palate 6 " Dorsal surface of first finger 7 " Dorsum of hand over heads of metacarpal bones 8 " Mucous membrane of gums 9 " Lower part of forehead 10 " Lower part of occiput 12 '' Back of hand 14 " Neck under lower jaw 15 " Vertex 15 '' Skin over the patella 16 " Skin over the sacrum 18 '' Skin over the sternum 20 '' Skin over cervical vertebrae 24 " Skin over middle of back 30 " Skin over middle of the arm 30 " Skin over middle of the leg 30 " Certain precautions must be taken when using the sesthesiometer, or else our examination will be unsatisfactory in the extreme ; we must not depend in all cases upon the patieot's statement, but exercise tact in get- ting from him satisfactory answers, and not guesses. There seems to be in some individuals a discouraging stupidity which prompts them, in an- swer to the question, " How many points do you feel ? " to oftentimes re- ply " Three," when they know that the instrument has but two points. It is of the greatest importance that the patient's eyes should be covered or that he should close them, as he will unconsciously look at the instru- ment during its application. It is also of moment that the points should be fairly and at the same time applied to the skin, one not being pressed 28 INTRODUCTION. more than the other, and finally, it may be stated that they should not be applied at any place where the clothing has rubbed or chafed the surface. Diagram for making Records. — Roman numerals show ancestlietic indications, the others normal sensibility. Since the appearance of the first edition of this book Dr. Hughes, of St. Louis, has devised a very convenient instrument, a new feature being an ingenious scale of measurements upon its bar, with a standard for reference. Various tests of sensibility are simpler than those of the kind I have described. For gross tests the finger tips of the examiner may be applied and separated like compass arms. Shape and pressure may be deter- mined by the application of various-sized bodies, weights, or coins, the subject's eyes being meanwhile bandaged. The Dynamometer. — Various forms have been devised, that in general use being invented by Burq and introduced by Mathieu. It consists of an elliptical spring, Avhich, when compressed in the hand, registers upon an in- dex the force exerted. When the needle is forced ahead it remains at the point it had reached when pressure was remitted, and the spring expands. Its disadvantage lies in the inequality of pressure made at diflTerent times, the bulky character of the apparatus, and its inadaptability to other uses. THE DYNAMOMETER. 29 Fig. 5. »«-fi£ YNO£13.i. -^ Mathieu's Dynamometer. Having recognized the necessity for an instrument that would meet the therapeutical requirements not possessed by those of Mathieu or Du- chenne, I have devised that figured in the appended illustration. It con- sists of a long glass tube (2) which dips into a small bottle filled with mercury. In connection with a bent brass pipe (3) is a rubber tube which terminates in a closed rubber bulb (5 \ When this bulb is com- pressed the mercury is forced up in the glass tube, the end of which is closed. Attached to the tube is a scale (1) registered on one side in pounds, and on the other by marks separated by regular intervals for the purpose of making comj)arative estimates. As fifteen pounds' pressure to the square inch is required to compress a given body of air into one-half its original space, of course a force of fifteen pounds' pressure brought to bear upon the bulb would be required to press the column of mercury halfway up the scale. The advantages of this apparatus are the follow- ing:— 1. Its simplicity. 2. The adaptability of the rubber bulb to receive pressure exerted by all the flexors of the hand. Mathieu's spring is only acted upon by a limited number ; at the same time, therefore, the test is not a true one. 3. The action of the muscles is the same at difiTerent times. The same group of muscles always being brought into play, accurate comparative tests may be made from day to day. 4. The part receiving the pressure is of a convenient shape to be used by persons with either small or large hands. 5. It is accurate and always gives reliable indication of the pressure brought to bear. Dr. Birdsall of this city has recently invented a most ingenious foot dynamometer for testing the strength of the lower extremities. The dynamometer is at best an instrument of questionable value, as are others requiring an effort upon the part of the patient. In rough tests of power it is useful, but in accurate case-taking, very little importance can be attached to the detailing of small variations as recorded upon the dial or scale of any dynamometer. I have combined the rubber bulb with the drum of Marey, and am enabled to obtain gro'ss variations with tolerable accuracy. The drum has 30 INTRODUCTION. two pipes, one of which is connected with the rubber bulb, while another is attached to the lower end of an open glass tube. The bulb-drum cavity Fig. 6. The Author's Dynamometer. and a part of the tube are filled with colored fluid, so that the fluid in the latter reaches a mark at about the middle of its length. The patieut grasps the bulb and makes enough pressure to force the fluid in this tube to a mark slightly above the other. The sustained voluntary effort required to keep the fluid at this point necessitates some delicacy of muscular co-ordination, and should this be impaired there will be expansion of the drum-head and consequently irregular tracings upon the cylinder of the registering appa- ratus. This cylinder should be covered by a piece of smoked paper, and the stylet placed in apposition thereto. In alcoholic tremor, commencing sclerosis, and the metallic tremors, we may obtain very beautiful tracings. The Ophthalmoscope. — The parts composing the ordinary ^ophthal- moscope are the following : A concave mirror perforated at its centre, a series of lenses by which the refraction in the subject's or observer's eye THE OPHTHALMOSCOPE. 31 may be corrected, and a bi-convex lens The three forms in common use are those of Liebreich, Loring, and Knapp. The two latter are essentially- alike in construction, and the first is quite primitive, usually of bad con- struction, and quite unreliable. Fig. 7. Loring's Ophthalmoscope. In the examination with this instrument great care should be taken by the observer to determine whether he or his subject possesses errors of re- fraction, and if so, to correct them with the proper lenses. In the modern ophthalmoscope a number of lenses are held in a revolving disk behind the mirror. For more specific directions the reader is referred to Dr. Loring's ad- mirable little work.^ To examine the eyes of a patient properly, the observer may follow the concise directions laid down by Hutchinson.^ " Having placed the patient's head in such a manner that the light (a lamp, candle, or gas-light) is on a level with his temple, and slightly be- 1 Determination of Errors of Refraction with the Ophthalmoscope. E. G. Loring. Wm. Wood & Co., N. Y. '■^ Jonathan Hutchinson. Clinical Reports of London Hospital, 1867 — 8, p. 182. 32 IXTRODUCTIOX hind it, and his face, as a consequence, in shadow, the observer sits in front and applies the ophtlialmoscope mirror to his own eye. He should keep both eyes open that he may see where the light falls, and then move the mirror until the light falls full on the pupil of his patient. In a mo- ment he will perceive the first fact which this instrument reveals, that the fundus is not black, as it has always appeared to be before, but that it is of a brilliant fire-red. He will, however, see nothing of the fundus dis- tinctly, only a general red reflex. Now at this point the student must stop awhile and use his mirror, to inspect, first, the transparency of the cornea, and, next, that of the lens and vitreous, and to do this he must make the patient move his eye in various directions. After a little prac- tice he will be able to manage his light well, and to throw it with preci- sion wherever he may wish, and to keep it steadily on any given part. At a first lesson he may even, with advantage, practise for a while by illumi- nating the second button of the patient's waistcoat. Tact in directing the light having been obtained, we may now proceed further. Instruct the patient to look, not full in your face, but over one shoulder ; if you are inspecting his right eye, over your left shoulder. You will, when he does this, notice at once that the tint of the light reflected from his fundus is changed, that it is no longer fire-red, but canary yellow. The reason of this is that a difl^erent part of the fundus is exposed to view, that, namely, of the optic disk itself, which is much lighter in color than the rest. The area of yellow is very large — occupies, indeed, the whole of the field, while we know that the disk itself is very small. This proves that the objects thus indistinctly seen are immensely magnified. Magnified by what? By the patient's own eye, which, as we have said, is equivalent to a lens of one inch focus. " Hitherto we have seen nothing distinctly, but if the observer now brings his head very close to his patient's face, he will be able with more or less facility to observe the details at the bottom of the eye, the trunks of vessels of the retina, the optic disk, etc , etc. All these will be seen very large indeed, being still magnified by the patient's eye. What he sees now is equivalent to type looked at through a one-inch lens, placed exactly one inch in front of it." Without entering into an extended discussion as to tho value of this Note. — Dr. Loring says, in concluding an admirable paper : " By the experiments considered in the foregoing remarks two alternatives are forcibly presented to our mind: either that the circulation of the eye is not a reflex of the circulation of the brain, though derived directly from it ; and thus agents which affect profoundly the one have little or no influence on the other; or, if the retinal circulation is a reflex of the cerebral, it follows that the influence exerted on the circulation of the brain by agents at our command, remedial or otherwise, is very much less than heretofore supposed. " I cannot but think that the former alternative is the more rational, and from that very independence of the two circulations there is reason to fear, so far as functional, and especially mental diseases, are concerned, that there never will be, any more than there now is, any art to read the mind's construction in the eye." THE PERCUSSION HAMMER. 33 Fis. 8. instrument as a means of diagnosis, it will be well to state frankly that I do not believe that it possesses any positive value in the diagnosis of brain disease, except ivhere the condition of the fundus is the result of an organic disease of the brain or cord, or when it is possible to connect such disorders with errors in refraction. In making this statement I s-hall, perhaps, find many opponents, but I nevertheless have many powerful allies. Bouchut,^ Panas,- Albutt,"* Bull, and others have written extensively, and have furnished a large number of clinical reports of ophthalmoscopic changes co-existent with cerebral tumors, menin- gitis, softening, efi'usion, cerebral hemorrhage, gen- eral paralysis, locomotor ataxia, and other forms of sclerosis, epilepsy, and the syphilitic and ursemic neuroses. Hutchinson,'* of Philadelphia, in an admirable article, gives many of these cases, and shows the real value of the ophthalmoscope, espe- cially when an examination of the fundus reveals choked disk and optic neuritis, but I will speak more fully in regard to this subject when we come to the discussion of special diseases. My friend Dr. Buzzard, of London, demonstra- ted to me at the National Hospital for the Epi- leptic and Paralyzed, a useful application of the ophthalmoscope, for the purpose of testing the sen- sibility of the iris. The patient sits in a dimly- lighted room and looks at some object at a distance, so that the pupil is not contracted in accommoda- tion. A pencil of light is then thrown upon the eye-ball to one side of the pupil, and gradually changed in direction, so that the iris is suddenly stimulated. Erb prefers for this test the use of arti- ficial light concentrated by a convex lens. The Percussion Hammer — For the purpose of rapping the patellar or other tendons, the ordi- nary percussion hammer with a rubber head, such as is ordinarily used by medical men in chest examinations, has been adopted. One with a flexible whalebone handle is the best. The patient seats himself with both feet upon the ground, with bared 1 Du Diagnostic des Maladies du Systeme Nerveux par I'Oplithalinoscope. Paris, 1876. ^ La France Medicale, Feb. 26, 1876. ^ Med. Times and Gaz., vol. i., p. 495, and seq. ♦Phil. Med. Times, May 8, 1875. 3 Percussion Haramer. 34 INTRODUCTION. legs and a smart blow is then struck just below the patella, with the effect of producing the " tendon reflex " movement. A sharp contraction of the quadriceps femoris generally occurs in the healthy person, and a more or less violent extension of the leg follows. This method of procedure may be resorted to, or the patient may cross his legs, and the ex- aminer may tap the tendon of the depen- dent knee. The position of the limb should never be constrained or uncomfortable, and there must be no voluntary contraction of the muscle upon the jDart of the patient. In cases where there is unusual excitability of the " tendon reflex " the blow may be struck upon the tibia. In fat persons the patient's leg may be supported upon the arm of the examiner, as figured in the an- nexed illustration. This subject will in another part of this work be alluded to more fully. (See "Diseases of the lateral columns, etc.") Producing the " tendon refiex " movement, (tiower.) APPARATUS FOR THE TREATMENT OF KERVOUS DISEASE. Electrical. — Two forms of apparatus are required^ — one for the pro- duction of galvanic, the other for the induced or Faradic current — as well as the necessary electrodes. As we know, the galvanic current is derived directly from a battery or pile, the first consisting of two elements, which are contained in a vessel filled with some exciting solution, and the latter of plates of metal placed one above the other, and separated by disks of felt or paper moistened with a solution of salt or acid. This last apparatus is rarely used. One vessel or cell of the form I have first described constitutes a simple battery, and two or more, with the poles alternately connected, a compound battery. Two qualities of electric force are generated by a battery of this kind : 1. Quantity; 2. Intensity. The latter is the characteristic which makes it valuable as a means for the production of muscular contraction and nerve stimulation. The Faradic current is derived from a galvanic cell primarily, and is developed by its passage through a coil of wire wound about a central core or bundle. Two currents are induced therein : one the primary induced, the other the secondary induced. The first is less ccarse and vi )lent in its effects than the other. For a more extended description of electro-physics, physiology, and RUBBER MUSCLES, ETC. 35 therapeutics, I would refer the reader to any of the works mentioned at the foot of this page. ^ For the production of the galvanic current, we may avail ourselves of either one of the permanent batteries ; the cells of which may be set up in the cellar, and the wires carried to a proper board in the ofiBce, containing apparatus for their selection ; or we may use the ordinary portable galvanic battery, many styles of which are made. I have given the Leclanche battery a fair trial, and now do not recommend it, as it is dirty, inconstant, and rapidly loses power. The " magazine battery " of Chester, in which the peroxide of lead is substi- tuted for the black oxide of manganese in the porous cell, is much better. The old Daniel's cell is, I am convinced, the best of all, and whether in the form of the Siemens and Halske, or Hill modification, is all that can be desired. The table board of Fleming of Philadelphia, or the arrangement known as the '' cabinet battery," which is made by the Galvano-Faradic Company of New York, is admirable for ofBce use. The Faradic instrument should be provided with an attachment for the slow or rapid interruption of the current, an addition to the ordi- nary battery, which will be found of immense advantage in certain forms of paralysis. The instruments of the two firms I have mentioned, be- sides those of Drescher and Kidder, are all good. Two or three cotton-cloth covered electrodes of difi^erent sizes, or fiat sponges with rubber backs, with fine wire pole cords instead of the flimsy gold-thread connections in present use, which oxidize and break, will be needed, as well as a bundle of fine wires held in a handle, which is known as an electric brush. Static electricity has lately received some attention. Beyond its moral eflTect upon the patient, especially if there be hysteria, I do not believe that it possesses any advantages over the chemical currents. KuBBER Muscles, etc. — Dr. Van Bibber, of Baltimore, has devised a very useful apparatus for the treatment, especially of lead paralysis. It consists of. a strap for the hand or other part which needs support, and one for a point of attachment of the muscle. When properly Either of these works will be found practically useful to the student : — Tibbit's Handbook of Medical Electricity. Beynolds' Clinical Uses of Electricity. Althaus's Electricity, Theoretical and Practical. Poore : A Text Book of Electricity, etc. Lincoln's Electro-Therapeutics. Beard and Rockwell's Medical and Surgical Electricity. Hamilton's Clinical Electro-Therapeutics. Duchenne's de 1' Electrisation localise, 1872. Onimus et Legros, Traite D' Electricity Med. Benedikt Electrotherapie, 1874-5. Ziemssen, Die Electricitat in der Med., 1872. Besides, the works of Rosenthal, Erb, Meyer, Eulenburg, and others. 36 INTRODUCTION, applied, the rubber pipe, which takes the place of the paralyze Iscle, raises the hand, so that the strain upon the enfeebled muscle i relieved. Dr. Van Bibber has also used court plaster for the treatment of ptosis and other minor paralysis. The Hypodermic Syringe, Ether Spray Apparatus, and Spinal and Cranial Ice Bags, should be procured by every physician who has occasion to treat this class of diseases. CAUTERiES.-Until a few months ago the old forms of cautery were used almost exclusively. These are of iron, and are sometimes platma covered. When needed, they are heated in the flame of a Bunsen burner, Russian blast lamp, or some such contrivance, but lose their heat very rapidly, and generally assume a dead red color when applied, ihe glass rods, heated in a like manner, though somewhat more convenient, become very quickly cool. ^ ^ ,, a • ^ Dr. J. J. Putnam, of Boston, exhibited at a meeting of the American Fig. 10. The Author's Gas Cautery. Neurological Association the first gas cautery seen in this country, though Alex. Bruce years ago invented a cautery of this kind, it CAUTERIES. 37 was constructed in such a manner that the jet of an ordinary gas blow pipe was directed upon a cup of platinum. Its advantages over the older variety were manifold, but it possessed faults I have tried to remedy in a modification. The advantages of this instrument are the following : — 1. The jet which prevents all hissing or noise, and still produces a very powerful blast. 2. The apron of wire gauze, which prevents the return of flame, thus obviating the danger of burning parts that we do not wish to affect. 3. The large bag, which acts as a reservoir, so that the operator need not use the rubber bulb nor watch the burner after it is filled. 4. The hook, which enables him to suspend the bag and tubing from his person, thus removing all drag. The general advantages of this form of cautery are important. A uniform heat may be kept up for hours with very little exertion. The furnace, which is not only inconvenient, dirty, and alarming to timid people, but is a slow method, is done away with. In less than a minute the platinum dome can be heated to whiteness. The cauteries of Pacquelin and Guerard, of Paris, are both good. In them the vapor of benzine (which should be impure) is forced with air upon a piece of hot platinum. These are excellent substitutes for the cautery I have just described, especially in the country, where there is no gas. Messrs. Stohlman, Pfarre & Co. have constructed for me an appara- tus which consists of the cautery, handle, and a hard rubber receptacle containing charpie which is to be saturated with benzine. There is no danger of explosions such as exist when we use the ordinary bottle that forms a part of the French instrument. It has been recommended that the spinal ether spray be used to deaden pain ; but not only is there danger of an explosion when this procedure is tried, but it seems to me that the very object of the operation, revul- sion, is not accomplished, as the peripheral filaments are of necessity be- numbed. 38 DISEASES OF THE CEREBRAL MENINGES. CHAPTER I. DISEASES OF THE CEREBRAL MENINGES. All of the investing membranes of the brain may be the seat of in- flammatory action, but it is almost impossible in certain instances to make distinctions between inflammation of the arachnoid and pia mater, though this has been attempted by Parent-Duchatelet, Lallemand, and others. "We will, therefore, have to content ourselves with a division founded upon the duration, intensity, and coexisting diseases of the general system, and limit our regional diagnoses to forms which may be called meningitis of the convexity and meningitis of the base. In respect to certain circumstances which modify the appearance of the disease we may divide its varieties as follows : — Cerebral pachymeningitis, ) p, '. (Inflammation of the dura mater,) / „, , ' . , . V Chronic, with hematoma. r Basilar, Acute cerebral meningitis, •) Of the convexity, \. Granular. Chronic cerebral meningitis. PACHYMENINGITIS (INFLAMMATION OF THE DURA). Two forms of pachymeningitis are to be met with, one of which is acute and is the direct result of injury or disease of the cranial bones, and is generally fatal in a short time; and the other, of a chronic nature, which may either remain after injury, or arise from some intracranial cause, or perhaps be the result of general disease, or old age. ACUTE PACHYMENINGITIS. Symptoms. — After the traumatism, or when the external disease has invaded the intracranial cavity, the first symptom is usually severe and localized pain, which finally extends with the inflammation, and becomes diflfused over the entire head. Rigors, alternating with elevation of tempei'ature, which may sometimes attain 105° or 106° F., head pain and occasionally spasms of the arms or legs, are ordinary symptoms ; and if the condition be a very acute one, there may be general convulsions, or perhaps a partial paralysis, which is unilateral. ACUTE PACHY3IENIXGITIS. 39 Delirium usually supervenes in from three days to a week, and coma ends the disease, should an effusion of blood take place, and this is a com- mon terroination. The pulse during the first two or three days varies from 60 to 70, while towards the end it becomes much more frequent and very full. Daring the invasion, and after the disease is fully established, especially if the inflammation extends to the base, the head may be drawn backwards and downwards. RamskilP has called attention to the hyper-sensitiveness of the cornea, and I have been often impressed by another symptom, viz., the redness of the conjunctiva and the constant tendency to lachrymation. Vomiting very commonly takes place, and is always quite a suggestive symptom of meningeal trouble. When the disease follows otitis its onset is not so sud- den as when it is the result of injury, but a train of symptoms of gradual appearance marks the extension of the morbid process step by step, though iu some instances rigor with sudden coma may be the first indica- tion of mischief. This is in most cases the purulent form. Cases of the idiopathic variety of pachymeningitis are quite rare, although several have been reported by Abercrombie and other older writers. One case related b\^ the former authority may be worth mentioning. This writer also gives six others which originated from middle ear disease or abscesses in other bony cavities. These latter cases are not uncommon, if we may accept the experience of aurists and surgeons. Abercrombie's ^ patient, in whom the disease was idiopathic, died in fifteen days. The first indication was severe pain in the left, temple, which continued for two weeks, when a "swelling" appeared beneath the left upper eyelid. Four days before her death violent convulsions took place, which were preceded by slight rigors. The swelling was punctured, and a considerable quantity of pus escaped. A probe passed into the opening came in contact with bone, and could be inserted for some distance, the end being in contact with the roof of the orbit. During previous days her condition had varied to a great degree, and at times she seemed to be very comfortable. On the day before her death she complained of vertical headache, became semi-comatose, and died in this state. Extensive discoloration, thickening, and other changes in the dura mater were found with adventitious membrane and pus. In a case detailed to me by Drs. White and Asch of this city, there was al- ternating paralysis associated with aural disease which afiTected the ears in turn. Fizeau^ mentions a case which closely resembled this one, and another quoted by Abercrombie, and seen by Prathernon, was also of idiopathic origin. Abercrombie's other cases presented common symptoms which' were traced to assignable causes. Dr. Clark* has presented five eases of the ^ Eussell Reynolds' System of Medicine, vol. ii., page 325. ^ Abercrombie on the Brain, page 21. ^ Journal de Medicine, torn, ii., New Series, page 523. * Transactions New York Pathological Society, 1876. 40 DISEASES OF THE CEREBRAL MENINGES. acute form, due to otitis. Dr. Bauduy another Avhich followed scarlet fever, and many of the same kind may be found mentioned by other authorities. CHRONIC rACHYMENINGITIS. A far more interesting class of cases are those which have lasted for some time, and have invaded the underlying membranes, ending in in- volvement of the cortex cerebri. The following is a fair example : — Symptoms. — John McM., age 30, of temperate habits. The patient was a young man of the laboring class, and was employed in a machine- shop at the time of the accident. Three years ago, while turning a piece of metal, it caught upon the end of his turning tool and flew out of the lathe (which was driven by steam-power), striking his head, and cutting a scalp wound over the upper part of the right parietal bone. He fell un- conscious, and was carried to his home, remaining in the same state for about eight hours. After this he recovered slowly, was delirious, and evi- dently had had convulsions. From this period to the time when I saw him his history was not very clear, but he had had convulsive paroxysms from time to time, and severe headache, which he complained of when he came for advice. This pain was limited to the right side of the head, and prin- cipally centered at the injured spot. His face was quite puffed and swollen, and his eyes were red and watery. Pressure upon the cicatrix caused intense pain. His right pupil was slightly enlarged, and he com- plained that his vision was imperfect. Sleep was disturbed by the pain which would often occur in paroxysms of a very intense character. He complained that his left arm felt stiff, and that his fingers were cold, but I was unable to find any loss of power. He continued in this state for a year or more, and when I next saw him his speech had become slow and hesitating, and his face wore rather a silly expression. He then com- plained of some feebleness of the left arm and leg. The headache had not abated, and the convulsions had been much more frequent. His friend who came with him stated that his mind had greatly changed, that his be- havior was eccentric, and that he had had delusions of various kinds. I subsequently lost sight of him. In some features this case resembles one of softening. This form of chronic pachymeningitis is much more obscure when it is connected with syphilis. There is not only a great /dispropor- tion between the severity of the symptoms and the extent of the morbid process, but symptoms of great variety may be evinced as expressions of pachymeningitis of syphilitic origin.^ Lagneau fils^ reports a case in which the only symptom was headache, which was most violent at night. Post- mortem examination revealed pachymeningitis over the anterior lobes of the cerebrum, with bony plates and some sclerosis of the brain -substance. There was, in addition, extensive perforation of the ethmoid bone. In- stances are related by Gama where the patients had ditd conscious, 1 Trans. N. Y. Path. Soc, vol. i., p. 13. 2 Observation 3, Lagneau, Maladies syphilitiques du Sysleme nerveux. Paris, 1860. CHRONIC PACHYMENINGITIS. 41 and their meninges were found to be decidedly affected. Keyes/ in a most complete and exhaustive memoir, presents a number of cases of hemiplegia which were the ultimate result of the meningeal inflamma- tion, and calls attention to the pain which precedes the hemiplegia, and which is always produced when pressure is made upon the cranium. A feature of the hemiplegia is the absence of any loss of consciousness. Syphilitic meningitis of this description is very often — I may say almost always — symptomatized by a decided failure in the mental powers, which begins in fact as soon as the pathological process manifests itself by any symptoms at all. I regard this slowness of intellectual action which, by the Avay is general, as almost pathognomonic. In some cases it has been almost the only symptom of a pachymeningitis which was not recognized until after death. I have, since the appearance of the first edition of this book, been called to see several persons, who have subsequently died, presenting an imperfect hemiplegia — that is to say, a hemiplegia of a comparatively light character, but associated with an equally light coma, lasting several days. There was not even laborious breathing, and it was possible to rouse the patients. It strikes me that in such cases the pres- sure had been quite gradually developed, and the cerebral mass had be- come to a degree accustomed to the pressure of the new deposit. ''Bum- stead and Taylor thus describe the later stages of syphilitic meningitis : "A general adynamic condition sometimes supervenes in patients affected with chi'onic inflammation of the meninges, which either ends fatally or renders them hopelessly bedridden. This weakness may be due to mere lack of innervation, or may be complicated by mild ataxic phenomena, characterized by unsteady gait and uncertain movements. The dullness of intellect by day is succeeded by nocturnal delirium. When lying in bed such a patient resembles one in typhoid fever, but there are marked points of difference. He is sleepy and dull, and his face is utterly expres- sionless. The tip and edges of his tongue are red, but the organ is never, unless late in fatal cases, dry, cracked and covered with sordes. Anorexia and constipation are often quite marked. The pulse ranges from 80 to 110, is full and not wiry. The temperature may be elevated in the morn- ing to 100° F., and at night to 103° or 104° F. If conscious, the patient complains of intense headache and weariness. In a week or ten days he passes into a condition of complete unconsciousness, perhaps broken by brief lucid intervals. The urine and feces are passed involuntarily. If not relieved, the condition soon becomes more serious; the temperature continues to rise, and the pulse increases in rapidity; no food is taken, and the stupor merges into fatal coma." The above account is a most graphic one, and is a striking picture of a common form of trouble. Fournier is inclined to fix the time for the development of syphilitic ^ Syphilis of the Nervous System. New York, 1870. 2 The Pathology and Treatment of Venereal Diseases by Bumstead and Taylor, 4th edition, p. 655. 42 DISEASES OF THE CEREBRAL MENINGES. meoingcal symptoms much later than those authors who have met with these symptoms in quite recent cases. Of my own cases I have never seen syphilitic pachymeningitis before the end of the third year, and in most instances at least six or eight years after primary infection. In the case seen with Dr. Asch the development of symptoms followed at least fifteen years after the primary disease. It is probable, however, that there are cases of acute trouble with early de- velopment of active meningeal inflaramation. A form of syphilitic pachymeningitis may follow^ external syphilitic dis- ease of the cranial bones. I may illustrate the features of such an attack by the following case, reported by Dr. Jas. R. Wood : — Marie C, aged 20, was admitted to Bellevue Hospital, on account of an eruption of two weeks' duration, which had steadily progressed from a few points until it had become general, being most profuse on the face, neck, arms, and scalp. The eruption presented a distinct co])pery hue, and was of two varietie-!. There were three rupitic phlegina on the head, each of whicli contained a little pus, and three or four on the shoulders and back of the same cha- racter. The rest wei-e tubercular. She stated that, though often exposed, she had never suffered from pri- mary syphilis, but that there was a sore on her thigh, near the vulva, which appeared two weeks before the eruption. On examination, a simple chancre was found at the point complained of; there was also a chancre of limited extent in the vagina. Soon after admission she was observed to have a shuffling gait, and when questioned ab )Ut it stated that her right arm and leg " seemed to be getting weak." The treatment consisted in the use of the corrosive chloride of mercury in Huxham's tincture of bark, combined with generous diet. The eruption on the scalp was left undisturbed. The quantity of pus contained in each point was quite small, and it was deemed best to let them alone. One of them situated over the parietal bone of the left side was something larger than its fellows ; none of them, however, increased in size materially. There was very little improvement in the eruption, but the hemiplegia steadily increased. Her appetite became poor, she began to have vomiting, and exhibited a cachectic appearance. The bichloride was necessarily discontinued, and mercurial vaporization substituted. The hemiplegia became more complete, and her mind began to be ob- scured. The stupidity gradually deepened into profound coma, in which condition she died on the 30th. Autopsy. — There was a denudation of the parietal bone of the left side of the periosteum, at a jjoiut corresponding with the rupitic spot above spoken of. On removing the calvarium, the dura mater was found inflamed and firmly adherent to the skull, just beneath the denuded spot on the parietal bone and the eruption. A small opening was found communicating between them, perforating the cranial walls, and looking very much like a worm-hole. The brain at a point correspondiug with the inflamed dura mater pre- sented a greenish appearance. CHRONIC PACHYMENINGITIS. 43 There was also an evident fulness and fluctuation. On making an in- cision an abscess was discovered which contained about ^iij of pus. The other organs were healthy. As a result of continued congestion we may have a form of pachy- meningitis such as follows chronic mania, I have seen this change repeat- edly as a secondary condition, but it must be confessed that the other meninges were as well affected. Causes. — They may be briefly enumerated as external injury, otitis, syphilis, alcoholism, and various acute diseases, among them rheumatism. Morbid Anatomy and Pathology. — In the majority of cases the inflammation is transmitted to one or more of the important sinuses. The most favorable points for the extension of disease of the temporal bone are the narrow space between the mastoid cells of this bone and the transverse sinus, and that between the cavity of the tympanum and the jugular fossa; and the proximity of the auditory meatus to the petrosal sinus, and the different canals which contain the nerves, to adjacent intra- cranial parts. The bony walls between these locations are of a perforated and lamellar character, and when attacked by caries are very apt to be destroyed. Fig. 11. Osteoma of Dura Mater (Laneereaux). — a. Bony Plate, h. Perforation. Mater, e. Parietal Bone. /. Scalp. c. Falx. d- Dura If the disease be of a syphilitic nature there is generally a gummatous deposit scattered through the tissues, and the under surface of the dura mater is often covered by a syphilitic exudation which can rarely be mistaken. If it be the result of a traumatism, the membrane is seen to be thickened, opalescent, and congested. In old cases it is found to be closely adherent to the cranial bones, or it may contain long plates. In this form of inflammation the morbid changes may be seen best at the convexity. 44 DISEASES OF THE CEREBRAL MENINGES. Prognosis. — The outlook is invariably bad, for in one variety the patient is carried off in a few days, or, should the disease become chronic, its progressive nature must lead us to expect an ultimate implication of other parts, and cortical softening or sclerosis and atrophy are probable terminations. Treatment. — Treatment should be directed in the beginning to the cause, and if there be otitis, a free escape of pus should be provided for, and counter-irritants, topical applications, and leeches should be em- ployed. If the pachymeningitis be attended by much pain, cold to the head and free administration of the bromides will be of service. The leeches may be applied to the tragus of the ear, or to the mucous mem- brane of the nostril. CHRONIC PACHYMENINGITIS WITH HJEMATOMA. It has been the custom, among certain writers lately, to speak of htema- toma as an inevitable result of pachymeningitis. This, I think, is a mis- take, for the production of blood-cysts is not the invariable rule. If, how- ever, the thickening of the dura mater is excessive, there may be a gradual destructive process, which will be described when we come to speak of the morbid anatomy and pathology of the affection. The disease may begin as I have already described, and may advance to a certain point before the grave symptoms which indicate rupture and consequent meningeal hemorrhage are expressed. These may vary in in- tensity in proportion to the extent of the effusion, which may be even so great as to produce sudden death, but sucii an early result is exceptional. The course of the disease is generally more gradual, and there is at first an initial hemorrhage of slight extent, which is followed in a great num- ber of cases by two or three others. In some respects this effusion resem- bles cerebral hemorrhage in the production of acute symptoms, but they are nearly always less profound; and it is not so frequently followed by complete paralysis. Symptoms. — The early symptoms of pachymeningitis that I have enumerated are those preceding the immediate evidences of the effusion. They may be reinforced by loss of memory and stupidity, and after a few months there may be a transitory loss of consciousness and incomplete hemiplegia which is characterized by much hypersesthesia. The phenomena of the attack are thus described by Huguenin:' "Se- vere headache, just before the attack; after loss of consciousness has oc- curred, contracted pupils, not reacting ; in a few cases, paralysis of the facial nerve, on the side opposite to that of the hsematoma; sometimes hemiplegia. These latter symptoms only occur in one-sided hemorrhages. A marked change in the color of the face is another of the symptoms re- ported. At the commencement of the attack, which is usually sudden, the face becomes flushed ; the pulse is full and rapid, but soon grows small ' Ziemssen, Cycloptedia of the I'ract. of Med., translation, vol. xii., p. 409. CHROXIC PACHYMENINGITIS WITH HEMATOMA. 45 and irregular, and pallor succeeds the flushing. In some cases the pulse is slow ; in others there is an increase in rapidity, continuing up to the time of death. Contractures of the extremities, and slight transitory twitchings, Avere present in a few cases." Instead of hemiplegia there may be one-sided convulsions, but these depend very much on the degree of pressure exerted upon the cortex- cerebri. The condition, strange to say, is sometimes arrested after an indefinite period, and there is a return to the normal state, but traumatic hsematoma is usually fatal. Schuhberg^ assents to the view held by Herschl, Virchow, and Cru- veilhier, that hsematoma is always the result of fibrinous inflammation, and believes that the prognosis is grave. In this paper he considers the duration of a fatal case to be about one month. Causes. — Hsematoma is a disease of adult life, and twenty-two per cent, of the cases collected by Huguenin were between the seventieth and eightieth years, and Durand-Fardel found that 77.4 per cent, of all cases were men, and 22.6 per cent, were women. As causes may be men- tioned various cachectic and other diseases, among them Bright's disease, scurvy, syphilis, typhus fever, rheumatism, smallpox and scarlatina, al- coholism and sunstroke, or any condition which is conducive to continued hypersemia of the dura mater. Morbid Anatomy and Pathology, — The process involved in the production of hsematoma is an exceedingly complicated one, consisting in the production of new vessels and new layers of fibrine due to the extrava- sation of blood. The first layer of this new tissue-formation takes place in contact with the arachnoid, and ultimately others form and become organized. The formation of the blood-cyst is due to the rupture of one of the new vessels, and the extravasation becomes surrounded by a layer of tissue which may be so firm as to pi-eserve the cyst contents unchanged. This is particularly the case in t,he smaller cysts. The skull is sometimes found to be thin as seen by Hyrtl,^ but this is not common, and some writers, among them Textor'' and Rokitansky,* consider that the reverse is to be seen in a greater number of cases. I may briefly enumerate the post-mortem appearances as follows : Beneath the dura mater may be found a layer of coagulum which contains fibrinous shreds binding it to the membrane itself. If the case be of long duration several layers of false membrane containing bloodvessels are to be found attached to the dura, and the late formations may be distinguished from those of early origin. Between these layers it is not unusual to find the results of interstitial hemorrhages which exist as blood-clots iu different styles of organization. The thickening of the dura mater is thus described by Fox : " In the non-purulent form of the new formation, the result of inflammation be- Schmidt's Jahresbericht, vol. 104, pp. 164, 165. Ziemssen's Encycl., vol. xii. Am. Tran., Art. " Meningitis." Wiirzburg Verliandlung, vii. 1857. Eokitansky, quoted by Huguenin. 46 DISEASES OF THE CEREBRAL MENINGES. comes very quickly the seat of vessels aud is composed of several layers ; those nearest the dura mater being composed of compact lustrous connee tive tissue fibres almost as dense as the dura mater itself, whilst the layer further removed from the dura mater is rich in cells with small narrow vessels, aud the layer nearest the arachnoid, often firmly uniting the arachnoid to the dura mater, is remarkable for very large capilla- ries." The size of the hematoma may vary from that of a small beau to that of an orange, and in one case, the autopsy of which was made by Dr. Huber of the Colored Home, the blood-cyst covered one entire side of the brain, and was fully an inch in depth. The patient was under the care of Dr. Whitall, who kindly contributes the following notes : — P. B., 60, widower, N. Y. ; mulatto ; father, mother, and one brother died of phthisis. The patient has been intemperate, but now drinks only in moderation. He denies venereal disease ; twenty-five years ago he had smallpox, and has since had intermittent fever aud cholera. His trouble dated from an injury seven years ago. He was thrown from a hay-truck to the ground, falling upon his head, and causing blood to flow from his left ear ; but he was able to walk to his home, one mile distant. He seems to have received no very serious injury, if we may judge from the immediate symptoms. Since the fall he has been troubled with headache off and on, increased by apjjroaching a fire. He cannot appreciate the ticking of a watch pressed to his left ear. About a fortuight ago he had a chill, fever, and cough, some pain in back, with soreness around the whole gluteal region. Urination was slow, disturbed, and at one time he was unable to pass water ; at another it would be too free ; has been growing weaker since. June 15, 1874. On admission patient was confined to bed ; owing to apparent weakness in lumbar region he was unable to stand. In a few days he began to improve under the administration of iodide of potash. AValks with a staggering gait, and cannot follow a straight line. On closure of eyes does not have a tendency to fall. Heavy expression of countenance. No diminution in acuteness of sensibility can be discov- ered over any portion of the body. Had incontinence of urine on ad- mission ; is not so troubled at present time. Can walk about the ward ; at times can dress without assistance. To-day complains of frontal head- ache ; sleeps very soundly, with stertorous breathing. Appetite good ; bowels constipated. 2Uli. Staggering gait, and inability to walk in a straight line, still present. If he closes his eyes while standing, there is a tendency (which by an effort he can overcome) to fall backward. Complains of pain on right side of head and face ; sleeps most of the day in a chair ; at night snores loudly. Bowels constipated. Nocturnal incontinence of urine exists. Feb. 6, 1875. To-day, while patient was sitting in a chair, he had a convulsion, and then became comatose. Urine albuminous. Ordered ol. tiglii vci iv, after the action of which he appeared much better. 15/^. Very little change in patient's general condition since above note. Is still apathetic, and complains of pain in the head, on right side espe- cially. There is still right facial jiaralysis, with somewhat diminished sensibility in this region. The tongue deviates, if auy, to the right. Pu- CHRONIC PACHYMENINGITIS WITH HiEMATOMA. 47 pils normal in size and reaction. No notable change in hearing. No loss of motion, though the right arm and leg are weaker than the left. The lower limbs (left more readily than right) can be drawn upwards, and extended with little trouble. He is unable to walk or stand without being supported, as the right leg gives away ; complains of a considerable pain in the upper portion of the limb. Has occasional involuntary pas- sages of urine and feces; as a general thing, however, the bowels are con- fined ; urine evacuated with considerable force. March 19. Appears to be losing strength very raj>idly. Will not an- swer when spoken to. Temp. 991°. 21st. Died about 9 P. M comatose. Autopsy 36 hours post-mortem — Rigor mortis marked. Body slightly emaciated. The dura mater was found very firmly adherent to the calvarium to the right of the longitudinal sinus, and over a considerable portion of the convexity. After removing the dura mater, the pia mater on the left side was discovered to be unusually dry and congested, with here and there slight patches of lymph. Ihe convolutions throughout this hemi- sphere were greatly flattened, and the sulci nearly obliterated. In the right cranial cavity a large hoematoma existed. The tumor pear-shaped, with a larger extremity anteriorly, extended from the anterior portion of the second frontal convolution to the posterior portion of the second tem- poral, and from within an inch of longitudinal fissure to junction of lateral portion with base of skull. The right hemisphere was correspondingly compressed downwards, backwards, and to the left. The depression corresponded to the shape of the tumor and was so situated that the greatest amount of pressure came uj)on the left lateral ventricle. The dimensions of this growth were as follows: 6} inches antero-posteriorly ; 4 inches vertically in greatest diameter ; and about two inches in thickness. In addition to the htematoma, a serous cyst (about the size of a hickory- nut), evidently originating from an old hemorrhage in the subjacent brain structure, the cicatrice of which still remains, was seen beneath the anterior lobe. Back of this another cyst, the walls of which were chiefly composed of softened brain tissue, was discovered, which, upon closer investigation, was ascertained to be continuous with the right lateral ven- tricle through the middle cornua. The right ventricle was greatly dis- tended by serum, while comparatively little could be detected in the left. In the left ophthalmic artery a long, slender clot, partly dark and pai'tly translucent and yellowish, existed. No thrombi were noticed in the slight atheromatous arteries at the base of the brain. No c.innection existed between the pia mater and the hsematoma; the relations between it and the dura mater were so intimate as to require dissection before a separation was possible. The petrous portion of the right temporal bone was considerably larger than the left, and, upon section, proved to be much more porous. No other abnormalities were present ; no evidence of fracture at the base. The way in which the tumor, though situated on the right side of the brain, pressed upon the left ventricle, explained the symptoms which, during life pointed to an involvement of the left side ; and also ofiei*ed an explanation as to the manner in which the fluid was forced through the middle cornua of the right ventricle. 48 DISEASES OF THE CEEEBRAL MENINGES. Heart. — Very flabby; cavities dilated, and filled with dark coagula. Aortic valves were slightly thickeucd, and the artery was atheromatous. Mitral valves thickened. Lnngs. — The right was firmly bound to chest; very soft and congested. The surface was studded with pigment. The left had also become adherent to parietes, and, at the apex, a few softened, cheesy points were discovered. Spleen. — Enlarged and congested. Xu-er.— Normal. Kidney. — Cortex somewhat thicker than usual ; both organs were waxy. Weight of the organs. — Heart, 10 oz. ; spleen, 7 oz. ; liver, 55 oz. ; right lung, 29 oz. ; left lung, 18 oz. ; right kidney, 6 oz. ; left kidney, 5 oz. Prognosis. — The existence of a blood tumor of this kind is not al- ways a serious matter. Even after two or three extravasations have oc- curred, a retrogressive course takes place ; but this is rare. Griesinger ^ reports a case in which partial recovery has taken place ; and in 1876 the patient was still alive, and j^resented slight evidences of his former serious trouble. This termination of the disease is exceptional, however. Treatment. — What has been said in regard to the management of uncomplicated pachymeningitis is applicable in this disease ; and, in addi- tion, venesection has been advocated by more than one authority. It should be employed during the comatose stage which marks the occur- rence of an effusion, and at the same time a drastic cathartic will be found to be of excellent service. High living and excessive use of to- bacco and alcohol are to be interdicted, and iodide of potassium may be given with the idea of producing absorption of the new growth. ACUTE CEREBRAL MENINGITIS. The term meningitis has been applied, clinically speakinir, to that form of inflammation which involves chiefly the arachnoid and pia mater, and in its acute form may be expressed by the following grave and alarming symptoms : — Symptoms. — The.se may be divided in regard to their appearance into three stages : 1st. The stage of excitement or irritation; 2d. The stage of delirium; 3d. The stage of stupor. An hypothetical case may be presented. The patient complains of a slight headache, which increases toward the end of the first twenty-four hours. It may not be attended by much annoyance, and he is usually able to attend to his daily duties, but during the succeeding six or eight hours it may become greatly aggravated, and is attended by rei-tlessnees, flushing of the cheeks, throbbing of the temporal vessels, and general dis- comfort. After a few hours there may be slight rigors or a severe chill, which is often mistaken for ague ; and the rapid elevation of temperature, 1 Archiv. der Heilkuude, 1862, ACUTE CEREBRAL MENINGITIS. 49 and hard, bounding pulse may strengthen the suspicion. The headache continues, and is still not confined to any particular locality, but is so in- tense that the patient seeks his bed, where he may lie, moaning, sighing, or tossing restlessly to and fro. The muscles of the legs may twitch, and the least noise, such as the creaking of a door, invariably irritates and startles the invalid ; bright lights distress him, and he closes his eyes in- stinctively. He keeps his hands over his ears so that he may not hear noises in the room, or firmly presses his aching temples. There may be vomiting which is not dependent upon the condition of the stomach, is not attended by retching, and occurs whether the stomach be empty or full. If the patient be a child, there are generally convulsions of a very violent character. These constitute the first stage. Active delirium usually appears during the first two days, and continues through the greater part of the second stage. The patient screams in an agonizing manner, and alarms those who may be with him, adding greatly to the distressing character of his sufferings. The delirium now begins to subside, or may be supplanted by coma. The temperature becomes lower, and the pulse loses much of its force and rapidity. The head is hot, and the respiration becomes irregular and sighing. The bowels, which were constipated in the first stage, still continue so, and the tongue is coated with a dirty-white fur. There may be convulsions at this time, which RamskilP says may precipitately throw the patient into the third stage, which is one of collapse. This stage may resemble that of advanced ty- phoid. Sordes on the teeth, pinched features, dark circles about the eyes, fluttering pulse, great prostration, with loss of muscular power, dilated pupils, stertorous breathing, and the unconscious passage of feces and urine, are all forerunners of death. Should the force of the inflammation be exerted at the base, the symptoms are much more violent, and j)araly- ses of cranial nerves are not uncommon. Causes. — In considering the predisposing causes of acute meningitis it will be well to inquire what are the influences of sex and age. The re- ports of the New York Board of Health show that during the years 1867, 1868, 1870, 1871, 1872, and 1873 there were 4321 deaths from meningitis in the city of New York, 2506 of whom were males, and 1815 females ; 3434 were children under 5 years; of these 1873 were males, and 1561 females. It will therefore be seen that males are more often affected than the other sex, and that the large proportion of cases occur among chil- dren. Rilliet and Barthez take an opposite view of the matter, and consider the disease to exist more frequently after the fifth year. My own experi- ence and the Health Board's statistics lead me to think that after this period of early life, the adult cases are comprised in the interval between the twentieth and fiftieth years, and I am unable to find the records of many cases after the sixtieth year, and am therefore disposed to believe that the disease is rare after that time. Various predisposing causes give ^ Article in Reynolds' System of Medicine, p. 369, vol. ii. 50 DISEASES OF THE CEREBRAL MENINGES. rise to the affection, and none, I think, plays a more important part in the production of the adult variety than continued dram-drinking and hard work in warm places. Over-use of the mental powers, and various disorders, such as syphilis and gout, are favorable to its development. Croupous pneumonia, acute rheumatism, diphtheria, extension of dis- ease from the tympanic cavity, blows upon the head, and sudden changes of temperature of any kind, are the direct causes of acute meningitis. la one of my cases the disease was the result of a sea-bath. The patient, after bathing, sat for some time with uncovered head upon the beach ex- posed to the heat of a noonday sun. Haeddeus^ reports a case of this dis- ease which resulted from typhoid fever. Diagnosis. — Acute cerebral meningitis may be mistaken or con- founded with cerebritis, typhoid fever, or delirium tremens. The deli- rium, headache, and disorders of motility are much less marked in cerebritis than in acute meningitis, and it must be remembered that the pulse in the latter disease is much more rapid and full, and the tempera- ture much higher. Typhoid fever is symptomatized by elevation of evening temperature, diarrhoea, abdominal tenderness and tympanites, muttering delirium, and the presence of petechise. Delirium tremens may be occasionally con- founded with the disease under discussion, but it must be remembered that the history of alcoholism — peculiar delusions and alcoholic delirium, the absence of headache and the condition of the skin, are all evidences of delirium tremens, which are not to be mistaken. Pathology and Morbid Anatomy. — When the pia mater and arachnoid become the seat of inflammation, we may roughly group the lesions and consequent symptoms into two classes, one indicative of basal trouble and the other of vertical. In the former, cranial nerve-trunks ■will be injured or diseased ; while in the latter, the investing membranes of the cerebrum will be the seat of morbid action, and the functions of the cortex must be consequently destroyed, so that the symptoms will be more of a psychical character than when the base is involved. The recent investigations and contributed cases of Landouzy,'' of which 104 are presented by this author, demonstrate the connection between cer- tain symptoms and lesions of the description to be hereafter mentioned, involving those portions of the cortex containing the centres of Hitzig' and Fritsch. These prove very clearly that violence of the inflammatory process in certain places may be attended by certain paralyses or contrac- tions of limbs which are innervated from these centres. A case which recently came under my obsei'vation is one of this kind, and possesses great pathological interest. E. B., aged thirty-six, born in Ireland, by occupation a blacksmith, is a stout, well-made man of nervous temperament, and up to the commence- ' Berliner Klin. Woch. 1869, p. 564. ^ Contribution k I'^tude des Convulsions et Paralyses lides aux Meningo-encephalitis fronto-pari^tales. Paris, 1876. ' Eeichert and Du Bois Reymond's Archives, 1870, Heft 3. I ACUTE CEREBRAL MENIKGITIS. 51 ment of his present trouble had enjoyed uninterrupted good health. He has not had syphilis, and his habits have been good. His mother and father are dead, the former having died of old age and the latter of phthi- sis. There is no family history of insanity, epilepsy, paralysis, nor of any organic nervous trouble whatever. Ten years ago, while working upon a fire-escape, he fell to the ground, two stories below, striking upon his head and shoulder. He was taken up unconscious, and remained so for four- teen hours. The only injuries he received were two severe scalp-wounds, one of which, from its slowness in healing, must have been attended by some bone injury, for he was unable to resume work until three months later. He says that purulent accumulations took place, and that " the doctor lanced them." Two cicatrices are now visible, one of which is about an inch and a half long, and is situated on the left side of the head and covers a depression about three-quarters of an inch in diameter and one-quarter of an inch in depth, the centre of which is about one and one- half inches below the median line, five inches above the left ear, and four and three-quarters inches above the centre of the left supra-orbital arch. This is the only depression visible, and the injury on the right side was apparently very superficial. He gives no history of serious head symptoms, and when he resumed work was in good condition, there being no paralysis. About three months later he noticed a tremulousness of the fingers of the right hand and afterwards of the arm of the same side. There was no pain nor loss of power, but simply a marked tremor whenever he attempted to do any- thing. This difiiculty increased to such an extent that he was obliged to resign his position as first-class workman, and become a helper, using his other arm to work the bellows. About six months after this the tremor affected the right leg, and he was obliged to leave his work. Present Condition — The patient does not complain of head symptoms, except a slight hypersesthesia of the right side of the face, of short dura- tion. Vision normal ; fundus of either eye presents no abnormal appear- ances ; pupils respond well to light, and are of equal size. Hearing unaffected. No tremor of face or tongue, speech unembarrassed, mem- ory good, and no intellectual trouble whatever. He has never had head- ache. Upper Extremities. — Left side unafiected. The right hand and arm are perfectly quiet during inaction, but when the most simple voluntary act is attempted they become agitated by a fine rhythmical tremor, which becomes more marked as the accomplishment of the act requires greater nicety of coordination. When he is asked to carry a glass of water to his mouth, he spasmodically grasps the vessel and carries it upward, the elbow being raised, the tremor meanwhile increasing until the mouth is reached, when the movements become so violent that he is unable to place the rim of the glass between his lips. Certain motions are almost entirely unat- tended by tremor. He can extend the arm and hand, or can hold them rigidly upright, and is able to pronate the hand, but movements of flexion are attended by increased violence of the tremor. Tactile sensation is 52 DISEASES OF THE CEREBRAL MENINGES. somewhat impaired, but susceptibility to painful impressions is not dimin- ished. There is absolutely no loss of muscular power, no atrophy of the hand or arm, the thenar eminences being covered by firm cushions, and the interosseous spaces being well filled. Loiver Extremities. — The left leg, like the arm, is in no way affected. The right leg, however, is agitated by muscular tremor when he attempts to use it, or approximates it with its fellow, as in standing erect. There is 110 loss of muscular power, but some anaesthesia, the patient being unable at any place to distinguish two points of the ^esthesiometer, unless they are separated at least eight centimetres. When he stands with his eyes closed he is "groggy," but does not fall. He can stand upon the right foot alone, but not upon the left. When he walks, the right heel is brought down first, so that the heel of the shoe is much worn. He has some plantar formication and coldness of the foot. He has suffered from pains of a pseudo-neuralgic nature in the right shoulder and right thigh, which were centrifugal, as well as some pains which darted from the heel up the inner side of the leg. The pains in the upper extremity are not so frequent as they were a year ago. There has been no history of body-constricting baud, pain in the back, or vesi- cal trouble of any description, but for the past five years he has been constipated and obliged to take purgatives. There are no contractions whatever. The peculiarities of this case seem to be the unilateral tremor (not disorderly movements) excited by voluntary exertion, its predominance in flexion, while certain movements of extension are almost unattended by any embarrassment, the absence of muscular weakness, contractions, or atrophy, and the evident dependence of the trouble upon a localized cerebral injury of the opposite side, which probably resulted from the fall. I am unable to arrive at any conclusion which would lead me to consi- der the symptoms due to cerebro-spinal sclerosis, or one-sided posterior spinal sclerosis, if the latter anomalous condition could exist. The utter absence of loss of power and permanent contraction of the affected limbs, and the non-extension of the affection to those of the other side of the body within ten years, are sufficient to invalidate such a diagnosis. The non-occurrence of convulsions and other symptoms of cerebral tumor renders this as a cause of the tremor quite improbable. Of course the assumption that this patient's symptoms are due to some irritative meningeal or cortical lesion must be based upon purely theoreti- cal grounds, but the features of the case convince me that such a _'condi- tion of affairs is by no means improbable. If we refer to the charts of Hitzig and Ferrier, we shall find that they have located a cortical region which is " situated on the ascending frontal, just behind the upper end of the posterior extremity of the middle frontal convolution," which " is the centre for the movements of the hand and forearm in which the biceps is particularly engaged, namely, supination of the hand and flexion of the ACUTE CEREBPvAL MENINGITIS, 53 forearjn." ^ Again, if we consult the admirable article of Turner/ we shall find very useful hints which will enable us to lay out the exterior of the cranium into regions corresponding with the convolutions beneath. One of these areas, which has been called the upper antero-parietal space, includes the ascending parietal and ascending frontal convolutions, and an injury at the point I have located in describing this case would be just over the centre, which, when experimentally irritated, produces movements of flexion and supination. It is quite reasonable to suppose that this irritation occurring with voli- tional movements is due to a natural increase in the blood pressure during mental activity, a consequent increase in cerebral volume, and a resulting meningeal contact with the depressed portion of bone, which probably does not impinge upon the cranial contents at ordinary times. Dr. James B. Ayer ^ reports an extremely interesting case of cerebral syphilis, the prominent feature of which was the presence of hallucina- tions of hearing, the lesion being syphilitic meningitis, evinced by great pain confined to the back part of the head, and psychical symptoms of interest, such as sluggishness of intellect, unreasonable dislikes, and insane hallucinations of hearing. The autopsy revealed a significant condition of affairs, namely, a patch of induration of certain occipital convolutions which bears out the statement of Ferrier that auditory disturbance ordi- narily follows lesion of this part of the brain. " Both tables of the skull were somewhat thicker than usual, at the expense of the diploe. The calvarium was heavy and dense ; in other respects normal. The dura mater was ordinarily transparent. A recent coagulum was found in the longitudinal sinus. There was nothing special in the pia, except that a patch, the size of a half dollar, over the upper occipital convolutions of the right side was adherent to the brain. " The middle cerebral artery of the right side contained a small spot of chronic endarteritis, which had diminished the calibre of the vessel about one quarter. There was a similar patch in the basilar artery, of somewhat larger size. The intitna ran smoothly over these projections. On section they were found to consist of a yellowish-white, opaque tissue, and presented a marked contrast to the surrounding healthy tissue. The convolutions were somewhat flattened ; the ventricles contained a trifle more fluid than normal. " !N ear the longitudinal fissure, in the upper part of the right occipital region, between two occipital convolutions, there was an indurated portion of brain corresponding to the patch of meningeal inflammation. The gray matter was found atrophied to one half its normal thickness. The neuroglia in the white substance beneath was increased, and the white substance exhibited a grayish tint, but nothing else abnormal." ^ Functions of the Brain, page 307. "^ Journal of Anatomy and Physiology, vols, siii., xiv., November, 1873, May, 1874 * Bo3ton Med. and Surg. Journal, Sept. 19, 1878, page 363. 54 DISEASES OF THE CEREBRAL MENINGES. In the majority of cases the inflammation begins at the base and extends upwards. The temporal lobe may often be its starting-point, while in other varieties the meninges covering the cerebellum may alone be in- volved. The appearance of the cranial contents cannot be mistaken, the membranes are red, hypersemic and attached to each other, and the arach- noid cavity contains a considerable quantity of serum. The fluid in the ventricles is increased and may contain pus, and the choroid jolexuses are found to be turgescent and enlarged. It may be stated upon the au- thority of Huguenin^ that in some cases the ventricular fluid is purulent on one side, while it may be simply serous on the other. In aggravated cases the quantity of pus may be considerable, and if the meningitis be of the basilar form the pia mater of the base will exhibit ex- tensive purulent infiltration. The ependyraa of the ventricles may be thickened granular, and contains yellowish deposits. In cases due to traumatism, or extension of other diseases, there may be found evidences of caries or fracture. The cortex in nearly every case of meningitis of the convexity is found to have undergone decided softening, and when the meninges are removed, some of the superficial brain-substance is carried with them. Microscopic examination will reveal cortical changes of more or less recent date. The vessel coats are shrunken or hard, and areas of sclerosis, or on the other hand breaking down, are to be recognized. Prognosis. — We should always hesitate in expressing our opinion as to the course of the disease, although so few cases get well that it is almost safe to say that our patient cannot recover. The prognosis of syphilitic meningitis is by no means hopeless. There may be a gradual return to health characterized by occasional exacerbations of pain, mental listless- ness, etc. If the patient improves after the first week, we may consider the prognosis much more hopeful, but there are often deceitful lulls which may mislead the medical attendant. '^ Dr. S. G. Webber reports a case in which there was a return of intelligence just before death, which, however, was temporary. If active treatment produces beneficial results, his chances are better, while any evidence of ocular trouble, and conse- quently basal involvement, lessens the patient's chances materially. Should the disease result from extension or inflammation of the temporal bone, the prognosis is also grave. Death may occur in four or five days, or even in a shorter time, but the duration of the disease may extend to the tenth day. Treatment. — Two indications are to be met promptly : one the ab- straction of blood; the other, cold to the head. When the delirium is furious, temporal vessels swollen, and the pulse hard and bounding, ab- straction of blood from the arm is to be immediately resorted to. A sug- gestion made by Holland many years ago is one of value, notwithstand- ing the fact, that it has been almost forgotten and generally disregarded, I allude to the application of leeches to the hsemorrhoidal veins ; to use his 1 Ziemssen's Encyclopsedia, vol. xii., translation. =»Bost. Med. & Surg. Journal, Vol. ci., p. 361. RHEUMATIC MENINGITIS. 55 words : " I know of no mode in which a given quantity of blood can be removed in equal effect in cases where it is required." ^ Cold to the scalp either by ice-bags, or by a bladder filled with pounded ice, or an arrangement of rubber tubes, should be employed, and will be found to very speedily relieve the pain. Accepting a hint from Dr. Chamberlain, of this city, I have had constructed, and have successfully used an apparatus such as I will describe. It consists of a long piece of rubber tubing wound upon itself and securely held in its spiral form by tape, forming a skull cap. The upper end is connected with an ice-cooler or a cold water tap, should there be one in the apartment ; and the other is fitted with a stopcock so that the discharge of water may be regulated. By this means the patient's head can be kept cool and his bed dry and comfortable, an impossible state of affairs where the douche is used. Iodide of potassium in large doses has been given with excellent effect, and its efficacy in this dis- ease has been praised by Flint, Alonzo Clark, and others. Aconite, ergot, and the bromides are all efficient remedies in depressing the pulse and quelling the delirium ; and elaterium, saline cathartics, or the old com- bination of salts and senna may be of service. Blisters applied behind the ears and to the neck are excellent adjuvants. Should the patient's strength be reduced, as is the case in the later stages, the free use of stimulants, nourishing food, such as milk, egg-nog, beef-broths, and nu- tritious but digestible food, are of great importance. In the other forms presently to be alluded to, we should be governed by the existence of rheumatism, or the advanced age of the patient, and for the former pre- scribe alkalies, colchicum, and other remedies of the same nature, and for the latter a generous diet and a liberal use of stimulants. EHEUMATIC MENINGITIS. A form of inflammation of the meninges may be connected with, or occur during the course of acute articular rheumatism, or again it may be found without any coexisting joint trouble. Trousseau^ has described three forms of cerebral rheumatism. One of these he calls apoplectic, and it is symptomatized by coma without paraly- sis ; a second form, first described by Gosset, is that in which delirium is followed by coma ; and there is a third in which delirium makes its appearance in the course of inflammatory rheumatism. Its co-exist- ence with joint-trouble is by no means the rule, though the majority . of cases reported have been of this character. Posner ^ reports a case in which the inflammation left the joints and attacked the meninges. Pain in the head, delirium, and slow pulse were the prominent features of the patient's illness, and recovery took place in about two weeks. The symp- toms of an ordinary attack of metastatic rheumatic meningitis are these : ^ Quoted by Solly. The Human Brain, etc., page 353. ^Schmidt's Jahresbericht, vol. 113, p. 25. ^Encephalopathia Rheumatica, Ibid., vol. 104, p. 167. 56 DISEASES OF THE CEREBRAL MENINGES. Either during an attack of acute rheumatism, or afterwards, the patient may become dull and stupid, and delirium makes its appearance. This delirium is of a violent character, and during its existence the patient may have delusions and hallucinations of sight and hearing. In a case reported by Mesnet^ the delusions of pergecution were a prominent fea- ture, but there is no regularity in this mode of expression. There is usually but a slight rise of temperature, though it may sometimes attain an elevation of 106°, or thereabouts, and the pulse at the same time be- comes very rapid and full. Headache of a very severe variety, such as I have described when speaking of the other forms of acute meningitis, may be present throughout the illness, and, after several days, choreiform movements may occur, and with their advent the delirium, which was before inconstant, but now becomes continuous. These choreiform move- ments are such as a nervous embarrassed person would make in health when suddenly disconcerted. There is an uneasy opening and closing of the fin- gers, and the arm is jerked backwards and forwards. The patient now finds considerable difficulty in swallowing, portions of food remaining in the mouth for some time. Great prostration and collapse may supervene, and he dies in a comatose state, or, on the other hand, there may be slow recovery, the mental symptoms being the last to subside. Vomiting and early headache, which are so characteristic of the other forms of meningitis, are absent. Recovery is rare, and of thirty-nine cases reported by Vigla,^ thirty terminated fatally. Should the patient sur- vive, he is very apt to become insane, the variety of such mental trouble being chronic mania. Huguenin^ considers that the connection of meningitis with rheumatism is threefold with respect to pathological changes : — " a. Endocarditis is the connecting link, so that the combination is rheumatism, ulcerative endocarditis, meningitis. " b. Purulent inflammations of the serous membranes form the con- necting link, endocarditis being present or not, as may be. In this case, purulent meningitis is secondary to purulent inflammation of the serous membranes ; this is very rare, and the exact connection is unknown. " c. Meningitis complicates rheumatism without there being any puru- lent deposits in the body, or any affection of heart ; the connection here is also obscure." Da Costa* is inclined to refer the brain symptoms in cerebral rheuma- 'tism to two agencies, the first of which is circulation of vitiated blood, and the second is the disturbance of cerebral circulation dependent upon the plugging of small arteries by fine embola, and he consequently considers cerebral rheumatism to be a disease which is not essentially an inflamma- tion of the cerebral meninges. * Archives Generales, June, 1856. ■•^ Actes de la Soc. Med. des H6pitaux de Paris, 1865, 3me fas. ' Op. cit. p. 624. * American Journal Med. Sciences, Jan. 1875. MENINGITIS OF THE AGED. 57 A case of rheumatic meningitis which recovered under the use of cold baths — and was treated by M. Fereol/ of Paris — is the following: The patient was thirty-four years old, of quiet and temperate habits, who was suffering from acute articular rheumatism. He was treated at first with emetics, sulphate of quinine, and colchicum, but in five days he was seized with delirium, and dyspnoea, and at the same time the pains in the joints disappeared. The temperature of the body rose to forty degrees (Centigrade), and leeches, calomel, and bromide of potas- sium were given without success. The temperature rose further to forty- one degrees, and blisters were placed on the scalp, and digitalis was given. There was then a little more rest, but the aspect was typhous, with stupor and continuous sub-delirium ; sleeplessness, agitation of the muscles, subsultus tendinum, dry tongue, etc. After some consultation with other physicians, it was determined to try the effects of cold baths as the only remaining resource. This plan was pursued for a whole week, the patient remaining under close observation the whole of the time, and the thermometer being almost fixed under the axilla. As soon as the temperature rose to 39.5° the patient was plunged into a cold bath. From the 25th of February to the 3d of March sixteen baths were ad- ministered at a temperature varying from twenty-one to twenty-five de- grees (Centigrade), and the duration of each bath was twenty minutes on the average. The patient always raised the temperature of the water from one to two degrees, and, on leaving the bath, his own temperature fell to thirty-six degrees. After several fluctuations and much anxiety on the part of the medical attendants, the patient eventually recovered completely. MENINGITIS OF THE AGED. According to Prus,^ meningitis of very old persons rarely presents the same symptoms as do the forms of early or middle life. In the morning the old man or woman is stupid, but conscious ; speech is thick, and there is general headache and moderate fever. The warmth of the body is nearly normal, except at the head, where it is markedly increased. In the even- ing it is elevated. The eyes are injected, and there is low delirium. Incoherence and restlessness, during the night, and an uneasiness which is expressed by walking about the house and going from one bed to the other, are mani- festations which are characteristic.^ If the disease is to end fatally, the patient becomes comatose, and dies within a week, or twenty days at the longest, from the commencement of the disease. These patients very ^Bull. G6n. de Thferap., Mar. 30, 1875. Med. News, 1875. ^ Quoted by Grisolle, vol. i. p. 430. ' Eamskill speaks of the eccentric behavior of these patients, who may use the spit- toon instead of the chamber pot, or commit other violations of decency. In one case which came to my knowledge, the patient urinated against the bed-post, and went about the house with his trowsers always unbuttoned. 58 DISEASES OF THE CEREBRAL MENINGES. often suffer for some time before the actual attack, when there may be partial paralysis, slight wandering of the mind, and insomnia. The general indications for treatment of the other forms are applicable ia these cases. The mental disturbances are those of senile dementia, and are distinctly asthenic. The old man is querulous and irritable. He delights to talk of his early life, but cannot tell you what has occurred within a few hours. If the condition be jjrofound, he will sit quietly by himself, groan- ing and complaining. He goes frequently to stool, or, more commonly, unconsciously passes his feces and urine. ACUTE GRANULAR (TUBERCULAR) MENINGITIS. Dr. Robert Whytt^ was the first to describe this disease, and so satis- factorily did he do so, that even after a hundred years there is very little to add to his accurate description. We shall have to study the disease as occurring in two different ways. It may be primary, and have a doubtful tubercular character, or may occur in connection with some thoracic or abdominal disease, and like the other forms of meningitis, may be confined to the base or convexity. Symptoms. — Though many of the symptoms are the same, there are a few points of difference, which are the following : — Predominant Indicative Symptoms. VERTICAL. Vomiting, constipation, infrequent or Convulsions with intervals occupied irregular pulse, unequal pupils, stra- by tremor, twitching of limbs and mus- bismui. cles of the face, turning of thumbs in on palms, clenching of fists, frequent pulse'. When the base is involved, the symptoms may be grouped in three stages, Avhich run their course in from four to twenty-four days. The child may be puny and delicate. He may lose flesh and complain of headache. His skin may be white and waxy, and there may be a ten- dency to flushed cheeks, loss of appetite, and capriciousness about food, and at night he does not sleep soundly, but starts and cries out. I have known children to seek the companionship of some other member of the family, fearing to be left alone. The child may moan in its sleep, grind- ing his teeth and lying with eyes widely opened. During the day he is disinclined to play, and seeks some quiet place in which to fall asleep or remain by himself. Study is irksome, and so are all other forms of men- tal application. Irritable or languid, he attracts the attention of the 1 Works of Dr. Whytt, Edinburgh, 1768. ACUTE GRANULAR MENINGITIS. 59 mother by his behavior, which is so markedly changed. During this period I have found that headaches and crying-spells are not uncommon precursors of the actual acute disease, which may begin after two or three months. Marshall Hall,^ in his description of the hydrocephaloid diseases, al- ludes to the importance of vomiting as an early symptom. "The most frequent and formidable in appearance ... is vomiting. Never, never allow vomiting in an infant to pass without paying the utmost at- tention, and making the strictest inquiry in reference to the functions of the brain." Vomiting is generally the first and most important symptom, and convulsions are next in importance, but these two may be associated or appear alone. Vomiting may be frequent, and is nearly always ac- companied by an aggravation of the symptoms of the premonitory stage. Headache and increased temperature are present, and are very decided evidences of the gradual development of the trouble. When we arrive at this stage, which lasts two or three days, we may expect the appearance of the following symptoms : A marked rise of temperature, say from 101*^ to 105° F., with greatly increased pulse. The bowels are still constipated, and there is but little appetite. The patient is delirious at night, and shrieks, cries, and tosses continually. At about the sixth or seventh day of the disease, there are various local troubles, such as unequally dilated pupils, slight strabismus, but no actual loss of consciousness as yet. There is a slight increase in the evening temperature, and the pulse is irregular and ranges from 110 to 120. The tenth day finds him much worse ; his excited condition being supplanted by one of stupidity. He does not re- cognize those in the room, and is utterly indifierent to the kind attentions of his mother or nurse. When the finger is drawn across the skin it leaves a vivid red mark, which has been considered one of the strong pathognomonic signs. The pulse is greatly accelerated, and perhaps reaches 170, while the temperature may be found to be 104° or 105°. His condition during the tenth and eleventh days is very little changed, though the apathy is if anything exaggerated. The belly is retracted, and his facies is highly characteristic, the patient having a worn and pinched look. The skin is dark and congested, and his eyes may be fixed and immobile, and there may be either strabismus or a rolling upwards of both eyeballs, so that a large part of the sclerotic is exposed. Subsul- tus tendinum and "picking at the bedclothes," with involuntary passage of feces and urine, are grave forerunners of a fatal termination. The pupils are dilated, the pulse small, thready, and quick, and respiration is very slow. The temperature is still high, though the surface may be cold and clammy, and just before death the pulse quickens and becomes al- most imperceptible. Slight rigidity now becomes apparent, the patient cannot swallow, stertor follows, and then death. Marshall HalP tersely ' Lecture on the Nervous System and its Diseases, L. and E. Philadelphia, 1836, p. 92. 2 Op. cit., p. 93. 60 DISEASES OF THE CEREBRAL MENINGES. describes this last stage as follows : " The third stage is denoted by coma and its concomitaut diminution of the sentient and voluntary system, and eventually of the powers of the excito-motory system. There are Illustrative Chart of Temperature. Pulse and Kespiration Variations in Acute Granular Meningitis. Days of Disease. / 2 3 V J- 6 7 ^ 9 /o Jl n /J /^ J5 /6 /7 /J 107° 106° T05^ 104° 103° 102° 101° 100°" "99°" ~98^ M£ ME M E ME ME ME ME M E ME ME ME M E M E M E M E M E M E M^E i 4 V a X h / / „A ^_/ ■^ A /* v 1^ / l/ / V a / h /^ / V^ I 1/ V 5 / ^ \A J v Y V a / / - IHO'^ Tzo^ 160° , /■■' /** ^ ^... 150 140 130 120 t\ / i- s / ^ s / Ho" 100 90 80 70 60 / \ J 5 t> / \ / [y « / V^ '^ / 2 / ^,/ r-f 50 45 40 35 30 25~ 20 15 S y k^ ,/S /> ^ ^ r^ ^ v/ /^ '\ ,/> I V r- -\ /- f V r^ v> V^ h s > V/ V A. Indicates sthenic character. B. Indicates irregularity. blindness, deafness, deep stupor, absence of voluntary motion. At first the eyelids are constantly half closed, but dill close completely on touch- ACUTE GRANULAR MENINGITIS. 61 ing the eyelash. Afterwards this excito-motory phenomenon ceases. The respiration becomes irregular, alternately suspended and sighing, and at length stertorous. The sphincters lose their power, and the feces and urine are passed unconsciously." The appeai-ance of the little patient just before death, is unmistakable. He lies with knit brow and flushed face, one side of which is drawn, while the eyes are fixed and glassy, and utterly devoid of expression. The duration of the disease rarely exceeds twenty-four days. It will be well to dwell more fully on certain symptoms. Temperature. — There seems to be at first an elevation of temperature, which lasts through the first few days, say three or four, and after this time the temperature falls, until the sixteenth or eighteenth day, when it may either go much lower, or be again increased. The variations are between the normal standard 98.2°, and 105°. It however rarely reaches this high point. The sur- face temperature of the body is much diminished during the latter stages, but the head is always hot. Pulse. — Infrequent and irregular pulse is characteristic of the earlier stages of this disease, and during the last days there is increased frequency and more evenness. During the first two weeks this infrequency is to be observed, but after this it may steadily increase ten, twenty, or thirty beats more each day until at last it cannot be counted. This rule is not without its exception, and I have found intervals when both temperature and pulse would fall to the normal stand- ard, and continue so for some days, and afterwards rise. The pulse is perhaps more rapid when the disease is being developed. I append a chart, which will enable the reader to see at a glance the condition of pulse, temperature, and respiration in a typical case. Various modifica- tions of the cutaneous circulation have been dwelt upon by Trousseau and various writers. There seems to be an extensive disturbance of the vaso- motor distribution of the skin, and when the surface is brushed or rubbed ever so lightly, or even when slight pressure has been made by the pillow, there will remain a bright red mark. This condition of the cutaneous cir- culation is not limited to the integument of the head, but may be present, especially towards the end of the disease, over the whole body. Trous- seau^ has called attention to the " tache-cerebrale," which is the name given to the appearance presented when the finger is passed over the sur- face, aud a red line remains. This author found that when he made cross-markings upon the abdomen, in less than half a minute the portion of skin which he had touched was suflTused with a very bright red tint, which disaj)peared slowly, the lines made by the finger-nails remaining after the others had faded out. The regions where this redness is produced most easily are the anterior parts of the thighs, the abdomen and face. Respiration. — There are the usual fall and irregularity which accompany collapse of all kinds ; and sighing and diminished respiration are features of the later stages. Sensorial Disturbances. — Headache of a deep and throbbing character is very severe ^ lectures upon Clinical Medicine, Am. edition, vol. i. p. 877. 62 DISEASES OF THE CEREBRAL MENINGES. and continuous, lasting until coma supervenes. Various indications of the patient's sufferings are conveyed by his behavior. He presses his thumbs against his temples, or locking his fingers on top of his head, holds his head in his hands, and gives vent to suppressed groans or shrieks, holding his breath sometimes as if fearing that the very effort of expiration might increase the pain. The cry of the patient is heart-rend- ing, but I am not disposed to agree with Trousseau that it has any decided periodicity, though there are intervals of silence. Hyperaesthesia of the scalp, photophobia, and tenderness of the muscles at different parts of the body are usual accompaniments. Bertalot' of Pfeddersheim, in an analysis of 24 cases, has found photophobia to be more commonly a symptom of the later stages, in which conclusion I am inclined to concur. The psychical symptoms are present in every case, though delirium is not so common among very young children, and when it does occur is followed by a state of semi-consciousness, and finally by coma. The patients will not speak, but rebel against food and interference of any kind, and after a time it is very difficult to arouse them. One very interesting fact is that the coma is never sudden, but is preceded in every instance by either somnolence or delirium of the muttering variety. The coma sometimes becomes less profound in character, and there may be a lucid interval be- fore death. Motorial Disturbances. — The eyes are nearly always affected ; and the ocular trouble is either strabismus, ptosis, or a pupillary change. The former is an early symptom, and is probably the first indication of paralysis of any kind, and is seen most perfectly when a patient is awa- kened or aroused. The pupils are sometimes unequally dilated, but when the coma supervenes dilatation is complete ; pupillary changes are, how- ever, by no means constant. Unilateral paralysis is not rare ; some of the facial muscles being alone affected, or there may be extensive hemiplegia, which is an advanced symptom. Spastic contractions are evidences of a condition of central irritability ; and rigid flexion of the muscles of the thumb, or muscles of the sub-occipital region, are examples of this kind. The patient commonly lies with his thumbs drawn into the palm of the hand and covered by the fingers, and it is sometimes difficult to open the hands. I have alluded to convulsions, and in addition may say, that they are more prominent in the first four days, and vary in severity if the coma be either very deep or there is a condition of semi-consciousness. In the latter case they may involve isolated groups of muscles. Ophthalmoscopic Signs. — Bouchut,^ Galezowski,^ and numerous observ- ers have called attention to the value of the ophthalmoscope as an in- strument for diacrnosis in tubercular meningitis. The latter has found 1 Jahrbuch fiir Kinderheilkunde, B. 9, H. 3. 2 Da Diagnostic des Maladies du Systeme nerveux par I'Ophthalmoscope. Paris, 1866. 3 Arch. G^n., 1867, vol. ii. p. 262. ACUTE GRAXULAR MEXIXGITIS. 63 two forms of neuritis as evidences of this disorder ; one a peri-neuritis, and the other an inflammation of the optic nerve itself. Whiteness about the papilla, deposits of granular matter in the choroid, and tortu- osity of the retinal vessels, are appearances which have been described by others. FrankeP and Steffen found tubercle in the choroid some weeks before the invasion of the disease ; and Broadbent,^ in examining the fundus, discovered that the optic disks were dusky red, and mottled by white spots ; and the retinal veins were enlarged, while the arteries were very small. Tubercular meningitis of the convexity rarely presents ophthalmoscopic signs, though every form of convexity disease may occasionally give rise to retinal trouble. ACUTE GRANULAR MENINGITIS OF THE CONVEXITY. In the table I presented when speaking of the basal division of this disease, I mentioned the prominent symptoms of this variety. When I add that delirium and other decided psychical symptoms are highly characteristic of inflammation of the vertical region, I have described the difference between the two forms. This variety runs its course in a much shorter time, death generally resulting in from a week to ten days. When the malady (either basal or vertical) occurs in conjunction with certain tubercular affections of the lungs or peritoneum, there are local symptoms which precede those of the meningeal disorder, but the inva- sion of the disease is often very sudden. Constipation, followed by a ty- phoid state and drowsiness, are the precursors of meningitis when ante- cedent lung disease has existed. ISTot only may children be subject to this disease, but adults are as well ; and we sometimes find it as a sequence of various zymotic diseases, typhus or typhoid, remittent and other fevers, as well as pulmonary tuberculosis. A marked elevation of the evening tem- perature, incomplete hemiplegia, vomiting, or convulsions, are the promi- nent features of such a termination. Strabismus, unequal mydriasis, high pulse, and temperature, with some of the other symptoms which charac- terized the disease in the child, that have already been described, are generally present. It is sometimes so insidious in its approach and development as to puzzle the observer. The phthisical patient may become listless, drowsy, or complain of headache. He often wanders and gives way to a mild form of delirium, which appears during the latter part of the day. This complication may occur during the early stages of the pulmonary affection. Causes. — The question of diathesis naturally arises before any other, and we are immediately puzzled, for on one side we find that Rokitansky, ^ Virchow's Jahresbericht, 1869, p. 621. ^ Trans, of London Pathological Society, vol. xxiii. p. 216. 64 DISEASES OF THE CEREBRAL MENINGES. Kobin, Empis, Clark, and others consider the disease not to be directly connected with the tuberculous diathesis, and they go so far as to ques- tion the identity of the granular deposit in the brain with tubercle ; while arrayed against them are Rilliet and Barthez, Grisolle, and a host of others who are equally positive that it is in every case an expression of tuberculosis. Leaving the discussion, which is by no means settled, as the nature of the deposit needs much more investigation than it has re- ceived, we may assume that the affection is usually associated with a " scrofulous " cachexia ; that it appears among children who are badly nourished, and in whom the nervous diathesis is well developed. That exposure, insufficient food, and various exciting causes, such as dentition and over-study, produce it, no one will, I think, deny. In some in- stances — and these are by no means few — it is impossible to find any hereditary tuberculous history. As to age, we may consider that the so-called primcwy tubercular meningitis rarely occurs after the fourteenth year, and it is probable that a great many of such cases are unattended by tubercle, but by a granular deposit of simple character ; and primary tubercular meningitis in after life is, I think, a genuine tubercular disease. Watson^ makes the statement that fifty children are attacked within the first five months of life to every one after that time. I have found it to be more common after the first year, between the first dentition and the fifth year, though general practitioners who see more of these cases undoubtedly find them before that time. In large cities the mortality is undoubtedly greatest in the summer months, when diarrhoeal as well as other diseases and high temperature are conducive to its development. In the year 1871, in the city of New York, 84 deaths from " tubercular meningitis " (the reported exciting cause being "teething ") are recorded in the Health Board Rej^orts, and the greatest number were found be- tween the sixth and fourteenth years, a fact which seems to be irre- concilable with the statement that it is generally connected with the first dentition.^ The table presented below demonstrates that males are much more frequently affected than females, and of 169 deaths 91 were of males and ^ Practice of Physic, p. 270. 2 An inspection of the table prepared by Dr. C. P. Russell, in the report of the Board of Health of the City of New York for 1870, will enable the reader to per- ceive the preponderance of mortality before the second year of life. Nati U.S. vity. For'n. Color- ed. Under 1 Year. 1 2 3 4 5 10 15 20 2S M. F. M. F. M. F. M. F M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. 82 70 9 - 30 28 17 21 14 9 8 5 4 7 7 3 1 4 4 . . 1 . . . . Also five males of 30, one of 50, and one of 55; this cause of death was .62 per cent, of the combined cause. ACUTE GRANULAR MENINGITIS. 65 78 of females. Bertalot, already referred to, found that of his 24 cases fourteen were boys and ten were girls. Two cases occurred in the first year of life, seven in the second, five in the third, three in the fourth, three in the twelfth, and one each in the fifth, ninth, tenth, and fourteenth years. The youngest patient was ten weeks old, and twenty-two out of the twenty four were attacked between November and the end of June. The children were all more or less delicate, they had frequently grown up under bad hygienic conditions, and were generally scrofulous or scrofulo- rachitic In twelve there was a distinct hereditary predisposition to tuberculosis ; two cases supervened upon chronic coxitis ; one upon trau- matic erysipelas ; two upon pertussis ; one uj^on measles ; and one upon the first signs of dentition. There are certain physical appearances belonging to children predis- posed to these forms of disease which should not be passed unnoticed. In nearly all of the cases I have seen the head of the subject was pecu- liarly long and large. The hair was usually silky and fine, and of light color, and in some cases hip disease and like troubles had been noted. Morbid Anatomy and Pathology. — From the immense mass of confused testimony before us (for the disease has been described by nearly every writer, since the time of Hippocrates), it is extremely diffi- cult to say whether the posi-viortem appearances are always those of a tuberculous character, or whether the granular substance is non-tubercu- lous, or again whether in some cases there is tuberculous dejDOsit and in others simple granular collections. Paisley, who, Watson says, was the first to clearly describe the affection without saying much about its tuber- culous nature, has given us a very admirable collection of facts bearing upon its morbid anatomy. Gerhard/ one of the early medical writers of this country, says : " It was not known, previously to the researches of Dr. Rufzand myself, that the tuberculous character of the disease was anything but a mere compli- cation." Guersent, Dance, Hennis, Greene, and others shared in Ger- hard's opinion, that tubercular meningitis was a " strumous" disease. Rufz^ collected 40 cases, and in every instance there was complicating pulmonary tuberculosis. Fenwick's^ tables are valuable in displaying the distribution of tubercle in the affection. In one of these, sixteen cases of meningitis occurring in tubercular patients are detailed in which tubercle was found in the lungs and other organs, but not in the brain. In these cases, of which ten were males and six females, there was tu- berculous deposit in the lungs in every instance, and in some of them other organs were affected. Positively nothing like tubercle could be found in the brain, but this organ was either congested or anaemic. The ^ Dunglison's Prac. of Med., vol. ii. p. 243. 2 Quoted by Marshall Hall, p. 94. ' St. George's Hosp. Eeports, vol. vii. p. 35. 66 DISEASES OF THE CEREBRAL MENINGES. membranes were " wet," and the ventricles contained fluid. Four cases were under ten years of age; three between ten and twenty, and three between twenty and thirty ; four were in the fourth decade, and one in the fifth and sixth. In other cases brought forward by him of general tuberculosis, it was found that of fifty-four examined, nearly four-fifths of the number were below twenty-five years. AH of these fifty-four had tuberculous deposits, both in the brain and other organs. The seat of the granular deposit seems to be chiefly the arachnoid and pia mater, though the dura mater has been found as well to be the site of granular accumulation. It is scattered mostly along the base of the brain and about the large arteries, where it may be found to consist of masses of little round pearly or yellowish bodies which may be almost as small as grains of coarse corn meal. The meningeal arteries are dotted over with these granules, and when the arachnoid is raised numerous under- lying miliary granules are exposed. Fm 12. Tuberculous Matter about the Vessel-. (Cornil and Ranvier.)-A. Tuberculous deposit. B. White blood-corpascles. C. Granular contents of vessel. The membranes are all more or less congested and dotted with opaque spots or patches. The cortex is hyperseraic and the ventricles distended by fluid. Their ependyma is toughened and rough, and presents a gran- ular appearance which may be likened to that of white shark's skin. Softening of various parts of the brain, the nerve trunks and optic commissure are not uncommon evidences of the violence of the disease. Patches of false membrane which contain in their meshes these granular bodies are scattered over the convexity and base, and render the removal of the brain or its membranes separately a somewhat difficult matter. The lungs, or other organs, may also present indications of tuberculous matter. Rendu ' affirms that whenever there is paralysis of permanent form there must be some arterial obliteration from fibrinous exudation and consequent softening, and he does not believe that scattered granulations or ventricu- lar effusion are alone sufficient for its causation. 1 Review in Gaz. des Hopitaux, Jan. 15, 1873. ACUTE GRANULAR MENINGITIS. 67 It is rarely possible to very closely localize limited deposits before death, but occasionally this may be done. A very interesting case is reported by Raymond which presented seve- ral suggestive points. One was that the motor centre of the right arm was the seat of granular lesion, and that there was paralysis of that mem- ber. This, then, is an exception to the rule to which I have just referred. " The patient, a man twenty-two years of age, was admitted into the hospital m the early part of the month of January last, and then presented obvious symptoms of pulmonary tuberculosis, not, however, very pro- nounced. The affection, indeed, seemed to be progressing slowly. He was thin, pale, coughed a good deal, and was a little feverish. " On January 28 he began to complain of violent pain in tiie right hy- pochondrium,_and two days later vomiting came on. This recurred fre- quently, the ejected matter having a greenish color. At the same time he suffered from severe headache, which affected chiefly the left side of the head. Fever then showed itself, the temperature rising to 140 ° ; the pulmonary lesions developed more rapidly, and the general condition be- came much worse. On March 24 he complained of great pain in his right arm, which seemed to be very heavy; at times he had great difficulty in moving it. On March 25 there were fresh pains in the arm, and motor paralysis was complete, sensibility being retained. In the evening, with a great effort, he succeeded in raising his arm to his head. The paralysis of the arm, up to the time of his death, presented the character of inter- mittence. There never existed any trace of paralvsis in the right leg nor in the left arm or leg. Perhaps there was a slight degree of loss of power m the bucco-labial muscle of the right side,, and a slight deviation of the tongue to the left, but these synjptoms were a little doubtful. In the whole case, there was nothing else comparable with the paralysis of the arm, which was indisputable. The patient died on April 4. _ " At the necropsy, far advanced tubercular lesions were revealed in the right lung, and the membranes of the brain were found to be the seat of tubercular granulations. These were found in the j^ia mater over the right lobe, and there they were disseminated along the parietal branch of the Sylvian fissure. On the left side, in addition to the tubercular granu- lations, there existed some meningitis with purulent deposits. The' men- ingitis was, if it may be so said, circumscribed and localized on two con- volutions, the anterior and posterior marginal near the paracentral lobe. There the tubercular granulations were very numerous, and formed a sort of tumor. The pia mater, covered with pus, adhered closely to the sub- jacent cerebral tissue. In other parts, where there were granulations there was no vestige of meningitis. Xo other cerebral lesions, foci of softening, or obliteration of capillaries, could be discovered. There was a snaali amount of fluid in the ventricles, but nothing to note in the spinal cord or nerves of the arm. "Such are the facts of this case, which may be summed up as follows: Motor paralysis of the right arm, somewhat intermittent in the sense that It was at times complete, and at other times less absolute; and to explain this paralysis no other lesion than the tubercular meningitis in the region of the motor centre of the arm."^ ' London Med. Record, July 15, 1876. Abstract from Le Progres Medical, April 22, 1876. ^ 68 DISEASES OF THE CEREBRAL MENINGES. Landouzy has collected a large number of valuable cases, showing the possibility of localization sometimes in tubercular meningitis, and has pre- sented 43, in which partial convulsions predominated in 23 cases. In these the distribution was as follows : The face alone, once ; the face and arm, twice ; the face, arm, and leg, five times ; the arm alone, six times ; the arm and leg, eight ; the leg alone, once. ^In half of these cases the convulsions were limited, in some cases the partial convulsions were preceded by those of a general character. He was enabled to diagnose the seat of the trouble in all of these cases. Prognosis. — No inflammatory disease of the brain or its membranes is more serious or rapidly fatal than is this. The termination is in death in from two to three weeks, though very rarely recovery may take place be- fore the disease has gone beyond the period of invasion. The ophthal- moscope is of service at this time. If there be optic neuritis, and basilar meningitis is suspected, there is very little hope to be derived from such an examination ; if the child recovers, it will be with impaired intellect, epilepsy, or some other serious life-long trouble. An anonymous writer in the Gazette Medieale upon the treatment of tubercular meningitis, says that, in a practice of thirty years, he has seen between eighty and ninety cases, and during that time there were but two recoveries.^ Bierbaum^ has reported three recoveries. Diagnosis. — This disease may be mistaken at different stages for several other acute conditions, viz. : — A. Typhoid fever — typhus fever. B. Scarlet fever or smallpox. C. Pleurisy or pneumonia. D. Eccentric irritation, such as that produced by worms, etc. E. Other forms of meningitis. F. Exhaustion. G. Syphilis. A. Typhoid, in some of its forms, or typho-pneumonia, may resemble tubercular meningitis, either of the primary or secondary forms. This is especially the case when typhoid symptoms are added to those of phthisis. The irregular varieties of typhoid are attended by absence of diarrhoea, tympanites, and other abdominal symptoms. The eruption of typhoid may also resemble the tache cerebrale of this form of meningitis, but it is usually confined to the chest and abdomen, and is an early symptom. Typho-pneumonia may bear a close resemblance to secondary tubercular meningitis, and this is particularly the case if moist I'ales can be heard all over the chest, and there is some dullness at the apex ; certain points are to be borne in mind, however, that will put the diagnostician on his guard. Uncomplicated typhoid is a disease of longer duration, and the abdominal ' Contribution a I'etude des Convulsions, etc, Paris, 1876. 2 Gazette Medieale, 1871, 412. =* Deutsche Klinik, 1873, 184. ACUTE GEAXULAR MENIJTGITIS. 69 symptoms are usually marked. There is tenderness in tlie left iliac fossa, high evening temperature, nose-bleed, and usually slight head symptoms, which vary. The eruption fades away under pressure, instead of being produced by pressure or contact, as is the case in the meningeal difBculty, and the prodromal symptoms of typhoid are not nearly so marked as those of the other disease. Typhus fever may sometimes make the diagnosis exceedingly difficult ; for, as we know, its duration is about that of the tubercular trouble, and head symptoms are its marked feature. The general absence of pulmo- nary symptoms, the appearance of the dark rash, and the antecedents of the patient offer us guides. B. Scarlet fever, which sometimes begins with vomiting and early head symptoms, may puzzle the observer. The throat trouble, the early appear- ance of the eruption, the peculiar "strawberry tongue" which, as far as I am aware, is found in but two diseases, diphtheria and scarlet fever, and the high and continued elevation of temperature during the eruption, are sufficient to put the medical man upon the alert. Smallpox, without the eruption, may sometimes mislead us. The pro- dromal symptoms, pain in the back, vomiting, and headache, are different from the same symptoms in tubercular meningitis. They are more severe, and may immediately usher in coma. Bleeding from the nose and mouth I have witnessed in three patients. This form of smallpox is quite rare. In the course of nine years, during which I was connected with the Health Department of the City of New York, I saw over one thousand cases of the disease, and I do not remember having encountered but ten or twelve cases of this terrible form of variola. These cases were all adults. If pronounced smallpox should suggest the other affection, it will be found that in two or three days any blush eruption (which could hardly be mistaken for the maculse of tubercular meningitis, which is a late symptom) will develop so that the characteristic vesicles may be seen. In both scarlet fever and smallpox the history of exposure often supplies the link. C- Pneumonia and pleurisy can Only be mistaken when we neglect to take into account the chill, pain in the side, and physical signs. The latter disease may sometimes be supposed to exist ; for Gee has heard the fric- tion sound of pleurisy in tubercular meningitis. D. Reflex irritation from ascarides may produce many of the early symptoms which also indicate tubercular meningitis, and even convulsions may appear ; but, unlike the tubercular disease, there is no further pro- gress. The use of an anthelmintic will clear up the diagnosis, if we have reason to suspect these parasites. E. From simple meningitis we may distinguish the disease chiefly by the late ajDpearance of the delirium. The j)atient lapses into unconscious- ness in the former disease in two or three days, while in tubercular menin- gitis the acute mental disturbance is not so immediate. Acute meningitis runs its course usually in a week. Various intracranial diseases may resemble at different times the dis- 70 DISEASES OF THE CEREBEAL MEXIXGES. ease under consideration ; but as I propose to treat of these hereafter, it will be well to omit them here. F. Exhaxidion. — The excitement aroused in England by the Penge case gives this part of the subject decided importance. It will be remem- bered that one Louis Staunton, with two accomplices, one of whom was his brother, and the other a woman with whom he was living upon terms of criminal intimacy, starved to death his wife, and that they all narrowly escaped capital punishment or transportation. The coroner's jury decided that the real cause of her death was starvation, while several distinguished medical men contended that she had died from tubercular meningitis, but did not deny that she had been neglected. The disputed points seemed to be, the rapid emaciation and great anai- mia of the tissues, as well as disappearance of subcutaneous fat. Her symptoms before death were drowsiness passing into coma, stertor, rigidity of one arm, and inequality of pupils. These symptoms appeared but shortly before death, and were supposed by Dr. Greenfield,^ who made a most sensible and convincing communication to the Lancet, not to account for starvation alone, but to be probably due to tubercular meningitis. Opposed to him are several observers Camong them Virchow, who re- viewed the English testimony) who held that the great emaciation, loss of weight of the internal organs, emptiness of the cavities of the heart, and certain forms of congestion were clearly indicative of starvation. Greenfield proved, I think, that none of these appearances were sufficient in themselves for us to say definitely that they were due to starvation ; that they may often be a result of exhausting disease ; that the congestion witnessed was an ordinary post-mo7'tem appearance ; and finally that tubercle existed in the lungs and brain ; while in the latter there were found primary indications of softening as well as adhesion of the meninges. Gee calls attention to forms of wasting disease with profound emacia- tion which may closely simulate tubercular meningitis, but are connected with digestive derangements and malnutrition ; and Sir Wra. Gull, in one of the English hospital report^, brought forward some years ago, several cases of hysterical anorexia, with emaciation ; and in the pro- found form of cerebral anemia there can be symptoms which may resem- ble some of those expressed in tubercular meningitis so greatly, as to possibly lead to an error in diagnosis. G. A case of cerebral syphilitic meningitis which closely resembled tubercular meningitis was reported by Webber. There were decided pul- monary troubles, and the tache cerebral, but antecedent pain for one year, mental dulness, etc., and recovery under specific treatment cleared up the case. Treatment. — More can be done for the patient in the early stages than at any other time. Cod-liver-oil, phosphorus, a nitrogenous diet, and preparations of iodine are all of great service. The syrup of the iodide of ' London Lancet, Oct. 6, 1877. CHRONIC CEREBRAL MENINGITIS. 71 iron is an excellent remedy in the earliest stages, if we recognize the sig- nificance of the somewhat irregular group of symptoms. The iodide of potassium has been by many used during later stages. Fleming ^ reports a cure in the case of a girl two and a-half years old by large doses of the iodide, and the experience of others is also encouraging. Cold to the head and the bromides in the later stages are of greater benefit than any other remedies. Ergot has been successfully used by Gibney in one case of so-called tubercular meningitis. It should be administered in full doses often repeated. It will be found that a drachm may be given every three or four hours without producing any disagreeable effects, and when the disease is well developed I have been able to do more with this drug than any other, and am confident that a case of simple granular meningitis so treated by me was saved by its early and free administration. Gee recom- mends closure of the eyelids by adhesive plaster, should there be aoy ulceration of the cornea. Blistering, bleeding, and violent treatment of any kind are to be strongly condemned ; quiet and darkness should be in- sisted upon as early as possible, and over-solicitous friends should be ex- cluded from the sick-room. Food of a liquid form may be given by enemata, or by the mouth, using a syringe, and being careful in intro- ducing its point between the teeth. CHRONIC CEBEBRAL MENINGITIS. This comparatively rare disease, which may be either the result of acute meningitis, or develop idiopathically, or after head injury, is of slow ap- pearance and progress, and resembles several organic diseases of the brain proper, among them softening, general paralysis, and brain tumors. Symptoms. — One of the early symptoms, especially of the vertical variety, is headache, which varies in severity. It is of a dull character, and is seated in the top of the head, and is increased by any effort which augments the cerebral blood pressure. In certain cases there is loss of memory, and other mental symptoms, which resemble closely those of general paralysis of the insane ; and this mental impairment may ter- minate in dementia. Insanity is by no means a rare sequence of chronic meningitis, and may follow inconsiderable early symptoms. In an interesting paper from the pen of Mortimer Granville^ seventeen cases occurred which began with sunstroke. In all of these insanity, usually dementia, followed the original trouble. The vertical form is generally complicated with encephalitis and muscular para- lysis, as well as spasms and twitchings of either a limited group of muscles, or the arm and leg of one side. Tremor and sometimes con- vulsions occur after a short period, while after the involvement of the vertical cortical substance we may have marked motorial symptoms, such as paralysis with contractures. Paralysis of the bladder or sphinc- ter ani, takes place, so that the patient passes his urine and feces in an involuntary manner. The disease is generally progressive, and there is an increase in the number of convulsions. The mental decay 1 British Med. Journal, 1871, p. 443. *" Brain" Partviii. 72 DISEASES OF THE CEREBRAL MENINGES. advances rapidly, and the patient finally dies, at the end of a few months, iu a comatose state. The basilar form of disease is much more interest- ing than that of which I have just spoken, the cranial nerves being more or less involved ; and symptoms of cranial paralysis of a progressive character form a distinguishing feature of the disease. Thus, in thirteen cases collected by Dr. Cross,' of this city, the third nerve was paralyzed generally on the left side in nineteen instances, and in one case the third pair on both sides was affected. In nine of these cases strabismus was noted ; in five of which it was external and existed on the left side. The pupils were dilated in eight instances, and contracted once. Obscureness of vision was observed to be prominent in four cases, while ptosis existed in five, occurring once on both sides. Double vision was present in many cases. Blindness occurred once in the left eye, which was the result of suppurative choroiditis. In another instance there was loss of sight in both eyes. I may select four of Dr. Cross's cases, which represent very fully the course of the disease : — Case I. — A young man came to the clinic who was affected with ex- ternal strabismus, ptosis, and dilatation of the pupil of the left eye. He had a most intensely agonizing pain in the head, vertigo, frequent attacks of vomiting, and paresis, if not paralysis, of the arm and leg on the same side. He was treated with mercury and large doses of the iodide of po- tassium. In a short time the pain in his head disappeared, and after the lapse of a few weeks the paralysis was cured. Two or three months sub- sequently he reappeared, with a corresponding set of symptoms in the right eye, and the right half of the body, and with pain in his head as severe as during the previous attack. He was again treated with mercury and the iodide of potassium, when his symptoms again disappeared, and have not since returned. In this case there was some slight suspicion of syphilis. Case II. — A man, twenty-eight years of age, came under my charge some two years ago. At that time he was suffering from pain in the head, vertigo, dilatation of the pupil, external strabismus, double vision, numbness, and slight paralysis of the opposite side of the body. As far as I was able to discern, the ocular paralysis was confined to the left in- ternal rectus muscle. Until within a few months prior to his coming under my observation, he had apparently enjoyed excellent health, with the exception of a severe headache, from which he had suffered quite acutely. He stated that the disease with which he was afflicted had come on slowly, and gradually increased in degree. He acknowledged that he had had a hard chancre several years previously. Under the influence of large doses of the iodide of potassium, the symp- toms rapidly disappeared, and he has since had no return of the paralysis, although he afterwards experienced severe headache, which disappeared under treatment. I examined hisretinsB, but found no disease. Case III. — Shortly after this I was consulted in regard to the case of a gentleman, thirty-five years old, who was suffering apparently from symptoms similar to those observed in the preceding case, with the excep- tion of the paresis of the extremities. He had well-marked head-symp- 1 Psychological and Medico-Legal Journal, New Series, vol. ii. p. 220. CHEONIC CEREBRAL MENINGITIS. 73 toms and numbneirs, which was limited to one side of the body, but the paralysis was confined exclusively to the ocular muscles. His eyes had heen carefully examined by an eminent ophthalmic surgeon, who had informed him that they were healthy, and that his trouble was probably cerebral. He was a very robust man, and had apjDarently suffered from no severe disease until the beginning of his present trouble. On question- ing him closely, he stated that he had had syphilis twelve years ago, for which he had been carefully treated, and consequently considered himself cured. When I first saw him, the double vision had existed several months, and during that time had been almost constantly present. I did not treat this patient, and consequently do not know the result. Case IV. — A married gentleman, forty-one years of age, came under my care in 1873. He was descended from a family saturated with rheu- matism, and gout, and five of whom had died of j)aralysis. At this time he was suffering from myalgia, which I found to be located in the muscles of the chest and back. This condition lasted about three months, and then disappeared under treatment. He stated that prior to this time his health had been good. He had been temperate in his habits, and had never had acute articular rheumatism, gout, nor syphilis. In July, 1873, he first observed that the pupil of the right eye was much contracted. This was followed by headache, vertigo, and obscureness of vision. In December he came to my office and informed me that his ocular troubles had increased. At that time his condition was as follows: He had a dull, heavy pain behind the eai's, which seemed to extend along the base of the brain, and was at times throbbing in character. There was vertigo and indistinctness of vision, which he described as a blurring of objects ; his right pupil was extremely contracted, and did not respond to the stimulus of light. Far and near objects were very indistinct, and ap- peared to be one above the other. AVhen he looked at the pavement it appeared to be raised above its natural position. There were double vision and strabismus. He kept his head constantly turned to the right and downwards, in order to bring the axes of his eyes parallel. All his organs were health}'', with the exception of his brain. There was apparently partial paralysis of the right internal rectus and right inferior oblique muscles. This gentleman was, by my advice, carefully examined by two eminent oph- thalmic surgeons of this city, both of whom were of the opinion that there was no disease of the eyes. An important point in this connection is the fact that this patient had been in the habit of using a magnifying glass with the affected eye to examine the delicate parts of machinery, in order to see that they were properly constructed ; and this operation was conducted in a dark room, lasting several hours daily. I carefully ex- amined this patient's spinal cord (as I always do in all these cases), but found no indications whatever of spinal disease. I ordered him to take the iodide of potassium, in fifteen-grain doses, three times a day, well diluted in water, and to rapidly increase the amount ; but the first dose caused him such intense nausea and vomiting that he could not be in- duced to take it subsequently. He consequently ceased taking any medicine, and for some time he continued to grow worse, all his symptoms increasing in severity. He was obliged to give up his business, and has since passed most of his time in out-door exercise. The pupil of the right eye remained permanently contracted for several months. A short time since I met him, and he told me that he was about 74 DISEASES OF THE CEREBRAL MENINGES. to resume his business, he had so nearly recovered. His pupil was still contracted, but not to the same degree that it was when he first came under ray care a year ao;o. He now holds his head straight ; there is no apparent strabismus, although his wife informs me that he occasionally sees double. His headache and vertigo have disappeared. The only medicines that he has taken during this period have been tonics and out-door exercise. I made particular inquiry in this case, in order to discover, if possible, a constitutional cause, but I was fully satisfied that none existed'. Both of these forms of meningitis may be connected with cerebral growths and syphilitic and tuberculous deposits. Causes. — Males seem to be oftener affected than females, and the disease is ordinarily one of adult life. It is connected oftentimes with the tuberculous diathesis, and is not rarely dependent upon constitu- tional syphilis; it may be seemingly idiopathic, or result from head injury, exposure to the sun, intemperance, the acute zymotic fevers, and the other causes of meningitis. Morbid Anatomy and Pathology. — The cerebral meninges have been found to be thickened, adherent to each other, or to the inner surface of the cranial bones, with effusions beneath, Avhich have under- gone partial organization ; sometimes gummy exudation of syphilitic origin will be found scattered over the surface of the brain, or calcareous plates of perhaps an inch in diameter will be found in the dura mater, such as 1 have already spoken of in chronic pachymeningitis. If the disease has involved the cortical substance of the brain, we may discover patches of softening of variable extent and depth, and perhaps superficial abscesses. At the base of the brain the meningitis is not generally so diffuse, but occurs in circumscribed spots, the cranial nerve trunks being generally softened and bound down by bands of new tissue. In a case of meningitis following sunstroke ^Granville found very interesting osseous changes. " Calvarium strongly adherent, the plates dense ; diploe obliterated ; membranes very vascular, thickened and adherent to the surface of the brain along the median fissure : this was found on separation to be caused by three or four bony plates, of the size of a sixpence, with small spicul^e passing into the surface of the brain on the left side ; the brain was smaller than usual and weighed only forty-four ounces ; the gray matter was deficient, and the convolutions flattened and apparently not so numerous." In this case sunstroke was followed by headache, most intense on the left side of the head, difficulty of articulation, defective memory, and subsequent symptoms resembling those of general paresis. Diagnosis. — The form of meningitis of the convexity presents so many symptoms that are common to other brain diseases, that the matter of diagnosis is often very difficult, and it is impossible at times to deter- 1 Brain, Oct. 1879, p. 314. CHRONIC CEREBRAL MENINGITIS. 75 mine the nature of the patient's disease until after death. Meningitis of the base, however, is much more easily diagnosed. There are nearly always ophthalmoscoj)ic appearances, which is rarely the case in the other form of disease and some one or all of the cranial nerves are paralyzed. The symptoms of tumor may counterfeit those of chronic basilar menin- gitis, but perhaps are more severe. If the disease be of a syphilitic character, the question of diagnosis is a puzzling one ; for in some respects a condition which favors the formation of syphilitic tumor and chronic meningitis is the same, and occasionally these two diseases are found to coexist. Prognosis. — Should the disease be syphilitic, the prognosis is favora- ble, unless the trouble be of long standing, but, if it be the result of injury, recovery is less likely to take place ; should it follow the acute exanthe- matous fevers, there is very little hope. Treatment. — Our main reliance is in the free use of large doses of iodide of potassium, or in the employment of mercurials. Active counter- irritation and the use of blisters and cauterization may afford a great deal of relief. A saturated solution of the iodide of potassium may be ordered, and the patient should be directed to begin with a dose of ten drops three times a day, and gradually increase one drop with each dose until he takes a hundred drops or more during the twenty -four hours. CHAPTER II. DISEASES OF THE CEREBRUM AND CEREBELLUM. SYMPTOMATIC CEREBRAL HYPEREMIA. Synonyms. — Cerebral Congestion, temporary Cerebral Congestion (A lid ml). Hyperemie Cerebrale (Fr.). Hyperiimie des Gebirns (Ger.') Definition. — A condition characterized by an abnormal increase in the amount of blood contained in the cerebral vessels and expressed by symptoms which indicate pressure and irritation of the cerebral nerve cells; such increase in blood pressure being the result usually of general bodily disease. Until a few years ago this trouble was considered as a form of organic cerebral disease, at least as a part of a morbid process terminating inevit- ably in softening or cerebral hemorrhage. Such is the treatment of the subject by ^Andral, ^Durand-Fardel, ''Calmiel and many others. Not- withstanding the fact that Andral describes a " temporary cerebral hy- peremia," the condition never received any extended notice until fifteen or twenty years ago. ^Schmidt describes functional hyperemia and anae- mia in his Compendium ; and Jaccord, Hammond and others since have clearly established a form of cerebral hypersemia which has not of neces- sity any connection with graver cerebral troubles. Before entering into the discussion of the affection, I desire to state that in very few cases do I consider cerebral hypersemia to be a distinct cerebra disease, but rather one form of expression of some general condition, and, for this reason, I prefer to use the designation symptomatic. The apo- plectiform variety originally described by Andral, and many years after- wards by Trousseau, is without doubt a result of vascular rupture, and should be classed under " cerebral hemorrhage." Symptomatic cerebral hypersemia includes those varieties of increased cerebral blood pressure dependent usually upon diseases of the heart, liver or kidneys ; such, for instance, as the symptom described by Bright as " the effect of cerebral blood pressure with venous turgpscence," either func- tional or organic, or upon any condition which impedes the return of venous blood from the head. ^Clinique Medicale. ^Traites des Maladies-Tnffammatoires du Cervean, tome 1. Paris, 1859. •''Traite du Rimollis«ement dii Cerveaii, Paris, 1843, p. 153. * Compendium der Nervenkrankheiten, Leipzig, 1869. 76 SYMPTOMATIC CEREBRAL HYPEREMIA. 77 Two forms of cerebral hypersemia have been recognized by the majority of modern medical writers, one of them which is active and connected with for- cible arterial fluxion, and the other passive, and the result of some impedi- ment to the venous return. I prefer to adopt the terms sthenic and asthe- nic, as these expressions denote pathological conditions much more appro- priately than do those in common use. Either may exist in a modified degree as physiological states, and it is often difficult to make the dis- tinction between a normal process and a diseased condition ; but when the cerebral fulness is constant or increased to a serious extent, we may safely judge the condition to be pathological. The division of the disease expressed by the terms I have just mentioned, though adopted by most of the authorities on nervous diseases, is for some reasons unne- cessary. Both varieties may lead to accidents symptomatized by attacks of coma, accessions of convulsion, a low grade of paralysis, mental excite- ment, and other serious results. These differ only in their manner of appearance. In one, they are early and sthenic expressions, and are pro- duced by rapidly exerted and violent force ; and in the other their ad- vent is more slow, as they appear to be produced by a sluggish force or tardy impairment of cell function, though sudden accidents which embar- rass the venous return may make their appearance as immediately as those of the first variety. Stupor is more decidedly characteristic of the passive or asthenic variety, than that in which rapid dynamic arterial action takes place. In this, the second variety, there seems to be a dila- tation of the small vessels, a crowding out of the perivascular fluid, and consequent pressure of the distended vessels upon the hyaline membrane next to the cells, thus preventing the removal of effete material, and consequently impairing their normal action. Symptoms. — The symptoms of this condition, as I have stated, may vary from evidences of what seems to be but healthy physiological func- tion to those which are unmistakably grave pathological conditions; from simple throbbing of the temporal vessels and flushing of the face, to coma, convulsions, or mania. Generally the symptoms are not serious, and out of the many cases I have seen (and, by the way, a large number of these mild cases are met with in private practice) they are of a type which may be recognized at once. The patient calls attention to the following troubles : A sense of head- fulness with throbbing of the temporal arteries. He may inform us that his " head seems to be of unnatural size and great weight ; that he feels as if the skin covering the head is much too tight." He complains of tinnitus aurium, and is troubled by subjective sounds which he compares to the buzzing of bees, the ringing of bells, and the rushing of waters. There seems to be an extraordinary acuteness of all the senses. He may inform us that there are bright specks or motes which flit across the field of vision, and may say that bright light is painful, complaining of his inability to read fine print, because the letters seem to dance upon the 78 DISEASES OF THE CEREBRUM AND CEREBELLUM, page, and the words appear hazy and blurred. Diplopia and other visual troubles may annoy him. Sharp noises, harsh voices, and monotonous sounds seem to produce distress and discomfort. His head is hot ; and Rosenthal has found that the thermometer introduced into the external auditory meatus recorded a rise in temperature. He may have hallu- cinations, but is generally able to appreciate their unsubstantial charac- ter. He arises in the morning unrefreshed and uncomfortable, complain- ing of muscular weariness, but feels better towards the middle of the day. After his dinner, particularly if it has been a hearty one, the cerebral condition is aggravated. At night he finds it impossible to sleep, and he tosses to and fro, his head being hot and his extremities cold. The mind of the patient is preternaturally active, and his brain seems filled with excited fancies and troubled thoughts — and at last he sleeps. This sleep, however, is not sound ; dreams of all kinds, or nightmare, keep him in a state of wretched semi-consciousness till the morning comes to find him utterly used up. With the patient, mental exertion is irksome, and study or concentration is disagreeable or impossible. There is headache or im- paired memory, thickness of speech, and various difficulties of articula- tion. He may substitute one word for another, even though it be one in common use and exceedingly familiar. The emotions are generally disturbed and altered. Irritability, over- sensitiveness, nervous excitement, and morbid exhilaration of spirits may make his conduct strange and unnatural to those about him; while slight things seem to disturb and harass him. The attentions of friends, though they may be of the most considerate nature, are met with explosions of temper, and the patient avoids them and prefers solitude. In such indi- viduals in whom the condition has existed for some time, this mental chano-e is striking. They are suspicious of their wives and best friends, and all sorts of eccentricities are indulged in. There may be a species of hysteria which prompts the individual to commit suicide, when he has no intention of doing anything of the kind. He may worry his friends by his capricious behaviour, and succeed in making every one about him miserable. Sometimes he takes violent exercise until completely ex- hausted, when wearied Nature asserts herself and sleep brings temporary relief. During the progress of the disease, cutaneous numbness or twitching of some of the muscles, or even paralysis, gives the condition a serious char- acter. The appearance of the patient is decidedly striking, and not to be mistaken. The face is red, the cheeks puffed and swollen, the eyes promi- nent, watery, and injected, and the conjunctivae quite red. He is anxious and excited, or, on the other hand, stupid. The sleepy expression is one of the most valuable objective symptoms. Occasionally, in the course of the disease, there is bleeding from the nose, which may temporarily re- lieve the patient. The hands and feet are usually blue and cold, and so remain. After a variable period, during which the patient has presented a number of these symptoms, he may suddenly, after a hearty meal, or violent exertion or some other exciting cause, suffer an incomplete loss of SYMPTOMATIC CEREBRAL HYPEREMIA. 79 consciousness/ wlncli is generally of short duration, and from which he can be aroused in a few minutes. When spoken to he seems bewildered and conl'used, and takes but little notice of what is going on about him. There seems to be incomplete loss of muscular power, more confined to one side than to the other, and he is able when less dazed to make simple voluntary movements. He seems to be annoyed by any bright light that may be let into the room. His pupils are contracted usually, and respi- ration is labored, while circulation is uneven, there being an irreo-ular pulse. At first the heart's action seems to stop altogether, but subse- quently it becomes quite energetic, and the pulse is bounding and full. Kthe attack be due to passive congestion, there may be a dilatation of the pupils, and the bloating and puffing of the face and fulness of the lips will be much more noticeable than when it is the result of the sthenic variety. During its continuance there is neither rigidity of the muscles nor stertorous breathing. The recovery is generally rapid, and after the attack there may may be some epistaxis and slight mental excitement. A form, which certain writers have called maniacal, may and does often occur without any of the characteristic symptoms of increased cere- bral blood pressure that I have described. It is the form Milner Fother- gill has so admirably described,'^ and characterizes usually the pathologi- cal condition, in which the nervous tissues attract an abnormal amount of blood to themselves. This variety is not necessarily connected with vascular excitement, suffusion of the face, etc. It results commonly from protracted intellectual labor and direct excitement, and the patients may be pale and bright-eyed, and active in all their movements. They are " high-strung," restless, and remarkably irritable, and at the same time are loquacious and voluble. Their thoughts and fancies seem crowded together, and are evidently originated much more rapidly than they can be expressed. " Sometimes their ideas seem to settle themselves around some prominent leading thought, the centre-piece of the rotatory chaos, while at other times there is mental excitement, with great volubility, on no subject in particular." The condition is one of exaltation, and there is a restlessness which is characteristic. There is rarely any forcible heart action, the pulse being normal, or, if changed at all, is simply small and irritable. This condition does not seem to be confined to any particular age, though in old people cerebral congestion is disposed to take this character. The mental features may be those of ordinary acute mania, and all the phases of psychical disturb- ance may be expressed at some time or other. Suicidal tendencies are sometimes present. A case of this kind is reported, where the individual, during an attack of congestive mania, cut his throat. The loss of blood relieved the cerebral fulness, and his reason returned, but too late to avert the consequences of the act. This condition is one of rapid produc- tion, and under prompt treatment may disappear. Embarrassment of ^Thesie symptoms are, without doubt, due to small hemorrhages. ^West Riding Eeports, art. Cerebral Hypersemia, vol. v. p. 171. 80 DISEASES OF THE CEREBRUM AND CEREBELLUM. speech may vary from simple awkwardness of articulation to decided aphasia.' The difficulty is rarely a serious or lasting one, and is relieved by appropriate treatment. As I have before remarked, the second variety is more apt to be asso- ciated with deep stupor, and recovery is less certain and rapid. There may, indeed, be a form in which profound stupor, stertor, and full hard pulse are present, and which is almost always fatal. This follows profound narcosis by alcohol or opium, and the death of the indi- vidual is preceded by involuntary discharge of feces and urine, and there is complete loss of voluntary muscular power. Before concluding the description of the condition, it may be well to call attention to a form which is chiefly confined to early life, and occurs in the course of other diseases, or it may exist uncomplicated. In many respects it resembles meningitis. It is characterized by elevation of tem- perature and other febrile symptoms, among them vomiting, flushed face, headache, broken sleep, twitching of the limbs, constipation, and wander- ing delirium. Convulsions occasionally occur, and the attack ends in deep sleep. Recovery is the rule, although the young brain is so delicate and the violence of congestive disease so excessive, that a passive condi- tion may take the place of, and remain after the acute condition, and death may ultimately follow. Epilepsy not rarely originates in this way. It cannot be doubted that mental worry causes cerebral congestion, and therefore accelerated action of the heart gives rise to contracted kid- ney and urajmic symptoms. Causes. — Calmeil ^ and others consider that men are far more subject to cei'ebral hypertemia than women, and I think clinical experience fully supports their views. Some occupations and vices of men are peculiarly apt to lead to disordered states of the circulation, while women, as it will be seen, are not affected nearly so often as the other sex, and generally suffer only at the menstrual periods or when there is a retarded flux. Andral calls attention to the symptoms complained of by women just before the time of the menstrual period — these are vertigo, flushing of the face, troubled respiration, flashes before the eyes, and other evidences ■which point to congestion of the brain. When the menses are irregular or suppressed these symptoms are more intense, but are promptly relieved by re-establishment of the flow. He relates the case of a man who every summer suflTered from an acute train of symptoms indicative of softening, which subsided after he had had an hemorrhage from the bowels. There was no history of hemorrhoids. It is not confined to any age, but is commonly a condition of middle life, though special causes may influ- ence its origin at other periods. As to the etiological bearing of climate and temperature, there has been much discussion. As far back as the time of Hippocrates^ we have been ^ Tliis grave form is probaWy due to some lesion. 2 Maladies inflainmatoire du Cerveau. ^ Aphor., Lect. iii. 16, 23. I SYMPTOMATIC CEREBRAL HYPEREMIA. 81 told tliat it is a condition produced or aggravated by low temperature, in whicli opinion he is sustained by Aretseus/ Cheyne and others consider that extreme heat favors this morbid state, and Andral contends that the greater number of cases occur in cold weather. As far as my own experience is concerned, I have found, that either extreme heat, or cold, may develop the disease, but the greatest number of my cases have arisen from exposure to the direct rays of the sun, or have been among men whose avocation led them to pass their time in hot places. Bakers, sugar- refiners, furnace-men, glass-blowers, etc. etc, are often affected, and it is hard to say whether these people or those who overuse their brains, form the largest number. I give below a table which details the occupation of 160 of my patients. One Hundred and Sixty Cases of Cerebral Hypercemia — Occupation. Bartenders, or Lic[uor Dealers . 18 Lawyers 16 Bakers 15 Masicians 2 Blacksmiths 19 Merchants 15 Carpenters 3 Paintei-s 2 Carpet-cleaners 1 ■ Physicians 6 Foundrymen 6 Printers, 2 Harness-makers 2 Reporters ........... 4 Jewellers 2 Tailors 1 ' Seamstresses 5 Teachers 13 Laundresses 3 Miscellaneous 17 Laborers 8 160 By this table it will be seen that 64 were individuals whose pursuits subjected them to exposure to heat, and 54 were among persons who were hard students, worried business men, and the like. Immediately after the heated term of 1872 I saw many patients whose cerebral condition was produced by the great heat; but the disease may be due in many instances to exposure and cold, or is at least greatly aggravated by low temperature. Perhaps a reason for this may be that in cold weather the cutaneous circulation is not so active as during the warmer season, when the sudorific apparatus requires a free capillary circulation, and for this reason there is a determination of blood to the surface. In cases of sunstroke, as we know, the skin is generally parched and dry. As to predisposing causes we may enumerate them as follows : The organization of the individual, the existence of other disease, his habits etc. Two classes of individuals may be the subjects of cerebral hypersemia. — those of the thick-set plethoric habit, which Reynolds calls the " lax- fibred constitution," and those who are spare, well-knit, and of nervous temperament. These latter individuals have generally hard, rigid arteries, are past middle age, and are usually brain-workers. In those individuals who possess a well-developed arterial system, but ^ Aretseus de Signi et Caus. morbd. d. lib. 1, c. 7. 82 DISEASES OF THE CEREBRUM AXD CEREBELLUM, such configuration of the neck and head as to prevent venous return, there is a tendency to cerebral fulness. There are several morbid conditions which markedly influence the development of this state — malaria, renal and cardiac diseases, and syphilis being among the number. In patients with enlarged and diseased kidneys which are unable to excrete the effete nitrogenous waste from the blood, it remains in the circulation, increasing blood pressure, and necessitating excessive activity and rapidity of heart action. Hypertrophy of that organ is a result, and the walls of the right ventricle become greatly enlarged ; and having much greater force than it possesses in its normal condition, it forces the blood with great energy into the cerebral vessels, and as a result there is produced the morbid condition of which we have spoken. Pulmonary disease, attended by diminished aerating space, sometimes has the same influence. Gout may be at the origin of cerebral hypersemia ; and, as I have said, malaria very often plays a very important part in the etiology. Syphilis I have found to have much to do with cerebral hypersemia. In this disease this condition of the cerebral ves^sels is not uncommon during the secondary and tertiary stages, but more often during the latter. Four- nier has described a form of trouble produced by syphilis characterized by head-fulness, vertigo and attacks of unconsciousness of an apoplectiform nature, and ^Chauvet thinks that such forms are but precursors of an inflammatory condition of the cerebral vessels, and that it is followed by narrowing of calibre and anaemia. Mental perturbation and hysteria seem to be connected with these forms. An excessive indulgence in alcohol, immoderate eating and drinking or the abuse of tobacco ; continued venery, and disregard of the ordinary calls of nature, are all predisposing, and some of them exciting, causes. Protracted or unnatural intellectual labor, emotional disturbance, mental strain, and intense excitement of various kinds, are additional causes of great importance. Intellectual labor at night, particularly when there is a gas-light above the head of the patient, or prolonged business worry, not rarely favors the determination of blood to the brain. Night editors, students, and workers by artificial light are subject to this condition, and eye-strain from these occupations is a powerful factor in the causation. Myopia and various errors of refraction and accommodation are some- times at the origin of severe headaches of the congestive variety. Pro- longed grief, especially when the patient neglects his bodily comfort, and passes long days in mourning, eating little, and gaining no sleep, is also a cause. The acute condition is not rare among nurses who have sat up at night ; and they, as well as other night-workers, are very apt to com- bat the disposition to sleep which is healthy, by stimulants, coffee, or other agents, and after a short period a disagreeable state of congestion follows. ' These de CoTicour.i, 1880. Influence de la syphilis sur les maladie du systenie nerveux. p. 9. SYMPTOMATIC CEREBRAL HYPEREMIA. 83 As distinct exciting causes I may mention alcoholic abuse — pressure made upon the veins of the neck by tight collars or other articles of dress — sudden exertion of any kind, such as straining at stool, or during child- birth, and lifting heavy weights. In one of my patients, the simple act of bending over to button his shoe was sufficient to produce an alarming condition of the cerebral circulation. In some persons the condition is aggravated, or attacks of the severer kind are precipitated by a visit to the theatre or some crowded place of amusement, where ventilation is bad and the room heated to a high temperature. Pathology.^ —Almost enough has been said to explain the changes which occur during the development of a morbid state of intra-cranial circulation. Fothergill intelligently divides the processes which may in- duce this condition as the following: 1. It may occur as a vascular form, with increased blood pressure, and be dependent upon extra-cranial agen- cies. 2. It may result from tissue alterations, in which the blood is at- tracted to the brain, or from toxic agents, when the two former modes are combined. Through the cerebral ventricular connection and the spaces in the arachnoid we have reservoirs for accumulation of the fluid, when the blood pressure is diminished, and a loose and capacious receptacle in the spinal arachnoid sacs for containing this fluid when the blood pressure is above the average, so that the balance is generally preserved. When the harmonv of this arrangement is disturbed, we may expect to find evi- dences of such inequality. JSTow the question of the extent to which the brain may be compressed without injury, is one which I think will bear more discussion than it has hitherto received. IS^ot only are the present means for experimentation ' By far the most important and interesting part of the study of brain histology is tiie intricate and beautiful arrangement of the perivascular space discovered by Robin* and His, f and described by them as well as by Bastian, % Fothergill, and others. His demonstrates the existence of these small spaces which surrounded the vesssels, than which they were several times larger. He found them in greater numbers in the gray substance, and thought he discovered a communication between the spaces in the brain and cord and certain lymph-ducts in the pia mater. The office of these canals which loosely contain the vessels, with which they have no attachment, is a most important one ; for, notwithstanding the fact that the force of blood (particularly that which goes to the cerebrum) is moderated by the tortu- ous course of the arteries after they enter the cranium, and their complete subdivision when they are distributed over the pia mater, the nervous substance would be little prepared without such xin arrangement for sudden and violent accession of blood. This space or cavity about all of the vessels enables them to expand to a great ex- tent without any actual pressure being made upon the adjacent delicate tissues. When such a determination of blood occurs, the perivascular fluid is driven out of the nervous substance proper, and after the hypersemia subsides, returns to the spaces about the vessels. * Corapte Rendu de la Soc. Biol., Paris 1855. t Zeitschrift fiir Wiss. Zoologie, Band 15. X Xotes to translation of His's paper. Journal of Anatomy, vol. 1. 84 DISEASES OF THE CEREBRUM AND CEREBELLUM. inadequate, but there are certain puzzling questions that come up in the most unexpected manner. The experiment of suspending the subject, constricting the vessels, and measuring tlie blood pressure by instruments devised for the purpose, has been tried. Dr. Loring ' has related an in- stance where the first experimqnt was made, and I shall use his own words : " I would mention that a patient of mine, the acrobat known as the ' Cliampion Fly Walker,' informed me that in walking across the ceiling of a theatre, head downwards, he never felt the slightest disturbance in his vision, though the feat occupied fifteen or twenty minutes. This would go to show, also, that position did not have so marked an influence on the quantity of either blood or serum in the interior of the head as is now believed to be the case. For it hardly seems possible that the quan- tity of blood could be either increased or diminished to any considerable degree, even at the expense of the other fluids, and yet allow one to main- tain for so long a time such a complete control over the faculties, espe- cially that of co-ordination, as to perform so dangerous a feat, and one winch demanded so nice an application of the senses. Be this as it may, I must say I have never been able to see the great weight of Kellie's and Burrows' experiments with animals which were killed and then suspended by the head or heels, as the case might be." When an individual is thus suspended, we ai'e furnished Avith all the external indications of cerebral hypergemia — the flushed face, prominent eyes, etc. — but consciousness is unimpaired, and is not lost until some time has elapsed. This question is of interest, for it suggests the idea that perhaps after all many changes in cerebral function are due to the shock sustained by nerve-cells by the sudden accession of blood, and not so much to the mechanical pressure exerted. - In a very carefully pre- pared article by Cappie in " Brain " upon the balance of pressure within the skull, it is shown that the atmospheric pressure is exerted upon the veins as they leave the various openings in the skull, thus opposing the sudden exit of blood. He also alludes to the interlacement of vessels in the pia mater and the process of compression recurring when some of these vessels become distended. It is not difficult to realize that as a rule under ordinary circumstances the cerebral blood pressure receives no very rude modifications. As to the value of other methods for studying the state of the cerebral circulation by gauges, watch-glasses luted into the skull, etc., I am rather sceptical. The cranial cavity is, of course, a closed cavity, and the blood supply of its contents is modified by the pi-essure of the bony wall. Any perforation must admit the external air, and the intra-cranial blood is then circulating under an atmospheric j^ressure, and I am strongly con- vinced such variations as have been described are not those that take in the normal state. I have said sufficient in detailing the causes of cerebral hyperremia to ^ Am. Psycholog. Journ., Nov. 1875. 2 Brain, Part viii. 1879, p. 373. SYMPTOMATIC CEREBRAL HYPEREMIA. 85 explain any pathological processes, the description of which I may now pass over. Morbid Anatomy. — Upon removing the calvarium the observer of a fatal case will probably meet with some if not all of the following appear- ances Dura mater and underlying membranes injected and pink, or opales- cent, and sometimes quite free from moisture, resembling in this respect a piece of damp sheepskin. The sinuses may be filled with dark blood, and the surface of the brain flattened and of a deeper color than normal. The convolutions may be flattened and pressed down so that the sulci are defined in sharp lines, the inner surface of the convokitions being pressed together. The surface of the brain, as I have said, is dark, and if the pia mater is torn ofl" fluid blood may escape from the separated vessels. Upon making sections in a transverse plane the observer will be sometimes struck by the appearance of a pinkish blush, visible in spots, which is due to staining by hsematoidin. This appearance, alluded to by Fox ^ has been compared to spots of red sand dusted on the surface. The corpora striata are of a very deep red or even violet color, and the white matter contains small puncta which are red or dark purple. The vessels are generally enlarged, tortuous, and filled with quite dark blood. CalmeiP has presented the records of autopsies in a number of cases of temporary duration. He found " in three cases that the cranial bones were notably injected ; in three the vessels of the dura mater were con- gested ; in one case there was fibrinous coagulation in the longitudinal sinus; in one the internal surface of the dura mater was furrowed by capillary arborizations ; in two the cavity of the arachnoid contained liquid blood and bloody humidity ; in four the cerebral pia mater was generally congested ; in three cases it was reddened by extravasated blood ; in one the pia mater adhered in spots to the subjacent convolu- tions ; in one these convolutions on the right side were swollen ; in lour the cortical substance of the brain was generally injected and more or less colored by hsematosin," etc., etc. We therefore must arrive at the conclusion that there is nothing remarkably significant in regard to the seat of the congestion or its form. The violence of the symptoms will, of course, be proportionate to the extent of hypersemia, though this is not always the rule ; and I have seen cases, and I think others also have, in which profound coma and sjDeedy death were preceded by unmistakable symptoms of hypersemia, such as contraction of the pupils, etc., and after death very slight evidences of congestion were perceptible. Microscopical examination reveals in old cases a condition which has been called by various writers " I'Etat crible. This consists of a peculiar spongy, worm- eaten appearance, Arndt says that when these lymph-spaces are dilated they are filled with effete material from the brain resembling amyloid substance or leucin, called by him hyaline. The perivascular spaces are very large, and openings of some size are found at points where vessels ^ Pathological Anatomy of Nervous Centres, p. 55. ^Quoted^by Fox, p. 56. 86 DISEASES OF THE CEREBRUM AND CEREBELLUM. have beeu cut across. These are due to the abnormal pressure made by the distended vessel and the de-truction of adjacent nervous tissue. Cal- meil, Van der Kolk, Duraud-Fardel, and 1 ;tely Arndt/ have accounted for them as the result of oedema of the perivascular space. This appear- ance is a constant one in all brains where there has been continued hyperemia, and especially in the brains of drunkards. The bloodvessels, Fig. 13. ■^ Distended rerivaseular Spaces, with Atrophy. (Fothergill.) when not destroyed, w'ill be found to be tortuous and varicose, and coated oftentimes by a granular shining deposit. The pia mater is thickened, and its vessels present the appearance just described perhajDs better than any other tissue. Diagnosis. — The condition in its early stages may be mistaken for the opposite state, cerebral anicmia ; in fact, the diagnosis is always full of difficulties. An inspection of the following table may, however, furnish us with hints so that we may be enabled to separate cerebral congestion from cerebral ansemia. It will be observed that some of the symptoms are closely allied. CEREBRAL CONGESTIOX. Headache (eenerally difFused). Noises in the ears, generally " rum- bling,'' or singing. ilental disturbance — loss of memory, hallucination. Pupils contracted. No heart sounds, except perhaps those of insufficiency. Pulse full. Urine not increased, generally con- tains urates and phosphates. CEREBRAL ANiEMIA. Headache (chiefly vertical). Noises in the ears (generally sharp or short). Mental disturbance — incapacity for mental work. Pupils dilated. Pulse irritable, aortic murmurs, sphyg- mograpliic tracing almost straight. Urine passed in large quantities, is clear and limpid. ^ Virchow's Archiv. Ixiii. p. 24. SYMPTOMATIC CEEEBEAL HYPEEJEMIA. 87 In the apoplectic, convulsive, and paralytic forms there is little danger of making a mistake. These phenomena are sometimes liable to be mistaken for meningeal or cerebral hemorrhages, cerebral embolism or thrombosis, epilepsy, ursemic coma, etc. The apoplectic variety may be confused with cerebral or meningeal hemorrhage. When we bear in mind that in the former there is generally almost transitory loss of consciousness and motor power, that hemiplegia is not always present, and that marked stertor is rarely found, there is no room for a mistake in diagnosis. The other varieties of cerebral trouble, namely, embolism and throm- bosis, may be disposed of by calling to mind the sudden appearance of symptoms in the former ; its association with cardiac vegetations, and its permanent after-effects. A case of this kind presents itself to my mind. A gentleman, brought to me by Dr. Asch, of New York, had been told by some friend that his nervous symptoms were due to embolism. They were these: Three months before, while sitting in his studio, he lost consciousness, and fell over upon an unfinished picture. He was conscious of his condition, but could not help himself. The room became dark, and he " saw spots be- fore his eyes." He recovered himself in a few minutes, and resumed his work. A week ago a similar attack occurred as he was crossing the street, but he was unable to rise from the mud before assistance came. He had been worried by his business, had worked very hard, and had kept irregular hours. There was no aural disease. On neither occa- sion did the attack occur after a hearty meal. He had no heart symp- toms at all. After each attack he recovered when he took the needed rest, and then saw no evidence of permanent trouble. The suddenness of his attack suggested embolism, but as no paralysis nor aphasia fol- lowed, and no after-symptoms remained, it seemed out of the question to consider this his disease. I made the diagnosis of local cerebral hyper- semia. With embolism there is also generally pallor of the face, and absence of vascular excitement. Thrombosis is a disease of slow and steady progress, with well-marked symptoms, and finally decided hemiplegia. Aphasia is also a character- istic accompaniment of thrombosis as well as embolism. Cerebral softening can hardly be mistaken for the disease under con- sideration, because the former is nearly always preceded by partial cere- bral ansemia, or else some distinctly inflammatory trouble. In cerebral softening there is usually local pain. Convulsive movements, paralysis, and other decided indications mark the course of the softening. UrEemic coma may be distinguished by its deep character, and usually by an examination of the patient's urine. The epileptic attacks of cerebral congestion resemble those of true epilepsy very closely, and in many cases we must not be too positive. There is, however, rarely any disposition to sleep, and the attacks are 00 DISEASES OF THE CEREBRUM AND CEREBELLUM. generally preceded by some excitement, and are not ushered in by the cry. Prognosis. — The lighter forms of this morbid condition are usually amenable to treatment, at least this has been my own experience. Of course we must be governed by the duration of the disease, the existence of other affections of an organic nature, and the age of our patient. If he be over fifty his chances of ultimate recovery are bad, but if he has not passed middle life, and the condition is directly dependent upon some exciting cause that can be easily removed, we may express ourselves more cheerfully. The existence of calcareous vessels is not an agreeable circumstance, nor the' fact that he has had previous attacks of an apo- plectic or paralytic nature. Perhaps the most grave prognosis is at- tached to the maniacal form in which the delirium is not violent nor noisy, but incessant and muttering, and in which there is a restlessness and desire for constant muscular exertion. The great danger seems to be in the continuance of the hyperremic condition, and the possibility of its termination in cerebral hemorrhage, meningitis, cerebritis, or other or- ganic affections. With a hypertrophied ventricle and renal disease the patient has little to expect in the way of lasting relief, and we must always give in such cases a very guarded prognosis. Treatment. — Of course, the first indication, after inquiry into the patient's habits and mode of life, is to discover and remove the predispos- ing and exciting causes if possible. The next is to diminish blood pressure, and restore the lost equilibrium of the intracranial blood pressure both by local and general treatment. In the majority of cases, the most simple treatment, with attention paid to the patient's bad habits, will generally remove the condition. Absti- nence from alcohol in some cases, attention to the bowels, and the precau- tion of keeping the head cool and the neck unconfined, are the first obser- vances to be followed by the patient. If the condition be continued, or not relieved by these means, we may make use of several remedies, among them the bromides, ergot, and hydrobromic acid. The bromides, which were, I believe, first used for this purpose by Laycock, Clifford Albutt, and Drummond, promptly effect a diminution in arterial tension and cerebral blood pressure. Max Schuler is of the opinion that they contract the small vessels, while Nothnagle thinks their chief action is upon the nerve cells. The bromide of sodium 1 consider the most potent of these salts, and in doses of twenty grains, three times a day, we may expect the best results. It is well to combine it with some cardiac sedative when there is tumultuous heart action, or with some heart tonic when there is a suspicion that the heart impulse is not sufficient to properly drive the blood through the brain. Aconite in one case, or digitalis in the other, are good agents. If there be much ex- citement, and the mind of the individual be irritable, chloral may be advantageously administered either alone or with the bromides. Ergot or its aqueous extract is sometimes of great benefit in these cases. Dr. Kitchen has fully described its virtues, and my own experi- SYMPTOMATIC CEREBRAL HYPEREMIA. 89 ence is directly confirmatory of what he has said. In doses of 5j three times a day, the fluid extract may be safely administered. Squibb's or Bonjean's watery extract, in five-grain doses, may be given alone or in combination with the bromides. Should the patient be very much de- bilitated, for this condition is often connected with general debility, we may give strychnise, phosphorus, iron, or quinine, though extreme care should be taken in deciding when they are useful or contraindicated. If our patient should not be able to bear iron, we may substitute either zinc or arsenic, the oxide of the former salt being most serviceable. In the forms where this treatment is required, viz., those where there seems to be a sluggishness of the circulating blood, it is well to dispense with bromides or ergot. During sudden attacks, local blood letting is advisable, leeches being applied to both ears, and cups over the mastoid processes. Cold to the upper part of the head, applied by means of a bladder or ice bag filled with cold water or powdered ice, isan important form of treatment. I direct my patients to apply cold to the back of the neck for fifteen minutes, every night and morning, and find that it succeeds admirably. A drug spoken of before is hydrobromic acid, which I have found to be a valuable and powerful ansemiant. ^ I first advocated the use of a solution of hydrobromic acid in cerebral hyper^emia some years ago. Dr. Fotliergill in a subsequent article confirmed my views most fully, and I have since been gratified to find how my expectations were realized by a more extended use of the remedy. In small doses it acts very much as do the bromides, but with much more intensity. Half a drachm is fully equal to one drachm of the bro- mide of potassium. It differs, however, in the want of permanence of its effects, the bases of the bromic salts seeming to favor retention. AVith regard to diet, and indulgence in alcohol and tobacco, tea or cof- fee, it is impossible to lay down any arbitrary rules. I may begin, how- ever, by interdicting all the meats difficult of digestion, and recommend- ing a non-nitrogenous diet. Veal, corned-beef, pork, and certain vegeta- bles, such as cabbage, cauliflower ; or nuts, spices, bananas, and other aromatic or fatty substances, are not to be thought of. Simplicity of diet is to be insisted, upon. Meats should be broiled, roasted, or baked ; and vegetables boiled. If the patient's comfort is dependent uj)on tea or cof- fee, it would be well to permit him to indulge in them to a reasonable ex- tent. I do not consider tobacco the dangerous agent that it is often said to be, and if the individual be a smoker, I think his after-dinner cigar need not be cut off, and a glass or two of wine is not in the least harmful. Burgundy, Port, or other full-boiled wines should be given up as a matter of course. The abuse of alcohol and tobacco is to be looked after and stopped, if we have any reason to think that the patient has these bad habits. Open-air exercise ; cold baths, with fi'iction ; or the Turkish bath, and other agents that tend to improve the cutaneous circulation, do a ^ Philadelphia Medical Times, October 26, 1876. 90 DISEASES OF THE CEREBRUM AND CEREBELLUM. great deal of good, and are to be indulged in. We must insist upon the avoidance of excitement, dissipation, and late hours and theatre-going ; and it may be well to lay before our patient what may be the result of such imprudence. Should we be called in to find that the disease has manifested itself in either of the forms to which I have alluded (the apopletic, convulsive, paralytic, or maniacal), we must order perfect quiet, darken the room, and use every means in our power to reduce the cerebral blood pressure. CEREBRAL HEMORRHA.GE. Synonyms. — Apoplexy. Hajmorrhagia cerebria (Lat.). Apoplexie cerebrale ; hajmatoeucephalie ; coup de sang ; hiemorrhagie cerebrale (Fr.). Hiruapoplexieen, Schlagfiiss (Ger.). Definition. — When through disease of a cerebral vessel its walls are unable to withstand the pressure of contained blood, a hemorrhage takes place, and the nervous substance in the neighborhood is subjected to pres- sure, the severity of the resulting symptoms depending upon the impor- tance of the parts which may be the seat of the accident, and upon the extent of the hemorrhage. Symptoms. — I have already alluded, when speaking of cerebral congestion, to light forms of hemiplegia of temporary duration, which were dependent upon slight hemorrhages resulting from cerebral conges- tion. We will now deal with a form of cerebral hemorrhage of a more serious character, and it may be stated that the brain is probably more liable to hemorrhage than any other organ, with the exception, perhaps, of the spleen. ^ Bastian has made the classification which I think it well, to follow. He divides cerebral hemorrhage into three forms, in regard to the onset of symptoms : (1) The apoplectiform ; (2) the epileptiform ; (3) the simple, in which there is neither lo-s of consciousness, nor convulsions. The first may be considered as a sudden and profound loss of conscious- ness, which may or not disappear ; but, if it does, a certain amount of hemiplegia will remain. The epUeptifomi resembles the first, but, in addition to the coma, there are convulsions. As I have said, the mnjde variety may not be connected with any loss of consciousness, the patient, perhaps, awaking in the morning and finding himself deprived of power, or noticing such a lo;s when some movement is attempted. Prodromata. — Cerebral hemorrhage occurs generally in individuals in whom some well-developed chronic trouble has paved the way. This is the rule, although in many cases it may be the result of some recent dis- ease. When we come to speak of pathology and morbid anatomy, these general diseases, and their influence in the production of degeneration of the cerebral arteries will be discussed ; it is only necess^ary now to de- scribe the forms of expression of the preparatory stages. It is not always ^ Bastian : Paralysis from Brain Disease, p. 14. CEREBRAL HEMORRHAGE. 91 necessary to look for the indications spoken of by Hughlings Jackson.^ "The careful cliuical observer considers minor degenerative changes, baldness, grayness of hair, the state of skin, and worn teeth. He in- quires for the history of gout and intemperance," The appearance of those individuals in whom an apoplectic effusion may be looked for, may be of two kinds. 1. The thick-necked, red-faced, and full-blooded. 2. The fair, long-necked, or aged persons, in whom the radial arteries are hard, and feel very much like strings of beads or pipe-stems beneath the skin. The existence of renal trouble also con- tributes to the development of an arterial state which favors rupture, and we should search for other indications of this trouble. Many of the symptoms of cerebral hypersemia may be precursors of those that follow cerebral hemorrhage. For several days the patient may have headache, formication at the extremities as if pins and needles were being thrust into the skin, perhaps a slight ansesthesia of the arm or leg of one side; his speech may be thick and clumsy, or he may drop a word here and there, and his eyes may be red and full of tears ; dizziness, muscse volitantes dependent upon retinal isehiemia, and nose-bleed may all be indications of increased blood pressure. These last two forerunners of cerebral hemorrhage may recur at intervals for some time before the actual rupture of the vessel. The retinal trouble may be of long dura- tion, and is of decided importance as an evidence of the degenerate con- dition of the cerebral vessels, and should invariably be regarded with suspicion. An atrophy of the optic papillse with spots of blanching at the fundus, such as we find to be the result of Bright's disease, is also suggestive at times of a tendency to cerebral hemorrhage. To this list of prodromata may be added vomiting and stupor ; but these are con- nected with so many varieties of brain disease that they may only be con- sidered as important when occurring in conjunction with the trouble to which I have just alluded. A very serious premonitory symptom is paraly- sis of one limb or certain isolated muscles, which indicates organic dis- ease. After a variable time, during which some or all of these antece- dent symptoms may be observed, the vascular accident may occur. Its onset may take place in two ways : (a) In connection with profound loss of consciousness and suddenly. (6) Gradually, without loss of con- sciousness. We may call the first the apoplectic attack. Its common history is the following, and we may take as an illustrative case a male aged 50. The patient, who is of full habit, short, red-faced, and cor- pulent, had probably led a rather dissipated life. V^'hile reading his paper, after an unusually hearty dinner, he suddenly falls to the floor in an unconscious condition ; his breathing is stertorous, the cheeks and lips being pufied out by each expiration ; his face is dark, or perhaps very pale, the pupils dilated and insensible to light, and his eyeballs are fixed, turned upward, and drawn to one side. If the nostril be tickled no reflex movements follow, and the same is the case if the soles of the 1 Cerebral lieiuorrhage, '•Reynolds' System of Medicine." 92 DISEASES OF THE CEREBRUM AND CEREBELLUM. feet be titillated. He is limp, and lies upon the floor in an inanimate heap ; the pulse will be found to be hard and full, but not very rapid, and if his temperature be taken it will be probably not exceed 97°, or perhaps is half a degree lower. He is taken up and placed in bed, and after a while may make some slight voluntary movement with the limbs of one side of the body. It will be seen that the others are without power, for if the leg or arm of the paralyzed side be lifted and released it will fall to the bed as a dead weight. After an hour or two, tickling of the sole of the unaffected foot will be followed by a drawing up of the sound leg. The eyes are still rolled up and turned away from the para- lyzed side of the body, and the edges of the irides are covered by the inner canthus of one palpebral commissure, and by the outer canthus of the other. The eyeballs may be sometimes slightly agitated by a feeble movement of a nystagmic character. It will be found, on removing the patient's clothing, that he has unconsciously voided his urine and feces. This condition may last for a few hours, the coma remaining profound, and the temperature rising to 103 to 105 degrees, and the pulse advanc- ing, when death takes place ; or it may be followed in an hour or two by slight signs of returning intelligence, an increase of temperature, say to 100°, with slight abatement of the regular respiration, disappearance of stertor, and the unnatural deviation of the eyes, when his temperature may return to the normal standard, and the patient so far recover con- sciousness as to be able to recognize those about him, and express him- self by simple words, as "yes" or "no." The urine has to be drawn for a day or two, and the bed-pan used, as the bladder and rectum are implicated. This form of cerebral hemorrhage may be connected with an epilepti- form attack in the beginning, and the convulsion may be either confined to one side or be general. It would be well, before going further, to dwell upon certain elements of the apoplectic attack and analyze the symptoms. THE PSYCHICAL DISTURBANCES. Sudden compression of the cerebral mass is always attended by uncon- sciousness, but it is a seriolis fact that slowly developed growths, such as large tumors or abscesses, seem to accommodate themselves to the sur- rounding tissues, so that sometimes no loss of consciousness occurs what- ever. I have seen a large abscess occupying an extensive tract of one hemisphere without producing the least loss of consciousness. The large effusions which produce unconsciousness are, in the opinion of Mr. Hutch- inson,^ productive of the psychical condition, by inducing anemia of other parts thi'ough sudden pressure. Small clots are undoubtedly productive of suspended consciousness, by cutting off either a large vessel, or by in- jury to some important sensory ganglion. Consciousness is either restored through the re-establishment of the ^ London Hospital Reports, vol. iv., 1867. CEREBRAL HEMORRHAGE. 93 blood supply or the subsidence of shock, except where the hemorrhage has taken place in the medulla. The variation in the loss of conscious- ness is of great importance to the physician, especially in regard to prog- nosis. In severe cases there may be slight improvement in this respect. The patient's intelligence returns to such a degree as to inspire his friends with some degree of hope ; but there is often a sudden relapse to the ori- ginal state of coma, dependent upon fresh hemorrhage. RESPIRATORY DISTURBANCES. Stertor is an important symptom, and should always be looked upon with alarm. It is indicative generally of some lesion of the base, and nearly always lasts until death, if there be a very large effusion, but dis- appears after a few hours if recovery is to take place. Kespiration un- dergoes very decided modification. Hughlings Jackson,^ in speaking of disturbed respiration, says : " Again, not only is the rate of respiration to be considered, but the character of the respiratory movements are to be noted. As they quicken in rate, so do .they become more extensive in range though such respiration is still short. Thus in the first stage there may be only quiet action of the diaphragm, but at length the sides of the chest evert strongly in inspiration, the abdominal movement being less obvious, and at length the upper thorax takes part in the process. In severe cases the epigastrium sinks in during inspiration. This is proba- bly partly owing to elevation of the attachments of the diaphragm from increased action of the sides of the thorax, and partly to pushing down of the diaphragm by increasing bulk of the lungs from congestion or oedema " CONDITION OF THE EYES. Prevost,^ Vulpian, Lockhart Clark, and others were among the first to call attention to a peculiar diagnostic point which, though not always jDresent, is of great value when it occurs. This has been known as " con- jugate deviation.'" During the apoplectic condition the eyes of the in- dividual will be fixed, so that they look upwards and outwards, towards the side of the lesion, and away from the j^aralyzed side of the body ; the only excej)tion being when the lesion is in or, behind the pons. It is more often seen when the attacks are sudden, and it is a phenomenon of short duration, lasting at the most but a few days. During sleep the condition subsides, and the eyeballs are restored to their normal state, but immediately on awaking they return to this position, and in spite of the patient's effort the axis of vision cannot be changed. When the ef- fusion is a large one, or when the onset is epileptiform, the pupils are at first very wildly dilated ; but when there exists a lesion in the pons the pupil which corresponds to the sides of the lesion is greatly contracted. Unequal dilatation, however, is not of very great diagnostic value. If a lesion in the pons be extensive, both are contracted. 1 Op. cit., p. 548. 2 Gazette Hebdom., Oct. 13, 1865. 94 DISEASES OF THE CEREBRUM AND CEREBELLUM. TEMPERATURE AND PULSE. Thanks to Bourncville,' we are enabled to study systematically the variations of temperature. He divides the cases into four groups : 1. Copious cerebral hemorrhage, rapidly fatal, and attended by lowered tem- perature. 2. Cerebral hemorrhage, terminating fatally in from one to two days, in which the temperature is primarily lowered and afterward height- ened. 3. Fatal cases in which death takes place-in from two to six days. In these, as in other forms, there is at first depressed temperature, next a return to the normal standard, with slight variations, and finally a decided rise. 4. Favorable cases, in which there are the primary lowering, a sec- ondary rise, and final return to the standard of health. These variations in temperatui'e range between 96 and 108 degrees (rectal temperature). The pulse variation bears but slight rela- tion to the fluctuation of the body heat. In the four classes spoken of, we may consider in the first, that the pulse is full and slow, ranging from 55 to 6o. With the rise of temperature which characterizes the others, it becomes greatly accelerated, beating oftentimes 120 to 130 per minute, losing its full character, and becoming small and irritable, and if death occurs, grows gradually weaker. If recovery follows the attack, there is a gradual return to its normal rate. Of course, this must be a very unsatisfactory con5ideration of the state of the pulse, for the apoplec- tic condition is not always the same, collapse and reaction varying greatly in regard to their occurrence and duration ; so the pulse, as well as respira- tion and temperature, undergoes many irregular modifications. ATTACKS WITHOUT LOSS OF CONSCIOUSNESS. The other form, in which the individual preserves his consciousness, is not so serious a condition as that just described. The person may present some of the premonitory symptoms already mentioned, or, on the other hand, may receive no warning, but while engaged in any ordinary occu- pation may suddenly find one-half of his body to be paralyzed, and be un- able to communicate with those about him, there being slight aphasia. With the paralysis there may be anaesthesia. This state of affairs may begin during the night, and on awakening in the morning he may find it impossible to leave his bed. The paralysis is sometimes gradual, the loss of power affecting one member, and afterwards the other, an unexpected feebleness being suddenly noticed as he is about to perform some act. One of my patients, an acrobat of dissolute habits, while preparing for the performance, found, when he attempted to put on his tights, that his right leg was quite powerless; he made an effort to stand, but became dizzy, and grasped for support a pole that was near. After repeated efforts to dress he abandoned the attempt, summoned assistance, and was taken home; the same night the right upper extremity was affected. He had ^ Eludes cliniques et thermometriques sur les Maladies du Svsteme nerveiix. Paris, 1872. CEREBRAL HEMORRHAGE. 95 never had any previous warning. Attacks of this kind may be the fore- runners of others of a more serious nature. In illustration, may be men- tioned the case of S. C, a married woman, aged 41. She was drawing Avater at a sink, when she became suddenly giddy, and had to take hold of the banisters to steady herself. She stood thus until some friends put her into a chair and carried her to her room. She sat there that day, and was helped to bed, but did not discover her paralysis until next morning. Was not unconscious at any time of the attack. Her paralysis, when she discovered it, was somewhat worse than it is at present, and she could not speak as well as she now does. A few days after the attack she went to a hospital, where she remained one month. She entered the Epileptic Hospital July 6, 1875, and was put upon strychnine and belladonna, there existing an inability to retain her urine, I take the notes of her subse- quent history from the case-book of the hospital. " Sejot 22. At 7.30 last night it was noticed that she could not speak as well as formerlj'-. It was quite difficult for her to speak so as to be under- stood. She laughed a little immoderately at her inability to clearly enun- ciate the words. " An hour afterwards, in attempting to leave her bed, she fell, and since then has been scarcely able to speak, and can only say a few words. No other symptoms were noticed. Her strength of muscle and sensibility seems unaffected. She cries now continually, and seems to be depressed because she cannot speak. " Oct. 13. Patient can tell her name, and can name every article shown her. A little thickness in articulation. " Pupils react well. Lenses of eyes are a little opaque —the left a little more than the right. Face palsy almost passed away. Lower facial muscles act well. Sensibility in face fair. Tongue points slightly to the right. " Voluntary motion abolished in right upper extremity, the least motion in shoulder excepted. Articulations are all flexed in the right upper extremity, and the contracture is greatest in the hand, the fingers almost touching the palm. Elbow and shoulder are less rigid. " Extension is not painful, and there are no spontaneous pains in arm. Sensibility to contact in hand good. On finger tips feels the points of sesthesiometer at three millimetres. There is no numbness in hands. Pa- tient considers the paralyzed hand the warmer of the two. Between index finger and middle finger of right hand in three minutes' time the tempera- ture is 98°. Same place on left hand in three minutes' time temperature is 98}°. Right lower extremity, no motion in toes and ankles, consider- able motion in knee and hips, no numbness, no contraction. THE RESIDUAL PARALYSIS. A paralysis, remaining after the " apoplectic stroke,*' is generally uni- lateral, though in rare cases, where the pons is affected at the central portion, the paralysis may exist on both sides of the body; this one-sided paralysis is known as Hemiplegia, and may be complete or incomplete as 96 DISEASES OF THE CEREBRUM AND CEREBELLUM, regards sensation and motion. AVhen we examine our patient after the immediate grave symptoms have to some degree subsided, we will find the limbs of one side limp, powerless, and genei'ally without sensation ; the face jjaralyzed on the same side, and its other half drawn up by the healthy muscles, as their antagonists are unable to perform their functions. If the patient be sensible enough to put out his tongue, it will point to the para- lyzed side, while the eyes, if conjugate deviation exists, will turn in an opposite direction in a manner already described. Jastrowitz^ has called attention to a peculiar symptom, the tendency of the patient to slip out of bed on the unaffected side. This is caused by the inability of the paralyzed limb to support the weight of the sound part of the body. He also alludes to the fact, when pressure is made on the sapheua nerve, at the point where the vastus externus makes a groove with the vastus internus, that the cremaster muscle on the paralyzed side will not draw up the testicle, which is not the case on the other side of the body. In other forms of paralysis, to be hereafter described, there is not the same uniformity of symptoms there being perhaps paralysis of special cranial nerves, or those of the muscles of the face on the side op- posite to the body paralysis. This variety has been called cross paralysis. Both sides of the face or both sides of the body may be involved, in which event there is a speedy fatal termination. Occasionally the mus- cles of the pharynx may be paralyzed, and sometimes the larynx, A case of this latter kind is reported by Luys.^ He mentions the ease of " a woman who had a sudden attack of apoplexy with hemiplegia of the left side, but with no disturbance of sensibility or of the organs of special sense. The congestive phenomena of the onset being calmed little by little, the patient regained consciousness, and stated that four years previously she had been struck for the first time with left hemiplegia, and since then had been aphonic. Her intelligence was good, and she spoke distinctly, but in a low voice. She had no paralysis of the tongue, the soft palate, or the lips. A few days later, she was seized with new con- gestive symptoms, and died insensible." This laryngeal paralysis is undoubtedly a much more common affection than it is generally supi:)osed to be, and the probability is that many of the cases reported as aphasic are in all probability ai)honic. Our patient, after his return to consciousness, will then be found to be hemi- plegic, and, if he is amused and attempts to laugh, we will plainly notice facial distortion, which follows any such efforts. The surface temperature of the paralyzed parts is usually higher than on the other side, and the limbs may seem to be of greater contour, and true arthropathies may be presented. This appearance has been noticed by Hitzig,' who, in refer- ring to Charcot's cases, presents seven of his own, in all of which there was incomplete dislocation of the head of the humerus, with irregular 1 Berliner Klin. Woch., Aug. 2, 1875. ^ La France Medicale, Sept. 28, 1875, ^ Virchow's Archiv,, xlviii., p. 345. CEREBRAL HEMOEEHAGE. 97 pains of the arm, increased by pressure. The paralyzed arm was swollen, warmer and more moist than its fellow, and the pains alluded to began about six weeks after the apoplectic attack. Hitzig is of the opinion that this condition of affairs is not directly dependent upon the central lesion. Voluntary power is lost in proportion to the extent and situation of the lesion. Should it be in the cortex or corpus striatum, a very small lesion may produce very decided impairment of motility, while such is not the case in the white matter of the hemispheres. It will generally be found neces- sary to draw the patient's urine for a few days, for the bladder loses its expulsive force, and, if this procedure be not resorted to, there may be retention. Electric contractility seems to be exaggerated at first in the paralyzed limbs, and a very weak electric current may provoke the most energetic contractions. In certain cases there may be an increase of re- flex excitability and tactile sensibility. Sensations may be even some- times reversed, warmth being felt as cold, or vice versa, or, as in the case quoted by Bastian,^ a warm object may be appreciated as a weight. " A hot body on the face was recognized as pressure only ; on the arm it was felt as such, though the sensation was not distinctly localized, whilst on the left leg the same hot body was recognized correctly as regards situa- tion, though it gave rise only to a feeling of tingling." I have often witnessed hypersesthesia of the paralyzed limbs, which were very tender to the touch. Ansesthesia generally exists, however, and electric sensibility is greatly diminished. At the end of a few days it is not un- common to find marked rigidity of the paralyzed limbs, increased reflex excitability, and other evidences of slight cerebritis at the seat of the clot. The tendon reflex is markedly increased in the paralyzed limb, and the slightest tap will evolve an energetic contraction. Gradually there is a return to the normal condition, and articulation, which was imper- fect in the beginning, may become more distinct, or, should there be aphasia, the patient will begin to command a greater number of expres- sions. A week or so passes, and he is able to protrude his tongue in a much straighter line than before, while the paralyzed muscles of the face slowly recover their lost power ; but when the levator palpebral is para- lyzed and ptosis results, restoration is much more slow. In regard to this paralysis, Bastian has reminded us that very often deformities exist, such as the absence of teeth on one side, which may produce an appearance of facial paralysis, when in reality none exists. This is seemingly a trivial matter, but its neglect is likely to lead to grave en-ors in diagnosis and prognosis. As months go by, gradual amelioration of the patient's con- dition takes place, the limbs regain their power, the leg first, and finally the arm, and the patient may be at first able to move his toes, then to raise his leg, and, when he leaves his bed, gradually begins to acquire power of locomotion. The walk of the hemiplegic is not to be mis- taken ; his gait is shufiling, the toe of the boot is dragged over the ground, and the leg thrown outwards and forwards, the knee being stiff", and the 1 Op. cit., p. 128. 98 DISEASES OF THE CEREBRUM AND CEREBELLUM. arm swung helplessly by the side. As the gait improves, and the pa- tient gains more control over his limbs, he is able to perform movements which require the action of the muscles of the hip-joint, knee-joint, and finally the ankle and toes. Should he only partially recover, numerous secondary conditions may follow, as results of non-improvement of the cerebral condition. These are chiefly of a motorial character, and consist of spasms, permanent contractures, bed sores, atrophy, and in- flammations of nerve-trunks. Such sequela may be called — THE POST-PARALYTIC STATES. I may enumerate these as — 1. Permanent contractures ; 2. Trophic al- terations; 3. Tremor(post-paralyticchoreaof Mitchell and Charcot); and, 4. Slow clonic spasms (so-called athetosis). Of 32 cases of old hemiplegia seen by Bouchard ^ at La Salp^tri^re, in 31 there were paralytic contractures. The other case presented what he called I'hemiplegie fiasque. This form is of slow appearance, and affected in the beginning the muscles of the forearm. The fingers were flexed, and the forearm was pronated and flexed on the arm, and at the same time the humerus was drawn to the trunk. According to Strauss,^ this form presents several variations, and some- times the hand is brought in contact with the trunk, either on its palmar, dorsal, or radial aspects. Of a large number of cases that have come under my observation, I have found that deformities of the upper extre- mities are much more common than of the lower ; the fingers are com- monly flexed and rarely extended, while the muscles of the trunk seem to be exempt from this change ; and, indeed, I cannot call to mind a single instance of this kind. Contractures of the muscles of the lower extremities are apt to produce deformities which resemble talipes, equinus varus or valgus, and the toes are flexed upon the sole. Contractures of the facial muscles are quite rare, and of late appearance. The deformi- ties are always quite striking, because of the antagonistic action of unaf- fected muscles, and usually no amount of force can overcome them. Trophic changes are by no means rare, either in connection with contrac- tured muscles or alone. I have now several patients under observation who are hemiplegic. In one of these the skin of the paralyzed hand is white and puffed up ; the heads of the phalanges and metacarpal bones are reduced in size, so that there is no enlargement at their points of ar- ticulation, and a consequent depression exists. In other cases there is considerable muscular atrophy to be witnessed in the palm of the hand ; and in others the bones of the arm are greatly diminished in size, and the interossei quite wasted away. Charcot^ has written extensively about a form of neuritis following cerebral lesions, which is supposed to be of a central nature. That ascending (from the periphery to the centre) neuritis sometimes takes ^ Des Contractures, Pari.s, 1875, p. 16. ^ Op. cit. 3 Legons sur les Maladies, etc. Fasc. 1, and previous articles. \ CEREBRAL HEMORRHAGE. 99 place after cerebral hemorrhage there can be uo manner of doubt; and in one case, at present under observation, the neuritis began at several dif- ferent peripheral points of the nerve, and there were consequent atrophic muscular changes.^ The form of neuritis, however, most deserving atten- tion is that known as secondary degeneration, described quite fully since the first edition of this book, especially by Flechsig, Charcot, and Bris- saud. It is pathologically the invasion of the motor tracts, which extend downwards involving the pyramidal parts of the lateral columns of the cord, and, as a result, we find beside loss of motor power, the appearance of contractures and an exaggeration of the tendinous reflex. The disor- ders of motility are numerous, and depend more or less upon the lost or impaired inhibitory power of the individual, and the paralyzed muscles which are their seat. Dr. Gowers^ presents the following excellent table, which embraces all the disturbances of motility which may occur after the hemiplegic attack : POST-HEMIPLEGIC DISORDERS OF MOVEMENT. r Tremor Fine. Coarse. f Regular (continuous, or on movement) J ^ Certain, regular, move- « j ments, due to interos- Quick, clonic spasm, of j L sei, pronators, etc. intermitting type. i I r Choreoid C Continuous \ \ spasm, or L, Regular (continuous, or on movement) -l < inco-ordi- l 1 nation of V Jerking V. movement. {Continuous=" Athetosis " On movement =slow, cramp-like, inco- "j ordination [ " Spastic contracture " of [ hemiplegic children. Tonic spasm, varying fOf interossei, conspicuous J Fixed rigidity, unvarying ^Of flexor-longua digitorum, conspicuous Jate rigidity. The individual retains but little of his control over the affected muscles, though voluntary power exists usually to a variable extent The in- fluence of the will though often increases spasmodic movements. Spasms and tremor afiect first the smaller muscles, while tonic spasms affect the ^ These trophic muscular and cutaneous changes are of a most interesting nature Duncan* found in one case that an eruption had appeared on the thigh of the paralyzed side which disappeared with the return of power; and Charcot f and Payne J another. In a case mentioned by the former, a vesicular eruption appeared, which followed the distribution of the superficial ramifications of the peroneal nerve, and was coincident with the hemiplegia. In this case the hemiplegia followed em- bolism, and a branch of a spinal artery (rami medullse spinales, of Rudinger) was found obstructed by a plug. Pressure had been made on the spinal ganglion from which one of the branches of the sciatic originates. ^Med. Chir. Trans., vol. lix. * Journ. of Cutaneous Med., Oct. 1868, p. 69 ; quoted by Charcot. t Op cit., p. 72. t Br. Med. Journ., Aug. 1871. 100 DISEASES OF THE CEREBRUM AND CEREBELLUM. larger muscles of the limbs. One form of tremor of a post-liemiplegic character has been called by Mitchell " post-paralytic chorea ; " the tre- mor is suggestive of sclerosis, and may begin within a period ranging from one to several months, affecting generally the upper extremities, and it is aggravated by any exercise of volition. It may affect both extremities, but very rarely the face, and the movements are quite coarse, and may be associated with a certain amount of hemi-anresthesia. A variety of movement of a clearly post-hemiplegic character has been elevated to a distinct position, and given the name "athetosis" by Hammond. As this condition is ordinarily a secondary affection to other neuroses as well as hemiplegia, the undue prominence which it has received is entirely undeserved. Gowers says : " Neither clinical history nor supposed pathology of athetosis affords ground for separating it from other forms of disordered movement commonly seen after hemiplegia, but any one of which might occur in the primary affection." Charcot^ refuses to ac- knowledge its distinct character. He presents several cases, all of which followed some form of hemiplegia ; and the literature of neurology is re- plete with examples of so-called athetosis which are generally connected with hemiplegia, chorea, or even hysteria. ^Brissaud has studied the particular features of the rigidity of late hemi- plegia, or, as he calls them, the "permanent contractures of hemiplegia," which are found to involve the flexor muscles. There are often what are called associated movements ; for instance, when one of his patients was told to firmly close her left hand forcibly it was found that the movement of flexion of this hand was always accompanied by slow movement of flexion o{ the right moreover that when she opened and shut her left hand a number of times, the right became closed in the position of true con- tracture. This genesis of movements in the sound side is a feature of old contracture. The easy production of an increased tendinous reflex is always possible, and whether the tendons are lightly tapped or the member flexed or jarred there is a tetanoid state, or a series of spasms produced and the increased knee reflex commences, according to Brissaud, as soon as the appearance of secondary contracture begins. The myograph has been used to test the tendon reflex in hemiplegia. By the attachment of an ingenious instru- ment, constructed by Dr. F. Franck, it was possible to make some very val- uable records, showing the duration of the reflex, the amplitude of the con- traction and its character. ^Tochirjew and *Burckhardt established the duration of the normal reflex at from 32 to 34-thousandths of a second, while Gowers believes the time to be longer. Brissaud has fixed the time at 50-thousandths of a second, as that in which the reflex occurs in the nor- mal state. ' Op. cit, 4th part, p. 493. ^ Recberches, etc., sur la Contracture permanente des hemiplegiques, E. Brissaud, Paris, 1380. * Archiv. fur Psychiatrie viii. Band 3 Heft. * Centralblatt fiir Med. Wissen, 1878, quoted by Brissaud. CEREBRAL HEMORRHAGE. 101 It would be going into the subject to the extent of neglecting those of greater importance were I to do else than present the conclusions drawn by modern observers. One of Brissaud's plates shows the contraction on the healthy and contracted sides. The upper irregular line gives the contraction, the lower line the time tracings, and the time 'of exci- tation. Fi^. 14. Hemiplegia with contracture. Reflex on sound side. Time of reflex 40-thousandths. TRACINGS OF PATELLAR TENDON-REFLEX. Fig. 15. i' ■■■Imii ''l ' 1 1 ' ' " 'I " " '"'-■^" 1 1 ll Hemiplegia with contracture. Affected side. Time of reflex 36-thousandths. Causes. — Any agency which favors a degeneration of cerebral vessels leads to the occurrence of hemorrhage such as I have just described. The list of such causes is therefore a long one. Among the many formidable diseases, leading to that which forms the present subject are those of the heart and kidneys. Hypertrophy of the left ventricle, Bright's disease, and local disease of the arteries with deposits of atheromatous mat- ter, or obliteration of vessels by softening, pressure made by tumors, and through other diseases of the brain, may be mentioned as influencing the 102 DISEASES OF THE CEREBRUM AND CEREBELLUM. causation of cerebral hemorrhage. Cerebral hemorrhage is an affection of advanced life, though cases are on record among children. A careful inspection of the records of a great many cases discloses the fact that the majority are between fifty and sixty. With the advance of life and cor- responding impairment of vitality, the arteries become rigid, the heart hy- pertrophied, and the general vascular system undergoes important changes. I have already alluded to the annular and hard character of the arteries ; the arcus senilis, which consists of a small whitish circle which may be seen at the edge of the cornea, may be mentioned in addition as a suggestive sign, and attention may be called to the degeneration of the choroid. The color of the face is dusky red, and many of the capillaries of the skin covering the cheeks and nose are quite tortuous and dilated, and present minute varicose enlargements. As to inheritance of an apojilectic ten- dency, I fully agree with Hughlings Jackson, that the only heritage trans- mitted from father to son is the liability to arterial degeneration, gout, etc. This exception to the general rule is somewhat conspicuous, for the here- dicion of many convulsive and neuralgic, as well as the trophic diseases, is a well-established fact, and has long been recognized as an important etiological factor. Cerebral hemorrhage, as I have stated, is by no means confined exclusively to adult life. Xumerous observers have called atten- tion to cases which have occurred among very young children, though, in these instances, injury has generally produced the accident, especially such mechanical causes as convulsions, anaemia, etc- And now regarding the predisposing states which favor the rupture of a vessel. An hypertro- phied heart, enlarged by overwork in forcing the overloaded blood which must be formed when the kidneys do not properly act as eliminants, is the first factor of the disease. With this condition of affairs the small vessels must necessarily be subjected to abnormal strain, and consequently under- go such changes as thickening or aneurismal dilatation, or even actual destruction. The arterial changes, of which I will more fully speak when we come to consider the pathology of the disease, are fatty degeneration, aneurismal dilatation, and calcification. These conditions are produced by alcohol, and improper diet, such as continued indulgence in fatty food. A sedentary life, connected with great and protracted intellectual strain, as well as such diseases as rheumatism, syphilis, and other chronic mala- dies, enter the field as predisposing causes. Season appears to have some influence in the production of cerebral hemorrhage, the majority of cases occurring in winter. As to exciting causes, their name is Legion. Straining at stool, coition, violent muscular effort of any kind, the indul- gence in stimulants, and in fact any agency which either promotes an ab- normal blood supply to the brain, or prevents its return, will have the effect, should there be disease of the vessels, of producing rupture. I have taken from my case-book data showing the causes in a number of cases, which in some cases preceded the actual hemorrhage by some hours : Lifting a heavy weight, or other muscular effort 12 Excitement (alarm of fire) 1 CEREBRAL HEMORRHAGE. 103 Violent exercise in drawing water 1 Falls 4 Fright 3 Thrown down by husband 1 Head injuries 8 Straining at stool ■ 2 No history of cause 20 52 Time of Attach. — At night, in 30 cases ; during the day, in 22 cases. The fact that the large proportion of these attacks occur at night, is an interesting one. They were mostly hospital patients, and some were irre- sponsible ; so, of course, their statements are to be taken with allowance. One woman said : " I awoke in fright, and in attempting to rise found I was unable to do so." It is probable, therefore, that the condition was dependent upon disturbed cerebral circulation connected with nightmare ; nearly every one of these thirty patients found that they were paralyzed only when they awoke in the morning, and attempted to get out of bed. Exposure to the sun's rays, and the stoppage of any flux that is either normal or pathological, are often sufficient to produce an attack, and as an example of the latter hemorrhoidal bleeding may be mentioned. Hemiplegia may be a result of variola ; and the following case, in which epilepsy and hemiplegia dated from smallpox, possesses much interest. The paralysis was due undoubtedly to an epileptic seizure, during which some vessel was ruptured. M. J. T., 35 years, born in New York; no occupation; entered the Epileptic and Paralytic Hospital Feb. 11, 1870. Mother died of con- sumption ; sister had epilepsy. First fits appeared at the age of five years ; came on about three months after the attack of smallpox ; hemiplegia of the right side came on at the same time, she believes, as the epilepsy. Before the convulsions she had cramps in the paralyzed arm and hand, and a feeling of dizziness ; the attacks occur most frec[uently in the day- time, three or four together, and recur once in three or four weeks. But shortly before her admission she had them nearly every day. Circum- ference of skull, 201 inches; antero-posterior measurement, 12 inches; transverse, 1 3 inches ; memory good, mind rather weak ; speech good, sight good, hearing fair with left ear ; cannot hear with right ear, even when the watch is pressed against it, Sensibility to pinching and pricking ap- pear entirely abolished on the right side from head to foot. Drags right leg in walking ; has but little use of right arm and hand, the muscles of which have a tendency to spasmodic contraction ; temperature somewhat diminished on right side ; appetite fair ; bowels rather costive. Menstru- ated at 13 years, and has been regular since. Present condition, June 1, 1876: — Memory appears to be very good ; and the fits have decreased in seve- rity and in number. Had but two attacks last month ; none at night. Has hsemoptysis sometimes before the attack, and an aura of about a 104 DISEASES OF THE CEREBRUM AND CEREBELLUM. minute's duration ; flexor of muscles of right hand is contracted : thumb is turned again, so that its inner part touches the under part of the index finger; lastly, the whole hand is somewhat drawn up, and lies in her lap with the palmar surface up. When directed to put hand up to shoulder, it shakes right and left ; this shaking is very violent, but only so when she makes voluntary movement. It is, however, entirely quiet while in her lap. Has the irregular heraiplegic gait ; protrudes her tongue straight ; eyesight good ; hears perfectly well. There is facial paralysis (periphe- ral) on the side opposite the hemiplegia, but no ptosis. As an illustration of a curious case of cerebral hemorrhage, Eulenburg ^ relates the ease of a switch-tender who, during a heavy thunder storm, inserted an iron key in the lock of a switch signal. He was suddenly de- prived of power, and fell to the ground. After an hour or two, when sufficiently revived by the rain, he dragged himself to a neighboring sta- tion. He was paralyzed on the left side. Morbid Anatomy and Pathology. — A vessel impaired by disease, and subjected to even the normal blood pressure, will very soon sufter changes in its calibre, insignificant perhaps at first, but afterwards far more serious, but, when the blood pressure is abnormal, and a force is exerted which the resilient character of the vessels enables them to with- stand in the healthy state ; the weakened portion gives way, and the brain- substance in the neighborhood is subjected to dangerous pressure. The character of the loss of function depends very much upon the importance of the vessels and their areas of distribution. The middle cerebral artery is especially liable to rupture, being in direct communication with the left side of the heart; consequently, the corpus striatum, optic thalamus, and parts supplied by this artery, suffer injury. The other large vessels follow next, and may be affected in various parts of their course. Such strides have been made in the study of cerebral anatomy and physiology during the past four or five years that it is necessary that the whole subject of nervous pathology should be viewed in a new light. New interest began with the researches of Jackson, Hitzig, Fritsch and Ferrier, and has since the discovery of the cortical centres been greatly increased by the valuable researches of Flechsig, Meynert, Huguenin, Charcot and a host of others. In the matter of central localization it behooves us to study the relations of the cortical psycho-motor centres and the so-called jjyramidal trad comprising the descending fibres which run between the nuclei of the corpus striatum, and the optic thalamus, as the internal capsule, subsequently extending backwards and downwards as the peduncle (crus) and passing to the other side of the body, more or less fully in the pyramidal decussation. The sensory ganglia, and the fibres passing from thence downwards, and the connection of the bulb with the cerebrum, come in also for con- sideration. It will be only possible in this limited space to consider the anatomical relation and physiological functions of these parts so far as they concern the occurrence of lesions. 1 Berliner Klin. Woch., April 26, 1875. CEREBRAL HEMORRHAGE. 105 The cortex-cerebri has been found to be the seat of well limited centres, which when subjected to irritation from disease or mechanical injury, lose the function of localized sensory and motor innervating power. The gray matter of the cortical motor region is found to be peculiarly rich in large giant cells such as are met with in the anterior gray cornuse of the spinal cord, and by some authors are supposed to be identical with the latter. The more important of these centres are motor, and have been more or less appropriately called psycho-motor centres, and those of greatest significance are to be found upon either side Fiff. 16. Cortical Centres. (Morel.) of the Eolandic fissure in the ascending parietal and frontal convolu- tions, and preside for the most part over the movements of the face and its parts and the limbs of the opposite side of the body. There are more posteriorly other centres which have a sensory function. At the angular gyrus (pli Courbe), for example, a visual centre is found which fills a prominent office in the regulation of visual correction, while other limited regions exist which undoubtedly play an important part as centres for the sense of audition, taste and smell. The excellent plate (Fig. 16) from Morel's Atlas will enable the reader to appreciate the action of the cortical centres. It is based upon the investigations of Ferrier. 1- Speech centre of Broca. Posterior part of third frontal convolution. 2. Centre for the movements of the upper extremities, situated on the 106 DISEASES OF THE CEREBRUM AND CEREBELLUM. ascending frontal and parietal convolution circle (over the middle of the fissure of Rolando). 3. Centre for the movements of the lower extremities. Situated at superior extremity of ascending parietal convolution. 4. Centre for movements of head and neck. Over posterior extremity, or foot of superior frontal convolution. 5. Centre for movements of lips. Posterior extremity, or foot of the middle frontal convolution. 6. Centre for movements of eyes. Angular gyrus of parietal lobe. These are in the main the important psycho-motor centres, although they are capable of modification, and I would refer the reader for further details to Ferrier's admirable book. ^ The sensory centres, though more difficult to define, have occasionally been found to be the seat of disease, lesions beiug connected with limited loss of function. The centre of vision may be located in the supra-marginal lobule and angular gyrus in proximity to that centre concerned in the movements of the eyes, though it should not be con- founded with an anterior centre situated ujDon the superior and middle frontal convolutions, Avhich control lateral movement of the eyes and dilation of pupils. The centre for hearing is located in the superior tempero-sphenoidal convolution. The centre for smell has been found by Ferrier in the subiculum cornua Ammonis, and irritation of this region is associated with some closure of the nostrils. The centre of taste is supposed by this author to be located in close proximity to the last mentioned centre. Many hundred observations have been collected by Charcot and Lan- douzy, Pitres, Seguin and a host of foreign and American observers, and most of them have a bearing confirmatory upon this theory, although it must be confessed that the large majority of collected cases j^resent mul- tiple or extensive lesions, which too often cloud the diagnosis. The published cases prove in several ways, and first that cortical alterations in places found by experiment not to be the seat of psycho-motor centres are not followed by hemiplegia, and this is shown by the cases of Pitres. ^ Two cases are presented by Pitres, one of softening of the inferior parietal lobule and sphenoidal convolutions, and the other of abscesses of the occipital lobe without hemiplegia, while other cases brought forward by him show the connection of hemiplegia with cortical softening of the ascending parietal convolution on one side, and aphasia with destruction of the third frontal convolution. In cases where autopsies have been made it has been found that a de- generation of the motor fibres passing from this area of cortical centres had commonly taken place, and that such "secondary degeneration" had extended down into the cord involving certain parts of the lateral columns, to be alluded to hereafter, and this secondary trouble was ^ The Functions of the Brain. London, 1876. ^ Progres Medicale, August 7, 1880, and Kevue Mensuelle. CEREBRAL HEMORRHAGE. 107 found in some cases disconnected from any special lesion of the so-called motor ganglia, at the base of the brain, proving beyond doubt that the cortical psycho motor zone was that primarily affected. The disturbances of motility observed in connection with such cortical degeneration have been found to be of two kinds, spasm and paralysis existing together or apart, the latter being but an extended stage of the former ; and the interesting series of cases originally brought forward by Hughlings Jackson, who may be said to be the father of central localiza- tion, give to the matter an importance it really never has had accorded to it. It is the opinion of both Jackson and Brown-Sequard, both of whom have never been inclined to look upon the subject in anything like a narrow way, that the psycho-motor centres are not confined alone to the cortex, but exist throughout the brain as a complex system. My own experience has led me to adopt this view, especially as I have seen cases in which the cortical centres of Ferrier were involved and in which the only disturbances of motility were hyperkinetic, such as localized spasms; and it would seem to me that the destruction of the cor- tical centres resulted more often in an interruption of inhibitory control than in intrinsic and primiry abolition of motor power. There are numerous cases of cortical epilepsy in which no paralysis occurs, al- though the limitation of spasm to the member innervated by its particular cortical centre should always suggest the diagnosis. The occurrence of spasm in a monoplegic limb, that is to say a limb the seat of paralysis other parts being unaffected, is pretty certain to bear evidence of degenera- tion of a particular convolution. (Charcot.' When a large extent of cortical territory is destroyed we find a pecu- liar and extensive degeneration, which takes a well-defined downward course, as may be seen from reference to Charcot's admirable plate (Fig. 17). The zone which includes the psycho-motor centres above, and the inferior motor tracts, may be shown by a vertical cut which separates the hemispheres. A. represents the caudate nucleus ; 108 DISEASES OF THE CEREBRUM AND CEREBELLUM. B, the lenticular nucleus ; C, the oiJtic thalamus, while between them passes the collection of fibres known as the internal capsule. The rela- tion of the nervous tracts with the convolutions above and the basal ganglia below is also shown in the diagram. D represents the para- central lobe, which has been found to be the most important psycho- motor region ; E, the ascending frontal convolution ; F, the ascending parietal ; G, the fissure of Rolando. The various parts of the internal capsule are represented by H, K, and L. H represents the internal capsule ; K, the " pyramidal " region of the posterior segments of the internal capsule, and L the part concerned in sensation. The anatomical arrangement of the internal capsule may be diagrammatically represented by the tract of white represented by the letters H and K in the above diagram. It will be noticed that these tracts unite at an obtuse angle, which latter by the Germans and French is known as the "knee of the internal capsule." The anterior segment of this collection of fibres contains those which are essentially motor, while the posterior are sensory. The knee contains fibres which terminate in the bulb and have a con- nection with some of the great nerves of the medulla concerned in the voluntary innervation of the tongue and other parts of the face. In the diagnosis of cerebral disease it is well that we should bear in mind the relation of cerebral ganglia and their commissural connections, and a transverse section of the brain, when studied microscopically and otherwise, will enable us to see that not only are the two hemispheres connected together, but the various gray segments are brought into rela- tion by diiferent sets of fibres which may be briefly enumerated as follows: Fibres which connect the optic thalamus and the lenticular nu- cleus and the caudate nucleus with the periphery of the brain ; fibres connecting the lenticular nucleus with the gray matter of the sphenoidal lobe. These internal intercommunicating fibres form a system by them- selves, Avhile a second set of fibres having a direct course, (peduncular fibres) serve for the direct reception and transmission of sensorial impres- sions and motor impulses. After the fibres of the internal capsule reach a lower and more posterior level ihey unite in the peduncle, which, according to Brissaud and others, contains four sets of fibres, each having a well defined ofiice and correspond- ing with the arrangement in the internal capsule. They are as follows : 1. A posterior bundle, the ofiice of which is the conduction of sensory impressions. 2. A bundle composed of fibres especially engaged in the motor innervation of the trunk and limbs. 3. A small bundle of fibres connected with the angle (genou) of the internal capsule, and which con- tain motor fibres connected with the bulb ' and are concerned in voluntary movements of the face, and tongue. 4. An internal bundle of fibres going to the bulb. Evidences of secondary degeneration, after certain cerebral lesions in- ^Loc. cit. CEREBEAL HEMORRHAGE. 109 volving tlie motor track are best seen in the inner and middle thirds of the peduncle and sometimes occupy a pyramidal character the base being anteriorly. The course of the motor fibres has been studied most fully by Flechsig in the embryo, and he has materially overturned the old views — notably those of Brown-Sequard in regard to the total decussation of fibres in the pyramids. Flechsig has found that the extent of decussation is very variable, and that in the great number of cases there is by no means total decussation. This will explain the possibility of hemiplegia upon the same side as the cerebral lesion in individuals in whom the pyramidal decussation is imj^erfect. The study of sensory disturbances following brain lesions has not kept pace with that of the localization of motor troubles. Certain facts have been clearly brought forward, however, and the most important of these is that injury of the posterior segments of the internal capsule is produc- tive of hemianesthesia, Veyssiere^ was the first to make this clear, and Charcot, Ferrier and others have since proved the connection of such unilateral anaesthesia with loss of smell and vision upon the same side. Injury of the convolutions about the fissure of Rolando has not been so far found to be followed by general aniesthesia, although according to Ferrier the occipital convolutions seem to some extent to possess sensorial functions. The optic thalamus has undoubtedly much to do with sensory in- nervation, and Friedrich and Charcot have both found that hemorrhage or tumor in regions adjacent to the posterior part of this organ produced anaesthesia, and in certain cases of epilepsy, with peculiar sensory aur^e. Hammond has regarded the optic thalamus as the seat of the lesion. The blood supply of the brain is derived from two systems of vessels, a basal or central, and a cortical or external. It has been proved by Duret and others that there is no distal connec- tion between these two, and that the central arteries as a rule supply but a limited territory. The importance of the central arteries, which are much larger than those supplying nutrition to the cortical gray matter, is derived from the fact that in rupture or disease much more profound and sudden symj^toms occur than when the others are affected, because of the existence of anastomoses in the latter. Charcot alludes to several facts which in this connection should be borne in mind in the localiza- tion of symptoms. 1. Vascular lesions upon the surface of the brain and hemorrhages as a consequence do not occur so often as in the sub- stance of the brain, for the reason that the cortical vessels are protected in their course by their dura mater and other coverings, that they are smaller, and are not subjected to so much pressure as those of the cen- tral system. 2. Proximity of the arteries of the central system to the heart — their simple arrangement and liability to sudden pressure predisposes to acci- ^Kecherclies Clinique et Experimeutales, sur rhemianEestliesie. Paris, 1874. 110 DISEASES OF THE CEREBRUM A>'D CEREBELLU M. dents in deeper parts, and for this reason central or deep hemorrhages are serious. A reference to Fig. 18 will enable the reader to appreciate the vessels (Charcot.) Fig. 18., (Charcot). Central vascular supply. A. Territory of Sylvian artery. B. Ter- ritory of anterior cerebral artery. C. Territorj' of posterior cerebral artery. D. External wall. E E E E. Internal capsule. F. Walls of Trigonal arches. G. Lateral ventricle. H. Caudate nucleus. I. l.«land of Rail. J. External arteries of corpora striata. L. Sylvian artery. M. Internal carotid. N. Gray substance of third ventricle. 0. Optic chiasm. P. Section of optic nerve. Q. Lenticular nucleus. R. External capsule. S. Anterior cerebral artery. Vascular areas are indi- cated bv dotted lines. concerned in the supply of the central ganglia. The Sylvian or middle cerebral artery is the most important of these, and it will be found that when it leaves the internal carotid it sends up central branches to supply a part of the caudate nucleus, the entire lenticular nucleus, theiuternal capsule and a part of the optic thalamus. It will be seen by the dotted lines that nearly two-thirds of the hemisphere is sup- plied by this important vessel and its central and cortical branches. The posterior cerebral artery furnishes nourishment to the parts of the optic thalamus not supplied by the Sylvian — namely, the external and posterior parts. It also supplies the tubercula quadrigemina and the crura cerebri. The anterior cerebral artery is concerned only in the supply of a small part of the caudate nucleus. Fig. 19 shows the course of the middle cerebral artery which .sends off branches to supply the cortical portions of the brain after it fulfils an equally important office in supplying, at the base, central vessels to the ganglia. The cortical branches of this vessel are quite large, and are four in CEREBRAL HEMORRHAGE. Ill number. These severally supply the frontal, parietal, and sphenoidal con- volutions. The island of Reil is supplied by ajarge branch which leaves the main artery when it divides into the large terminal branches. The four vessels alluded to, break up into smaller or secondary arteries at higher points, such secondary arteries supplying a small track of convo- lution. There are still " tertiary branchlets " which anastomose with each other forming arborescent ramifications — though Duret does not agree with Charcot and others regarding this fact. Fig. 19. IVi N (Charcot.) Cortical branches of Sylvian artery. ABC. Frontal CoNvoLtrTiONS. D. Ascending FsoNTAt Convolution. E. Ascending Parietal Convolxttion. H. Infra-parietal convolution. G. Supra- Parietal Lobule. L Occipital Lobe. J. Trunk of Sylvian Artery. K. Perforating branches of central gray ganglia. L. Ext. and superior frontal branches. M. Ascending frontal artery N. Ascending parietal artery. O. Parieto-.sphenoidal and sphenoidal arteries. Upon the surface of the convolutions we find nutrient arteries of small size and capillary character, which are branches of the " tertiary branch- lets." These arteries enter the cortex at a right angle with its external surface and are called long and short, with reference to their extent of penetration. The lo7ig or " medullary " arteries, are terminal vessels of the tertiary branchlets and pass perpendicularly into the gray cortex and white substance, but have no connection ivith the cerebral arteries below, while the short cortical or nutrient arteries, which also come from the tertiary branchlets or ramifications, rarely extend deeper than the corti- cal gray matter. The only difference in the character of the two forms of nutrient arteries, for they have a common origin, is that they extend to different distances from the cortical periphery, and while one supplies chiefly one form of nervous matter, (the white) the other nourishes the 112 DISEASES OF THE CEREBRUJI AXD CEREBELLUM. gray. It will be found that a sort of arborization or net-work is found in the gray matter, which depends chiefly upon communicating arteries from the short vessels with an occasional reinforcement from the lo)iff, and also that the terminal branches of the large trunks are entirely distinct from those arising from a lower level, and which enter the brain at a basal point to become central arteries. Other cortical parts of the 'train are supplied chiefly by branches of the anterior cerebral, and posterior cerebral arteries. The pathological course of cerebral hemorrhage is the following : I . The stage of preparation, during which the arteries undergo the changes already spoken of. 2. The operation of an exciting cause, the rupture of the ves- sel, the injury of the nervous substance, and the formation of the clot. 3. Death ; absorption, or limitation. Bouchard^ and Charcot both affirm that cerebral hemorrhage is always dependent upon a peculiar kind of disease of the vessels. This diseased condition consists of a studding over with minute aneurismal dilatations which have been called by them " miliary aneurisms." These arise from a primary degeneration of the outer coat of the vessel, secondarily sclerosis, and finally atrophy, of the muscular coat and dilatation. Of sixty-five cases" of cerebral hemorrhage, they found miliary aneurism in every instance. Both of these authors consider the vascular change to be difterent from that of atheroma, which begins in the inner coat. These appearances are confined to the brain, and exist where there is no evi- dence of atheroma to be found in any other part of the body. Notwith- standing the fact that these views are endorsed by such men as Meynert, Bastian, and others, there are many observers who consider miliary aneurisms to be due only to careless manipulation, or to be identical with the " hyaline degeneration" of Gull and Sutton which is found in other localities. Dr. Barlow " has presented a case which fully demonstrates that cere- bral embolism may produce a conditon of the vessels which leads to the formation of aneurisms, first causing local arteritis and weakening of the wall of the vessel. In this case (that of a boy aged ten years) there was right and afterwards left hemiplegia, and aortic regurgitation. The autopsy revealed " cortical softening on each side of the lower part of the ascending frontal and the posterior parts of the second and third frontal convolutions. The clue to this condition was found in the middle cerebral arteries. On both sides these vessels were diseased at the spot where the fine branches were given oflT over the island of Reil for the supply of the cortex. Of these branches on both sides, the one supplying Bi'oca's convolution and the one supplying the ascending frontal were also diseased. There waa no aneurism to be discovered anywhere, but the walls of these vessels presented many small calcified nodules obvious to touch and sight " This calcification was not noticed in any other ^ Archives de Physiol., 1868. 2 Brit. Med. Journal, April 7, 1877, p. 372. CEREBRAL HEMORRHAGE. 113 vessel in the body, and emboli bad lodged in the spleen and kidneys. In Goodhart's cases actual aneurism had followed the embolism, and Dr. Barlow's case demonstrates that there is a primary weakening. Durand-Fardel ^ found that of 32 cases the arteries were only healthy in 9 cases, while in 21 they were thickened, and in 2 ossified. AndraP found that of 32 cases the arteries were apparently healthy in but 4. These miliary aneurisms have been said to be due to " periarteritis," but it cannot be denied that a large proportion of cases of renal and heart disease produce modifications in blood pressure, which would account for the rujiture of the vessel without any primary inflammatory condition. Fig 20. Miliary Aneurisms. I have repeatedly seen miliary aneurisms, and must confess that they appeared to depend upon some organic change which extended over a considerable space of time. Zenker difiers from Charcot and Bouchard, and considers the internal coat to be that which is first attacked. "When miliary aneurism exists, it is generally in conjunction with either gout, cancer, tubercule, leucocythe- mia, or other conditions, when leucocytes may jDass into the cerebral ves- sels in large number. In old drunkards and general paralytics this vascular change is not an uncommon one. In regard to atheroma there have been many cases brought forward where this appearance was so constant as to gain recognition as one of the chief factors of the cerebral hemorrhage. An atheromatous artery contains deposits of a firm, semi-fatty nature, between its inner and middle coats. At an advanced stage the deposit is more calcareous and hard, and the artery may be sometimes easily broken in two. Occasionally the deposit between the coats, by distension considera- ^ Traite clinique et pratique des Maladies des Vieillards, Paris, 1854, p. 228. 2 Clinique Med., vol. v. 114 DISEASES OF THE CEREBRUM AND CEREBELLUM. bly narrows the calibre of the vessel, and in this way forms occlusion at one point while at a weaker one hemorrhage takes place. The veins and capillaries are not so often involved as the arteries. In regard to the seat of cerebral hemorrhages, we find from a table prepared by Rosenthal.^ rimes. In the corpus striatum alone 32 " nucleus lentiformis alone 20 '' both these ganglia combined 8 " corpora striatum and optic thalamus 7 '' cent, nucleus and other parts (centrum seraiovale, occipital lobe, island of Reil, pons and cerebellum) 6 " optic thalamus alone 20 " " " and corp. striat. of both sides (recent hemorrhages and old cicatrices.) 2 " " thalamus and lent, nucleus of both sides 3 " centrum semiovale 3 '' parietal lobe 2 Total 103 It may be stated that large portions of both hemispheres are de- stroyed without serious symptoms ; but when we approach the base the danger is increased, and if the third frontal convolution be the seat, we find a very decided and serious result, which is aphasia. The majority of hemorrhages are in or about the optic thalami and the corpora striata, together or singly, and if they be extentive the ventricles will be filled. If the hemorrhage be great, pressure may be made on the opposite side, or the blood may find its way into other localities. In the anterior lobes the effusion is generally circumscribed, but from this site it may find escape into the lateral ventricles. In the ganglia and important parts at the base, the hemorrhage is generally small, but is all the more serious because of the importance of the parts it destroys. This is the case in the corpora striata. In the pons and medulla any con- siderable extravasation is followed by death or serious trouble. The shape of the cavity is variable, but in the gray matter it is circumscribed, and in the white it is irregular and elongated. Parrot" reports 34 cases of cerebral hemorrhage in new-born children. In these the clot was found at the inferior part of the brain ; sometimes on the right side, but more generally on both sides. Should the patient survive the apoplectic attack, and die subsequently of some other disease, the cerebral clot will probably prove to be well organized, hard, and separated from the brain-tissue in the vicinity by a sclerosed mass. The immediate changes are the following : At the end of a few days the serum is absorbed, leaving the solid portion as a gelatinous mass ; finally the clot contracts, becomes yellow, and assumes the appear- ' A clinical treatise on the diseases of the nervous svstem, translated by L. Putzel N. Y., 1879, p. 38. -Arch, de Tocolowje, 1875. CEREBRAL HEMORRHAGE. 115 auce I have alluded to. It is rare that an old clot is completely absorbed, but it is found encysted and firm, and, perhaps, has produced some soften- ing. It is not uncommon to find more than one clot in a patient who has had several hemorrhages. There may be a cyst filled with thickened blood, which is indicative of an eiFusion of recent occurrence, and there may be others of smaller size, in different stages of resolution. Small aneurismal dilatations are also found, while local patches of softening, or cysts filled with clear serum, are not rarely present at the same time. Much has been said about the relation of decubitus to brain lesions ; how- ever, there does not seem to be any special connection between disease of certain parts of the brain and the causation of bad sores, though Joffroy ^ has reported three cases in which acute decubitus was found with lesions of the occipital lobe and optic thalamus upon the opposite side. . Broad- bent, Dusaussay, Leloir and others have, however, presented a number of cases in which other parts of the brain were affected. A common form of hemorrhage is meningeal. Goodhart ^ has written an exhaustive paper upon this subject, in which 49 cases are given, prov- ing most conclusively its connection with diseased kidney and hypertro- phied heart. Of these 49 cases, 30 were due to renal disease, and six had uncomplicated heart trouble. When the hemorrhage takes place above the arachnoid, we are assured by Mr. Prescott Hewitt ^ that the blood very rarely gravitates to the base ; but when the hemorrhage is sub-arach- noid, the blood may find its way below, thus making the condition a most serious one. After death a peri-cortical collection of blood will be found ; which is extensive over the base, and probably produces death by pres- sure upon the pons and medulla. (See Chronic-Pachymeningitis with H^ematoma.) Diagnosis. — Coincident with the occurrence of the hemorrhage, symp- toms will be presented which may enable us to localize with some degree of accuracy the position of the clot, its extent, and character, and the fol- lowing statements are based upon the observations of Bastian, Wilks, and others : A lesion in or about the corpus striatum will be followed by hemi- plegia of the opposite side. The temperature being higher in the para- lyzed limbs than in the others ; the eyeballs will deviate towards the side of the lesion ; and the tongue, when protruded, will point to the hemiplegia side. The face is paralyzed on the same side as the arm and leg. A le- sion in or about the optic thalamus will present the same phenomena, only that the temperature is higher in the paralyzed limb than in the preceding form, A lesion in one crus is followed by very much the same symptoms. If the under and inner part be affected, we find cross paralysis, the face being paralyzed on the side of the lesion, while the extremities are para- lyzed on the other side of the body. Hemiansesthesia is quite marked ; and the third and seventh nerves are paralyzed, so that ptosis and profound ^ Archives de Medicine, Jan. 1876. ''- Guy's Hosp. Kep., vol. xxi. p. 131. ^Holmes's System of Surgery, 1870. 116 DISEASES OF THE CEREBRUM AND CEREBELLUM. facial paralysis result. A lesion in one lateral half of the pons is followed by hemiplegia of the opposite side, profound coma, deviation of the eyes away from the side of the lesion, facial paralysis on the side of the lesion, lowered temperature in the non-paralyzed limbs, paralysis of the muscles of deglutition, and anaesthesia or hyperesthesia of parts supplied by the fifth nerve. A lesion of the upper half of the lateral region of the pons will be expressed by pretty much all of the symptoms which follow the last mentioned lesion, except that the facial paralysis will be on the side op- posite the lesion, A feature of all forms of lesions in the pons is the very decided character of the facial paralysis ; and if there be extension of the lesion, there may be double facial paralysis, with hemiplegia of the body. A lesion in the posterior j^f^rt of the pons, beside the symptoms just alluded to, will produce paralysis of the fifth, sixth, and seventh nerves on the side of the lesion ; or, according to Brown-Sequard, it may sometimes produce cross-paralysis. A lesion in the centre of the jwns is followed by double paralysis, deep coma, marked contraction of pupils (while in the other forms one pupil may be contracted on the side of the lesion), lower- ed temperature on both sides, with ultimate rise and but slight loss of sensation. Liouville^ reports a case of hemorrhage into the pons, in which sugar was found in the urine. This he considers to be an ever- present symptom of disease in the lower part of the pons, but never a feature of disease of the upper part. A hemorrhage in the medulla is followed by paralysis of the cranial nerves on both sides, bilateral para- lysis of the body, and, generally, rapid death. Extensive lesions may produce a combination of these phenomena, and diagnosis may sometimes be an extremely difficult matter. A patient under treatment with sy- philitic disease of the brain, presents a combination of symptoms which are extremely interesting in a diagnostic sense. Wm. McG., aged 58 years, when about 21 years of age, had a primary chancre upon the dorsum of the penis, followed some months afterwards by secondary symptoms. After a few years all traces of syphilitic trouble seemed to have disappeared, as he enjoyed extraordinary good health. He has led for the last twelve or fourteen years a very intemperate life, and has regularly " gone upon sprees." Twenty-six months ago, after an attack of facial neuralgia, which was evidently specific, he became herai- plegic during one of his drinking bouts, but does not remember any of the circumstances immediately connected with the apoplexy. AV^hen he be- came sober he found that the left side was paralyzed, but the loss of power could not have been very great, for he was able to walk in a few days. About a year ago the right side of the face became aniesthetic, and he began to lose the sense of taste on the left side ; at the same time he found it difficult to arrange the food for mastication, and his power of articulation became embarrassed. Present Condition. — Eyes. Pupils of the same size, and not abnor- mal ; respond well to light ; no ptosis, nor disturbance of vision ; no retinal change. Face. — No impairment of buccal muscles, nor of superficial facial muscles, except slight contraction of those of right side when he ^ Gazette des Hopitaux, Feb. 8, 1873. CEREBRAL HEMORRHAGE. 117 opens liis mouth. When this is clone, the orifice is unsymmetrical. Anos- mia marked, taste impaired to slight degree. Warm substances produce an impression on sound side of tongue, but not on the other. Left side of the palate paralyzed, and lower than the other. Left side of tongue atro- phied, presenting the appearance depicted in Fig. 21 ; and when protruded the tip points to the right side, no apparent tactile loss of sensation as de- termined by the sesthesiometex. Saliva is secreted in large quantities, and Fiff. 21. Multiple Lesion with Tongue Atrophy. constantly drips from the angles of the mouth when he talks. Sensation of right side of face impaired ; feels points only when sej)arated 3 mm. on other side 1? ; some difiiculty of speech, especially with the letter r, pro- nouncing " righteous " "eightshus;" the left leg he drags slightly when he walks. Six months ago he slept upon his arm when drunk, and thereby added to his other troubles a decubitus paralysis ; slight loss of power in both arms. In this case there were evidently two lesions — one in the medulla, and the other on the right side of the brain — one hemorrhagic, the other of slow growth. We are to diagnose the symptoms of cerebral hemorrhage in its different stages from those of the following diseases : Actual attack from ursemia, drunkenness, opium poisoning, tumor, epilepsy, compression or concussion from injury, embolism, and thrombosis. There are certain general ap- pearances which symptomatize the unemic condition, and can hardly be mistaken ; the skin is waxy and oedematous, the eyelids are puffed, and 118 DISEASES OF THE CEREBRUM AND CEREBELLUM. the legs and feet swollen ; but, as Bastian suggests, it does not always follow, when Ave find these appearances in an individual over thirty years of age, that the coma is always purely of an urismic character, and that there may not be a complicating hemorrhage. The urine, when drawn, is found to contain albumen, but this symptom by itself is in- sufficient to settle the question. Ursemic coma is generally of gradual appearance, though Hughlings Jackson calls attention to a form which has a rapid onset, with convulsions ; but, on the whole, such sudden appearance is more suggestive of cerebral hemorrhage. It is nearly always preceded by prodromata for several days. The patient is stupid, and inclined to somnolence, and has headache. Bourneville has ascer- tained that the temperature rapidly sinks when the coma begins, to a point very much lower than it does in cerebi'al hemorrhage, and con- tinues depressed during the condition, while the converse is true in the other affection. Convulsions are much more prominent and constant features of uriemic coma than they are of cerebral hemorrhage ; and, be- side, there is no paralysis. Numerous other indications will serve to make the diagnosis clear in this respect. The coma is not dee]), and it is possible to arouse the patient, and there is great hyperkinesis, there being a tendency to muscular spasm and rigidity which is not unilateral. The character of the respiration differs from that of cerebral hemorrhage, the stertor being more superficial. From drunkenness the diagnosis is not always so easily made, the two conditions sometimes coexisting, and it may be necessary to delay until the effect of the alcohol has passed away, before we can determine our patient's true condition. The odor of liquor, the circumstances under which he was found, and his imperfect loss of consciousness, are sufficient to excite suspicion. If he vomits, we may chemically test the substances thrown up, or examine the urine. Anstie gives a delicate test which may be employed. If even only one drop of the urine of the patient who has taken a toxic dose of alcohol be added to fifteen minims of a solution of one part of bichromate of potash in three hundred parts of strong sulphuric acid, the mixture will turn to an emerald green. With a larger quantity this test will be much more certain. The articulation of an intoxicated person when aroused is so peculiar and so interrupted by hiccough that there need be no chance for mistake in this respect. Narcotic poisoning may resemble somQwhsxt the symptoms indicating cerebral hemorrhage. Like alcoholic coma, its advent is gradual, and there are convulsions, while the face is dusky, but the patient may be generally aroused. Much stress has been laid upon the condition of the pupil in opium poisoning as a diagnostic sign ; but, as this symptom is indicative of hemorrhage in the pons, it loses some of its value. Epileptic coma can hardly be mistaken (should it be a stage of the actual epileptic attack) for that of cerebral hemorrhage. In the former there is a history of convulsions ; the stupor lasts but for an hour or two at the most ; the temperature is elevated ; and there is sometimes an escape of bloody froth from the mouth. The previous history of the patient should set all other doubts at rest. Compression or CEKEBKAL HEMORRHAGE. 119 concussion from head injuries may be mistaken for the condition under consideration. In the former there may be a subarachnoid effusion, which may give rise to many of the symptoms. The latter is usually of short duration, 'so far as symptoms are concerned. The skin is pale, the pupils dilated, and vomiting occurs at some time or other. It is al- ways of decided importance that we should inquire into the nature and receipt of the injury ; for, should it follow a fall while the patient is in a safe position, we may suspect that he has had a seizure of some kind, the injury being secondary to the attack. The internal cause of the hemorrhage is always important, whether it be produced by an abscess, tumor, or other intracranial disease states ; and these things are to be taken into account. The antecedent history of the patient, the presence of pain of a localized character, subsequent convulsion, loss of vision, aural disease, and kindred conditions should all be ascertained. Serous apoplexy, as it has been called, when an immense effusion of serum takes place either beneath the investing membrane, or in the ventricles, or throughout the brain substance, is usually of gradual origin; and dependent uj)on the collection of fluid which takes the place of atrophied brain substance or attenuated vessels. Prognosis. — According to all observers it is an exceedingly difficalt matter to make a prognosis with any certainty, especially an early one, and, consequently, it is of the utmost importance that every circum- stance of the case should be taken into account and carefully considered before we give expression to any opinion. Certainty of prediction is made doubtful, by new complications, and fresh dangers that are likely to arise. There are several questions that are to be answered, and the first of these concerns the fatality of the actual attack. The character of the coma, its depth and duration, the appearance of convulsions, aboli- tion of reflex excitability, stertor, involuntary passage of urine and feces are to be regarded as indicative of an early fatal termination. If this condition be connected with unequal pupils, and double hemiplegia, the prognosis is, if anything, more unfavorable. Large hemorrhages into the ventricles, corpora striata, or into the crura or pons are then to be feared. The patient presenting these alarming symptoms dies usually in a very short time, say in from a few hours to two or three days, and there may be, perhaps, an aggravation of the symptoms towards the end as the result of fresh hemorrhage. If he survives the attack, what are the chances for the return of mental power? or, if not affected, will it subsequently become impaired ? This depends very much upon the occurrence of inflammatory action about the clot, or whether there be ursemic trouble or softening. We may augur well for his chances if these conditions are absent, and if he lives for eight or ten days after the immediate attack. In regard to the speech disturbances : if there be simple ataxia, there is no reason to fear ; if, however, any marked for- getfulness of words or genuine aphasia exists, the prognosis is less hope- ful. This condition of affairs often exists for years without the slightest 120 DISEASES OF THE CEREBRUM AND CEREBELLUM. improvement taking place. At first the mind is confused and dull, and, unless the hemorrhage is the result of softening or other degeneration, there is but little doubt that he will ultimately regain his mental activity. It is, however, well to qualify this statement by saying that in old people the tendency is the other way. Congenital apoplexies, or those occurring in early life, are apt to leave sequelas of the most deplorable description, such as imbecility and kindred conditions. The return of muscular power and normal sensation is the most important question to be next con- sidered, for much of the patient's future comfort depends upon the re- covery of his lost power. Should the limbs remain paralyzed, or second- ary neuritis take place, the consequence will be atrophy and contractures, such as I have described. It is, however, usual for recovery to begin in a few weeks, and in even a shorter time should the hemorrhage be unat- tended by loss of consciousness. The limb first to recover is the lower extremity. He is able after a short time to get out of bed and " hobble " about, or he may retain a certain degree of power from the first should the hemorrhage be slight. He is subsequently able to raise his hand to his head, and ultimately recovers entirely. But this improvement does not always occur, for during cerebritis, and secondary degeneration which may subsequently take place, a number of serious muscular dis- tortions of a permanent character may ensue. A case illustrating this is the following : — J. C. D., aged 53, born in Ireland ; carman. Family history, mother died of old age ; father died of renal disease. The patient in early life was very intemperate, and there are some evidences of syphilitic trouble, there being nodes, bald spots, and enlarged glands ; but he denies any venereal disease. For three months previous to the attack (it occurred three years ago) he suffered from headache, dizziness, and other prodro- mal symptoms ; none very marked, however. He went to bed one night feeling perfectly well, and awoke with " cramps," which affected his right leg ; he called his wife, and attempted to get out of bed, when he found he was paralyzed. There was no speech trouble whatever. He was placed in bed, and remained there for three months, during which time he had violent headache in the occipital region. Present Condition. — Hemiplegia of right side, sensibility slightly im- paired, and no atrophy of either the arm or leg. When he stands there is slight rigidity of the inner ham-strings. The toes and the end of the foot are adducted ; and when he walks, the foot is raised from the ground about one inch ; the knee is rigid, and there is motion only at the hip- joint. The fingers of the right hand are in a condition of extreme flexion, and cannot be extended by ordinary force ; but, when the hand is placed in hot water for some time, the rigidity is partially overcome. The thumb is not involved ; but, when the distal phalanx was extended, it could be bent backwards some distance, and remained in this condition until it was restored by me. The hand is slightly flexed, and the fore- arm pronated and flexed on the arm, and the arm adducted to the body. No lateral movement is possible. There was an early history of neuritis, which came on a short time after the attack, with decided pain in the shoulder-joint, during which the patient applied blisters and mustard poultices. The dynamometer indicates 20, outer circle, with the right hand, and 80 with the left. There is no visible facial paralysis, but the CEREBRAL HEMORRHAGE. 121 tongue points slightly to the right side. The surface of the paralyzed side is mottled and cold, and the nails are crenated and horny. The facial paralysis is sometimes a grave and permanent condition, and is very serious, especially if there be ptosis. Should the paralysis involve the muscles of the pharynx, the tongue, or the buccal muscles, the prognosis is very bad, and these symptoms suggest that the hemor- rhage has invaded the posterior basal parts of the brain, and perhaps the medulla. The organs of special sense are affected to a variable ex- tent, and greatly modify the prognosis. If there be involvement of the optic-discs, retinal extravasations, or structural changes of the fundus, a grave character is given to the disease ; while such symptoms as ptosis and diplopia, which depend upon paralysis of the third and sixth nerve, sometimes disappear after a time, though such disappearance may very slowly take place. The recurrence of apoplectic attacks is not uncom- mon, and if there be any special cachexia, they are to be dreaded. Sy- philis and gout, as well as renal disease, are highly conducive to a return of the trouble ; or advanced age is an important predisposing cause of cerebral hemorrhage. When we find a calcareous state of the arteries with cerebral hemorrhage, it is very probable that the other fluxions will follow. I remember a case in Avhich a succession of hemorrhages oc- curred in the person of a middle-aged lady, the third of which proved fatal : — N. G. A., aged 57. On the evening of February 3, 1873, I was called by Dr. Wm. H. Bennett to see the patient, whom I found in a state of coma. All of the characteristic appearances of a profuse cerebral effu- sion were manifested. The apoplectic seizure had taken place the day before, and she had continued in a comatose state until I saw her with Dr. Bennett. Her surface was cool, her breathing slow and stertorous, her pupils dilated, and cornea insensitive to the touch ; while reflex ex- citability was entirely abolished, so that tickling of the soles was followed by no withdrawal of either limb. In this state she remained until the 8th of the month, during which time, and in fact until the time of her death, in November of the same year, it was necessary to draw her water nearly every day. At the end of the fifth day there was a slight return of consciousness, but entire inability to speak, the patient making a pecu- liar short sound when she wished to communicate with those about her. There was complete paralysis of the right side, bat a faradic current readily produced muscular contractions. From this period until Septem- ber 13th, there was steady improvement, and the family, as well as our- selves, were very hopeful. She recovered considerable power over the leg and arm, but was unable to get out of bed, although she was lifted from it and placed in an easy chair, where she remained contented for several hours of the day. She was now able to utter two or three words, and seemed to take a lively interest in all that went on about her. On the 13th of September, while lying in bed, she suddenly became comatose, and presented all the symptoms of a fresh hemorrhage. Her tempera- ture, which had before ranged between 98° and 101°, now sank to 96° ; and her condition was so critical that I remained with her during the night of the 14th, when she slightly recovered, regaining her conscious- ness on the 17th ; but there was complete loss of power. The tempera- ture now rose to 104°, and she was restless and irritable. Her power 122 DISEASES OF THE CEREBRUM AXD CEREBELLUM. of expression had entirely disappeared, and she remained in this state until the l^th of November, -when she died in her last apoplectic attack. This patient, before her last illness, had suffered for some time from albuminuria, but her symptoms had been almost entirely relieved when her first cerebral hemorrhage took place. She was of spare build, her radial arteries were rigid, and the arcus senilis was visible to a limited extent. This tendency to cerebral hemorrhage is sometimes seen in gouty sub- jects. A patient recently sent to me by Dr. William Lockwood, of Nor- walk, Conn., had sufiered for years from gouty trouble. Besides the pain, her joints presented gouty swellings, with chalky concretions. Within the past five years she has suffered from slight hemiplegia of both sides ; on the right most severely. In this case it is probable that the rupture of a large vessel will some day carry her off. Treatment. — Our treatment must be, first, preventive, second, for the attack, and third, for the amelioration of the resulting condition. If we have to deal with cachexias of different kinds, appropriate treatment is indicated. Should there be gouty trouble, albuminuria, or syphilis, these are to be met with alkalies, diuretics, and specific remedies, such as mercury and the iodides. If there be depraved general health, weak heart action, and general debility, we are to support our patient by qui- nine, stimulants, and nourishing food. Cambiuations of digitalis and iron are especially useful when there is low arterial tension, and rapid heart action. In speaking of cerebral congestion I alluded to the conditions which might favor an excessive flow of blood to the head, and advocated special forms of treatment. It is not necessary to repeat these indications, but I will simply refer to the value of the bromides given in doses of from 20 to 30 grains three times a day if there be any tendency to head fulness, while ergot administered in half-drachm doses two or three times during the 24 hours, and the abstraction of blood from behind the ears, may be resorted to, should there be a suspicion of immediate danger. The patient is to be kept perfectly quiet in a cool room, cold applications are to be made to the head, and his bowels should be emptied by some such cath- artics as the compound jalap powder, senna, or Rochelle salts. Should we recognize the appearance of any prodromal symptoms, we must im- mediately inform the patient of the dangerous possibility, and enjoin upon him the necessity of regulating his mode of life, of breaking ofi' bad habits, and using every means in his power to improve cutaneous circula- tion. The flesh-brush, cold, and sometimes Turkish baths, moderate out- door exercise, and other agents which stimulate the surface capillaries and relieve internal congestion, should be as soon as possible resorted to. The patient's diet should be farinaceous, and the use of either strong drink or condiments is to be at once discontinued. He is to sleep in a cool room, and on no account wear tight neck gear. The feet are to be kept warm, and thick woollen stockings should be recommended. Violent exertion, especially forms requiring any fixation of the abdominal muscles or CEREBRAL HEMORRHAGE. 123 straining, are also to be carefully guarded against. Should we be called to find the patient in the actual apoplectic state, another line of treatment must be followed out. If in this condition he is found lying in a coma- tose state upon the floor, he is to be lifted gently, carried to a bed, and well propped up by pillows, so that the head is elevated. The room should be kept cool and well ventilated, and cold applications are to be applied to his head, while his feet may be kept warm by contact with bottles filled with hot water. The room is to be darkened, and his collar and shirt collar band should be cut or ripped off, so that the flow of blood to and from the head shall be unembarrassed. It is essential to keep him perfectly quiet ; so loud talking is to be forbidden, and officious friends kept away. In times gone by, it was customary always to bleed at this stage. I think experience has clearly proven how dangerous is such prac- tice, for hemorrhage in the brain is very apt to be started afresh by any such measure. If, however, the pulse be full, strong, and bounding, the patient's face flushed, and his condition one of plethora, the abstraction of a few ounces of blood, from behind the ears, with cold douches to the head and mustard plasters to the calves, will do much good. . This condi- tion may be so patent to the observer that, perhaps, in rare instances, and after careful deliberation, he may decide to abstract ten or twelve ounces from the arm. If we hear that he has been constipated for several days, a drop or two of croton oil or half a grain of elaterium may be given in a wafer, or applied to the tongue if he is unable to swallow ; it is advi- sable to give the first remedy, however, if the jDatient is profoundly coma- tose. Should there be much cardiac excitement, no better medicines can be recommended than tincture of veratrum viride, or tincture of aconite; the former in doses of from 6 to 8 minims till the pulse force is decreased, and the latter in rather large doses, say from 4 to 6 minims at a time, and after an interval of four hours, another dose, if the pulse has not decreased in volume or frequency. The medical attendant should not forget to draw the patient's urine frequently. I have known a neglect of this precaution to be followed by pain and distress which the patient in his helplessness is unable to express; and I cannot impress too strongly upon the student the necessity of remembering this simple procedure. When consciousness returns we may continue the aconite if it is indicated, and perhaps com- bine it with small doses (say 10 grains) of the bromide of sodium every two hours. Active medication of any kind, however, is injudicious in the extreme ; so it will not do to give large doses. Should there be a condi- tion of prostration, a tablespoonful or two of milk punch may be given every few hours. The subsequent management of the case is sufficiently simple ; continued quiet, a moderate quantity of food easy of digestion, and attention to the functions of the body are the three indications. He should not be allowed to get up to defecate, but the bed-pan may be placed beneath him. It may be found necessary to give an enema, which is bet- ter than the administration of purgatives by the mouth, and in this case the patient should not be allowed out of bed, even though he may seem bright and sufficiently strong. Cleanliness should be insisted upon, and 124 DISEASES OF THE CEREBRUM AND CEREBELLUM. generally necessitates the faithful care of a resj)onsible nurse ; for, if the patient is not carefullj' washed, the iri'itatiou produced by alkaline urine and his loose evacuations may favor the development of bedsores. As a precautionary measure, the buttocks should be rubbed with salt and whis- key, or, what is still lietter, tannin and alcohol. Bedsores may occasion- ally form, and sometimes are unnoticed by the physician if he is not on the alert, until his nose or the nurse remind him of their existence, the patient either being unconscious of such trouble, or unable to inform the physician even if he is aware of their presence. The patient should be immediately put on a water bed, and the slough removed by poultices of flax-seed and charcoal which may be sprinkled with iodoform. At the end of the 8th or 9th day, should the tendency be to recovery, and the tem- perature normal, we are left with an ordinary case of hemiplegia. What is to be done next? If the attack has been a serious one and signalized by marked loss of consciousness, and if the secondaiy rise of temperature be high, it is not best to begin electrical treatment for fully a month or longer. If the muscles respond too quickly to electric stimulus, we are not to use this agent, but to wait for some days or weeks, when we may cautiously employ the faradic current to the muscles of the affected side. Large sponge-covered electrodes moistened in a salty solution should be employed, so that all the muscles may be subjected to the electric stimu- lus in turn. Electrization may be direct or indirect, the muscles being made to contract either when both sponges are applied to their bellies, or when one is placed in contact with the muscle and the other is applied over the motor nerve by which it is supplied. In certain cases faradiza- tion fails to do any good whatever, and this is especially the case when there is delay in the absorption of the clot or any cerebritis. Two cases illustrating the possible advantages of this form of treatment are the fol- lowing : — , Right Hemiplegia. — O. S., aged 52, butler, came under my charge October 2d, 1872. He had been deprived of consciousness and power of motion a year before by a cerebral hemorrhage, and, after re- suming the duties of his avocation some months afterwards, continued well till three months ago, when a second attack prostrated him ; but, through the good treatment he received at Bellevue Hospital, he partially recovered the power of locomotion. When he came to me for treatment there was complete hemiplegia of the left side. There was no peculiarity in his gait, beyond a very slight dragging. The arm was slightly atro- phied, and the amount of power exerted by a forcible grasp of the dyna- mometer was indicated by 15° of the lesser circle. He could not button his clothes, nor lift his arm above his head. There was no difficulty in speech, except it might be embarrassment in speaking the words contain- ing the letters " b " and " p," when the labial muscles were required. Electric irritability in the arm was slightly exaggerated. After giving him a simple prescription for his constipation, I dismissed him. In three weeks afterward he returned in very much the same condi- tion. I then systematically applied the galvanic current to the head, and the faradic to the limbs. The improvement was marked and imme- CEREBRAL HEMORRHAGE. 12§ diate. The muscles lost their atrophic state, and became firmer and larger. The patient was able to perform many actions with his hands not possible before this treatment. Faradization to the lips and cheek has effectually overcome the facial paralysis, and he now speaks dis- tinctly. Cerebral Softening ; Right Hemiplegia. — H. Walker, aged 62, Germany, canal-boat captain, presented himself for treatment in December with a well-marked right hemiplegia. He had been injured some time before Avhile on the deck of his canal -boat, and then hit upon the head. He was senseless for some days, but recovered, with severe cerebral disturb- ance, which, from his wife's statement, must have been inflammation of the cerebral substance. He left his bed after some weeks, with persistent pain in the head, aphasia, trembling, and a heavy feeling of the lower limbs. His memory and other mental faculties became obscured, and there was an uneasy expression of the eyes. About a year after the receipt of his original injury, while working one day in the sun, he had an apo- plectic fit. After remaining in bed some time, muscular power and cutaneous sen- sibility slowly came back. He was able to walk with difficulty; his speech was indistinct; the muscles of both the leg and arm were greatly atro- phied ; and I determined to use faradism. The constant use of the veyy mild current for several weeks brought back, to some degree, the original contour of the paralyzed muscles. He was able to progress with a cane, but his speech remained imperfect. During the treatment he had repeated premonitory signs of a new attack. Faradism was resorted to to prevent atrophy, but its good effects were only temporary, as there is still softening. In connection with this treatment we may give at the same time either iodide of potassium, strychnine, or ergot. Iodide of Potassium. — Should there be a syphilitic history, I think we may begin at once with this remedy. If there be no such dyscrasia, I do not approve of the remedy at any time. It is administered very often with the idea of producing absorption of the clot, and is recommended by many writers. My limited experience has convinced me that its virtues have been very much overestimated. I have found that in many cases the patient's tendency to recovery was hastened more by rest, good food, and fresh air, than by any other form of medication. It is perhaps of value in old cases. Phosphorus. — Either in its pure state, or in combination with zinc, it is of great benefit in cases of long standing, especially if there be debility and tardy restoration of power in the paralyzed limb. The phosphide of zinc in doses of one-third of a grain, or dilute phosphoric acid in half-tea- spoonful doses, are perhaps better borne than pure phosphorus. Strychnine is entitled to more consideration. If used at the proper time, it is more powerful to do good than any other remedy I know of, perhaps excepting electricity. When the exaggerated electro-muscular irritability subsides, we may give it in doses of 1-32 of a grain three times a day, but before this time its use is attended with danger. 126 DISEASES OF THE CEREBRUM AND CEREBELLUM. Vance' has recommended hypodermic injection of strychnine, but I always hesitate -when injecting an irritating substance into the belly of a paralyzed muscle, for I have repeatedly seen abscesses follow the use of even a neutral solution properly injected. Impaired muscular vitality and tardy reparative nutrition do not favor its use. However, Bartholow, Eulenberg, and Echeverria recommend its employment, and have had good results. Perhaps in paralysis of central origin the trouble to which I have alluded is not so much to be feared as when the affection is peripheral. Each muscle is to be subjected to injection, one being so treated each day. Instead of the plan recommended by these authorities, viz., injections into the substance of the muscle, I prefer local subcutaneous introduction of the solution by the hypodermic syringe. In addition to electric treatment, it is well to resort to massage and passive movement of the contracted members. The patient may be directed to do this himself, and he should be told to rub the paralyzed limb several times daily for at least fifteen minutes at a time. Dr. G. M. Beard has recommended heat in the treatment of paralysis, and his plan is to place the affected limb in a heated earthen drain pipe, well lined with flannel. I can quite agree with him, but have found that alternate heat and cold applied to the sur- face jiroduce more rapid improvement in nutrition of parts which have lost their power. I originally recommended the instrument depicted in Fig. 22, which will be found a cleanly and convenient apparatus. One receptacle is filled with hot water, the other with cold. If the contracted limbs Fiff. 22. Instrument for .applying Heat and Cold. where lately rigidity has taken place are allowed to remain daily for fifteen minutes or half an hour in quite hot water, much benefit will follow ; or, should there be neuritis, we may use blisters, or the actual cautery along the course of the nerve trunk. It is of the utmost import- ance that evei'ything should be done to improve the patient's hygienic surroundings, diet, and habits. He should not remain in-doors, but stay in the open air as much as possible. Food of a nutritious but not of a fatty character, moderate stimulation if needed, and a course of tonics, may constitute our form of treatment during this late stage of the dis- ease. ' Journal of Psychological Medicine, April, 1870. CEREBRAL ANEMIA. 127 CHAPTER III. DISEASES OF THE CEREBRUM AND CEREBELLUM (Continued.) SYMPTOMATIC CEREBRAL ANEMIA. Synonyms. — Syncope, Anemie Cerebrale, Hydrocephaloid. Definition. — A morbid state charactei-ized by an insufficient cere- bral blood-supply, and expressed by impairment of consciousness, pallor, and much muscular enfeeblement. This disease is capable of quite as great modification as cerebral hyperasmia, as it may be what only appears to be a continued physiological condition, or a grave pathological state. Cere- bral anaemia may occur : 1, in an acute form (syncope) ; 2, in a chronic form ; 3, in an infantile form (the hydrocephaloid of Marshall Hall) ; and, 4, it is localized or partial, as a result of vascular obstruction. The acute form, which may be only a simple fainting attack, or the result of shock following severe hemorrhage, is the most familiar variety. It is hardly necessary to describe the alarming and familiar condition that we occasionally meet with after post-partum hemorrhage, or protracted decu- bitus, when the patient assumes the erect posture. The chronic variety is much less serious in its earlier stages, though, when continued, it is often the forerunner of certain forms of insanity. It is symptomatized by lowered function of the cerebral ganglia, depraved nervous tone, and general intellectual apathy; for, as normal circulation is necessary for the support of healthy brain action, and as we find that rapidity of thought and emotional activity are proportionate to the increase in the cerebral blood-supply, so must insufficient circulation bring with it an impaired state of intellectual functional activity. This loss of healthy action may be expressed by drowsiness, obscured intelligence, or by irritability and restlessness. The infantile form generally follows some of the continued fevers of early life, and is a disease of childhood. Occurring during the stage of convalescence of the acute form, it is symptomatized by semi consciousness, diarrhoea, great exhaustion, insensitive pupils, pallor, sighing respiration, and other symptoms. The last variety, local or partial cerebral ancemia, is that which is usu- ally productive of right hemiplegia, and is due, in the majority of cases, to thrombosis or embolism, and often has a grave termination. It is hardly necessary to allude to acute cerebral anaemia, for it comes within the province of the surgeon rather than within that of the neuro- logist. Following some grave accident when there is sudden and excessive loss of blood, we shall find a corresponding loss of consciousness, and muscular power, sighing, and slow respiration, generally vomiting, and involuntary discharge of feces and urine. 128 DISEASES OP THE CEREBRUM AND CEREBELLUM. The condition is not a lasting one, and provided the hemorrliage has not been too excessive, nor the shock too great, there may be a retrograde disappearance of the symptoms, and ultimate recovery. Symptoms. — A. Chronic Cerebral An.emia.* — Pallor of the skin, particularly of the face, which is of a dirty white color, while the sclerotics are milky blue, and the pupils widely dilated. The patient's expression is one of anxiety and depression, and if the condition be advanced and of long standing, he will spend hours with downcast eyes and a painful hopelessness, and hebetude stamped upon every feature. Coldness of the hands, heart-murmurs, and a weak, small pulse, are strong evidences of defective circulation of this description. The sphygmograph gives an almost straight tracing, the pulse-beats being weak and small. If the condition has gone on to the state where mental impairment has begun, we will generally find that there is venous stasis, and that the back of the hands is of a livid color, while pressure leaves a white mark which slowly disappears. The lips are pale, thick, and puffed, and the line between the mucous membrane and skin is less sharply defined than in the normal state. The urine is passed in large quantities, is colorless and limpid, and of a low specific gravity. The heart-sounds are weak, and it is not uncommon to find an aortic bellows murmur. Our patient complains of muscular debility, backache, loss of appetite, and somnolence, with great despondency, increasing loss of memory, marked headache, a regularly distributed cutaneous anaesthesia, sometimes nausea, hallucina- tions of sight and hearing, palpitation, indigestion, and constipation. I have been told very often by these patients that it was with very great difficulty that they could refrain from falling asleep in public places, and one lady was in the habit of becoming so drowsy in the street car on her way to my office that she very often unconsciously passed the street. Wo- men who suffer in this way are subject to fainting attacks, which occur most often during the menstrual period. Among the most aggravating symptoms are hallucinations of hearing ; noises — such as ringing of bells — are heard ; and they occasionally have visual hallucinations in connec- tion therewith. Delusions are very unusual. Insomnia is sometimes a distressing symptom, though during the day, as I have before said, the patient may have gi'eat difficulty in keeping awake. It is not uncommon for him to complain of a sensation as of falling through the bed ; and one of the prominent elements of his sleeplessness is the continuous roar- ing in his ears, which is sometimes compared to the sounds heard when a shell or other hollow body is placed over the ear. There may be amauro- sis, and other defects of vision. Digestive derangements are quite common, and vomiting, which is cerebral, is in some cases frequent and obstinate. The individuals presenting these symptoms are poorly nourished. There may be oedema of the legs and ankles, and sometimes albuminuria. * This term is used with caution, as it will not do to be too positive in making a diagnosis unless we .ire sure of the existence 'of some general cause. There are un- doubtedly many cases of chronic cerebral ansemia due to the existence of organic cerebral disease which present symptoms mistaken very often for those of functional disease. CEEEBEAL ANEMIA. 129 Feebleness and want of muscular power, of a light grade, are often ex- pressed ; and the comfort of a sofa or easy chair is sought by the patient, who seems disinclined to take any exertion whatever. B. Infantile Ceeebeal Anemia. — Marshall Hall has called atten- tion to a most interesting form of anaemia, to which I have casually refer- red, and to which he has given the name " Hydrocephaloid." The disease depends principally upon exudation, and has its origin in early infancy. A case is related by Hall : — " The patient, a boy, aged four, became comatose and perfectly blind and deaf. The finger might approach the half-closed eye without induc- ing any movement, but the moment it touched the eyelash, the eyelids would close. A spoon applied to the lips excited their action, and the food it contained was carried into the pharynx and swallowed ; the respi- ration was frequently suspended ; a sigh, and frequent respiration fol- lowed. The cerebral functions had ceased ; the true spinal functions were made."^ Marshall Hall lays down certain rules from which I may extract the following. We should especially be upon our guard not to mistake the stupor or coma into which the state of irritability is apt to subside, for natural sleep, and for an indication of returning health. " The pallor and coldness of the cheeks, the half-closed eyelid, and the irregular breathing, will sufficiently distinguish the two cases." He divides the affection into two stages, the first of which is one of irritability, the second, of coma. In the former there is some attempt at reaction, and in both stages there is some resemblance to acute hydrocephalus. " In the first stage the infant becomes irritable, restless, and feverish ; the face is flushed, the surface hot, and the pulse frequent ; there is an undue sensitiveness of the nerves of feeling, and the little patient starts on being touched, or from any sudden noise ; there is sighing, and moan- ing during sleep, and screaming ; the bowels are flatulent and loose, and the evacuations are mucous and disordered. If through an erroneous no- tion of this afiection nourishment and cordials be not given, or if the diarrhoea continue either spontaneously or from the administration of medicine, the exhaustion which ensues is very apt to lead to a very difier- ent train of symptoms. The countenance becomes pale, the cheeks cool or cold ; the eyelids are half closed, the eyes are unfixed and unattracted by any object placed before them ; the pupils are unmoved on the ap- proach of light ; the breathing, from being quick, becomes irregular, and aflEected by sighs ; the voice becomes husky, and there is sometimes a husky teazing cough ; and evidently, if the strength of the little patient continues to decline, there is crepitus or rattling in the breathing ; the evacuations are usually green ; the feet are apt to be cold." It is my opinion that this form of disease is very much more common than it is supposed to be, and that many deaths usually reported as ma- rasmus are evidently of this nature. 1 Op. cit., p. 181. 130 DISEASES OF THE CEREBRUM AND CEREBELLUM. Of local cerebral ancemia I will speak in another chapter. Causes. — As causes of cerebral anaemia we may roughly class all agents that interfere with the cerebral blood-supply, and consider them as remote or local. Whether the fault lies in a diseased heart, which is un- able to supply the brain with its normal amount of blood, or whether there is some mechanical obstruction through pressure upon the cerebral arteries, the morbid condition is the same. By far the most common cause of this cerebral condition is a general anaemia which may be dependent upon a number of conditions which drain the vessels. Among these may be enumerated uterine hemorrhages of various kinds, hemorrhoidal fluxes, cancers and other diseases attended by hemorrhage, as well as general dis- eases of assimilation which prevent the proper enrichment of the blood. A very slight reduction in the quantity of the blood will be followed usually by indications of the want felt by regions deprived of their nourish- ment ; but when the nervous system suffers this deprivation, the loss is immediately shown. Haller has calculated that one-fifth of all the blood in the body is sent to the brain, and with this fact in view, it will not be difficult to realize how any modification of circulation will result in im- mediate changes. Heart disease generally in the form of fatty enlarge- ment when there is mitral stenosis, or when functional activity is inter- fered with by emotional or other causes, may have much to do with cerebral anaemia. This cause enters, perhaps, more extensively into the production of chronic cerebral anaemia than any other. Owing to the delicate arrangement of the vaso-motor nerves which so beautifully con- trol the supply of cerebral blood, when through emotional or other causes the function is altered, there will be immediate intra as well as extra- cranial anaemia. We have all seen that sudden emotions not only blanch the face, but as well produce faintness. Various changes in the functions of the liver may be associated with states of cerebral antx^mia through modification of function of this system of nerves. Milner Fothergill has pointed out the association between the nerves of this organ and those which supply the vertebral arteries ; and Schrceder Van der Kolk and Lay- cock have held that those parts of the brain suj^plied by the vertebral arteries were the seat of the emotions. Fothergill reminds us of the fact that we may have functional derangement of the liver without affection of the intellect, but with depressed emotional states. There are other forms of abdominal trouble, such as an overloaded rectum and uterine de- rangement, which coexist with melancholia and depression of spirits, and every practitioner has seen the wonderful elation of spirits i^hich follows a free movement of the bowels after continued torpidity of the liver. The extension of the cerebral vaso-motor, and the involvement of other areas of blood-supply may, of course, make the condition a more extensive one, and disturbances of motility and intellection naturally ensue. Pressure made upon the carotid or vertebral arteries by various tumors or growths, or sometimes by aneurisms, is a mechanical cause of cerebral anaemia of decided importance. I assisted at an operation several years ago where the carotid on one side was tied by Drs. Sands and Parker, of CEREBRAL ANiEMIA. 131 this city. In less than twenty-four hours the patient died from extensive ansemia, owing to the failure of compensatory supply. Embolism is per- haps the simplest example of a cause of this kind. A detached vegetation or clot is washed into the circulation, up through the left carotid and into the middle cerebral artery for instance, cutting off the circulation, and producing extensive cerebral anaemia on the left side, while right hemi- plegia and aphasia follow. In thrombosis the artery is narrowed by the gradual deposit of plastic substances until finally its calibre is occluded, and the blood must take some other channel or not reach the part which it normally supplied. Apoplexy, or brain tumors of various kinds, and atheromatous narrow- ing of cerebral arteries, are also direct causes. In the first two instances pressure is made directly on the brain substance, and in the latter there is a gradual change in the vessels themselves. As a familiar illustration of how cerebral anaemia may be produced by a drain upon the general vascular system, I may allude to the case of a patient whose trouble dated from a series of miscarriages occurring within a very short period. One of these happened when it was impossible to procure medical attendance, and she lost a great quantity of blood. After the last event she never completely recovered, and her present disagreeable and annoying condition remained. She was drowsy, had frontal headache, ringing in the ears ; was constipated, etc. Another pa- tient was subject to attacks of despondency, when life seemed very dis- tasteful and gloomy. Her appearance was characteristic. White skin, cold hands, palpitation, and other symptoms enabled me to diagnose ce- rebral anaemia, and vomiting and vertigo were confirmatory symptoms. The cause was found to arise from very troublesome hemorrhoids. After cauterization and removal, she regained her previous health. Certain medicinal agents, as well as tobacco, produce cerebral ansemia. The bromides undoubtedly possess this property, while chloral and chlo- , reform, if taken for a long time, as they often are, are likely to provoke an anaemic state of the brain which is distressing in the extreme. I can recall the case of a young lady who confessed that she had been in the habit of putting herself to sleep at night with chloroform, besides inhaling it several times during the day. I have never seen such a typical case of this morbid condition. Her skin was of a hue of waxy whiteness, her pulse small and fluttering, her pupils widely dilated, and her languor and muscular feebleness very profound. Depression and the contempla- tion of suicide prompted her to confess her bad habit. Tobacco, though only affecting the heart, through its interference with pulmonary func- tions, undoubtedly produces in some individuals a condition of cerebral anaemia. The clammy, white skin, giddiness, dilated pupils, hurried respiration, and unsteady, weak pulse, and not uncommonly syncope, at- tendant upon nicotine poisoning, are, I think, evidences of cerebral anae- mia. Certainly the after effects are clearly suggestive of this morbid cerebral condition. That tobacco, in many individuals, in fact the great proportion, possesses stimulating effects, there can be no doubt ; but the 132 DISEASES OF THE CEREBRUM AND CEREBELLUM. variation of effects which follows the administration of opium, for exam- ple, when there is some idiosyncrasy, clearly leads us to infer that its ac- tion is sometimes different from that determined by the majority of phy- siologists. Physostigma, veratrum, aconite, and like cardiac sedatives may be mentioned as other ana^miants. Various conditions, such as lithiasis, are sometimes unsuspected, but nevertheless very important causes of cerebral anaemia. Morbid Anatomy and Pathology. — As we might expect, the ansemic brain is white, firm, reduced in bulk, and greatly changed. The vessels are empty, and there are no puncta visible when a cut is made through the white matter. We may find a distension of the perivascular spaces, the ventricles, and arachnoid spaces by fluids, and occasionally some thickening of the neuroglia. I have spoken in another chapter of the circumstances which modify the cerebral circulation. It only remains for me to refer to the experi- ments of Kussmaul and Tenner, Burrowes, and others, who have devoted a great deal of attention to the experimental study of this subject. The experiments of the first two observers were made upon six adults and a number of rabbits. When the carotids of the human subject were compressed, pallor, loss of consciousness, slow respiration, and dilated pupils were produced, which disappeared when the pressure was remitted, and could again be produced at will. Tying of the carotids was followed by convulsions, unconsciousness, and death, when post-mortem examina- tion revealed evidences of softening. In the first experiments, when pressure was remitted, there were evi- dences of a secondary cerebral hypersemia with flushing of the face. Ob- struction of the artery on one side may produce loss of motor power on the other, with immediate giddiness, loss of consciousness, syncope, and occasionally vomiting. There may be complete recovery after such an accident, but " it is always imperfect when the obstruction is situated on the further side (from the heart) of the circle of Willis."^ The obstruc- tion of the minor cerebral arteries, is followed by less complete intellec- tual derangement, by more marked vomiting and giddiness. Should the anaemia be quickly produced, as it is when severe injuries have been re- ceived and the patient literally " bleeds to death," convulsions form a prominent and almost constant symptom. Sighing respiration, and the other phenomena I have already named, are also expressed. In cerebral anaemia there is impairment of functional activity, while in congestion the reverse is the rule. Post-ynortem examination shows that the brain in cerebral anaemia is white, condensed, and less bulky, and the vessels are empty. We have already cited the causes of cerebral anaemia, and it now re- mains for us to consider the part they play. Cerebral anaemia depends upon — ^ H. Jones, Functional Nervous Disorders, p. 66. CEREBRAL ANEMIA. 133 1. The insufficiency of cerebral blood-supply, through actual defi- ciency. 2. The action of certain agents upon the nerve-filaments themselves. It is hardly necessary to again more than allude to the first of these. In this condition the effect of posture is said to greatly influence the cere- bral state. The erect position is conducive to an aggravation of the symptoms, while recumbency favors the flow of blood to the brain. This relief follows the supine position when the individual has an ordinary attack of syncope. Abercrombie relates a case which is quoted by Foth- ergill, and which is, I think, a beautiful practical example of this change. The patient, who was greatly reduced by some gastric disease, gradually became deaf, but heard perfectly well when he lay down or stooped for- ward. As soon as his face became flushed, the improvement in hearing began, and when he raised his head the blush faded away, and he relapsed into his old condition. Abdominal paracentesis is followed by syncope, if the patient is not made to assume the supine position, for during ascites the abdominal veins are so impinged upon that when pressure is remitted they are capable of suddenly receiving a very large quantity of blood — in fact, so much as to deprive the brain, and produce anaemia. A quan- tity of blood gravitates directly through the superior and inferior venge cavse, not being thrown over by the right ventricle, but passing down into the abdominal vessels. Insufficiency of cerebral blood may be due to a powerless heart, or aortic insufficiency, that organ being unable to lift a requisite amount of blood for the nutrition of the brain. Not only may this be a direct re- sult of a weakened organ, but it may follow strong emotional excitement. This assumption of the recumbent posture is one of the best therapeu- tical means in certain cases. Dr. Weir Mitchell has had extraordinary success in the management of certain intractable cases, some of which were directly dependent upon cerebral anaemia. Of the second mode of production, I may allude to the local efiect of some blood poisons, and the influence of the emotions. Bearing in mind the important physiological law that section of the sympathetic is followed by vascular dilatation, and that irritation of the proximal end produces contraction, we are enabled to realize many of the pathological processes which occur in the production of cerebral ansemia. Anteriorly the vaso- motor fibres are derived from the superior cervical ganglion, and poste- riorly the fibres come from the inferior cervical ganglion. These fila- ments follow the course of the large cerebral vessels, and in this manner supply every part of the cerebral mass. This close relation with the vascular system explains the prompt action upon the heart of certain exciting emotions, and secondarily the varia- tion in blood-supply. This is the idea held by Fothergill and others, and most admirably explained by that writer in an article in the West Riding Reports} ^ Art. Cereb. Ansemia, vol. iv., p. 108. 134: DISEASES OF THE CEREBRUM AND CEREBELLUM. The connection between variation in cell action and the function of the sympathetic fibres is, perhaps, the most interesting part of the sub- ject. Primarily the influence of impoverished blood affects the integ- rity of the cerebral nerve-cells, and secondarily the influence of the cere- bro-sjiinal fibres is suspended. I have no doubt that a certain train of symptoms, which is sometimes expressed during general amemia, is the result of a temporary local hypera^raia, through paresis of thevaso motor fibres ; and that parts of the brain are congested while others are anajmic, A result of continued emptiness of the vessels is an oedematous condi- tion of the brain, from distension of the perivascular spaces by the cere- bro-spinal fluid. This condition is sometimes so ext-^nsive as to receive the name "serous apoplexy," and profound stupor is the result. In relation to sleep and its connection with cerebral antemia, it will bewell to say a few words. A great many observers, among whom ■were Durham and Fleming, strongly held that the brain is ani3emic during repose, the anremia being the cause of sleep. Others have diflPered with them ; and experimental facts seem to favor this view of the case. Not only may ansjemia be unattended by sleep, but a condi- tion of unconsciousness closely resembling healthy sleep may be the re- sult of a hypersemic cerebral state. Opium, alcohol, and various agents ■which increase the cerebral blood-supply, act in this way ; but the stupor ■which foilo-ws a toxic dose of either agent must not be confounded with natural sleep. Certain curious facts militate strongly against the anemic idea, or, at least, against the assertion that sleep is directly dependent upon a diminution in the supply of blood to the brain. 1. There are many anaemic individuals who sleep only after taking stimulants. I think all who have seen the good effects of a bottle of ale at bedtime will be disposed to take this view. The sleep produced in no ■way resembles stupor, and there is no disagreeable sense of fatigue in the morning. 2. Dr. Janeway made an interesting experiment. This consisted in the administration of a few drops of nitrite of amyl to a sleeping person. Although cerebral congestion followed, the patient did not awake. 3. If mental action is dependent upon activity of the cerebral circula- tion, and sleep upon anosmia, it almost seems that dreams must be incon- sistent with sleep ; while, on the contrary, many individuals enjoy the most vivid and constant dreams, and do not awake till their usual hour. I am more inclined to think that the production of sleep depends upon some change in the function of the nerve-cell, and that this modified form of action is not necessarily dependent upon either anaemia or congestion in any particular case, but that, if there be ancemia, it is secondary to the cell-change, whatever that may be. The connection of a torpid condition of the liver with cerebral antemia ■will exjilain the constipation, which is anything but an uncommon accom- paniment of the disease. Intestinal accumulation, as Fothergill says, may " stand to cerebral anremia in a causal as well as a consequential re- lationship," and he alludes to the experiments of Ludwig and Daziel to CEREBRAL ANEMIA. 135 illustrate tbe connection. A finger passed over the intestines produced acceleration of the intracranial circulation. The general symptoms, such as languor, the various modifications of sensation, etc., are directly due to a diminution in nervous supply. Diagnosis. — Acute general attacks of cerebral anaemia may be con- founded with cerebral congestion, stomachic and auditory vertigo. I have already spoken of the distinction to be made between the disease under discussion and cerebral hypersemia, and it is not necessary to say more. Attacks of stomachic vertigo, or Meniere's disease, are symptomatized as follows : The first is characterized by a feeling of " emptiness of the head," reeling and swimming, general coldness ; " objects whirl around ;" 710 loss of consciousness, nor marked disposition to sleep. No dependence upon a very full or empty stomach, and the possible existence of gastral- gia. In Meniere's disease there is aural disease, and turning or whirling generally to one side, from left to right, and the condition is not continu- ous. The most important facts to discover are in relation to the cause, whether it be a secondary condition, the result of cardiac trouble, or whether it be simply a result of general anaemia, without any organic disease. Chronic cerebral ansemia presents various phases, and it is almost im- possible to go over the long list of general diseases which it may be a feature of, or, which, like hysteria, it m^y counterfeit. Cerebral tumor may give rise to symptoms which are really due to cerebral anaemia. So perfect is the resemblance that Dr. Hughlings Jackson told me recently that it would be impossible for him to make a diagnosis in many cases with any degree of certainty. Prognosis. — As cerebral anaemia is nearly always due to some cause which is easy of removal, the prognosis is good. If, however, there be organic heart trouble, the case assumes a difierent aspect- Old cases are extremely discouraging, particularly when the patients happen to be women. Irritability and hysteria generally enter largely into the com- plaint, and treatment is sometimes almost useless. If uterine, hemor- rhoidal fluxes, and other such drains, exist, of course their amelioration is attended by cure. Should the loss of blood be caused by a cancerous uterus or rectum, the prognosis is consequently very bad. Treatment. — It is of the utmost importance that the practitioner should seek out and remove, if possible, such conditions as diminish the amount of blood in the body, and consequently he must ascertain the existence of hemorrhoids, uterine hemorrhages, either periodical or irre- gular, and apply appropriate remedies in such cases. Without ventur- ing upon another field, I would call attention to the necessity, in cases where there is menorrhagia, of overcoming this condition as promptly as possible, for special treatment of the nervous condition is of little avail when the woman every month loses a quantity of blood largely in excess of what is made in the interim. I have, of late, had encouraging success in the treatment of cerebral anaemia by means of nitrous oxide gas. This gas is essentially a nervous stimulant, and while its action is 136 DISEASES OF THE CEREBRUM AND CEREBELLUM. somewhat like that of oxygen, it has the advantage of influencing the in- tellectual and emotional functions. The use, say of two gallons of gas mixed with one of air, will produce pulse quickening after two or three full inhalations, and such quickening will be attended by very slight flushing of the face, and throbbing of the temporal vessels. If the administration be carried sufficiently far a condition of tempo- rary unconsciousness results, which is attended by ansesthesia, and upon recovery, there is a certain amount of reaction. It is unnecessary to say that the extension of the eflects of the gas to this stage is entirely out of the question, and an extremely injudicious measure when the desire is to improve circulation and nutrition. Exhilaration of spirits is the rule after its use, not however, necessarily amounting to the abandon that so often follows the lecture room experi- ments of ten or fifteen years ago, but sufficient to indicate a very decided activity of ideation and the emotions. Melancholic and taciturn sub- jects became animated and cheerful in their address and behavior. One of the patients, of the late Dr. J. Ellis Blake who first used the gas in America as a therapeutical agent in nervous disease, declared that the figures upon his ledger bore an entirely different import after he had taken his dose of gas, and walked to his office, and the debit side looked wonderfully less depressing. In another case, the patient who had left home quite reluctantly, and desired at first to go back immediately, forgot all his worriments after the first two or three days of treatment. It is cer- tain that in hypochondriacal patients many minor aches and pains are forgotten, and a general couleur de rose tinges everything. My attention was forcibly drawn to this effect upon certain patients after I had used it with melancholies, both in my private practice and at the Insane Asylum at Blackwell's Island. One of these had suffered for several weeks from the most profound despondency. Her trouble had grown out of menstrual irregularity, and was evinced by religious delu- sions of a mild type, inclination to avoid the society of her friends, and an occasional refusal to eat. The use of the gas for several weeks en- tirely removed her mental trouble, and she became quite cheerful. In the presence of Drs. MacDonald, Pitkin, and Lesynsky, nitrous oxide was given to two melancholic patients at the Female Insane Asylum who had refused food, and had not eaten voluntarily for two weeks. Both of the women went to the table and ate heartily the same even- ing- In other cases of melancholia with defective surface circulation, the venous stasis which gave the hand a dusky purple color disappeared in a few days to a great extent, and the white mark which remained after pressure of the finger upon the back of the hand had been remitted, did not last nearly so long, nor was it so sharply defined as under other circumstances. The warmth of the extremities was decidedly in- creased, and the expression of the eyes was brighter, and much more in- telligent. CEREBRAL ANEMIA. 137 Mitchell ^reports seven cases of melancholia, mania and dementia treated with nitrous oxide, in all of whom interesting effects were wit- nessed. The gas was not administered however, for its stimulant effects alone, but given until the point of partial unconsciousness was reached. Active measures are necessary when there is general ansemia, and for this purpose we must resort to iron, strychnia, phosphorus in some of its forms, cod-liver oil, an abundance of nutritious food, with stimulants such as milk punches, porter, or ale. A word or two is necessary in regard to the diet, and the quantity of alcohol given to these patients. It is the physician's bad fortune to meet with cases of this kind in which digestive troubles are dependent entirely upon an enfeebled state of the viscera, and we should therefore use great care and not be impatient. A hearty regimen, and too much alcohol, may do mischief instead of good. It is well, therefore, in certain cases, to give the stomach as little work as possible, and at the same time to allow it to exert itself in a way that will most benefit its possessor. A very little food, given at short intervals, will be more perfectly digested and assimilated than a large quantity taken at long intervals. I have often given a few table-spoonfuls of cream or beef-juice every hour for days, and have ultimately seen such a marked improvement and an in- creased capacity for work upon the part of the digestive organs, that the more gross varieties of animal food, as well as alcohol, were after a while borne in large quantities. Should this enfeeblement of the digestive organs exist, we may give either pancreatine emulsion, or strychnia and muriatic acid. Extract of malt is sometimes very well borne, and hastens the improvement. This may be given in combination with codliver oil. One of the most useful forms of treatment to which I have already alluded — the " rest treatment " of Weir Mitchell — is of marked service in old cases, especially if the subjects happen to be women. Dr. Mit- chell has treated many cases which are almost identical with those that generally come under the head of chronic cerebral ansemia. He says : " These cases vary, of course, endlessly ; but their essence is a state of reduced nutrition, which no mere tonic will cure, while they are afoot and living on their capital. The main symptoms are the state of painful tire, the low temperature, the great or less ansemia, the quick pulse, the excess of white blood." He calls attention to the necessity for perfect quiet, and at the same time daily massage and faradization of all the muscles. His treatment is expressed in his own words thus : " The amount of feeding, of massage, and of faradic-muscle exercise which each case will bear and prosper under, is a matter to be told early in the case by watching the pulse, the temperature, and the appetite. In these cases the pulse is always rapid. If it fall, if the temperature rise, above all, if there be the least gain in flesh, I know that I am on the right path and am not moving on it too fast ; but if these symptoms be reversed, and if the patient ceases to be hopeful and looks weary, then I lessen the pas- sive exercise, and wait a little ; but, above all, I listen to what my 1 W. E. Eeports. 138 DISEASES OF THE CEREBRUM AND CEREBELLUM. masseur or masseuse tells me of the ease with which the limbs flush or the readiness with which the muscles grow firm under the kneading fingers, for in this matter I get to have a very shrewd judgment. As to the rectal feeding, which I rarely omit, I say little, as it is well under- stood. It should always include cod-liver oil. There is only this to be borne in mind : most medical men feed by the bowel when they cannot by the mouth. I like to use both ends at once." This treatment seems to be the very best in cases of long stand- ing ; but it is well to see first what fresh air, tonics, and abundant nitrogenous food will do for our patient, while she pursues her ordinary life. The selection of a climate for the nervous patient is a matter of great importance. Dr. Deuison, of Denver, who has written much upon this subject, and who has lived in Colorado, speaks with some caution regard- ing the benefits of high altitude. He says : " The more acute or severe the nervous symptoms, the more of an aggravating nature is the effect of an elevation." ' He does not recommend Colorado for patients who suffer from epilepsy or cholera, but only in such cases where the diseases of the nervous system depends upon certain dyscrasia. Organic diseases are aggravated. In cases of nervous exhaustion with anaemia and depres- sion, there can be no doubt of the advantage of the stimulating climate of Colorado, and to such a place we might send our patients, expecting great benefit. STOMACHIC VERTIGO. Synonyms. — Vertigo a stomacho Iseso (Lat.) ; Vertige stomacal (Fr.) ; Gastric vertigo. Definition. — A condition of giddiness, hallucination, nausea, head- ache, etc., without loss of consciousness, and probably dependent upon a reflex excitation of the cerebral vessels from some visceral irritation. Symptoms. — The condition, which is a very common one, is pro- duced, in most cases, directly after a hearty meal, or else when the stomach is entirely empty. A sense of gastric fulness at first, while headache, with buzzing in the ears, palpitation, and giddiness of a few moments' duration, follow. Should there be hallucinations, the patient is not wor- ried by them, but realizes their unsubstantial character. Trousseau^ in- sists upon the fact that the hallucinations of this condition differ from those attendant upon cerebral hyperajmia from the fact that in this form they do not occur when the head is loioered, which is the case in cerebral hypersemia. Causation. — Stomachic vertigo is more a condition of middle life and old age than one of youth. Young women occasionally suffer, but this is the exception. Certain forms of indigestible food may directly pro- ^ Rocky Mountain Health Eesorts, p. 14-5. ' Clinical Medicine, Am. edition, vol. ii. p. 358, AUDITORY VERTIGO. 139 voke the attack, or it may follow violent exercise after a hastily eaten meal. In one case of which I know, a gentleman ran for over a mile to catch a morning train. He had arisen but a few moments before, and had hurriedly eaten his breakfast. He fell to the ground, but did not lose consciousness. The disorder often occurs when the individual has been eating irregularly ; and business men or others who take but little exercise and eat hurriedly are very often the sufferers. Handfield Jones^ considers taenia to be a frequent cause of vertigo, and such has been my own experience. Treatment. — Trousseau, who has written most fully upon the sub- ject, recommends that the patient be directed to drink every morning a glassful of quassia infusion made by maceration of the shavings in water, or to use the goblet of quassia wood in which the water is allowed to re- main until it has become bitter. After each meal one of these powders should be taken : — R. Sodse bicarb., Magnesise ealc, aa gr. xv. Cretse prsep. Jss- — M. Divid. in chart, no. iij. — Sig. One after each meal. Strychnia, pepsine, and sometimes bismuth are excellent remedies, and should be given, while attention is to be paid to the patient's general habits. AUDITORY VERTIGO. Synonyms. — Labyrinthine vertigo ; Meniere's disease. Definition. — A morbid cerebral condition expressed by vertigo and rotatory movements, unattended by loss of consciousness, and dependent upon disease of the labyrinth, or other parts of the central auditory appa- ratus To Meniere^ belongs the credit of having first accurately described this disease, though Triquet^ gives the credit of its discovery to Saissy, of Lyons, who observed a nervous condition connected with diseases of the inner ear. Trousseau* says that Saissy did not mention vertigo as a symptom of the condition to which he called attention. It is enough to say that, prior to 1861, the form then known only as stomachic vertigo was always supposed to arise from digestive troubles, and the existence of a distinct variety, with aural disease, was not appreciated. Symptoms. — Generally there are some indications of otitis, whether they be simple inflammation denoted by pain, or a discharge of bloody pus, or even perforation of the tympanum. In many cases the disease ^ Functional Nervous Disorders, p. 444. 2 Bulletin de I'Academie de Mfed., xxvi. p. 241. ^ Lefons cliniques sur les Maladies de I'Oreiile, p. 113, Paris, 1863. * Loc. cit., p. 363. 140 DISEASES OF THE CEREBRUM AND CEREBELLUM. may be preceded by a chill, and this should be always looked upon as a serious indication. The patient is suddenly seized with vertigo, and at the same time experiences a feeling of nausea and buzzing in the ears, which may be double, or confined to one side. This vertiginous condi- tion calls to mind a sensation experienced when one is twirled in a swing. A boyish prank is to twist the ropes of a swing while the unhappy victim is seated therein ; then to suddenly release the board, which revolves with great rapidity as the ropes unwind. This description of the symptom was given me by a patient who sufiered from nausea at the same time with vertigo. The vertigo is attended by a loss of equilibrium. The patient sways or reels, and there is an impulse to turn from the left to right when the left ear is affected, and vice versa when the other is the seat of the dis- ease. Ferrier^ describes a sensation usually experienced. He (the pa- tient) feels " as if he were suddenly lifted from the ground and pitched forward and to the right side." There is also a tendency, when walking, to keep close to the side of the wall or house which corresponds to the affected ear. Deafness is generally present, but this is, of course, the result of the destructive aural disease.* Recovery is not ahvays to be ex- pected, but a great many cases improve under appropriate treatment pre- sently to be described. John B., aged 47, iron railing manufacturer. Nearly eighteen months ago, he became troubled by noises in the left ear, which he compared to the " singing of canary birds," and afterwards this subjective noise changed its character, and he described it as a continuous roaring like the escape of steam from a boiler. To this sound he has since become partially accustomed. He has never had earache, but nine years ago there 1 Labyrinthine Vertigo, W. E. Eeports, vol. v. p. 34. ^ Crum-Brown is of the opinion that, in addition to the other senses, the individ- ual possesses one of rotation, by which we are able to determine the axis about which rotation of the head takes place ; the direction of rotation, and its rate. In explain- ing some experiments performed by him, he says: "In ordinary circumstances we do not wholly depend upon this sense for such information. Sight, hearing, touch, and muscular sense assist us in determining the direction and amount of our motions of rotation, as well as of those of translation ; but if we purposely deprive ourselves of such aid, we find that we can still determine with considerable accuracy the axis, the direction, and the rate of rotation. The experiments that I have made with the view of determining this point were conducted as follows: A stool was placed on the centre of a table capable of rotating smoothly about a vertical axis ; upon this the experimenter sat, his eyes being closed and bandaged ; an assistant then turned the table as smoothly as possible through an angle of the sense and extent of which the experimenter had not been informed. It was found that, with moderate speed, and when not more than one or two complete turns were made at once, the experimenter could form a tolerably accurate judgment of the angle through which he had been turned. By placing the head in various positions, it was possible to make the verti- cal axis coincide with any straight line in the head. It was found that the accuracy of the sense was not the same for each position of the axis in the head ; and, further, that the minimum perceptible angular rate of rotation varied also with the position of the axis. It was also found that considerable differences of accuracy exist in dif- ferent individuals." AUDITORY VERTIGO. 141 was a discharge from the left ear, but there have since been no other symptoms. He has sufiered for a long time from post-pharyngeal catarrh, and there is now a catarrh of both Eustachian tubes. When a young man he had secondary syphilitic symptoms, but denies having had any primary sore. Sixteen months ago, during hot weather, he was seized in the street with dizziness and reeling, and was obliged to grasp a lamp- post for support. There was no loss of consciousness, and he realized fully his condition of helplessness. He said that he felt as if he was be- ing "twirled" from right to left, but did not fall. This attack occurred before dinner (about 11 A. M. ), and his stomach was neither filled nor completely empty, for he had eaten his breakfast at 8 A. M. He was perfectly well otherwise, and the only disordered function was that of the lower bowels, for he was constipated. He has had these attacks very frequently. For the six months following the first attack of vertigo they occurred about once a month, but since then they had been of daily re- currence. Present State. — The patient's digestive organs are in good condition, and his appetite is fair. He is ordinarily of constipated habit, but it re- quires but slight medication to overcome this. He is of medium height, weighs 143 pounds, and seems a well-nourished man. His face is some- what sufiused when he becomes excited, but he is ordinarily pale. His eyes convey an anxious expression, but the pupils are normal. His hair is scanty and gray, but not removed in patches, nor suggestive of any pre- vious syphilitic trouble. He has occasional headache, and still complains of the " roaring " noise on the left side. Hears the tick of a watch only six inches from left ear, and indistinctly at any distance within this limit. Watch tick heard at five inches from right ear, but more perfectly. Dr. C. S. Bull examined his eyes, and the following is his report : — 20 20 " Examination of J. B. V= : with convex 32 spherical V=-— — - 40+ 40+ 1 H — . Fundus perfectly normal." 30 His attacks occur nearly every day, and seem to have no relation with the condition of digestion. These " reeling fits " may take place at any time of the day, last for five or six minutes, and usually are not so sudden as to prevent him from taking hold of the nearest lamp-post or railing. In a recent vertiginous seizure he was taken just as he was about to get into a street car, and would have fallen had the conductor not dragged him upon the step. He tells me that he has asked his wife to " turn him the other way " when the attack occurs, and usually this has the effect of abating it. I placed him upon large doses of quinine at first, which have decidedly influenced the frequency and character of the ver- tigo, so that he often passes a week at a time without any seizure. Bro- mide of potassium had been prescribed for him before his visit by another physician, but he tells me that this drug increased the dizziness. The phenomena of these attacks are the following : He suddenly feels light headache; objects swim about him from right to left while he seems to be rotated the other way, and during this period he separates his feet and braces himself The outlines of the houses, trees, and sidewalks are blurred and distorted, and after a few minutes they suddenly assume their proper relations, and the attack passes off", and he has subsequent headache. 142 DISEASES OF THE CEREBRUM AND CEREBELLUM. Causes. — The disease being directly due to aural inflammation, aud the causes of this condition, whether they be exposure, the extension of other inflammatory processes, or the injudicious use of douches and injection, are only secondarily productive of the neurosis. Pathology. — The experiments of Flourens and Goltz^ have been the basis for our pathological study of Meniere's disease. Brown-Sequard '' and Flourens demonstrated that when the membranous canals of the labyrinth were divided, various disturbances of equilibrium followed. Walter aud Lincke ^ and others have divided the horizontal canals and produced oscillation of the eyeballs, swaying of the head from one side to the other ; and have seen the animal spin round like a top. Division of the posterior vertical canal causes the animal to toj^ple over backwards, and the head is moved backwards and forwards. When the superior ver- tical canals were cut across, the animal pitched forward. It may be seen that a diseased condition, not limited to any particular spot, may produce a couibination of these symptoms. Brown Sequard, in speaking of the relation of rofary movements to auditory irritation, calls attention to these familiar illustrations : — " 1st. Any one who has received an injection of cold water in the ear may know that it produces a kind of vertigo, and that it is diflicult to walk straight for some time after this irritation. 2d. A sudden noise makes the whole body jump, particularly in old people, or in persons attacked with ausemia, chlorosis, epilepsy, chorea, hysteria, hydrophobia, and in certain cases of poisoning ; in a word, in all circumstances in which the control of the will over reflex actions is lost or diminished. 3d. Vertigo and various convulsive movements in cases of irritation of the acoustic nerve have been observed in adults and children. Rotatory movements have taken place in cases of suppurative inflammation of the ear, and twice imme- diately after an injection of nitrate of silver." Ferrier,* who has written most clearly upon this disease, goes very deeply into the subject. In the normal state it is necessary for tactile, visual, and auditory impressions to be unembarrassed, so that the power of equilibriation may be preserved ; but it is of absolute importance that the labyrinthine functions should be perfect. It seems to regulate the state of equilibrium of the individual, and to preside over co-ordination. The mechanism of the labyrinthiue canals is admirably described by Crum-Brown.* The sense of rotation, as suggested by him, must, like other special senses, have a special peri- pheral organ, a brain centre, and a connecting sensory nerve. All experi- menters agree that the labyrinth is a special peripheral organ, and the auditory nerve is that which conveys the peripheral irritation to the centre. ' Pfluger's Archiv fiir Physiologic, 1870, and Recherches snr les Propr. et les Fonctions dii Systerae Nerveux 2d. ed. ^ Central Nervous System, Philadelphia, 1860, and Experimental Researches, 1853. * Wagner's Handworterbuch der Physiol., vol. vi., 1853, p. 420 et seq. * Ferrier on the Faactions of the Brain, New York, 1876. ^ Journal of Anatomy and Phys., May, 1874. AUDITORY VERTIGO. 143 "The bony canals are filled with liquid, in which float loose connective tissue, and the membranous canals with the contained endolymph. Rota- tion of the head about an axis at right angles to the plane of a canal will then produce, on account of the inertia of the liquid, etc., motion of the contents relatively to the walls of the canal ; and this may be expected to irritate the terminations of the nerves in the ampulla. If the rotation be continued at a uniform rate, fluid friction of the endolymph against the membranous canal, and of the perilymph against the membranous canal, and the periosteum will gradually diminish this relative motion, which will at last cease. We should therefore expect, as we have seen to be the case, that continued uniform rotation should be perceived less and less strongly, and that the sensation should at last die away altogether. The time re- quired for this equalization of the motion of the canal and its contents will depend upon the rate of rotation and upon the dimensions of the canal and the amount of attachment of the membranous canal to the periosteum. These latter conditions are not the same in the three canals, and there- fore we ought to find, as we do, that the rate at which the sense of rotation dies away is not the same for different positions of the head. Again, if the uniform rotation is stopped, the contents of the canal will continue to move on, thus causing an apparent rotation in a direction the reverse of that of the original rotation, and this also will die away owing to friction." The irritation of the auditory nerves which occurs is attended by anaemia of certain parts of the brain, which accounts for the reeling, dizziness, nausea, and other symptoms with which we are already familiar. Diagnosis. — Gowers,^ in a paper before the British Medical Associ- ation, pointed out the liability of its confusion with gastric trouble. He calls attention to the fact that violent and repeated vertiginous attacks, the sense of movement or actual turning, tinnitus aurium, and deafness, are more suggestive of the auditory origin than of gastric vertigo. Gowers' cases were connected with affections of smell and taste, and at the same time in one there was a gastric ulcer. He made his diagnosis by the de- tection of loss of function of the right ear and by one-sided falling. It is often necessary to differentiate from petit mal, from apoplectic warnings, and from general cerebral anaemia. In the first there is rarely vertigo, but there is loss of consciousness of temporary duration, and there is some convulsive movement, though sometimes so slight as to be unrecognized. The presence of aural disease is enough to throw out of the question the other condition I have named. Treatment. — Large doses of quinine have been of service in these cases, and Chai'cot's^ experience with this agent is extremely gratifying. He recommends the energetic use of revulsives in vertigo, the cautery being applied over the mastoid bone three or four times a week. He gave sixty centigramme doses of quinine in one case for a period of two months with happy results, and a short time after the commencement the 1 Br. Med. Journal, Aug. 26, 1876. ' Lepons sur les Maladies du Syst. Nerv. No. 4, p. 321. 144 DISEASES OF THECEREBRUM AND CEREBELLUM, vertiginous attacks ceased. It is necessary to give the drug in large doses, and at the same time the aural disease should not be neglected. In the case of " J. B." I combined infusion of digitalis with the quinine, and obtained very good results. He was also directed to turn in an op- posite direction to that caused by the disease. Subsequent experience has convinced me that strychnine is perhaps better than quinine, and I have been highly successful in relieving a case of much greater violence in which increasing doses of the drug were administered. In this connec- tion it will be well to call attention to attacks of malarial vertigo of a periodic character which are sometimes encountered, and which resemble auditory vertigo : quinine or arsenic is of course indicated. INTRACRANIAL THROMBOSIS. 145 CHAPTER IV. OCCLUSION OF I]N"TKACEANIAL VESSELS. THEOMBOSIS— EMBOLISM. The deprivation of an area of greater or less extent of its blood-supply constitutes a condition which has been called by some writers " Local cerebral ansemia," and it may take place through the existence of either of the above vascular states. Though very closely allied, these two forms of mechanical obstruction may be defined : in one case, as the local formation of deposits, or morbid changes favoring obliteration of blood- vessels ; and in the other, as the lodgment of clots, or organized tissues which have been brought from a distance. Their chief intei-est lies in the fact, that it is often difficult for us to distinguish the subsequent symptoms from those indicating an effusion of blood from a ruptured vessel ; that speech troubles are prominent ; and that the prognosis is nearly always unfavorable. Thrombosis and embolism, though usually followed by many of the same symptoms, and confounded with each other by some of the medical writers by whom they were first described, difier greatly in their manner of occurrence and pathology. The first, as we shall hereafter see, is of slow development, and is not so serious in its re- sults as embolism, while the latter condition is much more grave in all its features. INTKACRANIAL THROMBOSIS. Any local vascular change from the normal state which favors the de- position of fibrine in an intracranial . vessel, whether it be an artery, a vein, or sinus, produces the condition which is known as thrombosis. As a consequence, the calibre of the vessel is narrowed, and circulation of blood is impeded therein ; clots form, and either from actual obstruction of direct supply or by pressure, a region of greater or less extent becomes anaemic. Though the arteries are more frequently the seat of such an al- teration, the veins and large sinuses and the capillaries may be plugged up by clots which are of local origin. The condition, however, last men- tioned is fortunately a very rare one, but when it is met with it is a most dangerous and alarming morbid state. 10 146 OCCLUSION OF INTRACRANIAL VESSELS. THROMBOSIS OF THE CEREBRAL ARTERIES. Symptoms. — It is ii disease of slow development, and may affect several arteries simultaneously, or but one. For weeks, or even months before, distressing and important evidences appear, and the patient may present unmistakable expression of the cerebral change, such as head- ache, which is generally localized, confusion of ideas, and awkwardness of speech, these disturbances being, usually, varieties of aphasia. As the disease advances, this trouble becomes much more pronounced, and, in place of there being simply a difficulty in expressing a clearly originated idea, there may be a condition of amnesia. Clumsiness of speech, and want of delicacy in articulation are followed by an actual failure in re- membering words. Memory is also defective in other things, and one patient begins to become stupid and listless. The next indication of this advance may be the appearance of paralysis, which is sometimes slight, or incomplete, only involving the muscles of the face or eyeballs, or there may be hemiplegia. Should the thrombus be seated in a large artery, or softening occur, a complete and lasting hemiplegia may be produced. There is rarely loss of consciousness at any time, and in very few of the cases that recover, is there anything at all like the paralysis following cerebral hemorrhage. Recovery is generally to be looked for, provided the vessel be not an important one; and, though like its first cousin, embolism, it may be one of the causes of softening, such a termination is not always to be feared, xlphasia, which is insisted upon by most writers as a pathognomonic sign, is occasionally absent. In one case reported, though the left middle cere- bral was affected, there was no aphasia at any time.^ The following case is one that came under my observation, and is of interest, because of the seat of the thrombus, and the interesting character of the morbid appearances : L. C, aged 22 years, seamstress; admitted into hospital October 9, 1876. History from friend who accompanied her. The patient had been feeling unwell for about two months, having had pains in her head and back, loss of appetite, insomnia, and other troubles. About a week ago the friend went up to her room to assist her to dress for breakfast. When the patient stepped out of bed she fell upon the floor, and then first no- ticed that she was completely paralyzed on the right side. The friend knew nothing of the patient's antecedents. Her husband, who was seen subsequently, stated that he had left her because she drank ; and that after the separation she went to New York and became a prostitute. Two years ago he saw her, and at that time she had marks of syphilis on her face, and her hair was falling out. She conversed with him intelli- gibly, but said she was suffering from " general debility." She had head- ache, pain in the back, etc., and was at this time leading a very irregular life; sitting up during the greater part of the night, and sleeping only a portion of the day. She went to Ward's Island for treatment. The ^ St. George's Hospital Eeports, vol. i., 1866, vol. vi., p. 322. THROMBOSIS OF CEREBRAL ARTERIES. 147 following history was taken by Dr. Naylor, resident physician in hos- pital : — Oct. 10. Complete hemiplegia of the right side, limbs lax, and muscles flabby ; impossible to excite reflex movements by tickling ; right pupil irregular, and smaller than the left ; tongue drawn to left side when pro- truded, and when she laughs the right side of the face is drawn up. Con- trol over the sphincters good ; temperature 101°; patient aphasic. When asked, " How long have you been sick ? " replied, " Since Benny ; " this answer was given to many questions asked. " What do you hold in your hand?" (it was a piece of bread.) "Tobacco." Seemed puzzled, but when reminded of its true nature she brightened up and appeared to real- ize her mistake. 13^/i. In about the same condition. Muscles of the right arm and leg do not respond to the currents. When asked how old she was, replied, " So and so." " What did you work at ? " "So and so.' ' " What street did you live in ? " Appears puzzled. " Was it sixteenth f seventeenth f eighteenth f " " Yes." " How long has it been since you last saw your mother ? " " You long so, John." Expression intelligent, and she seems to understand all that is said to her. Does not hear so well on left side, with right ear perfectly. 11th. Appeared to be suffering great pain. When asked to locate the pain, she did not attempt to do so. She has passed no urine since yester- day morning. Has a hard and swollen erythematous spot on the outside of each knee, and two similar enlargements on each leg below. There is a hardened red spot over the fourth cervical vertebra. All of these parts are painful to pressure. \dith. Eight hand somewhat swollen. 6 P. M. Is drowsy this evening. Appears to suffer pain, and places left hand upon abdomen. One pint of straw-colored urine containing no abnormal constituents was drawn by the catheter. 19^/i. Still dull and drowsy. Said nothing to-day but "yes," " no," and " well ;" passed her urine in bed ; stupid and dull all day. Carotid on right side pulsates very distinctly. list. Somewhat brighter to-day ; bowels regular. 21d. Relapse to stupid condition ; passed urine in bed ; became choked while eating some beef at dinner. 2bth. Still absolute loss of power and sensation on right side, and con- tinued drowsiness. 2Qth. Involuntary discharges of feces and urine. 21th. She brightens up after receiving nourishment, but cries and seems distressed. 28i/i., 2 P. M. Nurse called the house physician, seeing that she appeared to have stopped breathing. Her eyes were turned upwards and her lips blue, and her pulse was very weak and feeble. Ordered stimulants. Nov. 2d. Feverish and restless ; temperature 101° ; discharges from the bowels have stopped. %th. Complains of pain in her thigh and legs ; cries a great deal ; re- fuses food, and appears to be very much run down. ith. Right pupil approaching more nearly the size of the left ; appetite still good ; bowels regular. Cannot write her name with the left hand, but makes a disorderly scrawl. Asked her to repeat several words ; pro- nounced " eggs " very distinctly ; for " cross," she said " cork." 7 P. M. Quite feverish and restless ; temperature 102°. 14:8 OCCLUSION OF INTRACRANIAL VESSELS. ISth. Has still fever ; temperature 102^. Ordered quinine and cold sponging She cries, and appears very sensitive when moved. 14th. Slept well last night. 7 P. M. Temperature 100^. Several in- guinal glands on the right side are somewhat enlarged and painful on pressure. 22d. Complains of great pain at the attachment of the adductors to femur. The month of December was passed without anything occurring of spe- cial note. The patient grew much more feeble ; there was no improve- ment in the paralysis, and she became reduced to a shadow. Tlie tempera- ture continued elevated, and she was restless and delirious at times. Of course the burden of her delirium consisted of two or three words, which were repeated over and over. Jan. 8, 1877. Dr. Naylor was called to see the patient at 4 o'clock P. M. He then noticed some fibrillary contraction about the right angle of the mouth, with an occasional spasm of the upper lip, when it would be drawn up with the wing of the nostril. Eyes closed, pupils more con- tracted than usual, face flushed and head hot ; temperature in axilla 101 1°. When left foot was pricked she turned it up ; pulse too rapid to count ; heart's action tumultuous. Tr. digitalis, gtts xv. 5 o'clock P. M. Spasm of lip still continues ; lies on her back with eyes closed, and gives no evi- dence of pain when any part of the body is pricked ; pulse in same state. 6 o'clock P. M. Breathing heavily ; »£yelids closed and eyes turned up- ward ; pupils do not contract to light, but lids contract slightly when con- junctiva is touched ; reflex irritability very much impaired; j^ulse 100 ; temperature 102° 7 o'clock P. M. Spasm of mouth has ceased ; respi- ration very slow and feeble ; pulse 80 ; temperature 102^. 10 o'clock p. M. Mucous rales heard over whole chest. 12 o'clock A. M. Patient remains unconscious. 2 o'clock P. M. Patient still breathes slowly and feebly ; small amount of frothy mucus comes out of her mouth ; patient remained in this condition until death, 10 A. M., 9th instant. Autopsy. — Head : dura mater normal ; sinuses empty ; moderate eflTu- sion into arachnoid cavity ; pia mater intensely congested ; left middle cerebral artery about ^ inch from its origin occupied by a firm thrombus ; beyond this the artery was thin, ribbon-like, scarcely percei^tible, and finally lost ; membranes readily detached from the brain, leaving the sulci gaping widely over the under surface of anterior lobe, left side about third frontal convolution and island of Reil. In detaching the membranes por- tions of brain-substance were removed with them, leaving an almost pul- taceous mass exposed ; indeed the whole of under surface of anterior lobe was much softened, but this was most marked near the lateral border ; under surface of middle lobe slightly softened ; superior and lateral as- pect of anterior and middle lobes from fissure of Rolando forwards was in a very softened condition, breaking down under the least pressure, of a pale yellowish-gray color, in marked contrast with other parts of the brain, which on section showed very numerous puncta vasculosa, and were of the normal color. Thalamus opticus somewhat softer than that of the right side ; corpus striatiim much softened and of a yellowish color. Thorax : lungs cedematous, and poured out an abundance of mucus on section. Heart : insufficiency of mitral valve ; no vegetations noticed ; left ven- tricle entirely filled by a firm white clot entangled in chorda; teudinae and projecting into aorta ; abdomen, kidneys, liver, and spleen much con- gested. THROMBOSIS OF CEREBEAL ARTERIES. 149 Causes. — Men are moi-e often subject to arterial thrombosis than women or children, though we find the great number of cases of throm- bosis of the sinuses to be among women, and this perhaps due to the ten- dency of this sex to chlorosis. Gintrac considers very young children to be subject to venous throm- bosis. Of 37 cases seen by him, 14 were among infants ; but arterial thrombosis is a condition peculiar to advanced life, and instances before middle age are not at all common unless they be of a specific nature. The exciting causes are numerous, but it may be assumed in nearly every instance that the blood is in a state of hyperinosis as a consequence of acute disease, such as rheumatism or pneumonia. Excessive heat is very often a cause. Dickinson^ gives four cases, in two of which heat was the cause, in one other intemperance, and in the fourth violent vomiting, In many of these patients there is old heart disease with some enfeebled action of that organ. The basilar artery, which receives its blood from the vertebral arteries, may be the seat of a clot at its remote end when heart force is preternaturally weak, but this is a rare form of the disease. I have already spoken of peripheral phlegmatous troubles, and it is only necessary to call attention to the danger which may arise from carbuncle. The puerperal state favors the formation of thrombi, and just as phleg- masia alba dolens is brought about, so may the thrombosis of the cerebral arteries be produced. The graver variety of intracranial thrombosis may be produced by internal or external cause. Lancereaux collected 89 cases, 30 of which were connected with caries of some of the cranial bones, and 24 with otitis. In one-half of these cases there were multiple ab- scesses of the brain. In conclusion I would allude to the possibility of traumatic origin, a variety of blood-states, and pressure from intracranial tumors, exostoses, and thickened meninges. Morbid Anatomy and Pathology. — You Dusch, Paruum,^ Grissole,^ Zahn, and a host of observers have devoted themselves to the study of this subject, and since the original observations of Kirkes'' were published in 1852, which were devoted to the pathology of thrombosis as well as embolism, a great deal has been written. Parnum and Burrowes^ both experimented by injecting substances into the circula- tion, and Burrowes probably relates the earliest case of recognized throm- bosis. Zahn gives the following concise description of the pathological process which attends the production of the thrombus. " The intensity and the duration of the injury, together with the previous condition of the individual, determine the durability of the clot. The process of ^ Loc. cit: 2 Virchow's Archiv, xxv. 3—6, pp. 308—328, 433, 530, 1862. 3 Pathol. Intern.; p. 247. * Med. Chir. Trans, 1852. 5 Med. Gaz., vol xvi. 1834-5, 150 OCCLUSION OF INTRACRANIAL VESSELS. formation is the following. Colorless blood-corpuscles adhere to a part of the intima denuded by an injury of its endothelium. They accumulate there, form a ring-like obstruction, and gradually the clot obstructs the vessel altogether. If the injury be slight, and the nutrition of the indi- vidual unimpaired, the current of blood soon breaks through the blood- clot and carries along the flakes of the colorless blood-corpuscles. The normal condition is soon restored. If the injury of the vessel be more severe, and the surrounding tissue already in a state of irritation, the thrombus, whilst forming in the same way as described, is firmer and larger. The obstruction is more complete, and lasts for twenty-four hours and more ; after that period the thrombus begins to disintegrate into granular fibrine, the outlines of the blood-corpuscles composing the thrombus cease to be visible, and thus an uninterrupted circulation is re- established."^ In more serious trouble the detached clots maybe the nuclei of larger ones in the sinuses if the condition of the arterial walls be such as to favor more extended formation of thrombi so that the vessels become entirely occluded. The consequence of arterial occlusion is the formation of an extended clot which blocks up the vessel more fully, and consequent ischsemia of distal parts. Through the agency of outside vessels collateral circulation is generally established in a short space of time. If, however, the ana- tomical site be such as to interfere with this provision of nature, softening or tardy degeneration will ensue. This softening, when it follows, is ex- pressed by a series of changes, which occur about as follows : Red soften- ing in from 24 to 48 hours, while the yellow change does not take place until after 14 days. But of this condition of affairs I will speak in a sub- sequent chapter. The carotid arteries and their termination are more often affected, and basilar vertebrals, anterior cerebral, and posterior communicating come next, in the order that I have given them. The pathological processes in the second form of intracranial thrombosis, viz., that affecting the sinuses and veins, are much more gross. Either through sluggish circulation of the blood on the part of a weak heart, pressure upon a sinus, or unusual density of the blood, coagulation oc- curs, the arterial flow is interfered with, a part of the brain is deprived of blood, and serum is eff'used. If the disease be due to outside causes, there may be an extension of inflammatory actioii from without in the manner I have described. By an extension of thrombosis, a form of meningitis resembling tubercular meningitis may be produced. Several of these cases have been seen by Scuch.' An artery which is the seat of a thrombus presents these appearances :— The inner coat is rough and perhaps corrugated ; the artery as a whole may be hard and discolored, with diminution in calibre and a deposition of recent or ancient date, in which latter case it will be pale and tough, while atheroma is not un- 1 Virchow's Archiv, Band Ixii., Heft 1, Nov., 1874. 2 Verhandlung dur Wurz., p. Med. Geselschaft, viii. 179. THROMBOSIS OF SINUSES AND VEINS. 151 commonly present. Fox^ has observed that the part of the plot ad- herent to the inner coat of the vessel is much more dense than that nearest the centre. When the capillaries are implicated, they are gener- ally found to be hard and calcareous. In thrombosis of the large sinuses or veins, the morbid appearances are much more striking. The thrombi are large, and, if old, of a gray color, and it is not rare to find pus- effusions of serum into neighboring parts, and perhaps some meningitis. Von Dusch has collected 57 cases, which are given by Fox.^ In 32 the thrombosis resulted from gangrenous, erysipelatous, and other inflamma- tions of the body (chiefly of head). In 15 it appears to have resulted from asthenic circulation. In 6 cases nothing positive could be ascer- tained. Diagnosis. — There are very few conditions with which that under consideration may be confounded. When we remember that in throm- bosis the development of symptoms is gradual, the loss of speech incom- plete, and primary ; and in cerebral hemorrhage the onset is sudden, the aphasia is secondary to a loss of consciousness, and the paralysis more marked, the diagnosis from this disease is not so difficult. Doubts may arise in our minds when we are to decide whether or not the case before us is one of thrombosis or uncomplicated softening. Thrombosis is rarelv attended by marked elevation of temperature, while the opposite is to be observed in cerebritis, which presents as symptoms trembling and per- haps muscular rigidity. The psychical symptoms are also more strongly marked. The more serious form can be diagnosed by the coexistence of other conditions which may favor its origin. Treatment. — The chief indication seems to be : The improvement of the condition which influences the j)roduction of the thrombus. If arterial tension be at all weak, we may combine digitalis and iron, give tonics and improve the patient's general condition by good food and stimu- lants. Nature will arrange the process of collateral blood-supply, and we may aid her by enforcing rest and quiet. THROMBOSIS OF SINUSES AND VEINS. When a large sinus or vein is involved, the resulting symptoms are much more complex and difficult to diagnose. Lancereaux,^ who has written quite extensively about this form of dis- ease, has divided into two grades, in regard to the variety of morbid action. One of these is inflammatory, the other is non-inflammatory. The first form is dependent upon the extension of some inflammatory pro- cess, usually from the ear, while the other is attended by coagulation of the blood in sluggish circulation. 1 Path. Anat. of the Nervous Centres, p. 32. ^ Loc. cit., p. 35. ^ De la Thrombose, etc, Paris, 1862. 152 OCCLUSION OF INTRACRANIAL VESSELS. Von Dusch^ does not agree with him, but Tonnele, quoted by Grisolle,'* makes the same varieties as Lancereaux. The seats of this pathological condition are the longitudinal, lateral, basal sinuses, and the large veins communicating therewith. Bastian' alludes particularly to the longitudinal sinus as the most common seat and describes the tendency to plugging up of the cerebral veins on both sides. As I have said, the symptoms are very obscure, but in every case we may consider them to be the indication of pressure. Headache, delirium, coma, convulsions, ocular troubles, and generally death in a very short space of time mark the course of the disease. Mr. Tuckwell* reports a case which is a representative of the anaemic form. It is as follows : — Eliza C, set. 16, was admitted to Radcliffe Infirmary on the 20th day of April, 1871. She ceased working a month before on account of pal- pitations, shortness of breath, weakness, irregularity of the menses, etc. Two weeks before admission she began to suffer from violent headache. She never had fits. A condition of decided chlorosis was diagnosed. There was a systolic murmur at base and venous murmur in the neck ; nothing eise abnormal was detected. She was put to bed. Ajjril 21. She sat up, but it was noticed that she lolled about in a strange manner, and seemed stupid. Her right hand and arm were weak, and she could not raise them to shake hands. Headache still severe. 24ih. Remained in same apathetic state ; the paralysis of arm had in- creased, and she could not move fingers or hand at all ; headache. She became comatose, and died after the visit of Dr. Tuckwell and his col- league. Dr. Palmer. Autopsy twenty-four hours after death. On removing skullcap, the dura mater covering right hemisphere was found to be of a dark color, and the longitudinal sinus, when examined, was found half way blocked up by a firm white blood-clot of some age. Cerebral veins on the surface of the middle and posterior part of right hemisphere were all occluded by dark clots. On removing the brain, blood was found effused in the right middle cerebral fossa, extending down into the spinal canal. Lateral and basal sinuses were filled with clots of some age. The pons and medulla were covered by a clot of recent date. General softening of the brain was observable, the optic thalami and corpora striata being par- ticularly affected. The arteries were all healthy, as well as the bone about the sinuses. Another case is reported by Dr. Tuckwell, which presented sj^mptoms which were very much like those of his own case. Von Dusch^ has spoken of epistaxis with thrombosis of the longitudinal sinus as a common symptom, and Meissner has called attention to grind- ing of the teeth, profuse diarrhoea, and exhaustion, together with certain changes in the configuration of the head. In children he has found de- 1 Zeits. fiir Ration. Med. B. vii., 1359, p. 11. 2 Op. cit., tome ii. p. 240. ^ Paralysis from Brain Disease, etc., p. 22. * St. Bartholomew's Hospital Reports, vol. x., 1874, p. 35. 5 Loc cit. THROMBOSIS OF SINUSES AND VEINS. 153 pressed fontanelles, lapping of cranial bones, and unequal distension of the jugular veins. Metastatic abscesses, indicated by local symptoms, have been found by many observers. Lancereaus estimates tbat nearly balf of all the cases are thus complicated. I have seen one case where erysipelas was undoubtedly the cause of the cerebral thrombosis, and after death the great sinuses were found to be filled with semi-purulent matter, and there were abscesses in the liver and other parts of the bod y. These cases are not so exceptional as they are generally supposed to be, but diagnosis before death is rarely made. An autopsy made at the New York Hospital by Dr. Amidon, who kindly invited me to be present, revealed the following beautiful evi- dences of thrombosis of the cerebral sinuses which followed septicaemia : The boy had died after several days' illness, the original injury being a compound fracture of the bones of the left leg. The autopsy was held on September 15th, the day of his death. The liver, kidneys, and lungs showed evidences of acute congestion, and the heart contained two ante-mortem clots ; one occupying the right auri- cle, and the other the right ventricle. The lungs were carefully exam- ined, and a pyramidal infarction was found at the border of the inferior lobe of the left lung. The head was opened, and the dura mater was found to be quite healthy, except in the superior longitudinal sinus, which was almost completely filled with a well-organized thrombus of a pale color. One of the large descending veins in the parietal region was occluded, and when the dura mater was removed, a large pouch, filled with limpid and perfectly clear serum, was found beneath, which pressed upon the pa- rietal convolutions just posterior to the fissure of Rolando. This was beneath the arachnoid. At no other point was there any abnormal col- lection of fluid, and in no place was there any evidence of structural changes of the brain-substance proper. The lateral sinuses were partially filled with thrombi, and contained some very fluid blood. The left pe- trosal vein was empty, as were others which were higher up. No arterial occlusion was found. The patient had died suddenly in convulsions with coma. Causes. — Blows upon the head, injuries of various kinds, extension of otitis, intemperance, and the causes I have already enumerated, may be mentioned. There seems to be no special dependence upon age or sex, though it may be said that most of the cases occur during adult life. What I have already said, and the excellent cases of Tuckwell, which have been presented, render it unnecessary to say more about the morbid anatomy, jjathology or diagnosis. In regard to the prognosis, there can be no question. It is about as bad as it can well be. As to treatment, the most we can do is lio build up our patient, and reduce the danger of external disease by favoring a free escape of pus if the original disease be otitis, and there be an accumula- tion. We may employ local cold and derivatives, but even these do little good after the disease is recognized. 154 OCCLUSION OF INTRACRANIAL VESSELS. EMBOLISM OF THE CEREBRA.L VESSELS. The cerebral arteries and capillaries are alike subject to this form of mechanical obstruction, but the former are perhaps the most common seat of the lodgment of fibrinous plugs. The little bodies which are forced into the vessels are always from some other part of the system, and are not formed in the vessel, as is the case in thrombosis. Embolism also differs from thrombosis in the fact that the latter is always developed, and attended by gradual narrowing of the vessel ; while the condition under consideration is a sudden accident, and may occur in a perfectly healthy vessel ; the converse is the rule in throm- bosis. Symptoms. — Unless there is previous acute endocarditis, there will seldom be any warning, the patient being suddenly stricken down as the little plug is violently forced into some vessel of the brain. There may even be no loss of consciousness, though this is the exception. Uncon- sciousness invariably occurs when a large embolon plugs up some such artery as the middle cerebral ; but if the embolon be small, and the ar- tery occluded is one concerned to a very limited extent in the vascular supply of the cerebrum, the unconsciousness may be but transitory, and psychical symptoms of slight moment will constitute the sole indications of confused mental activity. The eyes are sensitive to light, the pulse is small and rapid, and there is usually pallor. There are no indications of pressure, no stertor, no tu- multuous respiration, nor full pulse, and the pupils are either dilated or irregularly contracted. If the heart be auscultated, various murmurs or friction-sounds will in many cases be heard. Mitral murmurs are perhaps the most common. Paralysis taking the form of complete or incomplete hemiplegia is the result of such sudden arterial occlusion. Special facial muscles may be those affected, or various modifications of sensation, such as anaesthesia or hypersesthesia, may be detected, but rigid- ity or contractures are rarely present unless there is secondary disorgan- ization, and they are never seen during the early stages. Vertigo is a disagreeable and common symptom, and is sometimes attended by cere- bral vomiting. Of course aphasia is an almost invariable consequence of embolism, as the middle cerebral artery is so commonly occluded. This aphasia is of variable extent, and is ataxic or amnesic, but generally the latter. On the other hand, the patient may be simply stupid and taciturn, refusing to answer, or he may be troubled with a light form of clumsi- ness or slowness of speech. The headache, which is subsequent to the loss of consciousness, is coincident ordinarily with the re-establishment of col- lateral circulation, and if further changes occur there may be intense head-pain, delirium, mania, or symptoms indicative of softening. The duration of this stage varies greatly. I have seen examples where the symptoms were trifling and transitory, such as headache, awkward EMBOLISM OF CEREBEAL VESSELS. 155 speech, and paralysis of one arm. rapidly disappearing. Other cases are correspondingly serious. Mr. Shaw^ reports a case which proved fatal in twenty-four hours, and others have detailed examples in which death en- sued in from thirty-six to forty-eight hours. It is very common to find, at the same time, symptoms indicative of embolism of other organs. The spleen, lungs, and organs which receive a large supply of blood, or are in the direct line of arterial supply, are apt to be involved as well as the brain. It rarely happens that two or more cerebral arteries are simultaneously plugged. In such cases the symptoms are complicated. One case is recorded in which both middle cerebral arteries were occluded, and the following case reported by Sokolowski'^ is an example of coexisting splenic and cerebral embolism : — The patient was a servant, married, aged 23, who had always menstru- ated regularly, except when she was pregnant second year before, and then gave birth to a healthy child. Her health had been ordinarily good. Four days before her admittance to the hospital she had suffered from alternate chills and heat, with headache and constipation. On admis- sion her pulse was 100 ; temperature, 102.6°. Heart friction sound at apex, but nowhere else. Passed 53 oz. urine in 24 hours ; sp. gr. 1025. October ISth. She suddenly became paralj^zed on the right side, lost all power of speech, and only moaned and cried in a frightened manner. The third day after, acute idiopathic endocarditis was diagnosed. The right ventricle was found to be greatly enlarged. Temp. 101.2° ; pulse 100. After paralysis she lost hearing in the right ear ; pupils were normal ; left side of mouth was drawn up. Anseesthesia of paralyzed parts. Urine and feces passed unconsciously. Spleen tender and enlarged. An additional diagnosis was now made. Embolism of left middle cerebral artery, and embolism of splenic artery. The loss of speech was peculiar. She was unable to articulate at all, though there was sufficient evidence of mental activity and originating power, so she communicated with her friends by signs. The paralysis had begun to disappear in the right leg below the knee, and she could move her foot slightly. The temperature on the first day was 102.2° ; pulse 90. In the evening, 104.8° ; pulse 100. On the second day, Oct. 14, there was much improvement. The morning tem- perature was 102.8°, and the evening 103.8°. 15th. All paralysis and alalia have vanished. She is, however, ex- tremely weak. Daring the next two or three days a diarrhoea, loss of appetite, and considerable increase of tenderness over the spleen appeared. 28^/i. 35 oz. of urine were passed, which contained albumen, hyaline casts, and urates in abundance. November 10th. She has grown gradually worse, is no longer able to answer questions, but repeats words and sentences over and over. There is marked loss of memory. The fever has greatly increased, the evening temperature being 105.2° ; pulse 120, and quite thready. There are evi- dences of bronchitis and pulmonary difficulty. Urine greatly decreased in quantity, and albumen increased ; tongue quite dry. ^ Trans, of Path. Soc. of London, vol. iv. 2 Deutsche Med. Wocli., Dec. 15, 1875. 156 OCCLUSION OF INTRACRANIAL VESSELS. 20//!. She died. There was extensive hypostatic pneumonia ; conscious- ness remained to end. Autopsy. — Arteries at base healthy, except middle cerebral on left side. This contained a semi-transparent embolism of cartilaginous consistency. Right side of brain healthy, though pale. The left side in the same con- dition, except at the island of Reil, and gray matter of lenticular nucleus, ■which were small, hard, and yellow, and showed evidences of softening and subsequent cicatrization. The heart was enlarged, and yellow spots were found beneath the endocardium. The edges of the mitral valves were thickened and covered with coagula. The spleen enlarged, " blocked," and the splenic artery occluded. Cases have been reported where embolism followed, or was connected with, chorea, and this connection has been made use of in the explanation of the pathology of the latter disease. One of these cases, seen by Murchi- son,^ is worthy of mention. The patient, a boy 14 years old, had suffered from chorea when seven years old, from which he recovered. Two weeks before he died, irregular choreic movements appeared, connected with a bellows murmur at the left apex. "When seen, June 12th, the pulse was 120 ; temperature 102°. There was a pericardial friction sound, but no pain in joints or other symptoms of rheumatism or endocarditis. June 28. Sudden unconsciousness, head drawn to right side, extreme rigidity, twitching on right side. Pulse 145. Pupils normal and equal, but subsequently contracted ; no paralysis. Died June 29. Vegetations on mitral valves, spleen containing emboli. Left vertebral and left in- ternal carotid arteries blocked by pale, firm, and easily detached coagula ; left hemisphere considerably softened. Examination revealed no small emboli in capillaries. A case of my own, showing an accident which may occur in the course of certain acute diseases, seems to me to be of sufficient interest to present, as it may call attention to a cause of death which is probably sometimes overlooked. Mr. N., ret. 35, a stout, full-blooded man of good habits and no vices, took to his bed on the 25th of June, 1874. He had contracted a " bad cold " at the theatre, and the next day was seized with pain in the left side, was chilly and uncomfortable, and when I saw him on the evening of the same day, he had a violent headache. His skin was hot, and his pulse hard and rapid. The thermometer indi- cated a temperature of 101° ; pulse 122. At the base of the left lung crepitant rales were heard. Flaxseed poultices were applied, and quinine and other remedies administered. For the next four or five days the lungs underwent consolidation, and nearly all of the physical signs con- nected with the different stages of pneumonia were observed. The most marked of these was a high temperature, which ranged between 103° and 105° for six days. Resolution was slow, and but a few sputa were brought up, but the temperature had fallen to some extent. I was sent for in haste on the evening of the fourteenth day, an hour after my ordinary visit, to ^ London Path. Soc. Trans., vol. xxii. EMBOLISM OF THE CEREBRAL VESSELS. 157 find that the patient had suddenly, while taking his beef-tea, fallen back unconscious, and had remained so ever since. This was about half an hour before my being sent for. His pupils were widely dilated, and his cornese when touched were sen- sitive ; his legs and arms were extended. His temperature was not high, and his breathing had not changed very much from what it was when I saw him earlier in the day. After an hour and a half he made some movements which showed slight voluntary control, and vomited, turning his head -slightly to do so. He uttered no sounds except low moans. Towards morning his breath- ing became more troubled, and he rolled in the bed. At about nine o'clock in the morning of the next day he seemed to recognize those about him, and made signs which were not understood, when he knit his brows and seemed perplexed. He refused food, but permitted an enema of beef-tea to be injected, but this was not retained. It was then found that he was hemiplegic on the right side. Later in the day he passed his urine in bed. l(jth day. Did not sleep last night. The temperature 104° ; pulse, 130, full and hard. After my visit this morning he became comatose. 3 p. M., died. Autopsy 20 hours after death. — Lungs: right, rather more pinkish than normal ; some S]3ots of induration at base. Left, solidified through- out most of its substance ; when cut, bloody serum exuded. Heart some- what enlarged. Mitral valves were covered by stringy clots. The right ventricle contained a large fresh clot. Kidneys : right, normal ; left, somewhat smaller than it should be ; contained a small cyst beneath the caj^sule. Head : On opening the cranial cavity, the vessels of the dura mater were filled with dark blood. The longitudinal sinus contained a quantity of thick, clotted blood, which was almost black. The left hemi- sphere was oedematous, except at a point beneath the lateral ventricle, where there was a circumscribed patch of a pinkish hue, which seemed to be well defined. The left middle cerebral artery, at a point just before it gives off* its branches, was found to be swollen and hard, and when cut open a small, rather firm clot was found. Behind this there was a long, stringy clot of more recent date. About the vessel the brain was oedema- tous. Another patch of red softening was tbund in the same hemi- sphere somewhat more posteriorly. No other large arteries were affected, but when microscopically examined, I found considerable occlu- sion of many small capillaries, and great disorganization of the nerve element. I have seen several other cases of this kind occurring during acute dis- eases attended b}^ a hyperinosed condition of the blood. Causes. — Endocarditis is, above all other causes combined, the most important and common in the production of embolism. At the Patholo- gical Institute of Berlin^ there were 300 cases of embolism of all kinds associated with endocarditis during the years included in the period be- ginning 1868, and ending 1871. Twenty per cent, of these cases were of brain embolism. Of a large number of cases reported in the London Pathological Society's Transactions, nearly all of them were of this 1 Edinburgh Med. Journ., July, 1873. 158 OCCLUSION OF INTRACRANIAL VESSELS. nature ; and out of fifteen cases I have seen, twelve were connected with disease of the heart, and generally with deposits upon the mitral valves. Croup, the puerperal state, phlebitis, and other conditions where there is any tendency to the formation of clots, or the detachment of tissue which finds its way into the circulating apparatus, may all produce em- bolism. Numerous accidents which happen through carelessness, or perhaps unavoidable injury during surgical manipulation, may, by the introduc- tion of a blood-clot or foreign substance into the circulation, produce an occlusion of some cerebral or other vessel. This accident has occurred when pressure has been made upon large aneurisms, and is one of the arguments against the intravenous injection of substances which coagulate the blood, such as ergot, persulphate of iron, hair, or other organic sub- stances. Dr. Barker^ has given two cases of embolism following the parturient state, and Thomas has seen one or more cases of this kind. As to age, I have found that more young people have had cerebral embolism than persons of advanced life. An examination of twelve cases reported by different observers gives the relative frequency as fol- lows : — lietween 10 and 20 years . 2 Between 40 and 50 years . 2 20 " 30 " . 4 50 " 60 " . 1 30 " 40 « . 3 Of these, 3 were males, and 9 were females. Of my own cases, seven were between twenty and thirty ; five between thirty and forty ; and three between forty and sixty. Eight were women, and the others men. It seems, therefore, that the period between the twentieth and thirtieth years is that in which the disease is most common, and that women are most subject to the disease. According to the ob- servations of medical writers in general, mitral disease is more often an afiection of youth or early life than of advanced years ; so it seems pro- bable that people who have not reached middle life should be more sub- ject to embolism. Diagnosis. — The important distinction is to be made when we sus- pect the case to be one of cerebral hemorrhage. Next in order come thrombosis, cerebral congestion, meningeal hemorrhage, and cerebral tumor. Gelpke'- has given the following table, on one side of which are detailed the features of cerebral embolism ; on the other, those of cerebral hemor- rhage : — CEREBRAL EMBOLISM. CEREBRAL HEMORRHAGE. Youth of patient. Advanced age, atheroma. Sudden onset without prodromata. Prodromata generally present. ^ Puerperal Diseases, p. 270. " Archiv der Heilkunde, xvi., Aug. 1875, p. 485. EMBOLISM OF THE CEREBRAL VESSELS. 159 Previous articular rheumatism, val- Hypertrophy of left ventricle. vular sounds. Previous disease, which might lead to formation of clots. The Attach The Attach. Extensive muscular paralysis ; amne- Symptoms of cerebral pressure ; ataxic sic aphasia. aphasia ; involvement of the intelligence. Very rapid ; or quite imperceptible Disappearance of the residual dis- disappearance of the residual disorder. order after a moderate time. Eetention of early mental power. Keaction stage. Janeway^ relates an admirable case to illustrate the obstacles some- times encountered in making a diagnosis. As it will be seen in his case, there were many circumstances of a puzzling character which made the diagnosis exceedingly difficult. A young woman, while at work, fell to the floor unconscious, in what appeared to be a " fainting fit." There were some convulsive movements limited to the left side of the body. When admitted to Bellevue Hos- pital on the following day, there were irregular contraction of the pupils, coma, and high temperature. A loud systolic murmur was heard all over the chest. She remained unconscious for two days, and on the third day died. Her breathing previous to death was stertorous, her limbs flaccid, and reflex action diminished. The pupils were dilated. Her urine contained a small amount of albumen, but not enough, in the ab- sence of oedema and other symptoms, to suggest nephritic trouble ; be- sides, the quantity of urine passed was sufficient. The question of throm- bosis was excluded by the absence of premonitory symptoms. Congestive chill was suggested by the paralysis and meningeal hemorrhage, but ex- cluded when the absence of rigidity was taken into account. Janeway considered the lesion to be hemorrhage, and I will give his own descrip- tion of the autopsy and its result. "The j)os^?norfe7?^ examination revealed the following: Skull, normal. Brain and membranes : On opening the dura mater on the right side, a clot of blood, a little over half an inch thick, three inches long, and two inches wide, escajDed from the arachnoid sac. This clot was in the main, black, moderately soft, but provided with a buffy coat at one por- tion. It had produced a corresponding depression of the brain, over which it was situated, and in its centre was an oj)ening about an inch long and a half inch wide, leading fr'om a recent excavation in the middle lobe of the brain, through the torn pia mater and so-called arachnoid, into the sac of the latter. This excavation reached from the convex surface nearly to the corpus and optic thalamus at posterior extremity. The opening was situated a little nearer to the longitudinal fissure than would correspond to the middle of the convex surface. The excavation was about two inches wide and contained clotted blood, of which some had escaped in removing brain. The brain- tissue surrouniling this was soft, slightly blood-stained, and where it formed the boundaries of the space, ^ Am. Psychological Journal, ^N'ov. 1876. 160 OCCLUSION OF INTRACRANIAL VESSELS. numerous small torn vessels. The brain-tissue of the posterior lobe, espe- cially on its outer surface, was softer than natural. The posterior ex- tremity of the optic thalamus of the right side, over a small area, pre- sented an ecchymotic softened state. " In the clotted blood and disintegrated brain-tissue found at the mouth of the excavation, a small branch of the posterior cerebral was found torn across, presenting a widened extremity at the point of rupture, surrounded by thickened and firm tissue, and in the interior of this a firm reddish- gray clot, uniform in its structure and of older date than any others. I failed on careful examination to find the other extremity of the torn ves- sel, but from the condition of the portion found doubt not that it would have proved of similar shape to the other, and that together they would have constituted a cylindrical dilatation of this artery. " The left (opposite) hemisphere showed the convolutions flattened and so closely pressed together laterally as to nearly obliterate the appearance of sulci. The arach noid was dry, and there was no sub-arachnoid fluid present. The brain on this side appeared antemic, and on cutting the dura mater, pressed out. " The lateral ventricles were of normal appearance. The anterior lobe of right side was normal. Pons, cerebellum, etc., were normal. The arteries at the base were carefully examined, being followed to their smaller ramifications without finding any emboli. " The lungs were slightly edematous. " Heart : The left ventricle was slightly hypertrophied. On the auri- cular aspect of the mitral valve, and on the ventricular of the aortic, condylomatous excrescences were present, narrowing both orifices ; but the largest mass passed obliquely across the heart from the leaf of aortic valves nearest the septum to the anterior leaf of mitral valves, and above this, between it and the other leaflet of aortic valves, a slight dilatation of the heart-wall existed. " Small infarctions were present in the spleen and the kidney, and the latter showed at some points interstitial nephritis, around glomeruli, with atrophy of these ; but the disease was not advanced. The mesentery pre- sented two small aneurismal dilatations of little arteries, and at these points emboli were present : one was of the size of the head of a pin ; the other, of a pea. " In this case it seems exceedingly probable that the primary lesion of the artery, which finally ruptured, was embolism, and that this obstruction caused, secondarily, a dilatation of the artery at this point, and that, owing to the heat,' such an obstruction of the circulation in the brain oc- curred as to cause the rupture of the vessel described. This is rendered still more probable by finding two small arteries in the mesentery with aneurismal dilatation, and containing emboli. "A point of interest in this case is the absence of serious symptoms of cardiac disease, though there was so marked a lesion. It did not seem as if any regurgitation had occurred at the aortic orifice, simply obstruc- tion. The left ventricle contained such a firmly adherent clot that the hydrostatic test was of no avail. ^ The weather was excessivdy warm at this time, and the patient was at first sup- posed by those around her to be suffering from the effects of the heat. EMBOLISM OF THE CEREBRAL VESSELS. IGl " It also furnishes anotlier to the already long list of cases in which a heart-murmur is heard — sudden paralysis occurs — the patient moderately young, and yet the lesion is hemorrhage, and not embolism. I have met with several of these exceptions." From thrombosis there will be no difficulty in making a diagnosis when we remember the slow origin of the former. The " apoplectic form " of cerebral congestion sometimes resembles the condition presented by the patient ; howcA'er, the former history, the suffused face, contracted pupils, and rapid subsidence of symptoms, will put us on our guard. Morbid Anatomy and Pathology. — Burrowes and Kirkes were the first English writers and Virchow the earliest Continental writer to describe these conditions. Prevost and Cotard have since related inter- esting experiments. They injected tobacco seed into the carotids of dogs, and afterwards watched the changes that followed. One of these dogs was killed thirty-nine days after the seed had been introduced, when they found the middle cerebral artery obstructed, and induration about the fissure of Sylvius. The pathological processes which follow such mechanical obstruction have been sufficiently noticed in a preceding article, so it will be enough to call attention to the fact that the consequence of such an accident will be softening of the parts deprived of their nourishment, unless the collat- eral circulation be established at an early date, or the embolon is broken down and removed, which is a very unlikely circumstance. Kirkes ^ calls attention to the distribution of emboli in the following words : " The parts of the vascular system, within which these transmit- ted masses of fibrine may be found, will of course depend in a great measure upon whether they proceed from the right or left side of the heart. Then, if they have been detached from either the aortic or mitral valves, they will pass into the blood propelled by the left ventricle into the aorta and its subdivisions, and may be arrested in any of the systemic arteries or their modifications in the various organs, especially those which, like the brain, spleen, and kidneys, receive large supplies of blood di- rectly from the left side of the heart. If, on the other hand, the fibrinous masses are derived from the pulmonary artery and its subdivisions within, the lungs will necessarily become the primary if not the exclusive seat of their subsequent deposition." In regard to the side of the brain where the deposit occurs, I think we may say that the left side and the middle cerebral artery are the most common site, though many cases reported by Shaw, Glynne, Murchison, and others prove that the right artery may be affected as well. An interesting example, which is almost unique, is the following case of embolism of the right posterior cerebral artery. The history was read by Broadbent before the London Clinical Society : — ' " The patient, a young man aged 19, had suffered three years pre- 1 Eoyal Med. Chir. Trans., vol. xxxv., p. 281, 1852. ^Abstracted from Lancet, Monthly Abstract, April, 1876, p. 576. 11 162 OCCLUSIOX OF INTRACRANIAL VESSELS. viously from acute rheumatism. Ten days before his admission, he sud- denly became blind, and had great pain in the head. Five days later, vision having returned, he lost the use of his left limbs, while the right arm and leg were continually in motion; and, unless restrained, he rolled over and over towards the left, falling out of bed and bruising himself se- verely. The left hemiplegia and uncontrollable movements of the right limbs continued when he was admitted ; the hemiplegia not being abso- lute, but accompanied by slight rigidity and very considerable impair- ment of sensation. The patient took no notice of persons or objects, but answered questions, and put out the tongue on being urged. His pulse was variable, 120 to 160 or more. Temperature in the right axilla, 99.2°; in the left, 100.6°. A loud mitral systolic murmur was present. The bowels were confined, and, when opened, the feces and urine were passed in bed. A dose of three grains of calomel was given, and two grains of carbonate of ammonia, with two drachms of infusion of digitalis every two hours. Chloral also was given at night. He was ordered a diet of milk and beef-tea, with four ounces of brandy. There was gra- dual improvement ; and three days after his admission, an ophthalmosco- pic observation, previously attempted in vain, was obtained, and the disks were found to present the appearances of marked ischsemia. The pulse was now 108, soft, short, and strikingly dicrotous. A day later the pulse was 88, and more full. The temperature was still nearly a degree higher in the left (100°) than in the right (92.2°) axilla. Slight paralysis of the left external rectus of the eye was observed. At the end of a fort- night's stay in hospital, the right limbs were quiet, and there was considerable return of power and sensation in the left side. His speech was rather slow, but there was no obvious impairment of the intellect. Notwithstanding this, however, he not only passed his feces in bed, but threw them about and bedaubed himself and the bedclothes without any regard to decency. The optic ischtemia was marked, but vision was good. The temperature" of the right axilla was 99.3°; of the left, 10U°. At the end of three weeks he passed his excretions naturally. After five weeks he was up and about, eating well ; but pale, and still complaining a little of headache. Impairment of power and of sensation in the left limbs was still perceptible. The optic neuritis was subsiding. Distant vision was good, but small print was not easily read. A systolic mitral mumur was heard. The temperature was still never below 99°; usually 100° ; it was now equal on the two sides. But for this elevation of temperature, the patient would have been allowed to leave the hospital. Soon after- wards, however, there were symptoms of splenic embolism, and later of ulcerative endocarditis; and he died from this four months after admis- sion. On post-mortem examination, with ulcerative endocarditis and nu- merous recent embolisms, there was found softening of the occipital lobe of the right hemisphere from the posterior cornu of the ventricle down- wards, and the branch of the post-cerebral artery entering the calcarine fissure was occluded and lost in adhesions. It was considered probable by Dr. Broadbent that originally the posterior cerebral artery itself had been blocked up, and not only this branch. The interesting points in the case, on which comments were made, were the temporary blindness, the agitation of the right limbs, and rolling tendency, the usual association of loss of sensation, and of double optic ischiemia with embolism of a cere- bral artery, and the remarkable indifterence to decency persisting when the intellect was apparently good." EMBOLISM OF THE CEREBRAL VESSELS. 163 Fat globules may sometimes plug up the small capillaries, producing wide areas of softeuing. The morbid appearances indicative of cerebral softening are of interest and worthy of the closest study, not only because the brain is the point which suffers the most seriously, but because generally the heart, spleen, lungs, blood-vessels, and other organs may be involved as well. On the valves of the heart, either mitral or aortic, may be found excrescences, induration or recent clots, and the arteries themselves may exhibit patches of atheroma. In the brain we will probably find one or more of the ar- teries I have spoken of to be swollen, hard, and filled by one of these little masses of fibrine. They have been coinpared to grains of wheat, and resemble them very closely. Generally the embolon is separated from a second plug which has followed clotting of the arrested blood. Emboli are never attached to the walls of the vessels. Several arteries may, perhaps, be found obstructed in the same way. " Sometimes all on one side ; at other times some arteries of one side of the brain, and some of the other,"^ so says Fox. Softened masses are generally found on examination, and are usually the cause of death. The parts behind the occlusion are subjected to the full force of blood which is arrested, and not sent to the parts it should supply, and local hypereemia is a result. The resulting softening is generally confined to the left hemisphere at its base, for reasons I have before stated, and the frontal convolutions, corpus striatum, and adjacent parts are found to be either red or yellow, softened or in- durated OEdema of the brain is not an uncommon appearance, such oedema being seen in the parts deprived of blood. The perivascular spaces being enlarged, it is but natural that their fluid should rush in to fill up the in- creased space left by the bloodless, arteries. Prognosis. — The outlook for the patient is generally a very gloomy one if the accident be at all grave, and the artery be one of importance. The severity of the symptoms, the existence of emboli in other organs, the element of severe pain, high temperature, and gradual development of symptoms indicative of softening are of unfavorable import, and give affairs a very dark look ; therefore it is never well to make too hasty a prognosis. Treatment. — Rest, abstinence from stimulants, and agents which will diminish the arterial tension are the only remedial means to adopt besides the ordinary indications which appeal to the common sense and discretion of the medical man. Afterwards, resulting conditions, such as paralysis or softening, are to be treated. 1 Op. cit., p. 32. 164 DISEASES OF THE CEREl'.RUM AND CEREBELLUM. CHAPTEK y. DISEASES OF THE CEREBRUM and CEREBELLUM (Continued). CEREBRAL SOFTENING. Synonyms. — Reuipllissement (rouge, blauc, jaune). Eucephalitis aigue, chronique (Fr). Mollities cerebri, Encephalitis, Softening of the Brain (chronic, acute). Inflammation of the Brain. Definition. — A disease of the brain attended by destruction of ner- vous substance, and either of an acute inflammatory nature, with puru- lent formation ; or of a chronic non-inflammatory character, with less rapid disorganization of nerve-tissue. So much confusion has arisen from an incorrect appreciation of the morbid anatomy and its connection with pathology, that it is a difficult matter to attempt there conciliation of the many widely differing views of the legion of writers. " Inflammation of the brain " is the term which has led to all this confusion ; and I have been bold enough to base my classification rather upon the character of tissue-changes than upon the arbitrary law that softening of the brain is the only result of in- flammation. Sclerosis, as we know, is undoubtedly the result of a low grade of inflammation, but in this case the tissue-changes are quite diff'erent. Considering that the word " softening" means a mollification, and that it may result not only from purulent inflammation, but from low nutritive changes, I shall divide the subject as follows : — Diffused Cerebritis. Meningo-Cerebritis. 1. Acute Softening, \ (Inflammatory), ( Purulent Cerebritis 2. Chronic Softening, f Primary Softening. (Non-Inflammatory), I Secondary Softening. 1. Under the first head we may place the variety described by Elam,' which is a quite rare affection in its uncomplicated form, that is, when it involves the brain substance en masse; and meningo-cerebritis, which is by far more common. In a third variety the acute disease is character- ized by purulent collections, and perhaps by the ultimate formation of abscesses. 2. Chronic softening in its primary form we will consider to be de- pendent upon general disease, intellectual prostration, and like causes ; ^ Cerebria, and other Diseases of the Brain, London, 1872. • ACUTE SOFTENING. 165 while " secondary softening " may be used to express the form which follows vascular lesions, such as embolism, thrombosis, or cerebral hemor- rhage. ACUTE SOFTENING. In the first form it may be either cortical, diiFused, or combined with meningitis. Symptoms. — Cerebritis of either kind is preceded in nearly every instance by symptoms of functional disorder, such as cerebral congestion or cerebral ansemia, but these are not sufficient in themselves to arouse the suspicion of the observer as to the serious character of the disease which is to follow. The later prodromata of cerebritis, however, cannot be mis- taken, and finally the developed disease presents most pronounced symp- toms, which, if they do not always enable us to locate the brain lesion, are sufiicient to assure us that some violent inflammatory process is under way in the cerebral mass. The patient may for some months suffer greatly from headache of a diffused character, accompanied by burning sensations, and a sense of pressure behind the eyeballs. These headaches are quite intense, and are aggravated by exposure to heat, concentration of the mental powers, and alcoholic indulgence. His memory becomes gradually enfeebled, so that at first dates and names are forgotten, and afterwards faces, locations, and even information which may have been imparted to him a short time pi-eviously. Some slight clum-iness of speech may be indicative of the near approach of grave symptoms, but this clumsiness is not aphasic till later. Irritability of temper, restless- ness, and incapacity for mental application are attendant evidences of the smouldering fire which afterwards is to make itself known by still more decided symptoms,. Among these may be enumerated nystagmus, stra- bismus, diplopia, and optic neuritis, as ocular troubles ; contractures of the limbs, tremors of individual muscles, or groups of muscles, a twitching of the limb^, or other motor troubles, and hypersesthesia, followed by anaes- thesia, and other disorders of sensation ; these last sometimes being pe- culiarly prominent. Next we find that there may be an apoplectic attack or convulsions of an epileptiform character, which mark the violent stages of the disease. Should there be, as a result of the morbid process, cerebral hemorrhage, it will be found that the paralyzed limbs become markedly contracted, and that rigidity is a striking feature, as the result of descending degeneration. According to Jaccoud, the contractures may be bilateral, though the rule is the other way, the limbs of but one side being rigidly flexed.^ He has seen one case where the left arm and leg were the seat of contractures, and where the face was contracted and strongly drawn towards the left side, suggesting a right facial palsy, but the appreciable rigidity of the facial muscles of the left side left no doubt as to the origin of the deviation. The paralyzed members are generally 1 Traite de Path. Interne, vol. i., Art. Enceph. aigue. ]6G DISEASES OF THE CEREBRI'M AXD CEREBELLUM. those that are the seat of convulsive movements in the first place. The convulsions may be general, and assume an epileptiform character, and may be accompanied by vomiting. The patient's mental condition mean- while undergoes a great change. Delusions, which somewhat resemble those of general paralysis of the insane, are present ; the exaltation deli- rante of the French, which is by some considered to be an early symp- tom. This has not been my experience, and I am convinced that in the cases where it has been noticed as an early expression of the affection, the disease was probably general paralysis, and not cerebritis. The real de- partures from mental integrity are expressed in a want of decision and a restlessness which is shown in the impaired fixedness of purpose. The pa- tient repeats himself in conversation, and forgets that he has made the same statement but a few minutes previously. Memory is ultimately abolished, and finally dementia remains, which, should the patient live for some time, is expressed by all the other signs, drivelling of saliva, inane smile, hebetude, and total imbecility, while there may be aphasia of the amnesic or ataxic variety. The muscles concerned in articulation and deglutition are involved, and the patient may narrowly escape being choked by the masses of food which " go down the wrong way" or accumu- late in his mouth. Constipation and retention of urine are not uncom- mon accompaniments, and the urine is charged with urates, is dark-colored, and rapidly undergoes decomposition. The temperature and pulse are both changed, the latter becoming accelerated and irregular, and the heart- sounds sharp and " precipitative." A tremulous character of the pulse has been noticed by several observers. The temperature may rise to 110^ F., and generally attains its highest point at the end of the first four days. Coma precedes a fatal ending in the acute form at the end of a few days, and death occurs generally after seven or eight days by asphyxia. Should the patient survive, there is a remission of the symptoms, and the forma- tion generally of an abscess. Cerebritis does not always begin in the same way, and, as I have already stated, is not invariably symptomatized by all the forms of disordered function I have enumerated. There may be no premonitory symptoms .should the disease follow otitis or injury, but in the insidious form, which has been so admirably described by Elam and Eeynolds, the appearance of prodromata is gradual and progressive. In certain cases the paralysis is an early symptom, in others the defects of articulation and deglutition are more prominent ; in other cases psychical disturbances are decided, while in still others coma or convulsions are the striking features. The predominance of these different symptoms depends very much upon the region which suffers the most from the violence of inflammatory action. It must be borne in mind that the disorder is, as a rule, attended from the fir.st by febrile disturbances, and that all the .symp- toms are those indicative of a hyperaesthetic state of the cerebrum. Should the patient survive the immediate violence of the attack, he may recover to some degree. The temperature and pulse are lowered ; the ac- tive evidence of the central disease subsides, but it is not common for any amelioration of the paralysis to take place. The headache may become ACUTE SOFTENING. 167 more localized and less intense, or may subside altogether, and it may only reappear when the patient is fatigued. He may remain in this con- dition for several years. In one case that came under my observation I accidentally found a large abscess about the size of a horse chestnut in the white matter of the anterior lobe of the right hemisphere. The individual had died of phthisis, and during life complained of no symptoms which would direct suspicion to the brain lesion. He had had a febrile attack six years before, which was probably the time at which the abscess was formed. In many cases cerebral abscess follows disease of the temporal bone, and in the majority of instances it is not essentially necessary that there should be complicating general meningitis, though such is often the case. Causes. — Exposure to the sun's rays, alcoholism, inflammatory dis- ease of the bones of the head or face, meningitis, brain tumors, trauma- tism, and syphilis, as well as several of the zymotic fevers and rheuma- tism, are all predisposing and exciting causes of cerebritis. The simple form may be idiopathic, but that which results in the production of abscesses is more often due to' traumatism, caries of adjacent bones, or syphilis. Jaccoud has found that the proportion of patients in regard to sex was in favor of the males, nine men being affected to every four women, and that the disease was developed between puberty and the forty- fifth year. Cerebral abscess or traumatic cerebritis may be produced, of course, at any age by injuries or the extension of other diseases. I have seen one case in which cerebritis followed otitis in a child ten years old. Lead poisoning should not be forgotten as a rare cause. Morbid Anatomy and Pathology. — Cerebritis may either in- volve the cortex cerebri or some central parts, such as the corpora striata or optic thalami, or more rarely may affect the entire brain, but it pre- fers the gray matter, which is so richly supplied by blood vessels. The brain may be found to be the seat of many softened parts, and collections of pus, serous exudation from the vessels infiltrating the surrounding brain-tissue, or there may be ruptured vessels, and an escape of their con- tents. The brain-tissue may be stained by the hematin, and occasionally presents the appearance of simple non-inflammatory softening. The microscope enables us to see a multiplicity of changes — granular degene- ration, leucocytes, broken-down nerve-elements, rarely neuroglia-thicken- iug, and still more rarely amyloid bodies. I know of no more interest- ing field for the study of morbid microscopical anatomy than a brain of this kind, for nearly every appearance or grade of diseased structure may be found. The vascular lesions are capillary hemorrhage, miliary aneu- rism, etc. Suppuration takes place in several ways. The brain-substance may be generally infiltrated, so that it presents a yellow color through- out its extent, or there may be a localized infiltration or an encysted col- lection of pus. About the latter will be found a sclerosis of the brain- tissue, and about this a serous infiltration. Jaccoud has found that abscesses are more often to be observed in the white substance, in which 168 DISEASES OF THE CEREBRUM AND CEREBELLUM. conclusion he is supported by the observations of many writers. Lebert,' in fifty-eight cases, found the abscess to be located twenty-three times in the left hemisphere, eighteen in the right, twice in the corpora striata, twelve times in the cerebellum, twice in the pituitary body, and once in the spinal cord. I have already presented cases which will enable the reader to appreciate the origin and size of such collections of purulent matter, and the evidences of diseased bone, fracture, etc., that are to be discerned in cases of traumatism or disease. In certain pysemic condi- tions, such as erysipelas, abscesses may be found in other parts of the body as well, notably in the liver and lungs. In rare forms a rapid ne- crobiosis or " death " of tissues takes place, which is almost analogous with gangrene in other parts of the body, and large masses of brain- tissue are destroyed very rapidly. Of fifteen cases of cerebral softening of acute form, CalmeiP found in one fibrine in the sinuses of the dura mater ; in one, this membrane was bathed in purulent liquid, and it was also perforated at one point; in five there were recent spots of encephalitis on the right and left sides, in six on the left only, in three on the right only ; in three there were cellular cicatrices in the right lobe of the brain, in one in the left lobe ; in two the right hemisphere of the cerebellum was the seat of an acute inflam- matory spot; in four the principal recent inflammatory spots were still in a state of red hepatization ; in seven they were in a state of softening, with disintegration of the nervous substance; in four they were in a state of disintegration of the nervous substance, with a mixtui-e of a liquid that resembled pus ; in four the spots of acute local encephalitis without clot were studied microscopically. Of these, in one they were still in the state of red hepatization ; the diseased regions were reddened by the widening of the capillaries, and by the presence of extravasated globules of blood ; the cerebral fibres were not yet disintegrated ; already small granular cells had begun to be formed in the inflamed parts. In three the nervous substance of the diseased seats was disintegrated, and more or less reduced to fragments ; it was soaked in plasma, mixed with a con- siderable number of great cells collected together, and molecular granules ; sometimes in the preparation there were seen rare globules of pus scat- tered. The vessels and their principal branches were constantly very apparent. Diagnosis. — Cerebral hemorrhage, meningitis, cerebral tumor, embo- lism, and thrombosis are all conditions from which it is proper we should distinguish acute cerebritis and cerebral abscess. Some of the symptoms of general paralysis of the insane may possibly mislead the observer. From cerebral hemorrhage we are to distinguish cerebritis by the rapid amendment of symptoms in the former, while in the latter there is progressive evidence of advancing structural changes. Fever is not connected with cerebral hemorrhage, unless there be second- 'Virchow's Archiv, x. 1866. * Quoted by Fox. ACUTE SOFTENING. 169 ary inflammation of the brain-substance. The headache is not sugges- tive of cerebral hemorrhage, nor is the delirium or vomiting ; and, after all, the only symptom which deserves attention is the paralysis. It is im- portant to bear in mind that rigidity and contracture take place before paralysis, while we know that the converse is the rule in cerebral hem- orrhage. Should hemiplegia follow a number of the other symptoms, we may consider that the hemorrhage is secondary to the cerebritis, and that some vessel has been cut across. It is almost impossible to distinguish uncomplicated cerebritis from meningo-cerebritis. The pain is perhaps more marked in the latter, and the convulsions are bilateral, and apt to be local, and due to involvement of one or more of the psychomotor cen- tres. In uncomplicated cerebritis there is not nearly so much fever as in the meningeal form or in simple meningitis. Typhoid fever may simu- late cerebritis, and vice versa. Attacks of the latter begin with headache, vertigo, movements of the eyes, insomnia, delirium, nose-bleed, and diarr- hoea, with high evening temperature. The absence of tympanites, and gurgling in the left iliac fossa, and the apiDcarance of paralysis and visual disorders, are quite sufficient landmarks to prevent the diagnostician from losing his way. When there is suspicion of otitis or traumatism, it is exceedingly difficult to make a diagnosis from thrombosis of the cere- bral sinuses, and it is fortunate that no value is to be attached to such a diagnosis, as far as therapeutical indications are concerned. Prognosis. — There is very little hope for the patient, and should he survive the acute attack he is usually left paralytic and demented. If there be a purulent accumulation, which becomes encysted, the chances of recovery are very little better, and it only becomes a question of time when the patient will die. If there be such a cerebral abscess, subsequent symptoms very much like those connected with other brain tumors will be probably developed ; but, in numerous cases cited by various authors, a cerebral abscess has existed unsuspected for years. Treatment. — Acute cerebritis in either form must be met with ab- straction of blood, cold effusions to the head, agents which lower vascular tension, counter-irritants, and mercury in some one of its forms. The ice- bag, or the apparatus already alluded to for the application of cold wa- ter, may be used, and leeches are to be applied to the arms or behind the ears. Jaccoud and most of the clinical teachers recommend purgation, which may be obtained by the use of the compound jalap powder, fol- lowed by calomel carried almost to the point of salivation. This seems to me to be rather energetic treatment ; and I think that the purgative alone, with just sufficient calomel afterward to insure moderate cathartic action, is preferable. For the purpose of diminishing vascular tension, either tartar emetic, aconite, or veratrum viride may be used. Should the cerebritis be found to depend upon syphilis or lead, the iodide of po- tassium may be employed as the most serviceable remedy. Blood-letting is admissible in serious cases, and is recommended by nearly all of the older writers. The head may be shaved and blistered, or cauterized ; but I am convinced that sub-occipital vesication is in every way as good, and 170 DISEASES OF THE CEREBRUM AND CEREBELLUM, the infliction of this punishment incident to general cauterization of the head is not warranted. Some German writers recommend the application to the shaven scalp of tartar-emetic ointment, or croton oil, and claim good results. If there be any otitis, it is well to promote otorrhoea ; or, if there be a collection of pus beneath a depressed and fractured bone, it may be liberated by a free incision. CHRONIC SOFTENING. Definition. — A disease of the brain of a very serious character, gene- rally of a secondary nature, and dependent upon impaired nutrition of the brain-substance through occlusion of the cerebral vessels, and symp- tomatized by a numerous variety of mental, sensorial, and motorial symp- toms, such as mania or melancholia and subsequent dementia, headache, and cutaneous hyperse^thesia and paralysis and convulsions. Symptoms. — Much confusion has resulted from the use of a variety of terms, such as " red softening, " white softening," " inflammation of the brain," and other names which tend to mislead the student. For our purpose it will do to consider white and red softening as different stages of the same condition, which may result from a variety of causes ; and inflammation of the brain more as the condition which I have just de- scribed than that of which I propose to speak, viz., the variety spoken of by Reynolds and others as " non-inflammatory softening." The symp- toms of softening of the brain may follow a cerebral hemorrhage, embo- lism, or thrombosis, or perhaps be connected with symptoms of cerebral tumor; or, again, cerebritis may leave behind it a chronic condition ex- pressed by the symptoms I am about to detail. The early troubles of the primary form are those of intelligence; the patient loses his memory of events which have recently transpired, is unable to concentrate his atten- tion, becomes silly, restless and irritable, quarrelling with his immediate friends, and usually getting quite excited towards night. His speech may become affected, and he sits by himself for hours during the day, and mutters constantly a mass of disconnected rubbish. This condition ol stupidity increases ; he may become drowsy and complain of headache, with feelings of head-pressure ; he may tell us that his limbs feel heavy, and complains of muscular pain, from which he suffers in the attempt to make any movement. As to other sensory disturbances, hypersesthesia is much more common than ausesthesia; though cutaneous areas in which sensation is impaired, are by no means rare. Motorial troubles are of later appearance, commencing with gradual loss of power of an irregular character, which affects either the arms or legs in the beginning, but finally becomes general. This paralysis is not always constant, thei'e be- ing a greater loss of power at times than at others. The first indication of the motorial trouble may appear either in the execution of some ordi- nary act, which will be performed very clumsily ; or it may be shown in locomotion, when the patient will stumble or fall to the ground, as there may be a sudden giving way at the knee. When he walks he scarcely lifts his feet from the ground, but drags them after him in a helpless CHROKIC SOFTENING. 171 manner. With the paralysis there may be a certain amount of rigidity, or tonic spasms, affecting the muscles, so that there are occasionally spas- tic contracti ais, which last for some little time. Epileptiform convulsions often occur during the disease, as well as attacks of mania, which are quite violent. When the softening is secondary, and follows an attack of em- bolism, thrombosis, or cerebral hemorrhage, the initial symptoms make their appearance in from one to two weeks after the occurrence of the hemiplegia. The troubles of intelligence are those which first attract our attention, and are generally connected with high temperature and severe headache. The patient may become delirious ; he indulges in delusions, and grows abnormally sensitive; or, on the other hand, be is drowsy, stu- pid, and melancholic ; and after this may follow paralytic contractures, fibrillary contractions, clonic spasms, convulsions resembling epilepsy ; and he may finally fall into a state of coma. It is not uncommon for him to involuntarily joass his feces and urine. With the formation of cysts or abscesses, which constitute a late result of cerebral softening, convulsions of an epileptoid character may make their appearance ; or, should the condition be acute, and result from otitis, as is the case in cerebritis, these as well as other symptoms, may be among the first to develop. Af- fections of speech are quite symptomatic of softening, because in so many of the eases the middle cerebral artery is that obstructed or destroyed. The hemiplegia, which may occur, is unattended by any loss of con- sciousness, aud electro-muscular contractility is generally perfect or even exaggerated. The following may be presented as an illustrative case : — J. A., aged 45. The patient was brought to me by his wife during the summer of 1872. Four years before, while actively engaged in business which demanded the most devoted attention, and required a great deal of intellectual labor, he began to suflTer from headaches limited to the frontal region. These were so severe that while engaged in his office he was obliged to bind a wet towel about his head. He suffered very greatly from insomnia, and found it impossible to sleep unless he took large doses of opium. He very often awoke in the night, and went upon the house-top or out into the street, wandering about the city until morn- ing. He became very moody, treated his wife with indifference, and scolded his children without cause. He could not talk for five minutes at a time without rising and pacing furiously about the room, while he seemed to be annoyed by the slightest noises about the house. The trick- ling of water from the pipe over the water-closet tank, which was next to his bed-room, so annoyed him that, in a fit of impatience and un- governable irritability, he wanted to send for the plumber in the middle of the night. His wife persuaded him to consult a homoeopathic physi- cian, by whom he was treated for nearly a year, and at the end of that time went abroad. He had meanwhile grown much worse, his mental state was much more aggravated, and his headaches, though not so severe, were still constantly present. He complained of formication of the soles of the feet, and his gait was markedly affected, both feet being scarcely lifted from the ground and he dragged one after the other when he walked. He lost rapidly ia flesh, and though the sea-voyage did him 172 DISEASES OF THE CEREBRUM AND CEREBELLUM. some good, he relapsed into his previous state after he reached Europe. While in Switzerland he had an epileptiforna attack, and after recovery found that his right side was paralyzed. His speech was affected, and from what I can learn he must have been aphasic. The paralysis im- proved in a short time, and, strange to say, his mental condition also underwent a change for the better. After a few months he returned to New York, when I saw him. He was then in an almost helpless condition, and needed the assistance of a cane and his nurse's arm to make any progress. He was bent over, and his chin was depressed, so that it almost touched his chest. The mouth was open, and the lower lip drooped slightly ; while from the cor- ners of the mouth there was an escape of saliva which trickled down over his chin. His face bore a very vacant look, and when he attempted to speak it was clouded by an anxious and discontented expression, which arose probably from the vexation he felt at being unable to speak. Pho- nation w^as not affected, but w^ord formation seemed entirely lost, so that his attempts to speak consisted in the production of disorderly noises, the tongue being used extensively, the lips not participating. He could not protrude his tongue when told to do so. His right pupil was larger than the left. His right side was partially hemiplegic, and his wife stated that the loss of power was greater at times than at others. The right fore-arm was slightly flexed upon the arm, and the fingers seemed rigid. His control over the bladder was partially lost, and very often he would void his urine while upon the street, or at night. There is a history of trembling which affects the right arm and leg. This occurs during quies- cence, and seems to have no connection with voluntary movements. His appetite is voracious, but there appears to be some difficulty in swallow- ing, so that it is found necessary to cut up his food. About two weeks ago he had a slight epileptoid attack. During warm days he seems dis- posed to sleep a great deal ; but when excited by the presence of disagree- able people, or thwarted or crossed, he becomes extremely violent, and even dangerous. I saw him but once, and he was afterwards sent to an asylum. An extremely interesting form of cerebral disease of this character, is that occurring in syphilitic subjects, and attended by narrowing of the vessels, with inflammation of their inner coats, the so-called syphilitic endoarteritis. There is consequent diminution in nourishment of large tracts of brain substance, extensive anaemia and softening. The clinical features of such changes are numerous. In some cases the symptoms of non-specific thrombosis are presented, but the hemi- plegia is rarely preceded by unconsciousness. Epileptiform attacks, severe nocturnal headache, and impairments of the mental powers are conspicuous, while a very suspicious indication of the specific nature of the trouble is local paralysis of the cranial nerves. The symptoms develop sometimes very quickly, and may disappear with great rapidity under anti-syphilitic treatment, or on the contrary, if there be much mental enfeeblement, I have found the pi'ognosis to be grave in the extreme. ^ Chauvet, * Fournier, and ^ Mickle, and others have described a 1 Influence de la Syphilis sur les M. du S. N., 1880. 2 La Syphilis du Cerveau, 1879. ^ Br and Foreign Med Chir. Raview, April, 1877. CHRONIC SOFTENING. 173 spurious form of general paralysis, which is, in reality, a form of cerebral softening. It is the same disease as that denominated by Voisin — rencejjhalopathie syphilitique. In this pseudo-general paresis there is hebetude, delirium and incoherence. Unlike true general paresis, how- ever, the insane delusions do not possess the extravagance of the latter, and there is very little of the boasting and inordinate vanity. The disorders of motility are not so conspicuous as in the well recog- nised disease of non-specific origin, for there is not so much tremor. Labial tremor, according to Mickle, is much less common and violent, and, he says, that where such tremor exists it is always preceded by paralytic troubles, which is not the case in the ordinary paresis. An at- tack of hemiplegia is, as a rule, the first indication in the syphilitic subject, and the patient presents the peculiar cachectic appearance. A symptom referred to in another part of this work, and one which is pathognomonic, I believe, is the peculiar asthenic character of the mental trouble. There is a true enfeeblement of the intellect, which in some respects, re- sembles dementia. Memory, in regard to remote events, appears to be blunted, as well as in regard to events that have occurred recently. There is not, of necessity, much emotional 'irritability upon the part of the patient, although early in the trouble there is sometimes cerebral irritation and mental excitement. A disposition to sleep is not rare, and such sleep is usually quiet and may even approach stupor. In cases of syphilitic cerebral disease of every kind, the careful practitioner should be on the lookou.t for tertiary skin lesions and evidences of early general symptoms. In cases I have treated from time to time there has been severe neuralgia, which was much more intense at night than during the daytime, and besides, the facial and sub-occipital pain there has been a sense of vertical head pressure. The localized paralysis may in- volve organs which, as a rule, escape involvement in organic disease. In three of my cases there has been aphonia as a result of paralysis of the vocal cords, and in one of these cases there was, in addition, paralysis of the third nerve, and in another, alternating hemiplegia. Causes. — First and foremost are primary fornfs of disease, which either produce occlusion of an artery, or irritation from alblood-clot or tumor. Vascular degeneration, which may result from general disease, or renal trouble, acts as a predisposing cause in the development of cere- bral softening. Intellectual fatigue, sexual excitement, alcoholic intoxi- cation, head injuries, and local disease act as exciting causes. Exposure to cold has been given as a cause of cerebral softening, and exposure to the direct rays of the sun may induce the condition. Bamberger ^ has observed it as a consequence of typhus and acute articular rheumatism ; and Jaccoud ^ considers that it may be jDroduced by syphilis in two different ways, either by a gummy tumor, which gives rise to irritation of Wiirtzburg Verhandlungen, 1856. Pathologie Interne, torn, i, p. 177. 174 DISEASES OF THE CEREBKUM AXD CEREBELLUM. the tissue in the neighborhood, or by infiltration. According to Fournier and Huebner, syphilitic cerebral trouble may begin as late as the twen- tieth year of the disease, and according to the latter, as early as the first year, though it is usually until three or four years after the primary sore. Cerebral softening is more common among people of an advanced life as an idiopathic affection, and unless it follows embolism, injuries, or like causes, is quite rare in early life, Andral having found only 39 cases out of 153 in persons under 40. Djrand-FardeP presents the following sta- tistics regarding the period of life at which the softening began: — From 30 to 40 3 40 " 50 8 50 " 55 2 60 " 65 5 66 " 70 9 71 " 75 13 76 " 80 10 80 " 87 5 Jaccoud is of the opinion, which others hold, that males are more commonly affected than females. Season has nothing to do with its de- velopment. Morbid Anatomy and Pathology. —-There has been great differ- ence of opinion in regard to the patholog}' of brain softening. Those who described it in the early part of the century considered it to be an inflam- matory affection, while Rostan,^ who reported many cases, recognized a non-inflammatory form which he had met with among old people with rigid arteries. As Russell Reynolds^ very properly observes, '• much con- fusion has arisen from a tendency to misinterpret morbid anatomical ap- pearances, without paying sufiicient attention to their mode of origin." Cruveilhier* considered two forms, one of which was apoplectic, or " apo- plexie capillaire," which he did not consider inflammatory; and, later, AndraP announced his disbelief in the necessarily inflammatory origin of the disease, and considered it due to occluded arteries and insuflicient nu- trition. Among the powerful advocates of the inflammation theory are Durand-Fardel^ and Gluge,' while upon the other side may be mentioned such additional names as Kirkes,'' Laborde,' Hughiings Jackson,'" and many others. It may be said, I think, that softening of the brain is nearly always of an inflammatory character when it follows head injury and dis- eases of the cranial bones, while the majority of cases, which are second- 1 Traite du KamoUisement, etc. Paris, 1843. P. 491. 2 Recherche? snr le Rimolliseraent da Cerveau, 1820. 3 System of Medicine, vol. ii. p. 461. * Etude de Ii Med., etc., 1821. '" Precis d' Anatomic Path., 1829. * Traite du Ramollisement du Cerveau, Paris, 1843, and Maladies des VeillarJs. ^ Comptes Eendup, 1837. " Op. cit., vol. xxxv. p. 821. ^ Le Ram. et la Cong, du Cerveau, Paris, 1859. '" Op. cit. CHRONIC SOFTENING. 175 ary to occlusion of vessels, are dependent upon general disease o'f a non- inflammatory nature. If the disease be primary, Jaccoud considers that the lesion will be of the first form, that is, at a single point ; but that when the softening fol- lows typhus fever, puerperal, and other general diseases, the foyers will be multiple. If the softening results from embolism or thrombosis, or, in fact, from any other condition producing obstruction of the circulation, there will first be a congestion with exudation of serum, hypersemia of the vessels, and perhaps capillary hemorrhage, which is attended by colora- tion of the parts in the neighborhood, so that they become of a bright pink or red color, and are limited by other regions, which are ansemic and blanched, and a condition which has been called " red softening" ex- ists. If this morbid process takes place in the gray matter, the hemorr- hagic spot will be of a much darker color, and much more sharply circum- scribed. The next change takes place within a week or two, when the color of the lesion becomes much more pale, and the exudation granu- lar; fatty degeneration takes place, the softened spot extends, the neuroglia-cells, nerve-fibres, and nerve-cells become disintegrated, the axis Fig. 28. Diagrammatic. TrsSTTE Changes in Softening. A. Vessel. B, B, C. Nerve-tubes. D. Gluge's corpuscles. E. Swollen nerve-tube. cylinders disappear, and the bloodvessels alone may be distinguished, and even they are greatly disorganized. At this stage the softened spot be- comes much paler, is creamy in consistence, and contains stringy flakes of a fibrinous nature. It is extremely rare for resolution to take place even in the earliest stage. A form of softening, alluded to by Jaccoud, Du- rand-Fardel, and others, consists in the formation of yellow plates, chiefly in the convolutions (plaques jaunes) which are the result of a partial metamorphosis of the softened patches. There may be also a retrograde change, as is witnessed in the formation of cysts, which are filled by a 176 DISEASES OF THE CEREBRUM AND CEREBELLUM. chalky fluid containing fat globules. There is always i^resent a variety of cells known as Gluge's globules, which are composed of collections of small granular bodies, sometimes surrounded by a cell wall, and these are produced by the degeneration of neuroglia-cells, the debris of which are aggregated as masses of fatty granules. These little bodies, which rarely exceed 5J0 of an inch in diameter, have been found by Reynolds, Turck, and Bouchard in the cord, where their form of origin is the same. The various (colors may be seen in the brain at the same time, patches of red, brown, yellow, or white denoting different stages of the morbid process. The lighter shades generally indicate advanced stages, such being the opinion of Durand-Fardel. Charcot and various observers have found forms of white softening in old people ; and others, among them Cotard, Prevost, Bastian, and Reynolds have seen cases of the same kind. It is extremely doubtful whether the condition of degeneration was not preceded by some exudation of blood-elements, and, if it was not, whether the condition had not been confounded with sclerosis. Softened patches may be in the second stage removed by allowing a stream of water to fall upon the cut surface, and when the disorganized tissue is washed away a depression is left. If the cut be made through a brain which presents the appearance of red softening, the affected patch will be found to stand slightly above the normal tissue, and this is probably due to a hyperemia of the capillaries of the part. This fulness of the capillaries is undoubtedly due to collateral circulation of blood through the vessels contiguous to that obliterated, the normal functions being increased through double duty im- posed upon them. This is the view held by Weber,^ as well as by Prevost and Cotard.'^ If the yellow appearance of the softened patches be not due to altered coloring matter of the blood such as Ave find in the early stages, it may be found later in connection with gelatinous circumscribed masses scat- tered through the brain or about old clots or tumors. The parts most liable to this change both in chronic and acute forms are the corpora striata, optic thalami, white substance of the hemispheres, and sometimes the cerebellum ; or there may be multiple foyers scattered through different parts of the brain. Durand-FardeP has collected sixty-two cases of his own and from the writings of other authors, in which the locality of the softening was the following : — Convolutions and white substance 22 Convolutions alone 6 White substance alone 5 Corpus striatum and optic thalamus 6 Corpus striatum alone 11 Optic thalamus alone 4 1 Handbuch der Allgem. und Spec. Chirur., 1865. 2 Gaz. Med. de Paris, May 19, 1866, p. 336. ' Op. cit. p. 2. CHRONIC SOFTENING. 177 Pons Varolii 3 Crus cerebri . 1 Corpus calloRum 1 Walls of the ventricles (septum) 1 Fornix 1 Cerebellum .1 The invasion of tlie brain by syphilis is usually coincident with that of other organs, notably, the liver. The morbid process prefers the central arteries, but those of small size in every part of the brain may be the general seat of inflammation and narrowing, and as a consequence a large mass of nervous tissue may be deprived of its nourishment and undergo an alteration resembling that which attends non-specific softening. The ir- ritation of the syphilitic virus undoubtedly sets up an inflammatory process beneath the endothelium of the vessel with deposit of granular substance, nuclei and spindle-shaped cells. There is thickening of the endothelium and separation of this coat from the others. Subsequent organization of the sub-endothelial deposit and division with strata. The vessel becomes surrounded by new tissue which is also more or less organized and is ulti- mately supplied by capillaries. The next stage is marked by closure of the vessel. Diagnosis. — In an excellent lecture delivered by Hughlings Jack- son,^ he says : " I do not see how the diagnosis that there is actual soften- ing of the brain is in any case to be possibly arrived at, unless the ])atient has certain local 2?aralytic symptoms, as hemiplegia, or some other symptoms implying a local cerebral lesion, such as affection of sjjeech; or, again, un- less there be signs of cerebral tumor (severe headache, urgent vomiting, and double optic neuritis) or evidence of injury to the head. For, so far as I know, cerebral softening is always local ; I know nothing of general or universal softening of the brain. To be warranted in diagnosing soft- ening, you must have symptoms which point to local disease. I do not say that local cerebral softening cannot exist without localizing symptoms. I only say that in their absence you are not warranted in diagnosing its existence." This remark is made in connection with the lecturer's disbe- lief in various forms of functional disease which are so often improperly called " softening," and in which a few functional symptoms which disap- pear under appropriate treatment are vested by the careless or unscrupu- lous practitioner with an importance they do not deserve. These symp- toms are those which follow depraved states dependent upon venereal excesses, fright, and other causes which lower the tone of the nervous system. Jackson's warning is a pertinent one. If we have hemiplegia, some renal or cardiac disease, and valvular de- posits, with murmurs, our suspicions of softening generally turn out to be well founded. The history of the antecedent attack, should it be throm- bosis, embolism, or cerebral hemorrhage, has much to do with the making of a correct diagnosis. As I have said, hemiplegia, unattended by loss of * London Lancet, Sept. 4, 1875. 12 178 DISEASES OF THE CEREBRUM AND CEREBELLUM. consciousness at the outset, is a diagnostic point in favor of softening, and suggests embolism, and if the train of symptoms given on a previous page is afterwards expressed, there can be little doubt as to the nature of the disease. A point insisted upon by Jackson is that the general mental symptoms of softening are either expressed before the softening, or follow it. He denies that general mental symptoms (wandering, delusions, etc.) are directly caused by the softening, but that special mental symptoms (affection of speech) are. The general mental symptoms follow a few hours or days after the local softening. The "preceding mental symptoms " are irritability and altered disposition. Chronic meningitis may resemble cerebral softening, but in the former the pain is more diffused, and the motorial phenomena (spasms, etc.) are more pronounced. Softening with tumor may be made out from the ad- ditional presence of optic neuritis, choked disk, and vomiting. Some forms of progressive meningitis, such as pachymeningitis -with cerebral hsematoma (vide the case detailed in the chapter upon pachymeningitis), may closely simulate cerebral softening, and very often the diagnosis is exceedingly difficult, or may be impossible. The symptoms of hemor- rhage from rupture of a meningeal vessel, such as occurs in the course of these chronic varieties of meningitis, may closely counterfeit the apoplec- tic attack which occurs so often in cerebral softening. Prognosis. — Cerebral softening is one of the most unfavorable con- ditions with which we are acquainted. Death follows the establishment of the morbid condition sooner or later in nearly all cases occurring in adult life. An occasional case of recovery may be encountered in a young subject, but this is exceptional. Of 109 cases of both forms of cerebritis collected by Aitkin,^ he found that the duration of life in cases of this disease was the following, which also proves that there are more cases of the acute than the chronic form of the disease. 1 died in 12 hours. 2 died in 12 days. died in 30 days. 1 15 " 3 (( 13 tt " 36 1 24 Serratus j- j Stioulderl Hand (ulnar lowest) Intercostal Muscles J f- Abdominal Muscles Flexors, hip Extensors, knee t Adductors ~1 I SENSORY. >-Neck and Scalp /Neck and Shoulder Shoulder Arm Hand REFLEX. Uip Abductors Extensors(?) J Flexors, knee (?) Muscles of leg movins; foot Perineal and Anal J muscles .Front of Thorax >- Ensiform area Abdomen j- (Umbilicus loth) I Buttock, upper j part Groin and scrotum (front) f outer side Thigh J. front Scapular Epigastric Abdominal 1 '(_ inner side Leg, inner side f Buttock, lower part Back of Thigh and I . «^««P* , ,FootJ ^'I'^^'^Pai"* I Perineum and y Anus "j Skin from coccyx y to anus Cremasteric T I Knee reflex - Gluteal Ankle clonus Plantar Fig. 37. — Diagram and Table showing the Appkoximate Relation to the Spinal Coeds or the Various Motor, Sensory, and Reflex Functions or the Spinal Coed. {From anatomical and pathological data.) (Gowers.) 18 274 DISEASES OF THE SPINAL CORD. Spinal Congestion. — These serious symptoms of myelitis are never pro- duced by anything but a degenerative process, and there are rarely bed- sores, alkaline urine, or the profound disturbances of sensation or motion which characterize myelitis. Prognosis. — In every case much depends" upon the nature of the cause, and the extent of the cord involved. If there be a traumatism, of course this gives the disease a serious character, and death may occur in a few days. Acute myelitis may run an exceedingly rapid course carrying off the patient in two or three weeks, and in such cases there are usually febrile symptoms. Webber^ says, " It is not always easy to decide whether a case of myelitis should be called acute or chronic. The integrity of the whole cord is so essential to its proper function that if only a small por- tion is affected there are irregular and defective actions in all that part below, and perhaps in 2:)arts above. If an acute affection of one segment is recovered from with permanent injury of the diseased portion, the result- ing symptoms are permanent, and there is chronic derangement of function. Inflammation may begin in an acute form in the lumbar enlargement, and then advance upwards slowly, yet pathologically, with the same characters in each segment of the cord ; as no vital parts are affected, life is prolonged, and the cases seem to be chronic in time, while being acute pathologically. In fatal cases, then, the chronicity or acuteness depends upon whether vital centres are attacked early or late in the dis- ease." If the myelitis result from pressure from diseased and displaced verte- brae, the result, though more distant, is equally bad. Very few cases re- cover entirely from chronic myelitis, and in those that do, the lesion must either be due to syphilis, or be very limited The reparative action of a bed-sore is a valuable index of the central lesion. I have repeatedly witnessed the most varying and rapid changes, either on the result of an improvement, or the reverse in the diseased cord. Treatment. — Counter-irritation, cold, and ergot are useful in the early stages of the acute disease. The former may be produced by the actual cautery, but care should be taken not to burn extensively, as the tissues are too ready to slough. Ice-bags may be used, and the patient should be laid on a water-bed, and kept as clean as possible ; the thighs and nates being washed occasionally with salt and water, or with hot and cold water alternately. The iodide of potassium, with belladonna, should be given internally. Should the case be one of slow development, I pre- fer the use of ergot in half-drachm doses thrice daily ; or we may use the bromides. The sesqui-chloride of iron seems to have enjoyed deserved popularity in England, and it is preferred by Radcliffe to the iodide of potassium. In one case I obtained very excellent results with the tincture of the ^ Boston Medical and Surgical Journal, vol. cii., No. 7. ACUTE ASCEXDIXG PARALYSIS. 275 chloride of iron.. Phosphorus and cod-liver oil, those valuable builders of nervous tissue, may be employed here with every hope that they will do good. In chronic myelitis they are especially serviceable, and small and frequent doses of strychnine are, in addition, useful. The use of the phosphate of silver has been so often followed by good results in recent cases, that I believe it should be tried, not only in this, but in other organic diseases. It seems to have a noticeably good influence upon the bladder, and in several cases I have found the patient was able to hold his water after its use. There are forms of auxiliary treatment which not only increase the comfort of the patient, but go far towards ameliorating his disease. One of these is the assumption, if possible, of a position which shall favor the determination of the blood from the spine. Brown-Sequard has re- commended that the patient should lie upon his side or belly, with his legs somewhat lower than the rest of the body. I have found that wash- ing out the bladder with a dilute solution of carbolic or nitric acid, or chlorate of potash, prevents the disposition to cystitis which there very often is in myelitis. Warmth of the limbs, established by wrapping them in cotton batting, with a covering of oil-silk, or the new India-rubber tissue-paper, opposes contractions, and stimulates the cutaneous circula- tion ; while application of the faradic current, and the employment of massage, help the patient to a great extent. The electric brush should be used faithfully every day, and it is better that the physician should make his own electrical application, than trust it to a nurse or attendant. The descending galvanic current of moderate strength may also be used daily. ACUTE ASCEIs^DmG PARALYSIS. Synonyms. — Landry's Paralysis. Disseminated Neuritis (Gros). Progressive Paralysis (Graves). Paralysis ascendante aigue (Dejer- ine). Definition and Symptoms. — A form of advancing paralysis de- pending upon a rapidly developing central disease which affects succes- sive portions of the cord in its upward course until it reaches the medulla, when death occurs. From the absence of any distinct anatomical change it cannot be said to be a myelitis. Westphall could not find any changes whatever in cases observed by him,^ and Erb quotes various authors whose investigations have had the same result. The disease begins by vague sensory changes referred to the extremi- ties. There is an anaesthesia of the finger tips, so that the individual does not xeadUy feel small things, and finds some difficulty in buttoning his clothes. He is indisposed to walk and grows easily tired, and this weakness in from one to six weeks increases to actual paresis, so that he becomes paraplegic and cannot walk at all. The disease seems to be confined almost exclusively to the motor tracts of the cord, and as the disease reaches a higher level we find a gradual loss of power in 1 Abstract by Dr. J. .T. Putnam in Boston Medical and Surgical Journal, Sept. 4, 187Q, from original " Contribution a I'Histoire des Xevrites, Paris, 1879.'' 276 DISEASES OF THE SPINAL CORD. the parts above. The muscles of the abdomen become weakened, and the functions of the bladder and bowels are much hindered, a resulting atony taking place. The patient, through weakness of the muscles of the trunk, is unable to hold himself upright (Erb), and as the intercos- tal muscles become affected we find various respiratory troubles, such as shallowness of breathing and dyspncea. The arms in turn are paralyzed, and the muscles of the neck involved, and when the medulla becomes aflTected the symptoms of bulbar paralysis are presented, and the patient ultimately dies of asphyxia. Sensory troubles are very light, and occur only when the motor symptoms are well marked. As negative symptoms may be mentioned — 1. Absence of atrophy, except the slight amount resulting from inaction. 2. No abnormal in- crease of reflex excitability either cutaneous or tendinous. 3. No im- paired susceptibility of the muscles to electric stimulation. 4. No con- tractions are ever present. Gros alludes to the varieties of the disease with reference to the duration and severity. " There are three varieties : (1) the acute, usually fatal in the course of three weeks, often before the muscular atrophy commonly met with has had time (it is inferred) to develop itself; (2) the subacute, ending either in partial recovery or in death in the course of six months to a year, and liable, in the former event, to relapse ; (3) the chronic, the most common form, lasting many years, but liable, also, to burst out into the acute variety at any time. The onset of the disease is commonly rapid, and not infrequently marked by a short febrile attack." ^ Gros considers the disease a centripetal affection, and calls attention to the tenderness at the peripheral ends of the nerves. Causes. — The causation of the disease is not known, and all kinds of theories have been advanced — cold, intoxication, the poison of typhoid, diphtheria and small-pox have been alluded to as elements in its production, and syphilis has been suggested as a factor. The history of metallic poisoning would suggest the possibility that in some cases it might play an important part in the genesis of the disease. I know of one patient who died from acute ascending paralysis as a result of lead poisoning, and it is very probable that certain forms of acute paralysis following in the wake of the exanthematous fevers might reasonably be supposed to produce a peripheral neuritis. Pathology. — The cord, brain and medulla have been repeatedly examined but without success, so far as the discovery of lesions were con- cerned. The sympathetic nervous system is probably primarily affected, judging from what Gros has said, and like some other form of spinal disease, in which primary changes appear in isolated groups of muscles, and which are supjjosed by modern investigators to be due to terminal lesions, so may this affection have a peripheral origin. Dr. Grainger Stewart' in an admirable paper upon a rare form of ascending neuritis, which, in many respects, resembles the disease under consideration, only ^ Edinburgh Medical JourDal, April, 1881, p. 878. ANTERO-SPINAL PARALYSIS OF INFANTS. 277 in the trouble lie describes there is an affection of sensory nerve fibres, as well as motor, and there are nerve changes. From the general char- acter of the trouble he is inclined to believe the origin and pathology of the two diseases to be alike. This would point to the peripheral origin of acute ascending paralysis. Diagnosis. — It is necessary to distinguish this disease from a myelitis which, if transverse, is symptomatized by decided affection of motion and sensation, and is attended by atrophy and decided disturbances of the pelvic organs, such as incontinence. Adult spinal paralysis is much more apt to be mistaken for the disease under consideration, than anything else, but here there is atrophy which is so decided and irregular as to be unlike the slight wasting of acute ascendiug paralysis. Gros speaks of the difficulty of distinguishing the disease from simple spinal menin- gitis, which even after all, may be connected with the affection under con- sideration. So far as my own experience goes there is enough mus.cular rigidity and spastic trouble to make a diagnosis, at least in the commence- ment. Prognosis. — The duration of the disease may be very short ; even three or four days may be sufficient for it to run its fatal course. Wilks^ says, " In seeing such cases I am reminded of a spark alighting on a piece of touch paper, and the fire running through its length until the whole is quickly consumed." Erb speaks more hopefally, and refers to Landry, who cured eight out of ten cases. In some cases the disease may come to a stand still for a time, and have a fresh outbreak, which carries off the patient. It is pro- bable that the morbid process, whatever it is, may be of an exceedingly light grade, and affect the cord to a limited degree. Treatment. — Active counter-irritation seems to have been most suc- cessful. This may be produced by the actual cautery or the application of croton oil. Cupping, faradization by the wire brush, and cold douches, certainly have done good in the German cases. Of course the use of remedies and food calculated to build up the nervous system, are to be employed, and among these are phosphorus and the fats. Cod-liver oil, the iodide of potassium, or the syrup of the iodide of iron, may be given alone or in combination. ANTERO-SPINAL PARALYSIS OF II^FANTS. Synonyms. — Paralysie essentielle de I'enfance (Rilliet and Barthez); Infantile Paralysis (Radcliffe Volkman, and others) ; Paralysie atro- phique de I'enfance, Organic Infantile Paralysis (Hammond) ; Infantile Spinal Paralysis (Seguin) ; Spinale Kinderlahmung (Heine). Definition. — This form of paralysis may be described as a condition usually characterized by a primary febrile stage, a secondary paralysis generally of the lower extremities, and a tertiary atrophy. The paralysis is incomplete, as sensibility is never lost. ^ Diseases of the Nervous System, p. 225. 278 DISEASES OF THE SPINAL CORD. Symptoms. — The disease is marked by a febrile onset of greater or less severity, attended by restlessness, malaise, and pains in the joints or back, and there may be rigors ; or in some instances the loss of motor power is preceded by one or more paroxysms of convulsions. This febrile state is by many mothers mistaken for " teething," " worms," or other un- important childish troubles, and it is not till the development of paralysis that any alarm is created. This symptom appears within two or three days from the beginning of the fever, and may take place at night. The only condition of disturbed sensibility is one of hypersesthesia, which, however, is not a constant symptom. Sinkler^ has collected a number of cases in which he has noted the form of invasion of the disease. He found that the paralysis took place sud- denly, that is, with prodromata in but 6 of 108 cases, while Dr. M. P. Jacobi'^ noted this form of invasion in 12 of 163 cases that she had collected. The modes of onset are the following : — 1. The child, while playing, suddenly drops palsied. 2. The child may be paralyzed at night. 3. Fever, but no convulsions ; rapid loss of power. 4. Convulsions, followed by sudden paralysis. Sinkler reports but one case of this kind, and but two in which convulsions followed the par- alysis). 5. The paralysis preceded by one for the exanthemata, or by whoop- ing-cough. 6. Gradual development, perhaps limping at first, and afterwards com- plete paralysis, but no acute symptoms. In this exceedingly valuable lecture, Sinkler throws much light upon the symptomatology of the disease, and gives the details of a classical case. The paralysis may take the form of hemiplegia (Barlow and Duchenne have found cases of true cerebral hemiplegia, and Barlow has re- ported five such cases), or it may affect the voluntary muscles of all four extremities, and some of those of the trunk ; but the facial muscles, as a rule, escape. After a short time there is a return of power in many of those at first involved, and but a small number of muscles (notably the anterior tibial, peroneal, and others of the leg and thigh) remain pow- erless. The temperature of the paralyzed muscles is much lowered, and there is sometimes a difference of from eight to twelve degrees between the affected and normal sides. Heine considers the local reduction of tem- perature in old cases to be from ten to twelve and a-half degrees Fahren- heit. The bladder and bowels escape the paralysis, and their functions are consec|uently unimpaired. Muscular contractility is lost with the commencement of the paralysis, and the faradic current will rarely produce contractions. Such, however, 1 Clinical Lecture, Med. and Surg. Reporter, March 10, 1877. ^ Am. Journ. of Obstetrics, May, 1874. ANTERO-SPINAL PARALYSIS OF INFANTS. 279 is not the case with the galvanic, except in extreme instances, or when the case is one of long standing. So far there are rarely any evidences of atrophy or contracture of the paralyzed muscles, but it will be found now that certain muscles at first affected begin to regain their lost functions, while others become atrophied and utterly useless. Even the galvanic current fails to stimulate them ; and at this period, which may vary from four to five weeks to six months from the beginning of the disease, there may be deformities and muscular contractures, which may result either from the weight of the body upon the affected limb, or from the anta- gonism of non-paralyzed muscles ; but Volkmann^ considers that this in- capacity of the limb to support the superimposed load is of much greater importance as a cause of deformity than the mere antagonism of the unaf- fected muscles. The foot is apt to drop so that the toes hang limp and flaccid. Barlow alludes to the " talus pied creux," a deformity described by the French writer, the instep being prominent and the sole hollowed. Such deformities may take f)lace as lateral curvatures of the spine, talipes, and other distortions which appear as various muscles are par- alyzed, or, if there be shortening of the limb (which is by no means un- common), as a consequence of reduction in the length and size of bones which have become atrophied. The deformities that may result from the disease under consideration are of a j^rimary, and of a secondary or com- pensatory nature. The primary forms are those which are seen as talipes of both kinds, and result from loss of sustaining power of the muscles. The compensatory consist in spinal curvatures, such as lordosis or scoliosis.- The skin is usually blue and livid, and the temperature is much below that of the healthy limb. These deformities rarely disappear, but con- tinue throughout life, which is in no way shortened by the disease. The fol- lowing cases may be presented to illustrate the appearance and behavior of the disease. The first case is somewhat anomalous, as there were two forms of paralysis ; the primary attack being hemiplegia, and the second- ary paraplegia. Case I. — Robert B. (a seventh -month child) was sent to me by Dr. H. G. Piffard, of this city. During September, 1876, he became fever- ish, and, after two days, duriug which he was confined to bed, he had a general convulsion. Before his fever he had eaten a great quantity of cherries, and his mother supposed his illness to be due to this cause. The mother stated that the convulsion lasted three and a half hours. He became paralyzed two days afterwards, the right arm and leg being af- fected; but two days after this he could use even these limbs. A few days subsequently he went out to play, but came back feeling out of sorts; and, after a few hours' fever, aaother spasm took place. Within the next thirty-six hours both legs were paralyzed, so that he could not stand. Towards the first of November he regained some power, and can now stand when holding a chair. 1 Sammlung Klinisher, Vortrage, Heft 1, 1870. * Produced by attempts to restore disturbed equilibrium. 280 DISEASES OF THE SPINAL CORD. Present Condition. — He is a puny boy, about five years old, and is badly nourished. He has no voluntary power over lower extremities, but can move the arms perfectly. The legs are both very much reduced in size, and the muscles are flabby and atrophied. The peronei, solei, and ante- rior tibial muscles are reduced in size, and have lost their electric con- tractility. He perceives pinches, and changes of temperature, and the " wire-brush " produces much pain. The skin is cold, mottled, and dry, and here and there is dotted with patches of scurfy eruption. Case II. — Annetta F., aged 10 years. About three years ago she be- came quite ill after a sleigh ride, and it was supposed that she had " caught cold." Her feverish symptoms were quite decided, and she was slightly delirious. After several days she seemed to improve slightly, but on awaking one morning it was found that she was paralyzed and unable to rise ; and she complained of intense backache and tingling of the limbs, which, however, were of very short duration. About two months after this she began to recover the use of her arms, but the legs were more fully paralyzed ; and it was several months before she began to move her toes, and finally made feeble movements of a more extended character. The muscular contractions of the flexors were performed more easily than movements requiring extension ; and, after a time, she attempted to walk, but at first this act was impossible. During the next year she was obliged to use crutches, and needed the assistance of her nurse. When I saw her, there was talipes equinus varus of the left foot, while the right seemed to be but little affected. Flexion was possible, but extension of the leg or foot was beyond her power. There was some re- laxation of the ligaments of the knee-joint, so that when I made exten- sion I caused the tibia to form an obtuse angle with the femur, so that there was some anterior curvature. Her gait was peculiar, and she swung the left leg, bringing it down with a jerk. The skin covering the left leg was dusky and mottled, and seemed in close contact with the tis- sue beneath ; and the surface-temperature was several degrees below that of the other side. No rectal trouble. Case III. — A gix'l sent to me by Dr. Lockwood, of Xorwalk, had pre- sented, among other symptoms, mitral disorder, fever, general paralysis, residual paralysis, paraplegia, and paralysis and atrophy of the right deltoid, which cannot be made to contract when subjected to either cur- rent. Right leg more affected than the left. Case IV. — A girl 10 years of age. At the second year after a fall she became feverish, was delirious, and took to her bed. There was gen- eral paralysis of the right leg and thigh ; but after three months there was improvement, except of the leg, which remained paralyzed. There are now a pronounced talipes varus, complete atrophy of the antei'ior muscles, and utter loss of electro-muscular contractility. She has used various forms of orthopaedic apparatus without relief. Case V. — Frank X. C, 4 years old, a stout, rugged boy, enjoyed good health until January, 1877, when he contracted scarlet fever, with albu- minuria as a result. From this he recovered, but in August he again fell sick with what was pronounced to be rheumatic fever. There were high temperature, some diarrhoea, which lasted for a number of days, painful joints, and loss of power in both lower extremities. The power returned in the right leg, so that by the middle of Ssptember (three Aveeks from the invasion of the fever) he had control of that member. The left remains powerless, and there has been slow atrophy. The exten- ANTEKO-SPINAL PARALYSIS OF INFANTS. 281 sors of the leg and foot are now powerless, and there is decided atrophy of these and the posterior tibial, abductors of the thigh and anterior muscles. The knee-joints are quite weak, and there are projections on the inner side of both knees. He is knock-kneed, no eversion or inver- sion of feet, but there is slight talipes of the left foot. Case VI. — Mamie W., 6 years and 1 month old, always was a nervous, excitable child. Has had several convulsions in her life of an epileptic character, without any after-effects, or apparent coexisting disease. In July last she had whooping-cough. On September 4th she was taken with colic, malaise, and convulsions, during which the body became rigid, and she frothed at the mouth. These convulsions appeared at 5 P. M., and lasted until midnight. She was unconscious all the time. At 7 P. M. the corner of the mouth became drawn up by spasms. She had fever during the following day and for a number of days. Did not make any attempt to move for a number of days, and for twelve days she could not speak. She was found to be generally paralyzed, and after a short time the arms recovered their strength, but the legs began to lose their size and shape, and became smaller than they were before. Her mental condition is defective (five weeks after attack). And, though there is no impairment of bladder or rectum, she does not call attention to her wants, but defecates and urinates in her clothing. Power of upper ex- tremities good. The legs are cold and mottled ; there is slight talipes on both sides ; and great wasting of the flexors of the feet, especially of the right. Faint contractions are excited by the strongest faradic currents, but she can move her toes very feebly, but not flex the foot. She has control over the thighs. Both feet are slightly everted. There is redness of the skin covering the right knee, but no pain ; no pain in back ; slight impairment of sensation, but reflex irritability not embarrassed, as was demonstrated by pinching; pupils moderately dilated. The muscles of the leg are more often affected than those of any other part. In nearly every instance the tibialis anticus is paralyzed, and in 18 of the 23 examples I have noticed this muscle was affected. The peroneus tertius, longus; extensores longi digitorum, proprius polUcis; and the flex- ores longi digitorum, and longus pollicis, are usually affected. The deltoid is paralyzed more rarely, and of the cases I have enumerated there were but two in which this muscle was affected. The muscles of the upper extremities are seldom involved in comparison with those of the leg, and those that are usually paralyzed are the flexors of the hand. Though the muscles of the trunk may be sometimes involved in the early paraly- sis, it is extremely rare that we find any residual paralysis of any of them. Barlow and others have witnessed repeated attacks of paralysis in the same subject after apparent complete recovery. It is rare to find either arthritic enlargement or wasting, or bed-sores in uncomplicated essential spinal paralysis ; but this disease, which is limited to the anterior columns, should not be confounded with a transverse myelitis or compression myelitis that may be found among children which are not always clearly distinguished, and give rise to tissue changes. Causes. — The etiology of the affection is anything but clear. Expo- sure and bad or insufficient food are supposed to account for it, just as 282 DISEASES OF THE SPINAL CORD. they do for many other diseases of the same class. Barlow alludes to the fact that an unrecognized form of exposure arises from taking a child into a sleeping-room with newly-plastered walls. It is a significant fact that more of these patients belong to the lower walks of life than to the higher, and that the children of the destitute poor, who come of drunken parents, and are "knocked about" and half-fed, are those who are gene- rally the victims of the disease. As to age, Siukler has found that 84 of 108 cases were between the ages of six months and three years, and that half of this number were males. Barlow,^ speaking of the infantile form, states that he found that there was no great preponderance of the disease in either sex, and that of 63 cases he had collected, 33 were males and 30 females. His other statistics show that the disease more commonly be- gins before the second year, and that 42 of the 63 cases occurred between the first and second year of life. It will thus be seen that Barlow sup- ports the other authors I have mentioned. Of 53 cases in which the at- tack could be fixed with accuracy, 27 occurred in the months of July and August. Duchenne'^ holds that two-thirds of the cases begin before the second year, which view I am disposed to take. Warm weather seems to favor the development of the disease, and in nearly two-thirds of Siukler's cases the disease began in the months between May and October, Cases have been reported in which the exanthemata have preceded the paralysis, and varicella, measles, and scarlatina may be mentioned among these ; but it is probable that in the majority of such cases sclerosis not limited to the anterior columns has been the central condition. Morbid Anatomy and Pathology. — We are indebted to Char- cot' and Joffroy, Duchenne,* Echeverria,^ and others for reports of autopsies and microscopical examinations, and as the result of their in- vestigations the following appearances may be looked for. In the early stages of the disease there is probably a condition of sub- acute myelitis, with softening and destruction of nerve-elements, etc. This is confined exclusively to the anterior horns. Some of the nei've-cells of this portion of the cord are sometimes filled with granular pigment depo- sits, while others are disorganized and broken up. The nerve-tubes of the anterior roots will be found shrunken, the myeline absent, but the axis cylinder is nearly always intact. In other cases of longer standing there are evidences of atrophy of the anterior horns, perhaps amyloid degeneration, and sometimes sclerosis. The nerve-cells are found in an atrophic condition, or absent altogether. The white matter of the anterior and lateral columns is not rarely the seat of such degeneration, and proliferation of the connective tissue is some- ^ On Eegressive Paralysis. W. H. Barlow, M. D., Manchester, 1878, p. 4. ^ De I'Electrisation localisee, 3d ed., Paris, 1872, p. 417. * Archiv. de Phys., tome ill., 1870. * Ibid., tome iv., 1870. = Keflex Paralysis, etc., p. 29, New York, 1866. ANTERO-SPINAL PARALYSIS OF INFANTS. 283 times found. In 25 cases, collected by Seguin/ the constancy of the lesion is very clearly shown. The anterior horns together were affected in 11 cases. The right anterior horn alone was affected in 1 case. The left " " " " " 4 cases. Both affected in 6 " Sclerosis of antero-lateral columns (chiefly) and other white matter 13 " Tuhercules and blood-clots 2 " Meningitis and meningeal congestion 2 " Damaschino^ and Roger, Cornil,^ Clarke,^ Charcot,^ and Joffroy have added many histories to those given to the profession by the early writers, and it is now well settled that the anterior horns and lateral columns are the seats of the central lesion. Rosenthal® considers that the primary cause is dilatation and thicken- ing of the vessels, and does not believe that the morbid process begins by degeneration of the nerve-cells. Notwithstanding the appearance of well- defined lesions in nearly every case, there are occasional examples of the disease where no central changes are to be found. Ketli^ reports one of these in which extensive muscular alterations were visible, but not the slightest indication of centi-al disease. Elischer^ examined the muscles, which were seen to be the seat of both fatty and colloid degeneration. The sarcolemma and nerves were not altered. In the striated muscles, instead of the single normal cell-nucleus, there were seen three or four granular cell-nuclei, which seemed to be at the same time enlarged, and contained two or three, or even more nucleoli. The contractile material was diminished, so that it did not fill out the sheath, but drew away from it. This atrophy was so great that at the upper and under part of the spindle-shaped cell-nucleus of the sheath there was hardly to be found a breadth of .002 millimetre of cross-striped contractile muscular substance. Ketli thinks that these changes in the muscle without central disease point to the peripheral nature of the afiection, in which opinion he has but few followers. Lesions of peripheral nerves have been found by various ob- servers. Rinecker ^ reports an autopsy, made by Forster, in which these nerves were found to be thin, shrunken, and greatly degenerated. The bones and muscles present appearances which are perhaps more interest- ing than those of the cord. The muscular fibres are at first found to be reduced in size, and subse- quently the transverse striae gradually disappear, while the longitu- dinal fibres become more marked. There is increase in the connective tissue, and next a fatty degeneration, the oil-globules taking the place ^ Spinal Paralysis, etc., pp. 12-13. » Gaz. Med. de Paris, 1871. ' Ibid., 1864, p. 290. * Med. Chir. Trans., vol. ii., 1869, p. 249. 6 Op. cit. 6 Quoted by Fox, op. cit„ p. 290. ' Ibid. 8 Ibid. » Jahrs. fur Kinderheilkunde, 1871, 5 Heft 1. 284 DISEASES OF THE SPINAL CORD Fig. 38 A o. Normal fibre. A. Represents the normal fibres with well-marked transverse stria}. B. The transverse strife are not quite so distinct, but the longtitudiual fibres are well marked. Fig. 39. Fig. 40. < jr -%y a. Fat t.-ells. b. Interstitial fatty deposits. The stage of fatty degeneration. A. The lon- gitudinal fibres are only seen, and there is a de- posit of round and oval adipose cells and oil-glo- ules. B. Undulations of longitudinal fibres. a. a. Fat molecules. The progressive fatty degeneration and the disappearance of longitudinal fibres. Fig. 41. This illustration represents the final stages, in which it will be seen that the muscular fibre has lost its identity, and at last there is an absence even of oil-globules. of the normal muscular tissue, and finally nothing remains but the con- nective tissue and fat, which latter disappears, leaving the sarcolemma bound together by connective tissue. ANTERO-SPINAL PARALYSIS OF INFANTS. 285 The accompanying cuts, from Daclienne, show the changes that take place. The blood vessels running to the atrophied muscles are often of smaller size than they should be, and sometimes are the subject of atheromatous degeneration. The bones also undergo atrophic changes, becoming friable and thin, and occasionally the seat of fatty degeneration. The cartilage covering their articular extremities is roughened, and in some places detached. Though some observers have maintained the peripheral origin of the disease, the large majority have adopted Heine's original views advanced in 1840, and endorsed by Duchenne in 1855. The almost general opinion that the disease is of central origin has been conclusively proved, I think, by the large number of autopsies, the most valuable of which have been made in late years. Westphal's views in regard to the existence of trophic cells, which were also adopted by Duchenne, certainly receive decided confirmation in the constant atrophic processes which are connected with degeneration of the cells of the anterior horns. That it is not a disorder dependent upon the sympathetic system has been proved by the utter absence of any diseased condition either of the ganglia or the nerves. Diagnosis. — The existence of febrile symptoms, and the secondary complete paresis which changes its character and is finally confined to a few muscles, the unimpaired sensibility, and the rapid sequence of atrophy and deformities give this disease a distinct character which does not admit of any mistake in diagnosis. Forms of reflex irritation, such as ascarides, adherent prepuce, and like peripheral conditions may pro- duce some of the symptoms, but their non-progressive character, and dis- appearance with the removal of the cause, should make the possibility of an error very remote. Prognosis. — Much depends upon the behavior of the muscles under electrical stimulus. If the least response either to the galvanic or faradic currents can be recognized, the chances are extremely good, and it only remains for the physician to be patient and attentive. In regard to dura- tion and its bearing upon prognosis, I may state that many cases have been cured even after deformities have taken place. Klopsch,^ of Bres- lau, reports several of these cases. In one there was shortening of the thigh and deformity of the pelvis, as well as other serious troubles. Much of the hope of cure, however, depends upon the care taken in the treat- ment. Treatment. — The most active and useful agent in the therapeusis of this disease is undoubtedly electricity, either as galvanism or faradism, applied to the muscles. The treatment of the central lesion is also of importance, and it is advisable to begin an eaergetic course of ergot, with the actual cautery, before the atrophic condition commences. 1 Ullsburger's Prize Essay, Am. Journ. of Obstet., 1870-71. 286 DISEASES OP THE SPINAL CORD. After this the central disease is very difficult to manage. Heine recom- mended strychnine, which, in young children, may be given in doses of jhth of a grain, and afterwards increased. Cod-liver oil and sea-air, good food, and tonics are of as much importance as anything else. When we come to the treatment of the paralyzed muscles, we may try electricity, massage, hypodermic injections of strychnine, and the applica- tion of heat and cold. If the faradic current be found to be incapable of producing contractions of the paralyzed muscles, we must make use of the galvanic. From ten to thirty' cells of any good galvanic battery should be employed, and the electrodes must be covered with sponge or cloth. When the positive electrode is placed in the groin (if the legs are paralyzed), and the negative over the muscle or muscles paralyzed, a con- traction may be seen ; if such does not take place, the current may be slowly intermitted by proper apparatus, or by simply removing the sponge from the surface and reapplying it again. If the cuiTcnt be too strong, or if the application be too protracted, we may be disappointed, for the small amount of electric irritability that exists may be quenched before an ap- preciable contraction is perceived. It is therefore better to use a current of low tension. If we are gratified by the appearance of a contraction, we should produce two or three more and then stop for the day. By increas- ing the muscular stimulation little by little each day, we may finally create powerful contractions with a minimum current, and after a short time we may substitute the faradic current. It is of great importance that muscu- lar relaxation should be produced during the use of electricity. I may repeat what I have already said, and add that a tired muscle naturally responds less perfectly to electric stimulation than one which is unim- paired. If massage is used, it is well to knead and rub each muscle every day. Should electricity fail to relieve the contracted condition of the limbs, which may be present, we may avail ourselves of the knife. Tenotomy is often of service, but it should not be prematurely resorted to, but left as a last resource when all other remedies fail. Various methods for im- proving the temperature of the paralyzed limbs have been described by Roth.^ In brief they are the following : — 1st. The position should be attended to in all cases; a paralyzed part should not be permitted to hang down, and to dangle about ; it should be placed in a horizontal position, and the coldest part should be the highest, which assists the reflex of venous blood. 2. Clothing. — Spun silk, a mixture of silk and wool, wool or fur gar- ments should be worn next to the skin ; it is only in exceptional cases that the hypersesthesia of the cutaneous nerves does not permit any of these materials to be used. Here silk is placed next to the skin, and wool 1 It will rarely be found necessary to use this number, and it is advisable to begin with the weakest current that will provoke contractions. * On Paralysis in Infancy, Childhood, and Youth. London, 1869, p. 83, ch. 62, quoted by Barlow. AXTEEO-SPINAL PARALYSIS OF ADULTS. 287 or fur over it. The paralyzed part should be well warmed before it is covered with bad conductors of heat. Eoth recommends also exposure of the leg to direct heat of the fire, a screen with a hole for protection of the rest of the body to be provided. He also recommends the use of Turkish baths, the application of a bag filled with hot salt or sand, and the usual form of massage and electricity to which I have before alluded. Yolkman speaks in glowing terms of the use of Junot's boot, which, with the rubber muscle of Sayre, and the plaster bandage, is a useful form of treatment in cases of long standing. The paralyzed limb is placed in the boot and the air exhausted, so that a determination of blood to the part shall be induced. AyTERO-SPi:N"AL PARALYSIS OF ADULTS. Synonyms. —Acute anterior spinal paralysis. Subacute general anterior spinal paralysis (Duchenne). Spinal paralysis of adults (Meyer, Charcot, Gombault). Myelitis of the anterior horns (Dujardin-Beaumetz, Seguin). Acute spinal pa- ralysis of adults (Petitfils). Anterior poliomyelitis (Erb, Eisenlohr). Acute anterior poliomyelitis (Kussmaul). Definition. — A myelitis of the anterior horns of the spinal cord, either symptomatized by an acute invasion attended by fever, and followed by sudden paralysis, or by the gradual appearance of the paralysis which becomes complete and next par- tially disappears, leaving certain muscles affected ; unattended by loss of sensation, or vesical and rectal trouble. Symptoms. — I am indebted to the little me- moir of Dr. E. C Seguin for assistance in the prepa- ration of this article, and for the report of a case which afterwards fell under my observation when I followed him as visiting physician to the Epileptic and Paralytic Hospital. Duchenne ^ first called attention to this form of paralysis as early as 1853, and recognized its identity with infantile paralysis. Li 1863 Charcot^ was struck with the similitude be- tween the two diseases, and in 1872-73 and later years Gombault,^ Dujardin-Beaumetz,* Petitfils,^ and Bernhardt ^ have presented cases, and decided the fact that infantile Antero-spinal Paralysi? (Seguin). 1 De 1' Electrisation localis^e, Paris, 1872, p. 437 et seq. ^ Papers of Petitfils. ^ Archiv. de Physiol, norm, et path., 1873, pp. 80-87. *De la myelite aigiie, Paris, 1872. ^ Consideration sur I'atrophie aigiie des cellules motrices, Paris, 1873. ® Arch, fiir Psvch. und Xervenkrank, 1874. 288 . DISEASES OF THE SPINAL CORD. paralysis had an analogue in adult life. Gombault brought forward the first case Avith an autopsy confirming the theory enunciated by Duchenne, and in this country the admirable little works of Seguin epitomize all that has already been brought forward. The first case seen by Seguin^ has since fallen under my observation, and from his published notes I copy her history. Female, unmarried, aged twenty years. Admitted to the Epileptic and Paralytic Hospital, Blackwell's Island, service of Dr. E. C. Seguin, No- vember, 1871. Patient presents a paralyzed and extremely atrophied left leg, and gives the following imperfect history : The trouble began nine months ago, suddenly during sleep, with painful conti'actions ; she then gradually (?) lost power in the left leg ; no other limb affected. The patient cannot state how long a time elapsed between the first symptom and the discovery of palsy. She adds that, on the day before the attack, her left leg felt quite cold and a little numb ; and that her menses were suppressed. No cause is apparent — no hereditary influence, no injury. Examination: Left foot is drawn up in moderate pe.s eqidnus, with in- ward inclination. No voluntary movements below the knee. The pa- tient's answers to the sesthesiometer test are unreliable ; sensibility to painful impressions is somewhat impaired, that to temperature preserved ; tickling is felt equally on both feet. Pressure shows tenderness over the lumbar vertebrje ; no spontaneous pain. The right calf measures 26.9 c. in circumference, the left 23.7 c. There is absolute loss of electro-mus- lar contractility in all the muscles of left leg. The left leg is very cold, and its circulation feeble. I frequently called the attention of the resident staff" and of friends to this remarkable case as one of the same kind as that which, occurring in the early years of life, we call infantile spinal palsy. The subsequent history need not be reported. No treatment did any good ; the girl remained in the hospital without any acute symptoms, and went away October 3, 1873, carrying this wasted left leg. She was em- ployed as a help in the wards of the Convalescent Hospital on Hart's Island, and was there much exposed to cold. The second attack, of wdiich patient gives a good account, came on late in December, 1873. Had pains " like rheumatism " in right leg ; there was a feeling of pins and needles in the limb, this numbness extending above the knee. She is positive that on the fourth day the right leg was completely paralyzed. No symptoms in left leg. No bedsore, and no affection of bladder or rectum. Re-admitted to the Epileptic and Para- lytic Hospital, March 3, 1874, with atrophy and paLsy of both legs ; no acute symptoms. During the spring and summer this patient rather gradually lost strength in the thighs, in the right most. She also exhibited a variety of interesting visceral disturbances, consisting of amenorrhoea, lasting two or three months ; the menses then appearing with much pain, the blood abundant and in clots ; there were also pains in the back and lower ab- domen. On many days in this period the urine had to ba drawn oflT with the catheter, and it often was bloody, exhibiting a heavy mucous deposit, and containing albumen. The microscope showed only leucocytes and a variety of epithelial cells — there being probably both pyelitis and cystitis . * Spinal Paralysis, N. York, 1874, and Anterior Myelitis, 1877. ANTERO-SPINAL PARALYSIS OF ADULTS. 289 Since the middle of September has not required the catheter, and, with exception of palsy, has been better. Re-examined October 25, 1874. Patient, when she first came in this year, walked ill with a crutch and stick ; is now able to walk with two sticks (result of education). Cannot stand or walk without help. The patient is a stout and healthy girl, exhibiting nothing abnormal above the hips. Both lower extremities are extensively palsied and much* wasted. The left leg (first attacked in 1871) shows no voluntary move- ment below the knee, with exception of slight separation of the toes. As the patient lies on the bed she is able to raise the extended limb as a whole ; but the strength at knee-joint is small. The thigh is thin and flabby ; the leg is the seat of extreme atrophy, and looks just like the same part in cases of infantile spinal palsy, there being apparently only connective tissue and fat around the bones, the skin being bluish and very cold to the touch. The right lower extremity (paralyzed in 1873) is in a very similar though less extreme state. All voluntary move- ments are possible with the foot, though they are feebly performed. The limb, as a whole, cannot be raised from the bed, and flexion at knee-joint is weak. The quadriceps extensor femoris is wholly paralyzed ; the flexors of the thigh upon the body act feebly ; the adductors fairly. Both feet lie extended and adducted ; toes flexed. The right leg is, like the left, extremely wasted, bluish and quite cold. Sensibility to contact, pain, and temperature are preserved in both limbs. Tickling is felt, but produces no reflex movement in the palsied parts. The electro-muscular reaction of the- atrophied muscles of both limbs is lost (both currents). At present, urine is passed normally. The patient's arms, shoulders, and chest are large and rounded, standing in remarkable contrast to the dwindled legs. There have been no bedsores and no spinal epilepsy. Circumference of right thigh (lower third) 31.5 c. left " " " 30.5 " right calf 24.0 " left " 21.5 '' forearms 25.0 On a healthy girl (non-palsied) of same proportions as the patient, the following measurements are obtained : — Circumference of right calf 35.0 c. " . left " 34.5 " forearms '. 24.0 The patient having been in bed some time, well covered up, has a thermometer held between the great and second toes of each foot for three minutes, with results: — Right side, 84.25° Fahr. ; left side, 86° Fahr. In March, 1876, the patient came under my charge, when I found that her condition was somewhat aggravated. She manages to go about with the aid of crutches, but has utter loss of power below the knees. The tactile sensibility is much lowered, and tickling can be borne without any reflex movement being produced, and she has lost control to a great ex- tent over the bladder and rectum. 19 290 DISEASES OF THE SPINAL CORD. Another case reported by Lincoln is well worth presenting, as illustra- tive of this form of disease beginning without fever. A tall, stout man/ 49 years of age and of previous good health, noticed one morning, without any previous symptoms, a feeling in his legs as if they had fallen asleep. The feeling came on again and again through the day, and he began to be a little weak in the legs. In the afternoon, when trying to step upon the platform of a street car, he failed, and had to be helped in. On arriving home, he was able (with assistance) to walk up stairs to his bedroom, and went to bed, where he remained. When seen by Dr. L., two days later, he felt well, no giddiness, mus- cles of face and eyeballs under perfect control, pupils normal in size and contracted well, speech natural, vision and hearing without defect. The bladder and rectum performed their functions normally. The senses of touch, pain, and temperature were normal in the hands, and nearly so in the feet. Reflex contractions could scarcely be obtained from the soles. There were no abnormal sensations. Pulse, 80 ; temperature, 98°. No albumen in the urine. The muscles of the neck and limbs, except below the knees, were gene- rally in a condition of semi-paralysis. He lay on his back almost help- less ; could not raise his head from the pillow without some help, and could not raise his knees from the bed by flexing the thighs. The grasp of his hand was very feeble indeed. There was no paralysis of any mus- cle. Below the knees he seemed to have more strength. The weakness was much more marked on the left than on the right. Treatment consisted at first in nux vomica and cinchona, and subse- quently tincture of iron with strychnia, and Horsford's acid phosphates of lime and magnesia. On the fifth day of the attack, treatment by the induced electric current was begun, when it was found that some at least of the muscles had lost part of their susceptibility to this stimulus. The loss went on increasing until the twenty-first day, when the galvanic cur- rent was substituted, a descending current being applied to the spine, and interrupted currents to the muscles, three times a week; the faradic cur- rent was also continued for a few weeks. The hot-air bath to profuse perspiration was used just before the appli- cation of the currents, together with regulated gymnastic exercises. The paralysis of the muscles was gradually relieved under this treatment to a very considerable degree. The patient's improvement was very gradual, and it was six months before he was able to ride out. He finally was en- abled to attend to his business pretty much as before the attack. Other cases begin much more slowly, and several of this kind are re- ported by Duchenne, but the origin of the disease is nearly always sud- den. There may be pain or dyssesthetic symptoms, or no warning at all, the patient awaking in the morning and finding himself paralyzed, as was the cass with Seguin's patient. Like the infantile form, there may be an acute attack of fever, which may last for several days, during which there is usually delirium or rigors. The paralysis appears during this time, and may be general, so that the upper and lower limbs are af- fected and the loss of power is complete. The functions of the bladder 1 Boston Medical and Surgical Journal, March 25, 1876. ANTER0-8PINAL PARALYSIS OF ADULTS. 291 and sphincter ani are always normally performed until other parts of the cord are affected, and there is neither incontinence of urine nor involun- tary evacuations. At the end of a few weeks there is a commencing im- provement, some of the muscles regaining their lost power and contracting quickly under electric stimulus, while atrophy of those already paralyzed begins to take place. The skin over the paralyzed limb is quite cold and blue, and there is diminution of temperature and faradic excitability, while ultimately it is impossible to provoke any response, and the limbs become deformed and twisted. Atrophy of deeper parts follow, and the bones become reduced in size, while the articular ends appear large in contrast with the attenuated size of their shafts. Sensibility is rarely disordered, though exceptional cases of anaesthesia or hypersesthesia are met with, but after the inflammation has involved the posterior columns the phenomena of general myelitis are presented. Dyssesthesise are com- mon, and the patients complain of subjective cold, various pains, and the waist-constricting band. The muscles of the face, neck, chest, and abdo- men are rarely afiected, but the extremities remain deprived of pain after there has been a considerable retrocession of the original complete paral- ysis. The atrophy is rapid, and differs from that of progressive muscu- lar atrophy in the tact that whole groups are affected at a time, while the peculiarity of progressive muscular atrophy is that muscles are irregu- larly affected. There are never bedsores. The disease may be so rapid in its development as to suggest the mal- ady known as acute ascending paralysis, and it is probable in such case that the extension of the disease proper is not always confined alone to the anterior columns. Erb ^ alludes to a light variety of spinal paralysis, which has been de- scribed by Kennedy, Fry, and others. To this variety has been given the name " temporary spinal paralysis." The paralysis is characterized by its brief duration, and may involve a limited group of muscles or seve- ral groups. It would seem, therefore, that there are two varieties : the temporary and permanent ; but Seguin and others have made the classifi- cation acute, subacute, and chronic, which is based rather upon the variety of myelitis than the paralysis. Ducheune applies the term sub-acute to the former, which begins without fever, attacks the lower extremi- ties first, and, extending upwards, involves the muscles of respiration and deglutition. Causes. — The same unsatisfactory history of exposure, fatigue, and peripheral irritation is connected with the history of this as well as other spinal diseases. In four of Seguin's cases surface exposure to cold is said to have produced the attack, and in three other cases, " refrigeration " is named, while in others dysentery, measles, and other acute diseases were at the origin of the trouble. As regards age and sex, I can do no better than refer to the tables of Seguin. All of the patients whose histories he collected were of middle ^ Archiv. fur Psychiatrie, Band v., Heft 3. 292 DISEASES OF THE SPINAL CORD. age. " The greatest age at the time of seizure was 62 years, the least 18 years." Among 17 cases reported by various observers, there were 13 men and 4 women. Morbid Anatomy and Pathology.— But very little light has been thrown upon the morbid anatomy of the cord, which accounts for this form of paralysis. Chalret' and Gombault' have reported two cases. The appearances found may be briefly enumerated as these : The hori- zontal fibres which pass from the anterior horns to form the anterior spinal nerve-roots were diminished in size, and the large ganglion -cells of the anterior roots were atrophied, having undergone yellow pigmentation. Some of the nerve-cells which had not undergone this form of degenera- tion, were also reduced in size. This information is very meagre, though these two cases illustrate the pathological anatomy of the dis- ease. Charcot and the majority of observers believe that the situation of the lesion is always in the anterior horns. The only matter of dis- pute seems to be whether or not there is primary degeneration of the cells, or an acute interstitial myelitis and .secondary injury of the nerve- cells. This latter view is held by Erb,-' and, I think, is being generally adopted. -u- i • The muscles were found to be in a state of fatty granulation, which is the case in the infantile variety. In some respects the disease resembles progressive muscular atrophy and bulbar paralysis, the lesion being atro- phy of the motor and trophic cells, but it is probable that the trophic cells are primarily affected in these latter diseases. Diagnosis.— Antero-spinal paralysis is likely to be sometimes mis- taken for progressive muscular atrophy. If we bear in mind its sudden or almost sudden and complete origin ; the absence as a rule of fibrillary tremors (only two cases which presented these symptoms having been re- ported) ; that the paralysis precedes the atrophy, and retrocedes after the first general attack ; that electric irritability is primarily lost ; and that the atrophy involves the muscles of one or more (usually two) extremi- ties, there need be no error made in diagnosis. Anaesthesia, incontinence, and paralysis of the sphincter ani prevent it from being confounded with general myelitis, these symptoms belonging to the latter in addition to the loss of power and atrophy. Spinal congestion may sometimes give rise to some of the symptoms, and Cartwig* presented a case which he called " intermittent," somewhat resembling the lighter form of true antero-spinal paralysis. A sugar-baker, aged 23, who was exposed to great heat and sudden changes of temperature while very lightly clothed, had suffered m his eighteenth year for four or five weeks from an attack of tertian ague, from which he recovered- One day lie perceived a numbness in his legs, which rapidly attacked his arms also, and finally led to complete para- 1 These de Paris, 1872. 2 Archives de Physiol., norm, et path., tome v., 1873. * Op. cit. * Centralblatt f. d. med. wis., June 15, 1870. ANTERO-SPINAL PARALYSIS OF ADULTS. 293 lysis of the muscles of the neck. Speech, deglutition, and respiration were somewhat impeded ; the muscles of the eye were unaffected, as were also the alvine and urinary excretions, and sensation. After twenty-four hours there was a remission of the symptoms ; first the neck began to become movable, then the fingers, arms, body, and finally the legs. All this took place in half an hour, and was followed by an increase of per- spiration. During the next twenty-four hours the patient remained free from paralysis, but was dull ; after which, the above-described symptoms returned. The brain was always free ; the cervical portion, especially the upper, was not always equally affected ; the movements of the neck were often free ; and difficulty in deglutition and respiration, inequality of the pupils, and myosis, were frequently present. The phrenic nerve was always unaffected. When there was not complete paralysis, the affected limbs were generally stiff, and there was contraction of the pre- dominating groups of muscles ; when complete paralysis was present, the muscles were soft and flabby. Electro-muscular irritability was almost conipletely absent during the paralysis, and the violence of the muscles varied. Under the use of quinine, the patient's condition was on several occasions quickly improved, but he was not cured. He was under obser- vation for more than six months. The author believes that the case was one of masked intermittent, and that the phenomena were due to hyper^e- mia of the cord and occasional increase of serous exudation. In spinal congestion there are no deformities, no atrophy, and nearly always vesical trouble and constipation. Acute ascending paralysis resembles very closely certain forms of the disease under consideration. In one remarkable case reported by Des- j^rine,^ no morbid appearances were found after death. A man entered the hospital suffering from undefined pain in the lower limbs, and two days after became paraplegic without any loss of sensibility. The paralysis rapidly succeeded, and, after four days, he died ; no trace of disease after paralysis of the respiratory muscles could be found except dilated vessels. Seguin considers that this involvement of the respiratory muscles is a diagnostic sign. Prognosis. — Antero-spinal paralysis is not a disease which is rapidly fatal, and many cases recover within a short time after the beginning of the attack. I am not disposed to think that the lesion is an ascending one;^ but rather that, if it progresses at all, it involves the posterior and laterial parts of the cord in the majority of cases, and does not sjijread longitudinally. This ia probably the condition of affairs in the case of S. W. Should the paralyzed muscles become atrophied to such an extent that deformities result, I think that there is very little hope for the patient. If, however, the muscles can be made to respond to the galvanic current, we should never be discouraged. Of the cases reported by Duchenne, Meyer, Bernhardt, Seguin and others, I find that of 16 cases there were but 2 deaths. In one observation there was improvement in six months, in another in four, and in others two, ^ Archives de Physiol., etc., June, 1876. 294 DISEASES OP THE SPINAL CORD. three, eleven, and twelve. In two cases the patients were cured, and in several there was progressive unfavorable advancement. Treatment.— In electricity we possess a remedy of the greatest value. I have already called attention to its use in the infantile form of the disease, so there is no need for going into details. It is well to use both the galvanic and faradic currents, and in the acute form of the trou- ble we should begin with counter-irritation of the spine as early as possi- ble, and for this purpose may employ blisters or the actual cautery. Ergot and belladonna in rather full doses should be employed in con- junctfon therewith. Seguin recommends leeching and dry cups, which are both excellent. Should the pain be severe, we may use morphine by means of the hy- podermic syringe ; or spinal galvanization. The after treatment should be with the galvanic current. The use of warm applications, such as have been spoken of as of benefit in the infantile variety, are worthy of trial. PROGRESSIVE MUSCULAR ATROPHY. 295 CHAPTER X. DISEASES OF THE SPHSTAL CORD (Continued). PROGRESSIVE MUSCULAR ATROPHY. Synonyms. — Wasting palsy ; CruTeilhier's paralysis ; Progressive muskelatropliie ; Progressive muskellahmung. Definition. — This is an essentially progressive atrophy of certain groups of muscles. It is not preceded by any paralysis, but followed by loss of power, and terminates usually by involvement of the respiratory nerve-centres. Cooke,^ in 1795, directed attention to a condition he called " anomalous hemiplegia" which was clearly progressive muscular atrophy, and his was probably the first recorded case. Bell,^ Abercrombie,^ and Darwell* each published cases which were undoubtedly of this kind; and, in 1836, Mayo ^ related two cases. It was not, however, till 1849, when Duchenne de Boulogne ^ presented a memoir to the Institute of France, entitled " Atrophie musculaire area transformation graisseuse," that the present disease was recognized. In 1853, Cruveilhier^ described some cases in which the atrophy was general, all the voluntary muscles being affected. In 1850-1861, Aran,' Duchenne,'^ and Eisenmann^'^ brought forward ad- ditional facts, and the latter agreed with Cruveilhier that the " nerves or nervous centres are at fault anterior to the muscles, and that the atrophy of the latter is a secondary process." Since that time we are in- debted to Roberts" and Friedreich^- for most clear and instructive de- scriptions. Symptoms. — The appearance and progress of the disease are most gradual. The affected individual may first notice a slight weak- ness in one of the upper extremities. Perhaps the first indicattion of trouble which suggests to the patient the commencement of the 1 Cooke on Palsv, p. 31,1822. ^ The Nervous System of the Human Body, London, 1830. 3 On the Brain and Spinal Cord, p. 419, Edin., 1828. * Lond. Med. Gaz., vol. vii-, p. 201. 3 Outlines of Human Pathology, p. 117, London, 1836. 6 Memoires de I'Acad. des Sciences, 1849- ^ Archives Gen. de M^d., May, 1853. 8 Ibid., Sept., 1850. ' De I'Electrisation localisfee, Paris, 1855-61. " Canstatt's Jahresbericht, 1859. 11 An Essay on AVasting Palsy, London, 1858. 12 Ueber progressive muskelatrophie, etc., Berlin, 1873. 296 DISEASES OF THE SPINAL CORD, (Fig. 43). disease, is when the act of writing is attempted. According to Roberts, the disease begins, in two-thirds of the cases, in the upper extremities, and the muscles of the hands are the first to suffer loss of function. Very often several muscles are affected together, and they soon become agitated by what are known 2l^ fibrillary contractions, or, as they have been called, vermicular contractions, which in their nature are probably a divided re- flex excitation. The subcutaneous contraction of muscular filaments sug- gests the appearance of worms crawliug beneath the skin, and there is sometimes a species of muscular shivering. These fibrillary contractions may be excited by sharply striking the muscles with a ruler on the hand, and they sometimes follow the passage of the galvanic current through a nerve-trunk. As I have said, the hand may be affected first, and there may be extensive wasting here before other parts are attacked. The muscles of the palm of the hands, when atrophied, give to that member a most unsightly appearance. The bones stand out in strong relief, and the thenar and hypothenar eminences are flattened, and the flexor ten- dons are prominent, and increase the deformity. With this there is con- traction of the flexors, and the hand resembles more the claw (Fig. 43) of an animal than anything else, so that it has been called "main en griffe." The back of the hand also presents a most skele- ton-like aspect, the extensors, the interossei muscles, and sometimes the adductors of the thumb having been reduced in size. The forearm and arm are next to follow, and rapidly lose their normal conformation. The deltoid and serrati muscles may be involved, while those of the arm proper may occasion- ally be passed over. The head of the hu- merus and angle of the scapula are quite dis- tinct, and this bone may be drawn out of place by the healthy muscles, this being the rule when the serratus magnus is the seat of atrophy. The angle of the scapula is drawn upwards and inwards, and stands out from the trunk. It is rare to find symmetrical atrophy, and in the majority of cases I have seen there has been a great difference in the invasion of muscles on the two sides. The right upper extremity appears to be the favorite seat of the atrophy, while the lower extremities are quite rarely affected, and in the proportion of 1 to 12 to the upper extremities. The muscles of the face and head are sometimes the seat of atrophy, but this is unusual, though muscles may occasionally be so extremely wasted that there is no appearance of intelligence whatever. The eyes, of course, being unaffected, are the only agents of expression. There may be atro- phy of the tongue and buccal muscles, with disturbances of speech and drooling of saliva, and in such cases death usually follows in a very short time. Sometimes the muscles of the neck do not escape the extension of " main en griffe' (Duetienne.) PROGRESSIYE MUSCULAR ATROPHY. 297 the disease, and the chin falls forwards and downwards. The last mus- cles involved are generally those concerned in respiration ; and not only are the intercostals the subjects of such a change, but the diaphragm is finally paralyzed, so that the action of the lungs is interfered with, and ultimately the patient is literally asphyxiated. Subsequent to atrophy, a loss of power takes place. The affected muscles preserve for a long time their electric contractility ; but this is finally lost as they decrease in size, and loss of power increases till finally the patient becomes helpless. Duchenne is of the opinion that the loss of voluntary muscular contractil- ity is rather the contequence of atrophy or textural alteration than of paralysis, i. e., loss of motor innervation ("C'est-a-dire du defaut d'action nerveuse motrice"). Tactile sensibility is, however, rarely blunted. One of the earliest symptoms of progressive muscular atrophy is the presence of dull pains in the affected limbs, and this has led very frequently to a mistake in diagnosis, the condition being often considered rheumatic. In one case sent to me by Dr. E. G. Loring, I found that the atrophied mus- cles were the deltoid, serratus magnus, and biceps, but none of the lower muscles of the forearm were attacked. The man had consulted another physician, who considered the case one of chronic rheumatism, and pre- scribed liniments and alkalies. The patient was an upholsterer, and had been obliged to use his right arm to a great extent, especially in ham- mering on cornices, and putting up decorations which were above his head. He had had violent pain in the shoulder for some months, and subsequently the atrophy began in the deltoids. When I saw him the head of the humerus was promitient, and there were fibrillary contrac- tions in some of the muscles of the back. When the upper extremity is affected, it will be found that when the forearm is flexed the belly of the biceps wijl be often found to be reduced to the size of a small ball. The progress of the disease is marked by the occurrence of well-marked inter- missions, and a year or two may often pass without any extension, while at the end of that time a fresh start is taken, and two or more of these stationary periods are not uncommon in the course of the malady. The ordinary tendency of the affection is however progressive ; and although, as I have said, the disease may pursue the most eccentric course, attack- ing groups of muscles here and there, it will involve ultimately a very great number, and finally those supplied by the lower cranial nerves, un- less it be checked by proper treatment. I may illustrate the symptomatology of progressive muscular atrophy by a case which ran a somewhat irregular course by attacking the muscles of the lower extremities : — J. F. H., 31 years old ; U. S. ; engineer. Twenty-one months ago the patient, after exposure, developed what he says was articular rheumatism, which chiefly affected the legs. On recovery he noticed that the right leg " began to grow smaller at the calf," and that afterwards his left thigh became smaller. His pains continued at intervals, and were in- creased by damp weather. Present Condition. — The muscles of the anterior part of legs and thighs 298 DISEASES OF THE SPINAL CORD, are much wasted, the abductors of thighs aad the recti femoris on both sides being notably so. The knees seem very large, and the condyles of the femur are felt to be superficial and covered tightly by the skin. There is no loss of sensation, and electric irritibility appaars to be very generally preserved, except in the recti femoris. The glutei muscles have suffered to some extent on both sides. He has severe pain at night, which runs down the legs, and " seems to be deep." There is impaired motor power, and he finds that walking is difficult. He does not experience any urinary trouble, and his bowels are not constipated. There is no loss of co-ordi- nating power, no constricting band, no history of any kind of acute mye- litis. The muscles on the outer side of the thigh are the seat of fibrillary contractions, which occur sometimes when he makes a voluntary effort. There was at this time no atrophy of any of the muscles of the upper extremities, but when I saw him some months subsequently there was commencing atrophy of the muscles of the right hand. In the paralyzed Fig. 45. Atrophy of the Left Shoulder. muscles the temperature is much lowered, and this is a constant feature of the disease. Jaccoud^ and others have called attention to a temperature change, which they call " refroidissement variable," in which there are times when the temperature may fall several degrees, and this seems to be the result of a paroxysmal ischremia of the tissues. The pupillary con- dition is an interesting feature of the disease, the dilators sometimes being paralyzed, so that the pupils are widely or unequally dilated. 1 Op. cit., p. 326. PROGRESSIVE MUSCULAR ATROPHY. 299 It is the rule, in these cases, to discover certain trophic changes affect- ing the skin and its appendages, so we quite commonly find diseases of the nails, eruptions, and other cutaneous lesions ; but a patient now under treatment presents something in addition to these. It has been found that he sweats profusely upon the right side of the body, which is more atro- phied than the left, while the left side is quite dry. By careful experimentation I have found that when ammonia is held to his nose the right eye almost immediately becomes suffused with tears, while the left remains almost entirely unaffected. When salt is placed upon the tip of the tongue an abundant discharge of saliva from the right corner of the mouth occurs almost at once. Dr. Claddek, my assistant at the Hospital, painted with cantharidal collodion two spots of the same size upon either side of the chest, and upon the normal side only very slight changes took place, while upon the right, or affected side, a blister was formed almost immediately, and it was very slow in healing. In many cases the general health of the patient is unaffected in any way, and yet the atrophy may be of the most complete nature. I recently saw a patient thirty-eight years old, who had been a soldier in the regular army, and was exposed much to the elements. His illness has lasted but two years, yet in that short time nearly every voluntary muscle has under- gone a great diminution in size, except those of the face. His respiration is labored, and he cannot stand without support. He is 5 ft. 8 in. in height, and his anterior dorsal curve is four inches in extent. In a line measured at level of nipples his chest girth is 26 inches ; at inspiration there is a gain of two inches. The right arm at middle 'of biceps is 61 inches in diameter; the left 62- inches. All the bony prominences are distinct, the angles of the scapulae approximate, and he is almost a skele- ton in appearance. There is no loss of sensation : The atrophy in this case was as great as that presented by Duchenne's patient, ^ Bonnard, in which the pectoral, trapezii, with the exception of their clavicular portion, great muscles of the back, biceps and anterior muscles of the left arm, supinatores longii, had nearly entirely disap- peared. Duchenne alludes to the changes in conformation of the thorax when the intercostals or diaphragm are paralyzed, and presents two illustrations showing the perimeter of the chest in two patients affected with atrophy. These are presented in the accompanying illustrations. Thoracic troubles, such as bronchitis, are not uncommon as a result of impaired lung action. Causes. — These may be enumerated as heredity, which is found to enter conspicuously into the etiology of progressive muscular atrophy, exposure, the over-use of 2^(ii't'icular groups of muscles, injury of the spinal cord, and sometimes syphilis and the zymotic diseases. As to the heredi- tary influence which favors its development, Friedreich '^ reports several cases, which go to show that this disease, more than all others, commonly 1 Op. cit., 3rd ed., p. 500. 2 Qp. cit. 300 DISEASES OF THE SPINAL CORD, Fig. U. (Duchenne.) appears in several generatious of the same family. I have seen one case where it could be traced for three generations back, and in another, which I will presently detail, there were uncles and aunts affected. Eichert,^ in a very valuable article, gives the family history of one case. In a genealogical table he traced the disease back six generations, and repre- sentatives of these generations are still living. Seven cases are related by him. In two of the cases the parents have escaped, while the children have suffered. It is unnecessary to pursue this matter further ; but I am firmly convinced that there is no other disease, except perhaps it may be phthisis pulmonalis, which is transmitted so frequently as this terrible malady. Exposure to damp, neglect to change wet clothing, and like imprudences, are exciting causes in many cases. Neuralgic pains are very prominent in such cases, and the onset of the disease is rather pre- cipitate. Mechanics of all kinds, who are in the habit of using some muscles much more than others, are frequently the victims of the disease, and the muscles which have been over-used are aflfected before the others. I have seen the same limited atrophy in a cigar-maker and in a composi- tor, who used certain groups of muscles almost constantly. Roberts has dwelt upon the connection between injury of the spinal cord and the dis- ease under consideration ; and Valeutiner,^ Bergmann,^ and Thudicum have all called attention to the appearance of the disease some time after the receipt of an injury. Roberts reports a case in which atrophy of the ball of the right thumb, and subsequent complication of the respiratory muscles, and death followed a slight injury received six months before. The other cases are none the less interesting, and go to prove the import- ance of recognizing such causes. As to age and sex, it has been found that progressive muscular atrophy is not confined to any period of life, but the bulk of cases occur after puberty. Of 88 cases reported by Roberts, 1 Avas only 2 years old, and another 69. Of the 28 cases I have seen, the atrophy began in 2 between the 5th and 10th years; in 5, between the 10th and 15th ; in 18, between the 20th and the 30th ; and in 3 after the 30th. Of these, 23 were men, and but 5 women. This 1 Prag. Viert., 1855. - Berliner Klin. Wochenschrift, Oct. 20, 1874. * Petersburg Med. Zeitsch., 1864. PROGRESSIVE MUSCULAR ATROPHY. 301 seems to be the rule, and Roberts states that six men are affected to every woman, and he considers this due to the exposure and external violence to which males are subjected. Morbid Anatomy and Pathology. — The disputed point in regard to the pathology seems to be whether it is a primary peripheral condition, or whether it is a central affection in which the trophic cells are affected. The advocates of the first theory call attention to the fact that muscular atrophy occurs independent of any loss of the muscular function, and believe it to be purely a local degeneration. The authorities I have spoken of, in alluding to the early history of the disease, all believed in this intra-muscular origin ; but lately there have been so many proofs of its central origin brought forward, that the former theory has been aban- doned. This difference of opinion seems to exist in regard to the form of central lesion. The majority of observers are agreed that there is an affection of the anterior horns ; and that the change is one that affects the trophic cells of Duchenne and Westphal, and the fibres which con- nect with sympathetic ganglia. To Lockhart Clarke,^ who has so often decided questions regarding the pathology of nervous disease, belongs the credit of having discovered the central origin of this disease. He found atrophy of the anterior gray horns, and since his original observations many other o'bservers have come forward to endorse his views. Von Recklinghausen and Dumenil'* disagree, however, with this view, and the microscopical examination made by the former was unattended with any discovery of morbid appear- ances. Jaccoud has collected six cases in which fatty degeneration of the sympathetic had taken place, and one of them was observed by this author himself. Not only was there fibro-fatty degeneration of the sympathetic nerve, but there was atrophy of the anterior roots. The view held by Jaccoud is that the trophic filaments of the sympathetic which preside over nutrition do not perform their duty, and that the affection of a mixed nerve, which contains motor, sensor, and trophic filaments, at a point where they are intimately mixed, must result in a perversion of all their functions ; but if the separate filaments be attacked at a point be- fore they become blended, there may be independent loss of function of either one.^ Charcot and Gombault* have described the following interesting post- mortem appearances witnessed in a recent case : — 1 Brit, and For. Med.-Chir. Eeview, vol. xsx., 1862. ^ Gaz. Hebdom., 1867. ^ The localization of well-defined lesions in this disease is sometimes made before death and verified afterwards. Prevost and Cotard (Archives de Physiol., Sept., 1874) present such a case. There was atrophy of the right thenar eminence, with atrophy of the right anterior root of the eighth pair of cervical nerves, slightly marked atrophj' of the right anterior root of the seventh cervical nerves, and atrophy of the gray matter of the anterior horn at this level of about an inch in extent. * Archives de Physiol., 1875, No. 5, abst. Phil. Med. Times. 302 DISEASES OF THE SPINAL CORD. "No change in hemisphere, cerebellum, pons, or medulla oblotigata in these nerves. The gray substance of the cervical and dorsal medulla spinalis was greatly altered from the lower portion of the cervical enlarge- ment down, gradually decreasing downwards and outwards. The nerve- cells and nerve-fibres of the anterior gray cornua had disappeared; the capillary vessels were greatly developed ; the parietes of the smaller and larger vessels were thickened. The lumbar portion of the cord and the lateral columns were normal. In the cervical and dorsal region, the portions of the cord near the merging external roots were sclerosed ; the change being proportionate to the intensity of that which had taken place in the gray cornua. The few ganglion-cells present were very much diminished in size, without processes, more rich in pigment than normal, but still containing nuclei and nucleoli. The anterior roots of the cervical region were atrophic ; empty sheaths, frequently containing large nuclei, appeared in place of the normal fibrillar contents. The posterior roots seemed normal. " As to the peripheral nerves, one phrenic and several intercostal nerves were examined ; more than two-thirds of the nerve-tubules (in hardened sections) were wanting, by a process similar, as it would ap- pear, to that induced by an external wound. The muscles about the shoulder and the upper extremities were for the most part atrophic ; there seemed to be a peculiar atrophy of the primitive fasciculi, without any marked alteration in the fibrils, and without any excessive develop- ment of the interfibrillar fatty tissue." The changes discovered by Clarke' were in the gray matter. There was a granular deposit about the vessels, and corpora amylacea about the central canal. Lesions of the anterior nerve-roots were found, and in the cervical region there seemed to be more distinct appearances than at any other point, where it will be remembered there may be found sympathetic as well as motor and sensor fibres. The muscles present distinct evidences of fatty degeneration and fatty substitution. They appear to the naked eye as wasted bands which con- tain lines of fat. The appearance of healthy muscles of good contour in juxtaposition with others which have undergone atrophy is very peculiar, and it is difficult to realize that the disease can involve such isolated tracts. The muscles of the lower extremities may have undergone general fatty degeneration. A specimen prepared by my friend Dr. Weisse, of the Medical department of the N. Y. University, shows very beautifully this condition of affairs. Fatty substitution has gone on to such an extent that there ia no appearance of muscular fibre to be seen, but every muscle exists as a distinct band of adipose tissue. Atrophied muscles have been examined by Meryon,^ Galliet,^ and others, and their descriptions of ap- pearances agree very closely. The muscular structure suffers a complete change, the strice disappearing and the sarcolemma undergoing a granular change. Fox* divides the secondary changes into the fatty degeneration 1 Med. Chir. Trans., 1851, 1856. " Ibid., 1866. ' Archives G^n., vol. i., 5me R^rie, 1853, p. 584. * Op. cit., p. 266, et seq. PROGRESSIVE MUSCULAR ATROPHY. 303 whicli takes place inside of the sarcolemma, and as an interstitial deposit. These he calls the parenchymatous and the interstitial. Sometimes, as observed by Robin, the atrophy may take place as a fibrous degeneration, or species of muscular sclerosis. Some muscles appear as fibrous cords of a white color, while others may be found which have undergone the fatty degeneration just described. An instructive case in which very striking appearances were presented was observed by Dr. Janeway, whose observations are recorded below : — M. G., aged 62 years, widow ; admitted to hospital December 16th, 1873. Right hand : the muscles of ball of thumb are very much atro- phied, and she is unable to move it ; there is also slight rigidity of the joints of the thumb. Dorsal interossei are very much wasted; there is slight power of flexion and extension of fingers, especially Jittle fingers, and there is also a slight movement at the wrist. Sensibility good except in index finger, and here it is decided Ij'' dimin- ished. She can raise her arm to her head and place it in any position. Hands seem cold. Left hand is not so much affected ; the muscles of ball of thumb are partially wasted. The abductor opponens and outer head of flexor brevis are almost gone ; the inner head of flexor brevis and abductor partially, and capable of acting to a slight extent. Has slight power of ab- and ad- duction of fingers, especially the little finger, most on the ulnar side, and decreasing toward the radial ; has slight power of extension over fingers, none over thumb, but flexioQ power is more marked. Has no power of extension, but considerable of flexion at the wrist. Dynamometer L. H. 28. Sensibility normal ; hands cold. The mus- cles that are capable of acting respond to the induced current very well. July 9. Complains of dizziness and nausea nth. Dizziness still. Her hands are in same condition. She expe- riences some difficulty in walking, and moves with her body '' sloping over " She cannot use her hands, and when she attempts to do any- thing, they drop, and she cannot raise them. The muscles that remain unaffected respond well to electricity. She still vomits at times after eating. August 3 Is quite weak ; has chilly sensations. 4:ih. Had a severe fever last night ; temperature 104° ; passed feces in bed, and did not know it; to-day temperature is almost normal ; is quite apathetic. 5th. Has chilly sensations ; complains of no pain ; arms and jaws trem- ble; temp. 102°. 2 P. M. Temp. 102°. Qth. She is very much worse ; mucous rales heard all over chest ; respi- ration accelerated ; temp, high ; pulse very feeble ; pupils normal ; bowels moved once to-day ; swallows with great difiiculty. 2. P. M. She sank gradually and died at 12.45 P. M. Post-mortem, held twenty-seven hours after death. — Rigor mortis mode- rately well marked. Nearly all the muscles of the hands are atrophied, especially the dorsal interossei and the propria muscles of the thumb ; the change is nearly symmetrical in both hands. The forearms are extremely wasted, both on the flexor and extensor surfaces. There is no marked 304 DISEASES OF THE SPINAL CORD. wasting in the arms, the shoulders are well rounded ; both pectoral regions appear wasted ; there is no marked wasting in the lower extremities, un- less it" be in the adductor region of" both thighs. Incisions made into the pectoral muscles, show well-colored fibres also in the deltoid, biceps, and triceps. The extensors of the forearms are of whitish-yellow color, being nearly as pale as the skin. The flexors of right hand are very much wasted, but not so much as the extensors. The flexors of the left side are small, but seem in good condition. The muscles of the right thenar eminence show extreme degeneration. In left thenar eminence the inner head of flexor brevis and adductor are red and large; the external is white, as on the other side. The adductors of thighs are small, but well-colored. The quadriceps extensor femoris is of good color. The anterior tibial muscles are of good color. Heart: Valves are normal, muscular substance soft, and yellowish- gray. The diaphragm is not atrophied. Brain : Convolutions and corpora striata appear normal. There is some atheroma of the carotid and basilar arteries. The substance of the cord and brain is quite soft. The viscera are nor- mal, except the kidneys, and these are granular; their pyramids are small, and they contain small cysts. Diagnosis. — Progressive muscular atrophy may be mistaken for seve- ral conditions of a paralytic nature, among these lead paralysis, antero-la- teral sclerosis, partial paralysis from traumatism, and infantile or adult paralysis. For an illustration of the first of these I do not think I can do better than mention a case in which there appeared to be lead paralysis, but which subsequently turned out to be progressive muscular atrophy. Several months ago, Mr. N., a Cuban gentleman, came to me with a letter from his medical adviser, Dr. Findlay, of Havana. The doctor's history of the patient is as follows : " Mr. N., about eighteen months ago, began to experience a tremor in the fingers and wrist of the right hand, together with muscular debility, which caused some inconvenience in writing, and in carrying food to his mouth, as well as in other move- ments of the hand. Having on a single occasion submitted to local fara- dization of the arm (some ten months ago), the tremor was much sub- dued, and, as was thought, the fingers and wrist were strengthened. It was not, however, until four months ago that the patient returned to put himself under a regular course of treatment. " Condition of the patient in July, 1876. — General health good ; no signs of cachexia ; no antecedents of specific taint ; no lead poisoning. Sufl^ered on two or three occasions, at some years' interval, rheumatic pains and neuralgia in the arm and shoulder of the left side, but never in the right side, which is the one now affected. The outer appearance of the right arm showed but little muscular atrophy ; the tremor was incon- siderable ; the patient could close the hand tightly, but not well grasp larger objects, such as a tumbler, owing to incapacity to maintain the first PROGRESSIVE MUSCULAR ATROPHY. 305 phalanx of the third, fourth, and fifth fingers extended. The wrist was inclined to drop forwards (in flexion) and outwards. " On inspection it was found that the common extensor of the fingers was considerably weakened, most so in the portion attached to the ring- finger, the weakness being manifested both to voluntary and to electrical contractility. The same condition existed also, though a little less, in the extensor of the little finger, and in the radial extensors. The contractil- ity was not totally absent, but would vary in degree without apparent cause. The disease continued to progress (notwithstanding treatment), the portions of the common extensors losing all excitability to my small Gaiffe's battery, and the extensors of the thumb being also implicated. " The left arm was now examined, and although the patient did not notice any weakness in the hand, yet some deficiency of electric contrac- tility was observed in the common extensor, especially in the extensor of the ring-finger. The constant current was now used for six weeks without much benefit. The extensor carpi ulnaris is now becoming also afiected. The patient, however, finds that he can write and perform various acts with the right hand better than before. Within the last week he complains of some pain along the back of the left forearm when he has been holding an object in the air, and feels an inclination to relax his grasp." The doctor also gave a history of hereditary trouble, which was proba- bly in one case (the patient's uncle) progressive muscular atrophy. I carefully examined the patient, and found that the right arm was that most affected. Motor jjower. — The power of extension of the muscles of the right forearm was lost completely, and on the left side the power of exten- sion of the two middle fingers was to some degree impaired. Flexion was perfect. Atrophy. — The following muscles were more or less affected and re- duced in size. Right forearm : Extensor communis digitorum ; extensor minimi digiti ; extensor carpi radialis ; extensor longis pollicis ; extensor carpi ulnaris ; extensor communis of the left. Sensation. — Slightly impaired on the right side. The teeth of the sesthesiometer were separated by a space of about ten centimetres before two points could be appreciated. This loss was not so great on the under surface of the forearm. There was no history of recent pain either con- stant or neuralgic, nor were there any dyssesthetic sensations. No fibrillary contractions were observed. There was a slight tremor in the right hand when voluntary movements were made. Electric con- tractility to a very slight degree was observed in the extensor communis digitorum when a strong faradic current was applied. The galvanic cur- rent also seemed to have some influence upon the weakened muscles. The fingers were covered by small flakes of skin, and the nails were crenated, irregular, and evidently badly nourished. This trophic defect disappeared under the use of the galvanic current. Diagnosis- — In the order I name them I proceeded to dispose of lead paresis, amyotrophic sclerosis, cerebral paralysis, traumatic paralysis, and progressive muscular atrophy. That it might be lead paresis seemed reasonable at first, because of the loss of electric contractility, the seat of the paralysis, etc ; but when I bore in mind that the trouble was one-sided at first, that there was a subse- quent invasion of the muscles of the other arm, that sensibility was also 20 306 DISEASES OF THE SPINAL CORD. impaired, and that the patient used neither hair-dye nor drank impure water, nor was expo.^ed to the dangers of lead poisoning of any kind, I was forced to abandon this idea. A species of spastic contraction drew down the fingers of the right hand and tliere was some cumulative tre- mor, such as characterizes sclerosis (expressed by a gradually increased tremor, aggravated by will control, and terminating in a species of spasm). This at first led me to suppose that there might be some degene- ration of the lateral columns, but as the tremor disappeared and there ■were no other symptoms of such degeneration, and especially as there was gradual atrophy and muscular paralysis, I dismissed this possibility. The loss of electric contractility, and the limited field of the paralysis, ex- cluded cerebral paralysis ; and the fact that the patient had never received an injury, and that the affection was beginning to affect the opposite group, negatived the theory of traumatic paralysis. All that was left was the diagnosis of progressive muscular atrophy ; and the subsequent appearance of fibrillary contractions made me quite sure of my decision. The slow progress of the trouble and its site were, however, doubtful points. The individual had not exercised any particular member, and as he was a man of leisure, there was no trade or occupation in which constant use of the hands or excessive labor was required that could ac- count for its origin. The hands preserved their contour ; there was no atrophy; no prominent thenar eminences; nothing suggestive of the main en griffe. Xone of the muscles of the back were affected, and the deltoids were of good volume and power. The fact that others in his family had suffered, that the disease began on one side and extended to the other, that fibrillary contractions were present, that subsequently I ■was enabled to get slight, and afterwards stronger contractions of the .paralyzed and atrophied muscles, determined me in my diagnosis of this anomalous case. I call it anomalous, because I have been taught, and my own experience convinces me, that this is a very rare seat of pro- gressive muscular atrophy. Protean as is the malady, I have not seen paralysis of the extensors, as a primary symptom, in any one of the twenty eight cases of the affection I have met with from time to time. In lead paresis the invasion is rapid, the paralysis the same, and the atrophy is secondary, which is not the case in the wasting palsy. There is sometimes the lead line or lead colic, and electric contractility is im- paired from the first. From traumatic paralysis it can be diagnosed by the irregularity in situation of the muscles atrophied. In traumatic paralysis we may look for atrophy of groups of muscles which are sup- ported by a common trunk, as well as loss of electric contractility and secondary atrophy. The diagnosis from some forms of adult and infantile paralysis is not so easy. In fact Duchenne believed the pathology of the two affections to be nearly the same. The sudden origin of the infantile cases of course precludes any mistake in the majority of cases, but in adult cases even after the disease has existed for some time. In such cases the paralysis and atrophy may co-exist to a dispropor- tionate degree. If it is possible, however, to ascertain the early occur- rence of paralysis, and if the loss of muscular substance be rather general, no mistake need be made. PROGRESSIVE MUSCULAR ATROPHY. 307 Prognosis. — Occasionally the malady may be arrested or cured en- tirely, and this fact seems almost incredible when we bear in mind its organic character. The duration of the disease is variable. Some of these patients recover, while in other cases it runs its course in from five to twenty years, the atrophy meanwhile involving fresh groups of muscles with more or less rapidity. In a case shown at my clinic, the disease had lasted for two years, and the atrophy had involved nearly all the muscles of the upper part of the body. In another patient I have recently seen, the disease has progressed very little during the last ten or twelve years. I have succeeded in arresting the disease in ten cases, and think that, when there is the least muscular response to electricity, there is still a chance for improvement, if not complete relief. This is, of course, in proportion to the extent of invasion. If the atrophy be confined to the muscles of one forearm, there need be no reason to give a bad prognosis. The majority of cases, however, go on to an unfavorable termination, and perhaps one reason is, that patients delay so long to seek medical advice, considering their disease to be rheumatism, and amenable to do- mestic treatment. When the diaphragm or the intercostales are invaded, the prognosis is as bad as it well can be. Roberts^ thinks that the prognosis is bad when hereditary predisposi- tion can be traced, or when the upper and lower extremities are both implicated. Treatment. — I know of no other remedies than those which are local (except when a syphilitic taint is suspected). Electricity is one of these ; muscular rest is the second when the affection has followed over-use of certain muscles. The galvanic current from not less than twenty cells should be used, one electrode being placed over the nucha, and the other in the supra- clavicular space. Applications of ten minutes every day cannot fail to do good. In addition to this, the faradic current should be employed for the muscles themselves, making each muscle contract several times, and then allowing it to rest, and repeating the operation some minutes after- wards. Violent electrization, I am convinced, fatigues these crippled muscles, and does more harm than good. Duchenne gives the following directions for the use of the induction current : " Place the wet electrodes, so that they are as near together as possible upon the surface of each of the diseased muscles, using an induc- tion current of greater or less tension, so that all the anatomical elements of the muscle shall be excited. Excite the muscles generally and mode- rately and apply an intermitted current. Faradize only the atrophied muscles which still respond to electric excitation, among the latter, fara- dize by preference those which enter most frequently and usefully into important muscular movements. End each seance by the slow faradiza- ^ Art. Wasting Palsy, Reynolds's System of Medicine, American Edition, vol,, i., p. 796. 308 DISEASES OF THE SPINAL CORD. tion of the more important muscles among those threatened by the inva- sion of atrophy." Vivian-Poore and Fagge^ have had wonderful success with this agent, and have cured a number of apparently hopeless cases. I have been induced to try the " rubber muscle," as arranged for lead paresis. This forms an admirable means for support of the hands, should the extensors be affected, as was the case in the history I have just related. In every case it is well to insure perfect rest, if possible, for all affected muscles. If the muscles of the shoulder be so atrophied as to allow the arm to drop, it is well to arrange some contrivance to sustain its weight, and relieve the strain upon the affected organs. Sulphur baths and mineral waters have been recommended, and in some hands have been successful. PAETIAL FACIAL ATROPHY. Synonyms. — Trophic neurosis of the face (Romberg) ; Laminar aplasia (Lande) ; Unilateral progressive atrophy of the face (Eulenburg'*;. Definition. — A disease of a trophic nature, involving usually one side of the face, beginning with discoloration and cutaneous changes, and ending in loss of tissue of underlying cellular tissue and bone, not accom- panied by loss of motor power or sensibility. The disease was, according to Eulenburg, first described by Parry ^ in 1825, and afterwards described by Bergsou* in 1837. It subsequently received attention from Romberg,^ Lande,* Samuel,' Eulenburg,* Fremy,® Moore'" and others, who described many cases. Eleven cases are reported by Lande alone. The first American case was presented by Dr. Draper" before the New York Society of Xeurology, Dec. 20, 1875, and other cases have been brought forward since by Se- guin, Robinson, Bannister and others.'^ A photograph of Dr. Draper's case is presented below. The patient, who was a stout, hearty Irish girl, aged 18, and without any hereditary predisposition, presented herself, with the following his- tory : About two years ago the muscles under the body of the lower jaw of the left side began to diminish in size, and after a few months there I London Practitioner, December, 1868. 2,Ziemsseu's Cyclopaedia, p. 57, vol. xiv. 3 Quoted in Eulenburg's article. * De prosopodj'smorphia sive nova atrophise facialis specie, Berlin, 1837. » Klinische Ergebnisse, 1846, and Klinische Wahremung, etc., 1851. ® Essai sur I'aplasie lamineuse de la face en particulier these de Pari.s, 1869- '' Die trophischen ^serven, Leipzig, 1860. 8 Wiener Med. Wocli. und Lehrbuch der functionellen Xervenkrankheiten, 1871. 9 Etude critique de la trophonevrose, Paris, 1873. 10 Dublin Quarterly Journal, 1852. II Am. Psychological Journal, Feb., 1876. Also consult recent cases in Bull, de la Soc. de Chirurgie, vol. 2, 1876. Gaz. Hebdomidaire, No. 13, p. 196, 1876. Br. Med. Journal, Aug., 1876. 1' Journal of Nervous and Mental Diseases, 1876, vol. i. PARTIAL FACIAL ATROPHY. 309 was gradual extension of the atrophy, so that finally a district bounded by the symphisis of the lower jaw, angle of the nose, and middle of the upper lip in front, lower edge of zygoma above, and ramus of the inferior maxillary behind, became entirely affected. The skin is bound down to the periosteum of the lower jaw, and is shiny, tense and white. There never has been pain of any kind, but the only sensory alteration occurred in the beginning, when a slight itching was felt. There is no anaesthesia anywhere, not even in the tongue, one side of which is markedly atro- phied. In the beginning there were occasional cramp-like pains about the insertion of the masseter muscles on the left side, but none on the other. There was slight paresis in some of the muscles involved. Fig. 46. Partial Facial Atrophy. In twelve Continental cases collected by Draper, eight of whom were women and four men, the atrophy appeared in one at three years of age, and in another at twenty-two years of age. The beginning of the atrophy in these cases was not always the same. In two instances it began by pallor ; in the others by red spots, next followed by loss of color ; and finally there was a parchment-like appearance of the skin. Sensibility was not lowered in any instance, but in two there was itching, as in Dra- per's case. In one the disease was preceded by spasms of the masseter muscles ; in six the tongue was atrophied ; in one the tonsil ; and in the rest the soft palate. In two cases there was deafness. In no case was there affection of the secretion of saliva ; but in one there was diminished pulsation in the carotid of the affected side. In none were there indica- tions of central disease. The cutaneous changes alluded to are peculiar, and a variety of trophic alterations may attend the disease ; such, for in- stance, as falling out of the hair, or changes in color and the appearance of eczema. The sweat-glands do not seem to be involved, but the seba- ceous secretion disappears upon the affected side. The atrophy is some- times quite extensive, involving the bones, which, in some cases, have 310 DISEASES OP THE SPINAL CORD. been measured and found to be greatly reduced in size. Electric contrac- tility of the muscles does not appear to be in the least diminished. The temperature of the affected side is generally lowered, but there is no di- minution of sensibility. The left side appears to be the more common seat of the disease, and of the twelve cases already alluded to, but one was of the right half of the face. Causes. — In some of the reported cases there was a history of pre- vious intermittent fever, scarlatina (Hueter refers to whooping-cough as having had something to do with the genesis of this disease), and scrofula, and in one case there was a fall upon the head, but it is a question of great doubt whether these were concerned in the development of the atro- phic condition. Courtet reports a case of right-sided facial atrophy in a subject who had been delivered with forceps. In this case the right pupil was the largest, which suggests the fact that there may have been some intracranial lesion. It seems, however, to be a disease which is more common between the tenth and the thirtieth year, and women are more often affected than men. Pathology. — Undoubtedly this disorder is one of a trophic nature, and of central origin. The absence of motorial or sensorial disturbances makes this theory very plausible. If the lesion were of a peripheral char- acter, it is highly probable that both sensation and motion would be af- fected, for I cannot conceive a diseased condition of trophic filaments alone when they are found in company with other sensor and motor fila- ments, as in a nerve-trunk which is diseased. This hypothesis seems more reasonable when it is borne in mind that the parts atrophied are supplied by other cranial nerves than the seventh. I therefore think that the the- ory of degeneration of the trophic cells of the bulb is a much more ac- ceptable one than that held by Bergson and others. Eulenburg considers it to be essentially a lesion of the fifth pair, in which opinion he is sus- tained by Romberg, Samuels, Charcot, and Vulpian. Against this it may be urged that lesions of the fifth nerve of a trophic nature are gene- rally followed by corneal changes, which, so far as I can learn, have never been witnessed in this disorder. Brunner is of the opinion that the con- dition is connected with a continued irritation of the cervical sympathetic upon the affected side. Diagnosis. — Progressive muscular atrophy and facial paralysis seem to be the only diseases with which this may be confounded. Against the first it may be said that there are never the peculiar cutaneous changes of the disease under discussion — no dark spots, no falling out of the hair, no tightness of the skin; and moreover, this site of atrophy is very rare in progressive muscular atrophy. Facial paralysis is nearly always of sudden appearance, and the muscles lose their electric con- tractility. Prognosis. — As far as I can learn no deaths have been reported, and no cures by drugs. From its progressive nature (and particularly if we concede it to be a central disease of a degenerative character) the prog- nosis must be bad, though two or three cases have been related, however, PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS. 311 in which there was an arrest of the atrophy without any treatment. In Belot's^ case the disease became stationary after a year. Treatment. — Electricity is indicated, but its use has only once been attended by slight improvement in the hands of Moore,^ who reported a case which was benefited. PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS. Synonyms. — Myosclerotic paralysis ; sclerose musculaire progressive (Requin) ; myosclerosis. Lipomatosis musculorum luxurians (Heller). Definition. — A disease of infancy, expressed by increase of volume and hardness of certain muscles usually of the lower extremities, such in- crease being due to fatty substitution; by secondary atrophy and paresis and by conservation of cutaneous sensibility and the functions of the bow- els and bladder. Though first described by Sir Chas. BelP in 1830, by two Italians, Coste * and Gioja in 1838, and subsequently by Meryon'' in 1852, it was not un- til 1868 that the disease received much attention, when Duchenne® presented his collection of thirteen cases, with a critical analysis. At about the same time Meredith Clymer' was the first in this country to describe the condition. After him, Ingall and Webber,* Pepper,'^ Weir Mitchell,^" and others, and among them Poore," of New York, has fully discussed the subject, while numerous continental writers have published cases. Of late, Gowers ^^ has embodied his carefully made and valuable ob- servations in a well written volume in which the history of the disease is illustrated by brief reference to the cases reported by Continental, Eng- lish and American authorities, one hundred and seventy-six in number. Of these, all but eight were among children. Symptoms — Duchenne details the symptoms in the following order : 1. In the beginning, feebleness of the lower limbs. 2, Lateral balancing of the trunk and widening of the legs during walking. 3. A peculiar curvature of the spine or saddle-back, both in walking and standing. 4. Talipes equinus, with an over extension of the first phalanges of the toes. 5. Apparent muscular hypertrophy. 6. Stationary condition. 7. Generalization and aggravation of the paralysis. These are the strik- ing features of the disease, which is far from common, — and, so far I ^ Quoted by Draper, Am. Psy. Journal, Feb., 1876. ^ Op. cit. 3]Srervous System of the Human Body, etc., 2d Ed., 1830, 3d Ed., 1836. *Eeferred to in Schmidt's Jahrbuch, xxiv., p. 176 and by Gowers. » Transaction of Medico Chirurgical Soc, xxxv., 1852. 6 Archives General de Med., January, 1868, and following numbers. ^ Appendix to Aitkin's Practice of Medicine, 1868. 8 Boston Medical and Surgical Journal, Nov., 1878. 'Philadelphia Medical Times, June and July, 1871. 10 Photographic Review, Oct., 1871. 11 New York MedicalJournal, June, 1875. 12 Pseudo-Hypertrophic Muscular Paralysis, a clinical lecture, London, 1879. 312 d'iseases of the spinal cokd. have seeu less than a dozen cases. In illustration of the development of the disease, I may present the history of a well-marked case which I was permitted to examine by Dr. V. P. Gibney. F. S. M., aged 13. Previous health excellent, her only illnesses being whooping-cough at the age of 9 months, and scarlatina one year ago, which was followed by some otitis. Her family history is good, so far as nervous disease is concerned. Her father died of phthisis, and her mother is alive and healthy. Her ancestors were long-lived people. She tells us of an injury received in 1870, a boy having thrown a brick at her, which struck her in the small of the back. No fever or pain preceded her present trouble- Her disease was of gradual development, and the hyper- trophy followed the injury which has just been alluded to. At the end of six months she found it difficult to go up stairs, and her helplessness in- creased until the time of admission into the Hospital for Ruptured and Crippled, April 7, 1876. The following history was then taken: Com- plexion, light ; hair, brown ; eyes, hazel. She is small for her age, though well developed. She stands with abdomen prominent, chest and head thrown backwards ; walks with an unsteady, waddling gait. Upper ex- tremities, with exception of elbow-joints, which permit extension beyond an angle of 180°, normal. From the sixth dorsal to the sacrum there is a lordosis of three inches, the point of greatest incurvation being at the third lumbar vertebra. There is tenderness on deep pressure over the twelfth dorsal vertebra, while both trochanters stand out prominently, and the limbs are widely separated, and there seems to be no trouble about the hip-joints. There is marked diminution in power of the extensors of the legs, preventing her from holding the limb at a right angle to the body. There is no marked loss of power in the flexors. But there seems to be some loss of power in the anterior foot muscles ; no comparative atrophy of limbs. The muscles of the back seem small and poorly nourished. The girl has difficulty in arising from, or assuming the sitting posture. The lordosis can be overcome by the voluntary act of stooping forward. Treatment. — Spinal brace and electricity. Through the kindness of Dr. Gibney, I was permitted to examine the patient, whom I found to be a rather well-nourished girl. I was immediately struck by her gait, which was characteristic of pseudo- hypertrophic paralysis. The feet were planted widely apart, and when propulsion was attempted, the whole pelvis was seemingly twisted, and the legs clumsily swung forward. The body swayed from side to side, the abdomen was prominent, and the shoulders drawn back, so that the ex- treme lordosis described so clearly by Duchenne was very beautifully shown. When stripped, this exaggerated curve was found to be very great. A plumb line held at the seventh cervical spine fell about four inches back of a line drawn, across the upper edge of the sacrum. When my hand was placed upon her abdomen, and an attempt was made to force her to stand erect, the nates were immediately thrown backwards, and she would have pitched forward if not supported. When she at- tempted to walk, the pelvis seemed to be lifted on the side of the limb which was raised, and at the same time the corresponding side of the ab- domen became quite flat. Her gait was waddling, and she progressed very slowly. There was some spinal tenderness, but no other disturbance of sensibility either in the sound or hypertrophied muscles. The latter were those of the back of the leg, which were much larger on both sides PSEUDO hypeet|rophic^ muscular paralysis. 313 than they should have been, and were quite hard and in marked contrast to the other muscles of the body, which were flabby and poorly nourished. The muscles of both thighs at the inner side seemed to be atrophied, as were all the muscles of the back ; but the arms were of normal contour, and apparently unaffected. There was considerable loss of power in the lower extremities, the patient being unable without great effort to rise from her chair, and when she attempted to do so, she planted her feet widely apart and approximated her knees. The color of the skin was rather darker than it should be, and especially on the feet, legs, and hy- pertrophied calves, was there mottling and imperfect incubation. No difference in tactile sensibility could be noted. Measurements of different parts gave the following results : — About shoulders 29 inches. About waist 24 " Middle of right thigh 14 " Middle of left thigh 13J " Eight thigh, just above knee 11 " Left thigh, just above knee 12 " Eight calf 12 " Left calf 12 " A case reported to me by my friend Dr. G. H. Swazey is the following. This patient was also seen by Dr. J. Lewis Smith : — J. D., aged 2 years 8 months. Has always been a healthy boy until four weeks ago, when it was noticed that he seemed weak in his legs, especially in the morning, or after sitting awhile. Has not complained of any pain. When the child walks, it is in a peculiar wabbling sort of a way, with his legs wide apart, and his shoulders carried well back. He cannot stand well with his legs close together, but soon totters and falls. After he has walked awhile this peculiarity of gait is not so perceptible. The left leg measures around the calf eight and one-eighth inches, right leg around the calf eight inches. Just above the knee left leg measures nine and a quarter inches ; right leg, same place, nine and one-eighth inches. The weakness in the legs has been steadily increasing from the first. The grandmother of the child on the maternal side has epilepsy ; and the grandmother on the father's side has what the mother calls weak spells, apparently of an epileptic character. An aunt and uncle on the father's side have epilepsy, and there is also a history of syphilis in the family. The mother has had miscarriages, apparently due to that cause. The father has had eruptions and other symptoms. March 28th commenced treat- ment with the faradic current to the muscles, which was continued three times a week for six weeks ; the disease slowly progressing. At this time the patient left off coming, and has not since been seen. Weakness of the lower extremities is one of the earliest symptoms, and is gradual in its appearance, and not preceded by fever, as is generally the case in infantile spinal paralysis. This impairment of power may begin imperceptibly, and first attract the attention of the parent by the inability of the child to walk at the usual time, or may appear subsequently, the child falling frequently or moving clumsily. In Poore's collection of 85 cases, it is shown that " 3 never walked at all, 24 never walked well, 314 DISEASES OF THE SPINAL CORD. 1 is reported as coming on gradually, 52 walked well at first, and in 5 eases no mention is made of the period of walking." " Of those who walked well, 2 began to walk at eighteen months, 3 at two years, 3 at two-and-a- half years, 4 at four years, 1 at five, and 5 are reported as walking late and badly." Fig. 47. (Gowers) Pseudo-Hyperirophic Paralysis. Duchenne and Drake reported cases in which convulsions were the beginning of the disease. Pain in the calves of the legs or back is some- times the first symptom, but is by no means one to expect as a rule. The appearance of the patient is most striking. The belly seems to be thrown out, the lumbar curve is increased, and the feet are widely separated. When the child attempts to walk, his movements are very much like those which we might expect to see in an individual laboring through a quag- mire. There is a certain amount of waddling, the legs being separated, and the feet planted at some distance apart. In progression the body is inclined to the side on which the foot is planted, and there is some jerk made in the effort to carry the foot forward. The patient rises from the sitting posture with some difficulty, as there is great impairment of the extensor muscles of the spine. This weakness is the cause of the difficulty in keeping his balance. The next stage of the disease is the development of the hypertrophy. Very often this change is an early one, and may follow closely after the commencement of the impaired motor power. The calves are generally first enlarged, and this enlarge- PSEUDO HYPERTROPHIC MUSCULAR PARALYSIS. 315 ment may begin with the difficulty in walking, or within a period any- where from six months to several years after the beginning of the disease. This enlargement is not, however, always confined to the calves, but may affect the other muscles of the lower extremities, or even those of the upper. The glutei, gastrocnemii, deltoid, and many other muscles have been involved in cases reported by different observers. When the mus- cles are contracted, they stand out quite prominent, and in one of the cases reported by Barlow^ the child's appearance resembled that of the Farnese Hercules. The child is unwieldy and awkward, and though there is at this stage some increase in strength of some of the members used in locomotion, the child does not seem to have very much motor power, for he can scarcely walk. The muscles not hypertrophied may undergo an atrophic change, greatly adding to the deformity. In regard to the talipes that may be produced, the extensors are agitated by spas- modic contractions, which become more aggravated as the attempt to walk is persisted in, so that, after a few steps, the child is quite likely to fall. Dr. Gowers has devoted much time to the discussion of the sub- ject of muscular enfeeblement as a symptom.'^ He alludes to certain pe- culiarities of the patient's behaviour, which are striking and pathognomo- nic. One of these is the manner in which the patient arises from the floor. Owing to the weakness of the muscles of the back, the little pa- tient always places his hands on his knees, " apparently to push the trunk up, to help the extension of the hip-joint." This, Gowers says, is met with in no other affection, and I am inclined to agree with him. He first places his hand on the knee-joint, and when the knees are ex- tended he works his way up, putting his hand upon his trunk until he effects extension of the hip. " The reason why this action affords such help in extension of the knees, says Gowers, is obvious on a little consideration. In rising from the ground with the knees flexed, the weight of the trunk, resting on the hip-joint, is at the extremity (Fig. 48, W.) of a lever (the femur) of the third order, the fulcrum (F) being at the knee, and the power, the con- traction of the quadriceps extensor, being applied (P) between the weight and the fulcrum, — i. e., in the position in which it acts to least advantage. But by placing the hands on the knees, — i. e., on the end of the femur, — a large part of the weight (the larger the more the patient bends forward) is transferred to the lever (at W) close to the fulcrum ; the lever is, in so far, transformed into one of the second order, in which the weight is between 1 Op. cit., p. 11. ^ Even so far back as 1830 Sir Charles Bell* recognized this as a striking symptom. " The paralytic debility of the muscles came on gradually : he was first sensible of it at a public school, about eight years ago. It began with a weakness in the thighs, which disabled him from rising ; and it is now curious to observe how he will twist and jerk his body to throw himself upright from his seat. I use this expression, for it is a different motion from that of rising from the chair." * Op. Cit. Third Edition, p. 432, case clxxx. 316 DISEASES OF THE SPINAL CORD. the power and the fulcrum, and the power is economized in the greatest de- gree. Moreover, if the patient bend down, the centre of gravity may- even be carried in front of the knees, and then, if the hands grasp the knees firmly, the weight of the body, instead of being the weight to be moved, becomes a force applied to the upper end of the femur, effecting the extension of the knee without the slightest action of the quadriceps ex- Fi'AL SCLEROSIS. 335 in the disease under consideration, and if the aid of his vision be denied him, he is utterly helpless to regulate his muscular movements. In the daylight he still has the power of helping himself, for vision comes to his assistance. In health this delicacy of co-ordination may iDe trained to a marvellous degree. I have repeatedly witnessed the feats performed by a French juggler, which illustrated the nicety of appreciation of weight it is pos- sible to arrive at by practice. He would throw into the air a heavy cannon ball and a pellet of paper, alternately catching them and tossing them up again, and the muscular movements were regular and harmonious, and indicated no effort what- ever. In locomotor ataxia this power of appreciation is sometimes lost to a marked degree. To some ataxic individuals a four-pound weight seems no heavier than one of two pounds would if the patient were in normal condition, and if his mus- cular movements were properly co-ordi- nated. One of the most interesting features of the disease is the question of absent tendon reflex. I have already expressed my doubts in regard to the universality of this symptom, but when the tendon-reflex is absent it indicates beyond all doubt a lesion of the cord above the third or fourth lumbar nerves as Prevost has demon- strated. Some authors believe the " tendon- reflex " to be purely a local phenomenon and among them, my friend. Dr. Augustus Waller,^ of London, has advanced the idea that there is no such thing as a true spinal tendon reflex, basing his conclusion upon the fact that the appearance of the clonic spasm occurs too soon after the application of the stimulus. This he demonstrated by the myograph. He, therefore, consid- ers that the phenomenon is due to a changed condition of the muscular contractility dependent upon some alteration in local innervation. Dr. Buzzard, on the contrary, in a series of elaborate papers, takes the opposite view, and says that it is a spinal reflex in every way, and that the shortness of interval between the application of the stimulus and the appearance of the contraction which is apparently inconsistent with phy- The Course of Posterior >'erve-Roots. (Clarke.) 1" Brain" Parts. 1880. 336 DISEASES OF THE SPINAL CORD. siological mensuration of time, is quite possible when the sensibility of the nervous arc is exalted or in a favorable condition. He, therefore, can not take the physiological standard of time as the pathological. Prevost has in animals made pressure upon the aorta, and as a consequence the ten- don reflex was abolished and did not return until the pressure was remitted. The arrangement of the sensory fibers of the posterior columns is such that a lesion of either the white or the gray matter must in- terfere with the conductivity of sensory impressions. Lockhart Clarke's histological researches have thrown much light upon the subject. Ac- cording to him, the posterior root-fibers enter the cord in three direc- tions, some passing in at right angles to the longitudinal fibers of the posterior column, then passing across the same as well as the gray sub- stance, then bending and continuing longitudinally downward, next passing into the gray matter of the anterior cornua, and finally termi- nating in fasciculi which intermingle with the fibers of the anterior roots, or extend into the anterior columns. Other fibers (those of the second class) run across the posterior columns, or cross to the other side of the cord in the posterior commissure, or extend deeply into the poste- rior columns of the same side ; and others pass forward into the gray matter of the anterior cornua. The third kind of posterior spinal roots enter obliquely ; and certain fibers pass upwards and downwards, and become associated with fibers above and below them. The remaining fibers take an oblique course, and run upwards and downwards, the greater number taking the former direction and passing finally into the gray matter. It will be seen that a lesion affecting the posterior columns of the cord will destroy the communication of the nerve-roots with the gray matter, or press upon the sensory fibres, causing peripheral pain. The communication with the parts above is destroyed, and should the sclerosis involve the anterior gray matter there may be paralysis and atrophy. A favorite theory, accepted by many writers, is that which considers that there are numerous centres of co-ordination in the cord, which are connected by longitudinal fibres, and that when these fibers are destroyed there results a species of inco-ordiuation. Dienlafoy^ divi- ded the posterior fasciculi at diflferent heights, but without producing any marked defects in co-ordination, a result which seems to disprove this idea. Onimus^ explains the rigidity and awkwardness of the movements in locomotor ataxia by the theory that the stifiness of the muscles is perceived by the individual, and to overcome this he expends a greater amount of force than is needed for the particular act. The initial stiffness comes from the irritation of the anterior and lateral columns by the 7iyechanical presence of the deposit in the posterior columns. Diagnosis. — It is important to distinguish locomotor ataxia from chronic myelitis, progressive mitscular atrophy, chorea, cerebellar disease, aud hysterical paraplegia. The former occasionally resembles ataxia, but with ordinary care no mistakes need be made. The paralysis of ^ Th^se de Concours, 1875. * Gazette des Hopitaux, July, 1878. POSTERIOR SPINAL SCLEROSIS. 337 transverse myelitis is very marked, and the implication of the bladder and sphincter ani causes the patient to void his urine and feces involun- tarily, which is not the case in locomotor ataxia. The strong ammoniacal odor of decomposed urine is itself almost a sufficient diagnostic mark. There is an absence of power in the legs, and none of the pain which characterizes sclerosis of the posterior columns. Ocular trouble and in- co-ordination are likewise absent. If the gait of the two diseases be com- pared, it will be found that in the former the legs will be thrown out with some degree of violence, and the heel will come down forcibly. In the paraplegia of myelitis, the legs will be drawn after each other, the inner edge of the sole scraping the ground ; and there is often a shrug of the body required to bring the feet forwards. The walk of the hemiplegic is also different, as one leg is swung forwards, the toe describing an arc, or else the foot is advanced in a straight line, the sole hardly clearing the floor. Myelitis in its early stages sometimes resembles posterior spi- nal sclerosis. The pain in the back, however, is characteristic, and the ulterior paralysis and bladder trouble are sufficient in themselves to clear up the diagnosis, though the constricting band about the waist may ex- cite our suspicion. Cerebellar disease has been spoken of by Radcliffe^ as a condition that may sometimes be mistaken for locomotor ataxia. The movements are somewhat different, however, for the patient rolls and sways to a greater degree, and does not present the peculiar jerking gait of the ataxic. Local pain is another symptom peculiar to the cerebellar condition, and vomiting is also suggestive of this affection, but not of locomotor ataxia. Progressive muscular atrophy in its earlier stages may be mistaken for locomotor ataxia. The wasting of the muscles in anomalous cases may be imperceptible, and the unsteadiness of the indi. vidual may alone attract attention. This, with the pain, may raise a doubt as to the true nature of the malady. Hysterical ataxia, such as has been described by Webb, as a rule, is not symptomaized by pain, and the ataxia is not genuine. Syphilis, in some of i^s forms, also occa- sionally produces symptoms which are very much like those of this dis- ease ; and there may be paralysis of cranial nerves, with pain over the tibia, which may be misleading, when in reality no spinal disease exists. Chauvet,' in his excellent article upon the influence of syjDhilis in the genesis of nervous disease, dwells upon the connection of syphilis with locomotor ataxia, and quotes many authors to show that the co-existence of these two diseases is a pure coincidence. In a table showing their relation, eighty-five cases of ataxia are presented ^ Reporter. Syphiliti' Patients. Ataxics. FoLirnier 24 among 30 Vulpian 15 . " 20 Feretjl 6 ..... . " ...... 11 Siredey 6-8 " 10 Caizergues 8 *' 14 iQp. cit., vol. ii. p. 683. ''■ Influence de la Syphilis sur les^ Maladies du Systems Xerveux Central, p. 53;_ Paris, 1880. 22 338 DISEASES OF THE SPINAL COED, His conclusion is that syphilis has nothing to do with the actual de- velopment of primitive sclerosis of the posterior columns, but the presence of syphilitic deposit in this region may undoubtedly give rise to symptoms closely resembling those of the uncomplicated disease. Buzzard holds, however, that in nearly all cases of locomotor ataxia, either that some remote or recent history of syphilis is disclosed. Prognosis. — Among the number of cases reported by various ob- servers, I have not found many well-authenticated cures. An interesting fact, however, has been observed by Gowers, who states that in the cases of this disease he has seen — and they wei-e a great many — that in families, those persons who reached the age of twenty-five without showing symptoms are exempt, although other members of the same family may have been affected. So important does he consider this fact that in one family in which there were three members affected, he recommended the application of a fourth member who presented himself as an applicant for a life-insu- rance policy. In regard to this question of age, it must be admitted that it is often a most difficult matter to say when the disease began, for the early pains are mistaken for other troubles. The following table gives, besides other facts, the ages and sexes of eight individuals affected. And it will be noticed that the disease began in these cases as follows: 37, 41, 40, 32, 45, 55, 36 and 42. It is barely possible that in some of these cases the first stage was not characterized by pain intense enough to engage the patient's attention. AN ANALYSIS OF EIGHT CASES OF LOCOMOTOR ATAXIA AT THE HOSPITAL FOR EPILEPTICS AND PARALYTICS, NEW YORK CITY. •2 1 2 ! o! Duration. Probable Cause. A taxic Members. Locationandl Character} of Fain. Tendon- Beflex. Disturbance of Surface Sensation. Ocular Symptoms. Cerebral Symptoms. 1M45 2iM53 3 M 54 4 F J52 .'m.J59 M57 8 years. Syphili.=and^ Legs. Back and thiglis. exposui'e. Unknown. Excessive venery. Unknown. Intemper- ance. Legs and I Arms, legs, arms. viscera. Legs and arms. Legs and arms. Legs. Legs and arms. Legs and arms. Legs and arms. Legs. Back, legs. ;c < Legs. Absent. Increased to marked degree. Well Marked. Increased. Increased. Angesthesia None. None. Atrophy of optic nerve. Atrophy of optic nerve. Atrophy of optic nerve Normal. Impaired vision. Dimness of vision due to atrophy of disks. " Vertigo. None. Vertigo and epilepsy. Occasional epileptic attacks. None. Frontal head ache (a cc incidence! None. POSTERIOR SPINAL SCLEROSIS. 339 A peculiarity of the disease is the long intervals of improvement which occasionally occur ; and the disease may be stationary for years, but this is very rarely the case. I know of two cases which were so much im- proved, and remained so well for three or four years, that I flattered myself that I had cured them, but I have since seen a change for the worse in both patients. Balfour^ presented a case of locomotor ataxia which he claims to have cured. Pollard^ reports a case which began rather suddenly, and disappeared quite rapidly under treatment. Vidal,^ Duqueit,* and Herschell,^ all report cures. Vidal's patient, a man of 45, recovered in three months, and Duqueit's and Herschell's cases I consider doubtful as regards diagnosis. Treatment. — From the very nature of the disease, the treatment must be empirical. Nitrate of silver has been recommended by Wun- derlich, Charcot, Vulpian, and others, and has enjoyed great popularity as a remedy. Balfour, already alluded to, states that he cured q, patient in three months by half-grain doses of this salt repeated three times a day, and by the use of a foot-bath in which a quantity of common salt had been thrown. The feet were also submitted to the influence of a faradic current passed through the water by proper appliances. The salts of silver may be used with considerable impunity without discoloring the skin, and an unnecessary degree of timidity has been shown in their employment. It is well, however, to begin with a quarter-grain dose, and it may be increased to a half, or even a grain, thrice daily." One case of my own was greatly benefited by this drug in combination with nux vomica. I have lately tried the phosphate of silver in one-third of a grain doses, with great success, and prefer it to the nitrate. In admin- istering the silver salts, it is well to give them continuously for several months, and then permit an interval to elapse before beginning again. In the early stages of the disease, I prefer the fluid extract of ergot, either in combination with the bromide of sodium or alone. It certainly seems to control the pain. For this purpose a simple remedy often aflbrds great relief. If a few drops of the bi-sulphide of carbon are placed upon a piece of cotton in the bottom of a wide-mouth bottle, and the same be held for a few minutes over the painful spot, great ease will be obtained. Large doses of salicylic acid have an anodyne effect. Among the more efficacious remedies to which I may allude is the sulphur bath, which is too little used at the present day, but has been praised by the French writers especially.^ It seems to possess, in some cases, powers that are 1 Brit. Med. Journal, 1875. 2 Lancet, 1872, vol. i., p. 437. . 3 Gaz. des Hop., 127, 1862. ^L'Union, 122, 1862. 5 Bulletin Gen. de Therapeutique, Ixiii., Oct., 1862. ^ De remploi du nitrate d'argent dans le traitement de I'ataxie progressive. Bull. G^n. de TMc, 1862. '' It has acted wonderfully in cases even of long standing, and deserves a faithful trial. 340 DISEASES OF THE SPINAL CORD. almost marvellous. A small lump of sulphide of potflssiura is to be thrown into the tub in which the patient bathes, after which he is to be thoroughly rubbed. In regard to electricity, xMeyer has reported several cures by the galvanic current. Onimus has used the inverse current, and I believe has done some good. The indication seems to be that the positive pole should be placed over the painful point, if one can be found, and the negative above. These cases in which cures have been wrought were. I infer, ataxic conditions of a functional character. Faradization of the muscles of the legs and thighs seems to comfort the patient more than anything else. Duchenue thinks that the muscular ausesthesia is benefited greatly by its use, and that co-ordination is improved. Dr. Drinkhard, of Washington,^ suggested that strychnine injected hypoder- mically, is a remedy which should not be lost sight of In one case it promptly relieved the pain. He, however, compares the dangerous ap- petite of possible formation to that which grows out of the medicinal use of large doses of opium, and fears such trouble. I have used the actual cautery to the spine quite frequently, and have found that constant re- vulsive effect kept up for some weeks not only diminished the pains, but really improved locomotion. It should be applied down the whole length of the back, on either side of the spinous processes ; and, after the epider- mis has shrivelled off, subsequent applications are to be made. ^ Belladonna and turpentine internally are recommended by Trousseau, and not only relieve the pain, but stem to help any vesical trouble that there may be. Should we suspect syphilis, the iodide of potassium will he indicated, and a saturated solution should be prepared, and given in increasing doses till forty or fifty grains are taken three times a day. Above all, it must be remembered that nutritious food, cod-liver oil, and moderate stimula- tion are perhaps more important than medication. I have observed the necessity for quiet and rest. Prolonged muscular exercise is bad, and drives are to be preferred to walking. The patient should seek a warm climate, for this disease is affected by damp, cold weather, very much as is phthisis, and a cold winter always tells upon the patient. The pains also are aggravated by cold and sudden changes, and I find Florida or other southern states to be the most comfortable places for these inva- lids. Much benefit has been derived from the dark room treatment, and I saw one gentleman who had been greatly improved by a few months of bed-rest in a dark chamber. Nerve-stretching has been tried in this disease with some apparent success, especially by Langenbeck ; but though two thirds of the reported cases were helped, there was usually a relapse. Dissipation thwarts any chance of success, and late hours or a debauch will produce a relapse sometimes after encouraging improvtmeut has taken place. Sexual indulgence (when it is possible) is likewise to be interdicted. ^ Am. Jour. Med. Sciences, July, 1873. SCLEROSIS OF THE COLUMNS OF GOLL. 341 SCLEEOSIS OF THE COLUMNS OF GOLL. (^Ascending Degeneration of Posterior Columns^ The localization of myelitis in this part of the spinal cord is a matter of great clifBculty. Charcot has studied the appearance of degenerative changes in connection with locomotor ataxia, and has found that when limited disease of the columns of Goll was found, the symptoms were those of ascending trouble. In his last work (1880) upon localiza-' tion, he has presented illustrations which show the invasion of the disease process and its significance. (Charcot.) A. Total sclerosis of the posterior columns (columns of Goll and posterior root-zones), ordinary locomotor ataxia. B. Sclerosis of the two posterior root-zones (columns of Goll exempt), locomotor ataxia. c. ScIerosi3 limited to the columns of Goll — ascending degeneration. Cases of degeneration of the columns of Goll are cited by Charcot,^ Erb,' Simon and Lange. In all of those of the first writer the disease began below, and in fact the German investigators agree the disease begins as a rule by tumors or other forms of disease in the region of the chorda equina, and while at this inferior part it may result in a quite transverse myelitis, it extends upwards, being limited to the columns of Goll. This is beautifully seen in the upper part of the cord, where the degeneration may be well defined. The disease resulting from a transverse myelitis may be transmitted upwards, and degeneration of the columns of Goll be found to extend as far as the floor of the fourth ventricle. Disease beginning at a higher level is very apt to be complicated with a morbid extension into the adjacent parts, so that the appearance figured in Plate a results, and this is explained by the arrangement of commissu- ral fibres found in this part of the cord. In nearly all cases it is impossible to make a diagnosis between the limited disease of the posterior columns and that which constitutes true " locomotor ataxia." In the cases of Charcot and Pierret the symptoms 1 Lecons sur les localisation, p. 259, et seq., Paris, 1880. Article in Ziemssen's Cyclopsedia, p. 773, vol. xiii.. Am. Trans. 342 DISEASES OF THE SPINAL 0ORI>. differ but little from those of the latter disease. It would appear that the success of our diagnosis should depend upon the recognition of irregular- ity in the appearance of symptoms, the absence of vertigo and ocular trouble ; and the predominance of other symptoms rather than the acute pains, Tvhich suggest disturbance more of the root-zones than any other part of the cord. Pierret^ has found the waist constricting band (parses- thesia), unsteadiness when the eyes were closed, and impaired power of preserving the equilibrium, but none of the striking symptoms of locomo- tor ataxia, in a case of uncomplicated disease of the columns of GoU. ANTERO-LATERAL SPINAL SCLEROSIS.^ Synonym. — Amyotrophic lateral spinal sclerosis (Charcot). When the anterior tract of gray matter and the latei-al columns of the cord are conjointly the seat of the destructive changes, we find perma- nent contractures following loss of muscular power in both upper and lower extremities, together with extensive atrophy and subsequent bulbar symptoms. Symptoms. — The disease begins without fever ; with loss of power in the muscles of the upper extremities, which becomes quite marked after a short space of time, and then follows a general atrophy of the muscles of the paralyzed members. In this way the malady differs from progressive muscular atrophy, in which one group of muscles, or even a single muscle, becomes atrophied before others, and in advance of any paralysis. Charcot calls this wasting process " atrophic en masse." At- tendant upon the paralysis are deformities, and these are highly charac- teristic of the disease, and result commonly from contractures of muscles which are less paralyzed than others, so that the stronger muscles over- come the weaker. The flexors of the hands are commonly affected, and these members are flexed and distorted, the fingers being drawn up so that their ends press into the palms, as is the case in other forms of post- paralytic contractures. The arm may be adducted to the side, and forci- ble adduction or extension is impossible. Pain is usually produced by any violent effort made to overcome the deformity, and the physician is obliged to desist. The patients are able, though their muscles are paralyzed and contracted, to perform certain limited movements, but the same tremor takes place which we observe in other forms of sclerosis when a voluntary effort of any kind is made. In the late stages the emaciation is complete, and the appearance of the hands resembles that seen in progressive muscular atrophy. There are the elevated thenar eminences and the flat fore- arms, but the limb is still contracted. Charcot alludes to a condition which sometimes affects the muscles of the neck, so that they are con- tracted to such a degree that the head is fixed and immovable. He relates ^ Archives de Pliysiologie, etc., 1873, p. 74. * I prefer this compound title, as it obviates confusion and more definitely ex- presses the seat of the disease. ANTEEO-LATEEAL SPINAL SCLEE0SI9. 343 a case where the muscles of the inferior maxilla were so contracted as to greatly interfere with mastication. The progress of the disease is marked by involvement of the tongue, and later by the destruction of the nuclei of the several cranial nerves, so that various losses of special function rapidly follow, and death termi- nates the patient's sufferings. The inferior extremities are paralyzed in their turn, and are the seat of contractures which resemble in some re- spects those of the upper extremities, so that his condition is one of helplessness. The legs become rigid when lie attempts to walk, and are agitated by tremors so that he is obliged to desist. The contrac- tures in the lower extremities are much more marked than in the upper, and when finally the victim seeks his bed he presents a most abject and pitiable appearance, the legs being twisted and contracted so that he requires the services of an attendant, as he is utterly unable to do any- thing for himself.^ Fibrillary tumors may be present just as in progres- sive muscular atrophy, but are not so constant as in the latter disease. The symptoms which usually herald the approaching end of the disease are those which indicate invasion of the bulb. Paralysis and atrophy of the tongue, vermicular movements of that organ, and affections of speech, are among these, and the orbicularis oris and facial muscles are next attacked, when there may be drooling of saliva and other indications of bulbar degeneration. In short, the symptoms are very much like those of bulbar paralysis. Sooner or later the pneumogastrics are implicated, and death follows. The disease runs its course in from six months to three years. I have been so fortunate as to see one case of this disease, the note of which I append. E. S., laborer. About one year ago he noticed an awkwardness in holding his spade, and when engaged in the excavation of a cellar he was unable to throw up the dirt, and at the same time felt unpleasant formication and cramps. These became so distressing that he applied liniments to his wrist and arms, but without any relief whatever. He consulted a medical man, who tried electricity, with no good effect, and after passing two or three months without treatment, he came to me, and I was able to make a diagnosis almost immediately. Both hands were strongly flexed, and the muscles were greatly atrophied. The index finger of the left hand alone escaped contraction. There was some rigid contraction of the forearms, while the arm was carried upwards and forwards by the muscles of the shoulder and thorax, and there was no movement of the elbow or wrist. Fibrillary contractions were ob- servable in the triceps, pectoralis major, and biceps. "When I endeavored to straighten the arm he suffered great pain, and begged me to desist. There seemed to be no involvement of the lower extremities, and the pa- tient walked without embarrassment. Seeligmuller - saw several curious cases, which were not only valuable ^ There is never cutaneous ansesthesia, the bladder and rectum are not affected, and there is no tendency to bedsores (Charcot.) * Deutsche Medicinische AYoch., April 22 and 29, 1876. 344 DISEASES OF THE SPINAL CORD. as instances of heredity, but ^hich illustrated the course of the disease.' , „^ ,. n • t iq-c The cases came under the observation of Seehgmuller in January, 18/ b. The family history, which was carefully inquired into, was remarkably good with one significant exception— that the parents were first cousins. There was no evidence of syphilis. Seven children— six girls and one bov— were the result of the marriage. Of these, the eldest, aged eleven, was quite healthy ; the second, aged ten, was in an advanced stage ot the disease ; the third was, if anything, worse still, but was not seen ; the fourth a bov, a^^ed six years and nine months, was in the middle stage ; the fifth and six'th were'healthy ; and the seventh, aged one year and nine months, was in the first stage of the affection. The disease began in a similar way in all. Strong and healthy when born, they continued so up to the age of about nine months, when a change took place. Able pre- viously to sit up without trouble, they began to lose this power, and would fall to one or other side ; later, the head and chest sank forward. At the aor. 4. Ea«t Hampton. 5. South Hampton. 6. Ponquogue and Good Ground. 7. Quogue. 8. West Hampton 9. East Moriches. 10. Centre Moriches. 11. Seatuck. 12. Greenport. 13. Moutauk Point. 14. Bridge Hampton. Darkest spots indicate points of greatest prevalence. Cold climates have something to do with the production of tetanus, as we would infer from Dr Kane's statement that intense cold produced " an anomalous spasmodic aftectiou allied to tetanus," which aflected most of his party, destroyed two men, and killed all his dogs. Trismus neonatorum is supposed by Vogel^ to depend upon the formation of the cicatrix when the umbilical cord is roughly handled, and there is probably pressure of some nerve by the contraction of the cicatrix. ' Diseases of Children, p. 65. Translation bj Raphael, X. Y., 1S70. TETANUS. 377 Frost-bite may sometimes give rise to tetanus, and the following cases are examples of this kind : They occurred under the care of Dr. Bethune, of Toronto. The first was that of a farmer who was exposed to intense cold for about three hours while driving. His feet and fingers became severely frost-bitten without his becoming aware of the fact until he arrived home. On ad- mission to the Toronto General Hospital, four days later, the toes and the greater part of both feet were found in a condition of moist gangrene. The fingers and parts of both hands on the dorsal surface were black and dry. Four days after admission he was seized with tetanic symp- toms, which rapidly developed. Chloral hydrate in thirt3^-grain doses, with extract of Calabar bean in one-fourth-grain hypodermic doses, until five grains had been given, failed to combat the disease, and the patient died in thirty hours after the accession of the attack. The second case was that of a man who, having lain out in a barn all night, had both feet severely frost-bitten, subsequently becoming partially gangrenous. In this case trismus set in nine days after exposure, and soon developed into well-marked tetanus, to which the patient succumbed in about thirty hours.^ Morbid Anatomy and Pathology. — The older writers have written a great deal in regard to the morbid anatomy of tetanus ; but the collected facts throw no light upon the pathology, and are to a great degree valueless. Lockhart Clark ^ in 1865 found in six cases that there was degener'i- tion of the gray substance of the cord. " The first case was reported at some length, and the lesion was found more or less from the origin of the second cervical nerves to the lumbar enlargement. At the second cervi- cal nerve, streaks and irregular areas of disintegration were observed in different parts of the gray substance, and particularly around the central canal, on the right side of which was a space of considerable size con- taining a finely granular fluid, with the debris of blood-vessels and nerves. The posterior and lateral white columns, especially along the edge of the various fissures which transmit blood-vessels, were damaged in a similar way, and in some sections the deeper portions of the posterior columns which rest upon the transverse commissure were softened to a con- siderable degree. This disintegration was still more marked in the cervical enlargement, chiefly behind and at the sides of the canal. The posterior commissure was wholly and the anterior partially destroyed by a fluid transparent and granular area. Throughout the cervical enlargement similar lesions were discovered, varying from a state of softening to one of complete solution, and diminishing at intervals or almost disappearing, to return shortly in the same form. At the upper part of the dorsal region the shape of the cord was much altered, and extensive lesions of the same kind were everywhere seen. In both lateral halves of the gray 1 London Lancet, March, 1875. 2 Med.-Chir. Trans., 1848 and 1865, and Med. Times and Gazette, 1865. 378 DISEASES OF THE SPINAL CORD. substance, the left lateral columns, the right antero-lateral column, the superficial portion of the anterior columns, and iu the posterior columns similar ap])ea ranees were found. Below this point there was less disease as far as the fourth dorsal vertebra. Here, in addition to the areas of dis- integration, large extravasations of blood were found along the whole lateral part of the gray substance on both sides of some sections, in one side only of others ; while the lumbar region manifested the same lesions as the cervical." Dr. James Tyson ^ has detailed two cases in which softening of the pos- terior columns occurred. In one of these there was extravasation of blood in the po-terior columns, and to some extent from the vessels of the pia mater. The central gray commissure was destroyed. In the other case no extravasation was found in the posterior columns, but there was venous congestion of the dura mater. I was presented by Prof L. McLane Tif- fany, of Baltimore, with a piece of the cord of one of his patients who had died with tetanus following a severe burn- The pia mater was greatly thickened, and the small posterior arteries were enlarged. Throughout the section, which was viewed at first with a low power objective, I per- ceived a rather extensive increase of the neuroglia. The anterior nerve- roots appeared to be very well defined. Throughout the white and gray matter there was visible numerous round cells quite translucent and bright, which resembled somewhat colloid bodies. These were more plentiful in the posterior column. The vessels of the gray matter were all more or less enlarged, and some of them were surrounded by spaces which were considerably wider than the diameter of the vessel. The cells of the anterior coruua were quite disintegrated, and some had taken an oval form. Those that could be recognized were found to have broken processes, and many had granular contents. The nerve- trunks were un- aflfected. Arlong^ and Tripier, Erichsen, and Bouillaud found that the end of the nerve in the wound was diseased, and Lepelletier^ and Froriep* discovered in one case that the neurilemma of the nerves in the vicinity was the seat of inflammatory changes, which extended from the periphery to the cord. This latter appearance indicates an exceptional condition of affairs, and as for the nerve change in the wound, it is not to be wondered at, for if there is any importance to be attached to the circumstance of the morbid appearance of an injured nerve, it is certainly inconsiderable when we consider how frequent must be such a pathological condition, and still there is not a proportionate amount of tetanus. Dr. R. ^y. Araidon,^ has lately published very full notes upon a case of tetanus, which throw some light upon the question of morbid anatomy. In this observation the disease followed an injury of the median nerve, 1 The Practitioner, August, 1877. ^ Archives de Physiol., etc,. 1870. ^ Kevue Me-Jicale, iv., 1827. * Neue Xotizen, 1837. ' Some new points on the Path. Anatomy of Tetanus, Archives of Medicine, June, 1879. TETANUS. 379 and the patient died five days afterwards. Microscopical examination revealed a variety of interesting meningeal, vascular and other lesions — those claiming our attention chiefly being the presence of vacuoles in the medulla and very decided changes in the region of the spinal acces- sory root-fibers especially, while the vagus, hypo-glossal and glosso- pharyngeal nerves were found to be the seat of vascular lesions. The symptoms pointing to implication of these nerves were quite pronounced. Our knowledge of the pathology of tetanus is based almost entirely upon the experiments of physiologists, and we are left somewhat in the dark as to 1 he questions : 1. Whether it is a central disease resulting from a morbid peripheral irritation which is reflected upon the cord. 2, Whether it is a central disease per se, and the appearances noted after death are primary. 3. Whether the morbid changes are secondary to the symptoms, and due to mechanical causes. We have so far been taught how general spasm may be produced. Mitchell^ and Morehouse caused in animals very violent convulsions by injecting into the vertebral canal a half ounce of fluid, and very hot or very cold water seemed to aggravate the spasms. Cold applied to the spine, whether produced by the rhigoline spray or by ice, gave rise to the same phenomena. Cold to the medulla caused the animal to topple backward. Upon examination the vessels were found to be intensely congested. So far, we are furnished with the first link in our chain. Assuming that the spasmodic movements are due to a congestion of the cord, and con- ceding that pathological anatomy has furnished us in nearly every instance with evidence of congestion of the gray matter, we are to discover what is the factor of such congestion. It may depend upon a reflected impres- sion transmitted to the vaso-dilators, or it may depend upon local irrita- tion by impure blood which produces secondary hypersemia. In strych- nine poisoning, the symptoms of which resemble those of tetanus very closely, the spasmodic phenomena are undoubtedly due to the imperfect oxygenation of the blood ; consequently the cord is supplied with blood loaded with carbonic oxide. It seems to me very possible that the same condition of affairs exists in tetanus ; that there may be direct irri- tation of the nervous matter of the cord dependent upon some primary blood condition. Fox^ very clearly expresses himself as follows : " The abnormal blood imperfectly nourished the cord. An imperfectly nourished cord is ipso facto an excitable, an impressible cord ; this impressibility renders arte- rial spasms abnormally facile, whether the exciting cause is the circula- tion in the cord of more of the morbid blood, or reflected irritation from a diseased nerve at the periphery, or reflex irritation from any other cause and from any other point in the body, and if this arterial contrac- tion goes on for any protracted period, or is frequently repeated, we may ^ Am. Journ. Med. Sciences, 1866. ^ Op. ci'., p. 362. 380 DISEASES OF THE SPINAL CORD. find various lesions due to imperfect blood-supply in addition to those due to diminished nutrition from the original nature of the blood, while, as a sequence of the spasmodic arterial contractions, we get hypertemia, and perhaps exudation, and lastly the pressure of the exudation or some peculiarity in its nature may lead to some disintegration of the nervous centres." This theory seems to me to be tenable for several reasons: 1, Inju- ries of peripheral nerves are common, and the cases of resulting tetanus are out of all proportion to those presenting no subsequent nervous symp- toms. 2. Its endemic nature, its prevalence in certain districts and its not uncommon idiopathic origin when there is no ascertained eccentric cause. 3. The appearances of the cord are of a destructive character, and it is a matter of doubt whether they are not more a result than a cause. Considerable discussion has taken place in regard to the cause of the high elevation of temperature. Yerneuil does not consider it due either to myelitis of the superior part of the cord, or to asphyxia or muscular con- tractions ; but Mason is decidedly of the opinion that such increase in temperature is alone the result of muscular action. The experiment of Mason has shown that the temperature of a tetanized muscle is often increased from one to two degrees. The medulla has been found to be the seat of grave lesions, such as in Araidon's case for example, and it is probable that the trismus and other evidences of an excited state of cranial nerve innervation, which occur in the beginning, are indications of primary disturbances in the bulb. Diagnosis. — The diseases and conditions with which tetanus may be confounded are hydrophobia, strychnine poisoning, hysteria, and acute spinal meningitis. In the first there is no risus sardouicus ; the convulsions are clonic ; there is the noisy hawking and effort to spit ; the dread of water, the delirium, and finally the history of a bite by a rabid animal, which, however, is not always ascertained. Strychnine poisoning is very easily mistaken for tetanus. In poisoning by a large dose of the alkaloid the symptoms appear rapidly, and death takes place in a short time. The hands are clenched and rigid, but the jaw can be opened, which is not possible in tetanus- This resemblance between the two conditions has been made use of in more than one poisoning ca.se as a ground of defence, and in that of Cooke, who was poisoned by Palmer, the question was narrowed down to the appearance of the cord. Cases of hysteria sometimes present symptoms which not rarely counterfeit those of tetanus. The jaw may be locked, but there will be few of the other features. Hysterical pa- tients are nearly always seemingly unconscious, and there are no evi- dences of suffering whatever. In spinal meningitis the muscular rigidity seems to be dependent, in a great measure, upon the patient's efforts to relieve the pain which is produced by an uncomfortable position. The locked jaw, which is an early symptom of tetanus, is absent in acute spi- nal meningitis. TETANUS. 381 Prognosis. — Dr. Jones ^ has collected 480 cases of tetanus, 213 of wliicli recovered under treatment, the mortality being 49.2 per cent., or one death in 2.02. These were all cases of traumatic tetanus. The per- centage of death in the British army during the Crimean War was 91 per cent. ; and Baron Larrey's estimate of mortality of the French army under Napoleon was at about the same rate. In regard to the time of death Dr. Jones found that of 50 cases, in which the disease followed slight injury of the extremities, 43 proved fatal in a short time, and of the whole number of deaths reported 24.14 per cent, ran a rapid course after slight injuries, and terminated in death in a few days. One case died on the second day. Cases are reported which have terminated fatally in twenty-four hours after the appearance of symptoms. In one case, mentioned by Dazelle, they appeared on the third day, and the patient died the same night. One author lays stress upon the statement that the prognosis is governed by the interval that elapses between the receipt of the wound and the appearance of the symptoms, and that the longer this interval is the more favorable are the patient's chances. Many writers agree that elevated temperature plays an important part in the prognosis, and that any increase is to be looked upon with alarm. The duration of the attack is to be taken into account, and every day bridged over by the patient after the fourth or fifth in- creases his chances of recovery. Of course the gravity of the affection depends much upon the violence of the paroxysms. Treatment. — It would be useless to discuss the merits of the many drugs that have been brought forward from time to time. Our most effi- cacious remedial agents are the depresso-motors, and among these may be mentioned chloroform, chloral hydrate, Indian hemp. Calabar bean, and conium. Calabar bean, which has enjoyed a deserved popularity, has been made use of with great success by Eilert, Holhouse, Wood, Watson, and a host of others. Holhouse in 1864 reported two cases, one of which was cured after having taken 3-4? grains of the extract every two hours. Ashdown was not so successful, and Spencer and Dickenson had the same discourag- ing experience. Even Watson was one of the first to use the remedy, and three out of his four cases of tetanus were cured by the administra- tion of ten drops of the tincture every hour, and by a subsequent increase in the dose. The drug may be given in full doses, say from one-quarter to one-third of a grain of the extract every two hours. The chloral treatment has certainly been more efficacious. Surgeon- Major Hunter'^ reported two cases : one a boy, and the other a man of 40. In the first case chloral was combined with cannabis indica. R. Tr. can- nabis ind. 1T(,x ; potass, bromid. gr. v, every third morning ; and chloral hydrat. gr. xij, three times a day, together with inhalations of chloroform ^Medical and Surgical Memoirs, vol. i., New Orleans, 1876. 2 Indian Med. Gaz., Feb. 1, 1875. 382 DISEASES OP THE SPINAL CORD. as required. The other patient took 20 grains of the chloral thrice daily. Opium and chloral in combination have perhaps been more ef- fective than the chloral alone, and Delsal ^ saved three cases out of four by this treatment. H. C. Wood reports 9 cures by chloral out of 18 cases. Chloroform has not proved to be the valuable remedy that many have supposed it to be, and it has only the power to " crowd down the bad symptoms which burst forth usually with additional fury when the narcosis subsides." Aconite has been of service upon many occasions. It was lirst used by Page'^ in a case of traumatic tetanus. The toxic effects of the drug were produced, and during their continuance there was a remission of symptoms. The patient was first reduced to a condition bordering on syncope, and af- terwards stimulated. De Morgan and others cured tetanus with this reme- dy, and its place in the therapeutics of the affection is by no means an in- ferior one. The pulse is markedly lowered, the muscular rigidity relaxed and a condition cf akinesis and prostration takes the place of the irritable nervous state. Curare, nitrite of amyl. and belladonna, as well as a host of remedies of the same character, have been praised from time to time ; but most of them are useless. Chloral hydrate, either in combination with aconite, or chloroform, and cold to the spine, which may be applied by the ether spray as recommended by Carpenter, I think is the best form of treatment, and should be resorted to as early as possible. If these remedies fail, Calabar bean, hyoscyamin, curare, or nitrite of amyl may be tried, and conium, which is a powerful depressor of spinal exci- tability, may be given a trial. Warm baths have been recommended. "Dr. F. Franzolini^ relates a case of tetanus arising fi'om exposure by sleeping on the damp ground after great fatigue, successfully treated by prolonged warm baths and the continual use of chloral and morphia. The chloral was given frequently by the stomach, and the morphia by subcutaneous injection. The first bath was for six hours, at a tempera- ture of 40^^ C. (104° F.), and subsequent ones lasted five, four, three, or two hours. This treatment was carried out from the 18th to the 80th of the mouth ; but the daily use of chloral and morphia was continued some time longer. Of the first ninety hours of his disease, the patient passed forty-eight in the bath at 40^ C. In twenty-nine days he consumed nearly four ounces of chloral hydrate, and about twenty-two grains of hydro- chlorate of morphia were injected. Although kept so long in a state of almost constant narcotism, the mental powers of the patient were in no way affected." H. de Renzi,* of Genoa, has spoken highly of the dark-room treatment. His patient was kept absolutely quiet. He ascribes the success to the ' Quoted in Practitioner, August, 1877. ^ Lancet, April 4, 1846. 3 The Doctor, Oct. 1, 1875. Abs. in Phila. Med. Times, Oct. 30, 1875. * Gaz. Med. de Paris, No. 32, 1877. 1 TETANUS. 383 belief that the absorption of oxygen and elimination of carbonic oxide are impeded by darkness. The other indications seemed to be perfect quiet, and during and after the attack ample nourishment. Xiemeyer^ believas in clysters containing twenty or thirty drops of laudanum. He also recommends chamomile baths in the infantile variety. 1 Text-Book of Pract. Med., vol. ii. p. 352. 384: BULBAR DISEASES. CHAPTER XIII. BULBAR DISEASES. EPILEPSY. Synonyms. — L'Epilepsie (Fr.) ; Fallsucht (Ger.) ; Mai caduco (Ital.\ Definition. — This most familiar of all nervous diseases is character- ized b)' loss of consciousness of variable duration, attended or unattended by either slight muscular spasms or general convulsions. The relation of these two elements, the psychical and physical, is not alwavs the same, as in some forms of the disease there is a momentary loss of consciousness and perhaps no appreciable spasm, or the two may co-exist, there being protracted loss of consciousness and violent convul- sions. There are sometimes very peculiar combinations of symptoms which will receive mention hereafter. The modern investigation of epilepsy by Hughlings Jackson has mate- rially modified our views of the disease. His consideration of the patho- logy of the disease is exceedingly complex, and he is inclined to treat the subject with greater breadth, and give it greater importance than it ever has received. A disruption of the most transient description of the harmonious relation of the psychical centres gives rise to a genuine paroxysm or discharge, so that many temporary bizarre actions which most of us indulge in even in comparative health, become invested with a new significance. Certain phases of what we indefinitely call " absent- mindedness," leading us to commit absurd acts which we laugh at after they are performed, may be in reality genuine epilepsies, and in others may attain the importance of disease symptoms. The scope of this work does not permit me to consider the history of the disease ; suffice it to say, that its antiquity dates back to the days of Hippocrates and Aretjeus, and biblical references to its existence are common. Cook ^ thus speaks of the early writings: "Epilepsy has been distin- guished by a great variety of names such as morbus sacer, comitialis her- culeus, caducus, etc. Aretseus says, it may have been called sacred on account of the magnitude of the evil, it being customary to call what is great by that name; or because it is to be cured rather by the Divine than by human power, or because persons laboring under it have been thought possessed by demons.^ . . Some of the ancients were of 1 Treatise on Nervous Diseases, Am. ed., 1824, p. 326. * Aret. lie Caus- et Sign. Morb., lib. i. c. 4. EPILEPSY. 385 opinion that epilepsy was denominated the Herculean disease because Hercules was subject to it ; but Galen says, it was so called on account of its form or magnitude." "Epilepsy was denominated morbus comitlalis, either because it fre- quently occurred in the crowded assemblies of the Romans called comitla, m which the passions of the people were often much excited, by which it might^ be occasioned, or because it was customary to dissolve the comliia if during the sitting any person should be affected by it. " The application of the term caducus, a falling sickness, is too evident to need illustration." In our description of the affection it is impossible to make any well- defined division ; suffice it to say, that all writers recognize forms known as Rant mal or Epilepsia gravior, and Petit mal or Epihpsia milior. Reynolds divides the latter into two varieties, viz.: 1st. A form with evi- dent spasms, and another without evident spasms. Besides these, various irregular forms have been included, such as masked epilepsy and hystero- epilepsy. THE GRAVE ATTACK. ^ Symptoms. — The most familiar variety is known as Epilepsia gra- vior, and it may be described as an attack expressed in four stages : 1st. A premonitory stage ; 2d. Stage of convulsion ; 3d. Stage of subsidence ; and 4th. A stage of stupor, or " after-stage " (Reynolds). The first stage may often be absent, for in many cases there is a sudden debut; but*if such be not the case, the patient may have well recognized warnings which may be either psychical (mental or emotional), motorial, sensorial, or vascular, these latter being objective indications. Though these warn- ings are spoken of by many patients, it is almost impossible to rely upon their testimony, as the demoralization dependent upon the anticipation of the attack, or the short duration of such premonitory symptoms, is sufficient to prevent them from analyzing their feelings. It i^, however, possible in many instances to collect information from a number of cases which shall be a basis fur the general classification of premonitory symptoms. Very often the attack will be immediately preceded by a vague dread, or an undefined fear of some impending trouble. In one of my cases— a remarkably clever and intelligent young Iddy — there is a condition of exhilaration of spirit, and a mental activity which lasts for some hours. Although deeply under the iofluence of the bro- mide, she will come out of her apathetic state and chat with her friends upon all subjects in the most entertaining manner. Twitching of the eyelids or of the lower extremies, vertigo with rotatory movement, and tremor are examples of the disorders of the motility which occasionally precede the attack. Sometimes there is aa elevated sensitiveness of the organs of special sense. Hallucinations of hearing and visual hallucinations are not uncomn>on. One of my patients has often seen a fiery cross; and another refers to a 25 386 BULBAR DISEASES. locomotive with a glaring headlight, which rushes upon him, while a third hears voices ; and in two cases the patients say that they " smell smoke." Morbid sensations, which cannot be defined, are spoken of oc- casionally, and a vague sense of weight in the epigastrium, head, or some other part of the body is a frequent precursor of the attack. Occasionally the peculiar sensations begin at some remote part of the body, and seem to move rapidly towards the head ; such phenomena are known as aurie. These axme have been compared to the blowing of wind over the surface, the creeping of insects upon the skin, or the pricking of needles. They last but a few seconds, and are sometimes perceived, but not always. In the wards under ray charge at the Epileptic Hospital, the patients sometimes have perceived the aurce in time to seek the nurse or attract the notice of the other patients. Careful investigation of twenty-nuie cases resulted in the discovery that eighteen of them had a warnu>g ot some kind, four had none, and the rest gave us unsatisfactory answers After a long process of condensation of statements, I find that seven had an aura starting from the epigastric region, two con)plained of constric- tion of the chest, seven had slight vertigo, and one had an aura starting from the extremities, and in one there was trembling of the right hand Headache preceded the attack in four, and the " indescribable feeling "of the coming fit was alluded to by a number. In one remarkable case the first intimation of the attack was the violent jerking of the head to one side and a species of vertigo. In another case the patient muttered in- coherently for a full minute before the actual attack. A third case was equally curious. The patient, whose mental condition was good, would, without any apparent reason, attract the attention of persons about him by the repetition of the sylables " be-lub-be-lub, be-lub, lub, lub-a-lub, a-lub," pitching his voice in a high key, and gradually lowering the tone until' the last part of his utterance was hushed and low, and then, after giving vent to a species of groan, he would become convulsed. Trous- seau^ calls attention to the " vascular prodromata." A local determina- tion of blood may occur in the finger, for instance, causing it to swell, reddening the skin, and rendering it successively, within a very short time red, and of a more or less deep violet color; or, again, the skin may become excessively pale after having been injected for some time. The swelling is real, not apparent ; for rings previously easy suddenly become too tight for the finger. The only premonitory symptom may some- times be an involuntary discharge of urine. It is difficult to distinguish this accident, however, and it is very liable to be considered a part ot the attack, which it may be in reality. ^Dr. Hughlings Jackson has made a contribution of the study of auric with reference to localization. When the epileptic paroxysm is preceded by vertigo with apparent rotation of objects, the attack begins on the right side and indicates a cortical lesion of the opposite side. When the aur» consist in perception of odors, 1 Clinical Medicine, Am. ed., vol. i. p. 75. ' " Brain," July, 18S0. EPILEPSY. 387 or epigastric sensation, or when masticatory movements of the jaw occur, the convulsions begin on the left side. 2d Stage {Stage of Convulsion). — lu many cases the first indication of the attack is a wild cry, which startles those about the patient. I have seen a soldier marching in procession throw up his gun and shriek so loud as to be heard half a block away, and fall to the pavement in a convul- sion. This shriek is a psychical manifestation, and different from another form of cry which the patient may utter. This second variety is less noisy, and is produced by the forcible expulsion of air through the vocal cords which follows spasm of the thoracic muscles. It is more a species of groan. Simultaneously there is loss of consciousness, and the patient falls to the ground, and is agitated by tonic contraction of all the muscles of the body, but usually those of one side more than the other ; so that his body is twisted and bent. The muscles of the neck are strongly contrac- ted, while the face is generally distorted. The stronger contraction of some muscles than others draws the weaker side so that movements are produced which are not the result of clonic contraction, but rather an evi- dence of unequally expended forces/ Respiration stops, or there may be a long expiration, and then stoppage altogether for a few seconds. The pulse is now rapid and very small, a result, probably, of compression of the arteries by muscular masses, and the heart-beats are strong. At the end of a few seconds, and rarely after a minute, the convulsions become clonic, the patient throwing his arms about violently, or bumping the back of his head upon the floor. He is still unconscious, and may have evacua- tions from his bowels and bladder, or, as in some of the cases that I have seen, there may. be an emission of semen. Reynolds calls attention to vomiting, a symptom which I have several times witnessed. The respira- tion now becomes labored and rapid, and there may be snoring. Froth collects about the mouth, which may be tinged with blood, as the patient sometimes bites his tongue or lips. The surface, which was in the first stage quite pale and cool, now becomes dusky, and of a dark livid color. The pupils may remain dilated as they were at the onset of the attack, or may be unequal. From my note-book I find that the following points were observed in the twenty-nine cases previously alluded to. In twenty- six the convulsions were quite general. In three the legs were more con- vulsed than any other part. In three the arms were especially agitated. In one patient the movements were confined to the left side. The cry was very piercing in five instances. In three there was only a moan or gurg- ling expiratory sound. Twenty -four of these patients bit their tongues. In twenty-three the pupils were wildly dilated. In two the dilation was not so marked. In four no appreciable difference was noticed. After the stage of tonic convulsion, which lasts a few minutes, the third stage is reached. In the large number of cases the attack may begin by local convulsive movements in the hand or in some of the muscles of the face. The thumb may be sharply turned in and the fist clenched — the convul- sion then becomes general, ^ Eeynolds. 388 BULBAR DISEASE!?. od Stage (Stage of Subsidence^. — This is marked by a gradual return of consciousness. The patient may stupidly turn his head or look up- wards, the eyes having a meaningless expression, and the balls oscillating slightly. He may strive to express himself, but only gives utterance to a series of unintelligible sounds. He may make some eff)rt to rise, but finds it impossible to do so. His pulse is small and thready, or sometimes full and bounding, especially when the first two stages have been short. His eyes are injected, and his pupils either normal or con- tracted. Ath Stage (Stage of Stupor). — Exhausted by his attack, he falls into a sound sleep, which is so profound that he lies where he has fallen, and re- sents any attempt to remove him. The stupor may be so deep, however, as to make him unmindful of what is going on about him. His sleep lasts for several hours, and is characterized by snoring. If the patient recovers without the stupor, he is very irritable and cross. He complaius of headache, or perhaps nausea and vomits; and his pulse is irritable and irregular. Thompson' calls attention to the tracings obtained in epilepsy when the heart is healthy, and it is possible to obtain good results. He as well as Lorain found that the sphygmograph tracing exhibited a distinct dicrotic notch. In regard to the time of attack, two divisions have been made — 7ioc- turnal and diurnal. I have thought it best to make another, viz.: ma- tutinal. Perhaps nocturnal epilepsy is much more common than the other forms, for a great many patients never have attacks at any other time, while some may have them at all times, and a few only during the day. A large number are attacked just as they awaken ; and I have met this form so frequently that I prefer to use the term matutinal for the attacks occurring between five and nine in the morning. The only sign of a noc- turnal attack may be the evidence of involuntary passages of urine and feces, and sometimes both. Blood upon the bed linen as a consequence of tongue-biting is another indication, and the trouble which is required to rouse the patient is a third. Of forty-eight patients, fourteen had their attacks at irregular hours, seventeen had thsra at night only, five in the day, and twelve in the morning. Tlie patient may sometimes do himself bodily harm during the convul- sion and Dr. Maury, of Memphis,, has communicated to me the following two cases of dislocation of the bones during an epileptic paroxysm. This is a rare accident in epilepsy, although it is not uncommon in tetanus. Case I. A man from Holly Springs, Miss., was sent to Dr. M. in Dec. 1876. The patient was sixty years of age, a planter, and of good habits. About one year before, after eating his supper, he became ill and had convulsions. In the night he had fresh convulsions, and suffered con- siderably from pain in the right shoulder The convulsions recurred at intervals of ten days. When he was brought to Dr. M. the 1 West Eiding Keports, vol. ii. p. 303. EPILEPSY. 389 shoulder was found to be shrunken, and the humerus dislocated and im- movable. Case II. A lady from Alabama, during the menopause, was affected with epilepsy about two years and a half before the Doctor saw her. She was attacked at night with convulsions and pain in left hip. These at- tacks occurred at intervals of from two to four weeks before she was seen by a physician. Left lower extremity found to be shortened about two inches, lemur evidently dislocated. Muscular contraction on outside of leg ; toes everted, and thigh turned inwards In this case no attempt was made to reduce the dislocation. Whenever she had convulsions there was pain in region of liver. THE LIGHT ATTACK. Symptoms. — The lighter forms of epilepsy are included under the head of- Epilepsia mitior, and are attended by a very transitory loss of consciousness. There may be little or absolutely no spasm, and the attack may be so unpronounced as to escape the notice of those persons who may happen to be present. The patient may be eating at the time, and sud- denly drop his knife and fork ; or he may be engaged in some occupa- tion, and suspend operations for a second. In one of my patients the only indication of the attack was the rolling upwards of the eyes. Another, a gentleman, when writing would stop for a moment and go on with his work entirely unconscious of any interruption. If walk- ing, there may be a sudden loss of equilibrium, but he rarely falls. The face may be blanched or flushed momentarily, and the patient may suffer no bodily discomfort, but is sometimes restless, depressed, or low- spirited. An aggravated state may exist, in which the muscular spasms are more marked. The attacks, which have been described as " weak spells," or " fainting fits," by uninfurmed people, consist in more protracted loss of conscious- ness, accompanied perhaps by strong muscular contractions of the muscles of the face or arms, pallor, and dilatation of the pupils.' I have a patient under observation who has a distinct epigastric aura; she then becomes rigid, holds her breath, grasps the arms of her chair; her head is drawn forwards, and so she remains for a minute or two. The foregoing forms may coexist, there being distinct attacks of grand mal, with repeated petit mal seizures, which seem to have no special rela- tion to the more serious convulsions. Twelve of the twenty-nine cases suffered from grand mal alone, and seventeen had both forms, and in these cases the petit mal predominated. As to periodicity and frequency of the attacks there is much to be said. There is a peculiarity in the regularity of the seizures which is to be observed in very many cases. A tendency to weekly, semi-monthly, or monthly recurrence is noticed. When the fits take place there may be only one at a time, or there may 390 BULBAR DISEASES. be a number within twenty-four hours, or two or three days, and then an interval of the duration I have just described elapses before a fresh attack or series of attacks takes place. In Reynolds's experience there are four times as many epileptics who have their attacks more frequently than once a month as there are who have them at long intervals ; but I am disinclined to agree with him " that males are more subject to monthly attacks than females, and that attacks in the latter are not as a rule monthly seizures." I discover every day numerous verifications of the menstrual influence. In forty patients I find that eighteen occur during or just after the days the woman has her catamenia ; and in more than one case much interest arises from the fact that there was dysmenorrhcea, and that when this was relieved the attacks disappeared. In many chronic cases, especially when there are complications, there is rarely any regularity in the appearance of the attacks. In the Epi- leptic Hospital, on Blackwell's Island, I find extreme variation in their number ; and there are patients under treatment who have had but three or four attacks in one year, while there are others who generally have from five to thirty each week; but this great frequency is exceptional. The attacks of petit mal are much more numerous, but from their very transitory character it is difficult to make any estimate which is at all useful. The irregular forms of the disease are of greater interest as curi- osities than anything else, but derive some importance from their medico- legal bearing. IRREGULAR ATTACKS. There may be a form known as aborted epilepsy, which consists in the expression of all the features of ordinary haid mal, without complete loss of consciousness. The attacks may occur in the course of ordinary epi- lepsy. The most peculiar examples of irregular seizures are described by Fal- ret, Hughlings Jackson, and others. While in certain states the patient will do the most eccentric things imaginable, the mind being apparently in a condition of vacuity, and the individual becomes more an automaton than a human being. ^ JNIesnet, of the St. Antoine Hospital, came across a very interesting case. The patient has been known as the " Automatic Man," and his history is as follows : — " A young man during the late war had a portion of the left parietal bone, about eight centimetres in extent, carried away by a ball. Hemi- plegia of the right side was the consequence, but this gradually disap- peared. For some time past he has been the subject of attacks, lasting from twenty-four to forty-eight hours, attended by very extraordinary phenomena. During these he seems to act exactly like an automaton, walking continuously, incessantly moving his jaw, knitting his brow, and 1 Gazette Hebdomadaire, July 17, 1874. EPILEPSY. 391 appearing absolutely insensible to all that surrounds him. i^ot uttering a word, he walks straight forward, and when he meets with an obstacle, stops short, explores it with his hand, and tries to pass on one side of it. Surrounded by a circle of persons, he stops at each, and endeavors to pass by the intervals formed by their joined hands, then turns back, comes in contact with the next person, and resumes his round. All this time he never manifests the slightest consciousness, just as if he were in a state of somnambulism. He is absolutely insensible to pain, so that pins may be thrust through the cheek or into the fingers, or very powerful electric shocks may be administered without the slightest sensibility being mani- fested. What, however, is very remarkable, is that by bringing him in relation with certain objects we are enabled to determine in him the entire series of acts which are correlative with the sensation thus aroused. Thus, if a pen be placed in his hand, he seeks for ink and paper, and writes a letter in a very good hand, in which he speaks very sensibly about differ- ent matters which concern him. If a leaf of cigarette paper is placed in his hand, he feels in his pocket for the tobacco, rolls up the cigarette very adroitly, ard, having found his match-box, lights it. If the match be ex- tinguished just as it reaches the cigarette, he finds another, and that several times, until he is allowed to light his cigarette. If at the moment when the match is extinguished, another already lighted is presented to him in its place, it is impossible to induce him to light the cigarette by means of the substituted match. He allows his moustaches to become burned without offering any resistance, but he will not employ the light thus presented to him. If chopped charpie be placed in his pocket in- stead of his tobacco, he makes the cigarette with this, and lights and smokes it without seeming to pay any attention to what he is smoking. Among the various experiments devised by Dr. Mesnet, there is one which is particularly curious. The young man is a singer at concerts by profession, and if gloves be placed in his hands he immediately puts them on, and searches for paper. When a roll of this, resembling music in form, is given to him, he places himself in the proper position and begins to sing. It would seem, in fact, that tactile sensation induced in him becomes the point of departui'e, and as if of escape, of a series of acts correlative to this initial sensation — acts which he accomplishes automatically, without letting them deviate from their habitual and regular succession. Lastly, it is to be noted that, while in this singular condition, the patient steals all that comes within his grasp. If he touches any person, he feels for his watch-pocket, and invariably detaches the watch and puts it in his own pocket, whence it may be immediately removed without his making the slightest opposition. The crisis once over, he has no recollection what- ever of what he has been doing, and becomes again perfectly reason- able."^ Equally curious cases are reported by Jackson of individuals who do purposeless things knoAving nothing about them afterward. A pa- tient of my own upon several occasions in a condition akin to " brown study," walked from the ferry-boat into the wrong car and rode some miles before he discovered his mistake. Many of the curious cases of absent-mindedness reported by various authors were undoubtedly irregu- lar forms of epilepsy. 1 Med. Times and Gazette, July 25, 1874. 392 BULBAR DISEASES. » An irregular form of the disease is known as " masked epilepsy." The patient in this state may not fall to the ground, but while in a state of unconsciousness will evince a great deal of muscular activity. An epileptic in ray ward is in the habit of tearing through the hall, col- liding with such patients as may happen to be in her way, and finally recovering consciousness, when she has no recollection of her attack. I have noticed the same phenomena in other cases. Another form is connected with the commission of purposeless acts such as I have cited. Cases of persons who have disappeared and travelled about the country for some days, and when found could not give the slightest history of their whereabouts are reported by various authorities. Snch individuals in reality, lead a double life, and while the automatic state pre- vails they may commit deeds of violence which may subsequently cause a great deal of trouble ; and in such cases only, the history of undoubted epilepsy should alone be sufficient to exonerate them. I believe it is strongly improbable that there is ever an attack of masked or aborted epilepsy without expression of some of the evidences of the true par- oxysm. The sequences of epilepsy are various, but it does not necessarily follow that any mental impairment should result. It is true that in some cases such a termination is possible. Idiocy and epilepsy sometimes go together, but it must be remembered that the former is a congenital state. Ex- amples of general mental failure are by no means rare, and in some cases the disease slowly undermines the patient's intellectual condition. " An apathetic state is the primary result. Any one who has seen one of these old cases (especially if the patient be the victim of petit mat), with dull fishy expression of eyes, dilatation of pupils, a leaden, sallow counte- nance, a full lip with imperfectly defined vermillion border, sluggish cu- taneous circulation, loss of memory, and dulness of wits, will recognize the condition I have endeavored to describe. Dr. Gray,^ of Brooklyn, has directed attention to what he believes to be a certain test of the epi- leptic state. He finds that the pupils of epileptics respond much more actively to the stimulus of light than in the normal individual. I cannot say that I have been struck with this condition Dr. Gill, the Resident Physician of the Hospital for Epileptics or Paralytics, made an examina- tion of the eyes of twenty-seven epileptics. Of this number, there was ready response in eighteen cases ; of the remainder, seven responded slowly. In one other case the pupils were dilated, and responded only when a bright light was brought directly upon pupil. In the remaining case the pupils were contracted, and responded with great difficulty. Of fifteen cases, most of which were of recent date, the pupillary response was not remarkably rapid. The first eighteen cases were of long stand- ing. In nearly all of these cases there was dilatation to a great extent under ordinary circumstances, and I attach much more importance to this appearance. When it is borne in mind that at best epilepsy is often a Am. Jour, of Med. Science, 1880. EPILEPSY. symptomatic condition of various organic troubles whicli may affect the eyes in different ways it is difficult to attach pathognomonic importance to ocular tests. An epileptic convulsion in infancy may give rise to cerebral hemor- rhage from a vessel ruptured during the paroxysm, but the accident is al- most unheard of in adult life. Epileptic mania, which Reynolds considers to occur in about one-tenth of all the cases, is not confined to any particular time. It may occur be- fore the attacks, or, as is more often the case, succeed them. In this con- dition ei^ileptics may be occasionally very dangerous, and give way to outbursts of violence, for which, of course, they are entirely irresponsible. A man who was a patient in the out-door department of the N. Y. State Hospital for Diseases of the Nervous System, and who had been treated by Dr. J. J. Mason, for epilepsy for a long time, was subse- quently discharged, as it was supposed, cured. A month or two after- wards, having an attack which was undoubtedly epileptic mania, he pur- sued his wife through the streets, and, drawing a pistol, shot her thi'ough the heart. After the deed he expressed great remorse, and gave himself up to the authorities, but, notwithstanding the medical testimony, was sentenced to the State's prison for life. Causes. — Of one hundred and eighty-three cases of epilepsy I have seen at various times, the ages at which the disease appeared were as fol- lows : — Male. Fermle. Total. Under 10 years 16 ]0 2G Between lb and 20 years 23 48 71 Between 20 and 30 " 14 41 Between 30 and 50 " 29 11 40 Over 50 " 4^ 1 5 99 84 183 Hugon- has recently made a valuable addition to the literature of epi- lepsy in an excellent brochure upon the subject of etiology. He gives a table prepared by Martinet to show the proportion of cases beginning between the 10th and 20th years. Of 307 cases collected by Musset, there were 107 " 68 " " Herpin, " 27 " 83 " " Maisonneuve, there were 46 " 306 " " Alegre, " 105 '• 106 " " Leiiret, " 42 " 230 " " Morean, " 76 " 43 " " Dunaut, " 26 " 70 " " Delasiauve, " 17 " 75 " " Dussart, " 40 ^ In two of these cases there was an indication of syphilis. ^ Eecherches snr les Causes de I'Epilepsie, etc., Paris, 1876. 394 BULBAR DISEASES. It will therefore be seen that nearly half of all the cases begin before the twentieth year. Beau collected 273 cases, 43 of which began between the 6th and 12th years; 49 between the 12th and 16th years; and 17 be- tween the 16th and 20th years. The attacks of early life are exceedingly irregular, and may begin as poorly developed paroxysms, which are by many classified under that most convenient terra eclampsia, which oftentimes means nothing. A number of these attacks of an undefined type usually precede the genuine explosion of the real disease. In regard to sex, it may be said that Beaumes, Esquirol, and Moreau were of the opinion that the disease was more confined to women than men ; but on the other hand Celsus, Joseph Frank, Leuret, and Sandras, as well »s Reynolds and others, take the opposite ground. From the number of cases I have collected and tabulated, I am inclined to adopt the same view as the latter. Ot' Hugon's^ cases, 32 in number, 25 were men, and 7 women. Professions seem to have very little to do with the production of the disease, if we except bar-tenders and liquor-dealers. In regard to the predisposing influences of temperament, climate, and season, it has been shown by Foville, Marce, Falret, and Delasiauve, that the nervous and sanguine temperaments predispose to the development of the disease. Maisonncuve found that of 65 cases, 25 were of a sanguine and 2U of a nervous temperament. Moreau considers that epilepsy is more frequent in winter than in summer, while others take the opj)osite view. Whether climate affects the development of epilepsy, I am unable to say ; but, after very carefully conducted experiments in regard to the influence of temperature, I am prepared to state most decidedly that the attacks are much more frequent whenever there is a sudden change of weather. A writer in the Bevista-Sperimentale, of May or August, 1875, has given tables showing the influence of atmospheric changes, temperature, etc., upon the occurrence of attacks. Before that time I began a series of observations at the Epileptic Hospital. These, when compared with the accurately taken charts of temperature, barometric pressure, wind, etc., of the Health Department, conclusively prove the truth of the as!:ertion I have just made. The number of attacks seemed to increase just at the change ; and a very hot day, followed by a cool one, would show an in- crease of from ten to fifteen seizures among my patients during the cool day, and vice versa. The influence of heredity is more strongly shown in epilepsy than in any other nervous disease, except it may perhaps be progressive muscular atrophy. In cases that I have seen the taint can be traced back for several generations either by epilepsy, neuralgia, insanity, or other nervous di.s- eases. In one case the maternal grandfiither died insane, the paternal grandfather died of apoplexy, the mother was living though subject to ^ Op. cit., page 7. EPILEPSY. S95 neuralgia, one brother had chorea, and the other had committed suicide in a fit of temporary insanity. Other examples are very much like this. Leuret^ found among 126 epileptic cases that there was a history of he- reditary epilepsy in seven cases. Beau's ^ experience was equally interest- ing. Of 273 epileptics, thore Avas hereditary predisposition in 18 cases. Leech and Fox^ fixed the proportion of epileptics in whom hereditary taint was found at 36.8 per cent., which, as far as I can judge, is no exag- geration. Reynolds* states that in the upper classes this hereditary pre- disposition exists to a much greater extent, but calls attention to the dif- ficulty of obtaining information. I have often been disappointed in get- ting reliable information, for this " skeleton in the closet " is kept closely guarded. I have been repeatedly astonished to find how strong this ele- ment is in the higher walks of life. In one family I find a long succes- sion of insane ancestors, idiot children, and dissolute progeny, which fully accounted for the transmission of the disease. It is a fact, however, that it does not follow that, because a parent has been epileptic, the offspring shall inherit the disease. Voisin found among 96 cases, 24 which fol- lowed hereditary alcoholism and phthisis. It is often due in the first in- stance to exciting causes, which, if removed, would probably be followed by disappearance of the disease. As to exciting causes, I may enumerate bad habits, excessive venery, syphilis, and uterine disease, which last I believe to be one of the mod important of all causes in the epilepsy of ivomen. Fright, grief, anxiety, overwork, blows on the head, and other traumatisms, also enter extremely into the etiology of the disease ; and the disorders of digestion and the exanthematous disease often play a part in its causation. Onanism is a very common cause ; and of 24 male cases I have seen during the past year, this vice existed in 9. I may extract the following data from a paper in which I analyzed the chronic cases under treatment at the Hospital ujDon Blackwell's Island : — One-third of these patients suflfered from intercurrent diseases ; two had advanced phthisis ; several had nephritic disease ; and a great many were anaemic. In regard to the complicating troubles, I find that twelve were subject to headache, two were hemiplegic (right), the epilepsy following the hemiplegia, two suffdred from sclerosis (one locomotor ataxia, the other diff'used cerebral sclerosis), and one was an idiot. When we came to examine into the causes we found more difficulty than we anticipated. The intelligence and memory were much below par in all. Scarlatina and variola preceded the disease in two, syphilis in one. In nine the attacks were connected with menstrual irregularities and ute- rine disease (versions and flexions), two of these were masturbators (by 1 Eecherches, sur I'Epileppie, Arch. Gen. de M6d., 1843. 2 Archives Gen. de M^d., May, 1836. ^ Manchester Medical and Surgical Keporter, quoted by Reynolds. * Syst. of Med., vol. ii., p. 295. 396 BULBAR DISEASES. confessiou), one of whom has been cured since the habit was broken. One case only was traumatic, four were congenital, and several gave absurd answers which were unsatisfactory. These are examples of chronic cases, and of course many are intractable. Morbid Anatomy and Pathology. — The variety of morbid appearances that have been found from time to time give no satisfactory explanation of the pathology of this disease, and we will not enter exten- sively into their discussion. Spicula of bone growing into the brain-sub- stance, thickened meninges, deformities, or depressions of the cranial bones, vascular anomalies, cysts, tuberculous deposits, softening, and a host of other changes have been observed. Some of these are important appearances which should not be dismissed too hurriedly. Undoubtedly the OJ-seous changes are quite satisfactory causes. In three cases I found spiculre or nodules of bone growing into or pressing upon the cerebrum. In one of these the exostosis had attained a length of one inch, and varied from one-eighth to one-quarter of an inch in diameter. In other cases I have seen decided depressions of the parietal bones, which impinged to a great extent upon the brain-substance beneath. As far as the deep lesions go, nothing very conclusive has been found. Vau-der-Kolk has dwelt at length upon the increased vascularity of the medulla a-jd the softened patches sometimes present, but these changes are just as likely to be the results of the disease as they are to be the lesion which produces the con- vulsion. It seems likely, however, that the investigations of Cazauvieilh and Bouchet, Bourneville, Charcot, and Delasiauve in France, as well as those of Meyuert iu Germany, must throw some light upon the pathology of this puzzling disease. All of these observers found distinct induration of the coruu aramonis, or pes hippocampi. Cazauvieilh^ reports eighteen autopsies made at La Salpetriere. In nine of these one or both of the cornua ammonis were indurated, and at the same time there was indu- ration of the white matter of the hemispheres. Bouchet,^ in forty-three cases, found the same condition of affairs. He says, " La corne d'ammon est la partie cerebrale qui a le plus frequemment presente I'induration. Cette alteration a souvent ete si frappante, et quelquefois si coustante, que bien evideute neuf fois de suite pour quelques medecins assistants, elle leur a donne la conviction qu'elle representait exactemeut la cause pathologique de I'epilepsie." Bourneville observed this lesion five times out of thirty-four during the years 1866 — 1874. Meynert has repeatedly discovered induration of this part, and considers it a pathognomonic sign. In his examination the cornua ammonis were found atrophied, and appeared to be of a cartilagi- nous hardness, and had undergone a general alteration. Of ten autopsies that I have made, six presented this lesion, and in one 1 Archiv. Gen. de MeJ., 3nie Anne, 1825, i., ix., p. 510, et 4me Anne, 1827, i., v., p. 5. ^ Sur I'Epilepsie (Annales Med. Psychologiques, 1853, 1. v., p. 209). EPILEPSY. 397 I found it to be uncomplicated. The other four cases presented nothing distinctive. In two the left hippocampus major was indurated, in three both were indurated, and in one the right was the seat of the same change. In one of these the extreme exterior part of the pes hippocam- pus was quite firm ; the little crenations or irregularities were more marked than in the healthy brain, as there had evidently been some atrophy with contraction. In one the gray matter just adjacent to the hippocampus major contained several indurated patches. In two cases the veins which skirt the inner edge of the corpora striata at the line of the velum interpositum, and receive branches from these bodies, were quite distended with blood, as were the ven^e galeni. The white matter in both anterior lobes was quite hard in three cases. In one case there were minute extravasations throughout the brain and in the medulla. In two cases there was effusion into the lateral ventricles. The cranial bones in one case were found to be considerably thickened. In all of the cases there were evidences of great meningeal hypersemia. In three of these cases I found microscopical disorganization of a granular charac- ter of the nerve-elements in the medulla. The vascular walls were thick- ened, and at certain points ruptured, the places of rupture having no special pathological relation as far as the nuclear involvement was con- cerned. In three cases which are not included in the ten referred to, I found osseous growths. Although this lesion of the cornua ammonis very rarely exists alone, it seems to be quite a constant morbid appearance, and it now remains for us to discover whether the condition is peculiar to epilepsy. Pfluger^ has made 300 autopsies at the Asylum of Ybbs, and in 25 cases of epilepsy, sclerosis of the cornua ammonis was found. The entire number of epileptics was 43. The cases in which their appearance was found to be most perfectly shown were those which dated from infancy. In three cases the disease did not begin until after twenty. Of twenty- three in whom the attacks were frequent and violent, seventeen presented this lesion. He supposes the alteration to be due to malnutrition fol- lowing vascular trouble. Epilepsy is, without doubt, an organic affection, the established disease beginning, perhaps, after a peripheral irritation has been transmitted re- peatedly to the centres ; but after the disease is fairly developed, the con- vulsions are not necessarily produced by the excitement of such distal irritation ; for, as Nothnagel shows, in cases dependent upon a cicatrix the attacks are not, as a rule, excited only by irritation of the cic trix. The clinical features of the disease prove the truth of this rule ; for, in any well-established case, gastric, uterine, or any other reflected irrita- tion may give rise to the seizures, or they may take place in an apparently spontaneous manner. We must, therefore, consider that epilepsy is a ■ Allegera. Zeitsclirift filer P.-ych. and Eevue des. Science.^ Med., 33, 1381, xxvi. p. 359. S98 BULBAR DISEASES. disease of an organic character, expressing itself after either some distal or central stimulation iu aa irregular manner, or the result of both. That it is connected with central changes there is no reason to doubt ; though these changes are by no means uniform. The experiments of Brown-Sequsrd have thrown much light upon its pathology, though Xothnagel and others do not unreservedly accept his views. The experiments of Brown-Sequard were chiefly made upon guinea-pigs. He produced epilepsy by division of the trunk of the sciatic, internal pop- liteal and posterior roots of the nerves inner seating the lower extremities, and by injury of various parts of the brain, the corpora quadrigemina, and cerebral peduncles. He also divided the cord at different points partially or completely, and shows that injury of the lower part of the cord seemed to have more to do with the subsequent epilepsy than when the upper part was mutilated. After these experiments, the first appearance of epilepsy occurred in from four to six weeks. The attacks were either spontaneous, or followed irritation of certain parts of the skin which were included in the so-called " epileptic or epileptigenous zone." This included the cheek, anterior part and side of the neck, and a portion of the back. This region became ante-thetic, and the hair usually fell out. Any irritation of this tract, such, for instance, as pinching, gave rise to an attack. Ultimately the antesthesia diminished, and the attacks sub- sided, so that it was impossible to excite them. The " epileptic zone " corresponded to the side upon which the nerve or cord injury had taken place. Other forms of experimentation have produced convulsive attacks, or a condition resembling epilepsy. These were blows upon the back of the head (Westphall) ; irritation of the cortex-cerebri (Hitzig) ; ligation of the carotids and vertebral arteries (Cooper, Hall, Kussmaul, and Tenner) ; irritation of the peripheral sensory nerves (Nothnagel, Krauspe). The labors of these, as well as others, indubitably show that the epileptic attack is connected with cerebral auremia,and the experimental production of this vascular state when irritation of peripheral sensory nerves has been made furnishes another link in the chain. The question of localization next arises. Brown-Sequard, Schiff, Rey. nolds, and Kussmaul and Tenner have all demonstrated that the medulla oblongata is the probable pathological seat of the disease. It has been proved by them thata so-called "convulsive centre" is here located, which, when excited, by reflex stimuli, gives rise to extensive spasms of both kinds of the voluntary muscles ; that whether the irritation comes ex chorda or ex cerebro, there is primary bulbar congestion, a cerebral anaemia, and a secondary cerebral congestion ; that such congestion follows reflex spasm of the cervical muscles, and that a condition of venous engorgement en- sues from pressure upon the large vessels of the neck. The pathology of the confirmed disease, as it has been generally considered heretofore, may be brieflv stated as — EPILEPSY. 399 A. The existence of a condition of reflex excitability of the medulla from a long-standing reflected irritation. B. An exciting impression transmitted from the periphery, or from a central part. C. The irritation of the vaso-raotor centre (described by Dittraar and others) through congestion at the floor of the fourth ventricle. D. A secondary ansernia and hyperreraia of the hemispheres. The production of symptoms probably due to — 1. a. Ansernia of the brain ; 6. Consequential primary loss of conscious- ness, etc. 2. Irritation of " convulsive centre," with tonic muscular contrac- tion. 3. a. Irritation of nuclei of lower cranial nerves ; h. Consequential asphyxia. Contraction of muscles of neck, pressure upon vessels, etc., secondary stupor, clonic convulsions. Van-der-Kolk^ explains the tongue-biting as the result of irritation of the nuclei of the hypoglossal nerves. The observations of Hughlings Jackson" and other modern observers throw much light upon the pathology, and give it a new and broader as- pect. The former proves "that those parts are wont to suffer first and most which serve in the voluntary (special) operations, aad those last and least which serve in the more autouiatic (general operations)." Briefly to illustrate this, he quotes from an article ia the Lancet demonstrating that the three points at which the convulsions often begin are : "(1) in the hand ; (2) in the face, in the tongue, or both ; (3) in the foot." This confirms the idea that the onset begins in the parts devoted more particularly to the execution of voluntary movements. He has been enabled to prove that in this manner the parts first attacked are those which are more commonly afiected in hemiplegia. He also calls attention to the phenomenon of aphasia, with epilepsy beginning in the right cheek. " Epilepsies," he says, " are the results of the second class of functional changes ; they are, speaking briefly, discharging lesions. But there are many varieties of discharges. Defined from the paroxysm, an epilepsy is a sudden, excessive, and rapid discharge of gray matter of some part of the brain ; it is a local discharge. To define it from the functional alteration, we say there is in a case of epilepsy, gray matter which is so abnormally nourished that it occasionally reaches very high tension and. very unstable equilibrium, and, therefore, occasionally explodes. . . . It will be observed that the discharging lesion of epilepsy is supposed to be a, j^ermanent lesion ; there is gray matter which, since it is permanently under conditions of abnormal nutrition, is permanently abnormal in function. That this permanent abnormality is a varying state, has been said ; it has been remarked that the gray matter occasionally reaches ^ Brain and Spinal Cord, Sydenham Trans. ^ W. Ridiog Reports, vol. iii. p. 315, et seq. 409 BULBAR DISEASES. high tension, and, therefore, occasionalhj discharges (or is discharged). There are waves of stability and instability. It follows from this that the first fit is supposed to be a discharge of a part which has for some time before been in a state of malnutrition ; and a still further inference is that such ' causes ' of epilepsies as fright are only determin- ing causes of the first explosion. Many of the premonitory symptoms of a first attack are probably results of slight discharges ; they are minia- ture fits.' That irritation of the auditory apparatus may give rise to a variety of epilepsy there can be no doubt, but such cases I believe to be rare, Browu-Sequard^ states that Mr. Hinton, an English surgeon, has reported several where, after deaih, no lesion was discovered, except evidences of disease of the middle ear. My friend Dr. Roosa tells me that out of five or six thousand cases of aural disease he has seen, he does not remember but one of this kind : — This patient was under my observation. John W. P , aged 15 years and 6 months, a stout and apparently healthy boy, well nourished, and presenting 7io external evidences of dis- ease ; family history good. His mother stated that he had always been a rather dull boy, and that at school he was generally behind in his stu- dies, and did not seem to learn easily, and when sent on errands, he was unreliable and forgetful. There is no history of injury or sudden fright, nor has there been any known predisposing or exciting cause; but at the age of eight years he had a severe attack of scarlatina, which left him with a remaining otitis, most severe on the right side, and resulting in a profuse discharge of pus, which still continues in a modified degree, but is not so excessive as it was a month ago. About six ■weeks ago he began to syringe his ears with a carbolic acid solution, which had the eflTect of removing a large mass of what was probably inspissated pus ; and his hearing, which had before been quite defective, became greatly improved, and he no longer complained of various subjective noises, such a? buzzing and roaring. When the quantity of discharge was diminished, his ears became painful, and pressure on the mastoid processes caused much suf- fering. Ever since the scarlatina he has had frontal and occipital head- ache, which is always constant. About a mouth ago he had his first epileptiform attack, and this occuried about noon one day when he was using his syringe. Without warning, he suddenly fell to the floor, be- came convulsed, and in a few minutes recovered, and did not fall asleep; but a semi-unconscious state, however, supervened. The next attack came on four days after, at 3 P. M. While he was chatting with a friend, he suddenly stopped talking, and fell. This attack was much more violent than the first one. They now become more and more frequent, until about two weeks ago, when on one occa- sion he had fifteen during twenty-four hours. Siuce then he has not had so many, having had between one and five attacks every day but one, which was the only day he missed the attack since the commencement. During some of the attacks he is very violent, while in others not so much so. His appetite has been irregular for some time past. An ex- amination made by Dr. Baldwin, House-physician of the Epileptic and ^ Central Nervous System, p. 93, ami Gaz. MeJ. de Paris, 1842, p. 2). EPILEPSY. 401 Paralytic Hospital, and myself, revealed tenderness on pressure over mastoid processes, but mostly on the right side. He has had no definite aura, but peculiar sensations which he cannot describe, jDreceding his attacks. He complains of vertigo and nausea, and muscular weakness after the slightest exertion. He invariably returns to consciousness almost immediately after the attack, attempts to rise and walk, but is usually quite feeble. Examination of Ears. — R. : Discharge scanty, thin, and sero-purulent ; and, on examination, the membranum tympani is found absent. The tick of a watch is heard only when the watch is pressed against the ear ; a roaring sound is always present. L. : The same examination shows more or less congestion of the tym- panum, Avith evident signs of otitis media ; but there is not so much joain on this side, and the hearing is better, the ticking of the watch being heard at three inches. Patient has complained lately of deep, severe pain in the frontal, but extending back to the occipital region. With this pain there is dizziness, especially when he stands, thus making it difficult for him to preserve his equilibrium, which is strikingly shown by his irregular movements. When sitting up in bed, he complains that objects move up and down, and not horizontally, as we should expect to find in ordinary auditory vertigo ; and a very interesting and peculiar symptom are the movements he makes to joreserve his relation with surrounding objects, his body moving up and down, and his head swaying strangely. He is very sus- ceptible to noises and bright lights, either being capable of inducing a spasm at times. Vomiting from an empty stomach is occasional, with dilatation of pupils. The vision of right eye is at times entirely lost, but at others is unimpaired. Muscse volitantes are frequently complained of. Examination of urine affords negative results. Observations during an attach or convulsion, which occurs at no regular intervals, but is a constant result of irritation of the internal auditory ajjpa- ratus : — Ear syringed at 9.55 A. M. Patient calm, and not at all nervous ; skin of normal hue ; pulse regular ; temperature normal ; pupils some- what dilated. He passed a good night, and suffered but little pain, though his vertigo was still troublesome. He was placed upon a bed, and the point of an ordinary two-ounce syringe, filled with tepid water, was inserted in the external meatus of the right ear, and the contents gradually expelled. This caused some pain and dizziness, which increased as more water was injected ; and when one ounce had been thrown in, the patient became suddenly unconscious, and the head was drawn from one side to the other by rapid clonic contractions of the muscles of the neck, and almost at the same time the convulsion became general, the muscles of the back being extensively involved. About five seconds after this, there were clonic spasms of the muscles of the jaw, so that the patient snapped his teeth, and, at the same time, forcibly inspired, giving vent to a peculiar noise which might be easily compared, by a person of lively imagination, to the bark of a dog. This paroxysm lasted two minutes, and during its continuance the pupils were widely dilated. The patient remained unconscious ; but there was neither pallor nor suffusion of the face. Thirty seconds after- wards, a period of muscular relaxation succeeded, a fresh attack followed, 26 402 BULBAR DISEASES. during -which there was more marked opisthotonos, much more noise, but no frothing at the mouth. Pupils still dilated, though perhaps not so much so as at first, while the skin was slightly suffused ; but there was no duskiness. Duration, one and a half minute. Ten o'clock and thirty seconds, after slight relaxation and subsidence of movements, the lateral jactitation of the head again began ; and at ten o'clock and one minute a violent accession of clonic, and afterwards tonic spasms made their ap- pearance. The eyeballs had throughout been uncovered, and at first Avere stationary and immovable, or almost so ; but now they were agitated by nystagmatic movements, and the pupils were dilated. This paroxysm lasted but thirty seconds. At ten o'clock and three minutes there was another seizure, during which the left sterno-cleido-mastoideus was in- volved in a prolonged tonic contraction. The pupils now partially re- turned to their normal condition, which was one of slight dilatation ; and at ten o' clock and four minutes the patient became semi-conscious, answered questions in monosyllables, and after a few minutes recovered entirely. The pulse suffered no variation, except, perhaps, after two minutes had elapsed from the beginning of the seizure, when it seemed to increase in volume, and perhaps slightly in rapidity. There was an entire absence of any external evidence of asphyxia, which is so marked in the more familiar form of epilepsy. I have ascertained that the convulsions may be precipitated by simply blowing into the external auditory meatus. Diagnosis. — Epileptic attacks may be mistaken for the convulsions of Bright's disease, infantile convulsions, hysteria, alcoholism, opium poisoning, syncope, and softening, and the disease is occasionally simu- lated by malingerers and others. I may briefly dispose of the above: 1. Ursemic convulsions are generally preceded by drowsiness or coma, delirium and stertor. The limbs may be oedematous, and the urine con- tain albumen. 2. Infantile convulsions from worms, dentition and other eccentric causes, are usually attended by a febrile condition. The convulsions are of short duration, and are characterized by complete loss of consciousness. The discovery and removal of the cause usually effect a disappearance of the attacks. 3. Hysteria (See article Hystero-Epilepsy.) 4. Alcoholism and opium poisoning are characterized by a more pro- tracted stage of unconsciousness, and by a contraction of the pujiils in the latter. 5. Fainting attacks may resemble the petit-mal, but there are no spasms, and the pulse is feeble. 6. Softening and other organic states give rise to convulsions, but the accompanying symptoms should enable the observev to make the diagno- sis in every instance. Simulated convulsions may deceive a careless person, but the normal condition of the pupil, and the eagerness of the individual to play his part perfectly which he does not do, lead to the detection of the imposi- tion ; and the excessive pallor of the first stage can never be simulated. EPILEPSY. 403 ^ Dr. Carlos Macdonald reports the case of a patient who feigned epilepsy and who was known as Clegg the " dummy chucker." Clegg was a criminal, and feigned epilepsy so successfully that he escaped hard work and was generally regarded by a number of prison physicians as an ob- ject of sympathy. He submitted to all manner of painful tests, and upon one occasion he actually fell twenty or thirty feet in one of his shammed attacks. Dr. Macdonald, however, was suspicious and watched him very carefully and finally compelled the man to confess. In his pretended paroxysm the hands were closed but the thumbs were not so closed, nor were they flexed at any time, and the sphincters were never relaxed. His facial expression at times betrayed him when he was closely watched. There was no lividity beneath his nails. These indications, together ■ with the patient's manner, which was ostentatious, so far as showing his scars and alluding to his feelings was concerned, convinced Dr. Macdon- ald of the deception. The syphilitic form of the disease resembles much the ordinary variety, but in some instances it is of the greatest importance to distinguish its specific nature, as of course the treatment is entirely different from that employed in the non-specific disease. Buzzard, who has given us an admirable little work on the syphilitic neuroses, lays great stress upon the necessity of recognizing the variety of pain as a diiferential symptom. "If pain in the head be associited with convulsive attacks," he says, " it generally precedes the attack in syphilitic convulsions, and is often localized in one particular spot In simple epilepsy (if it be present) it almost always follows the fit, is difl^'used over the forehead, and is at no time a strongly marked symptom." The age of the patient, and the time from which the attacks date, are also of great importance in this connection. It is not probable that syphilitic epilepsy would begin early in life, or, at least, before puberty, but simple epilepsy dates from early childhood. Prognosis. — The duration of the disease has much to do with the prognosis, and the mode of origin, form of expression, and complicating conditions must all be considered before an opinion is given. If the disease be of idiopathic origin, or if it be due to violence, i. e. injuries to the head, the prognosis is bad. If it be due to eccentric causes or syphilis, there is reason to be hopeful. Hereditary predisposition is an obstacle in our path which sometimes blocks the way to a cure. I have found that XhQ petit-mal {& also less amenable to treatment than the severe form, and that it is pretty sure to produce an impaired mental condition. Reynolds thinks that the attacks which recur rapidly are more amena- ble than those which take place at long intervals, but this has not been my experience. If there be any considerable congenital lack of intelli- gence the case may be considered as incurable. The unfavorable condi- tions are the occurrence of a great many attacks in a short space of time, the biting of the tongue, and a condition which has been known as the ^American Journal of Insanity, July, 1880. 404 BULBAR DISEASES. "status epilepticus," in which the patient lapses into a comatose state, and there are a number of fi's in close succession. Death in the actual lit is not common, and I know of but six fatal cases : five from the dis- ease, and one from falling upon a sharp iron point which penetrated the orbit. Treatment. — Before entering upon the discussion of particular modes of treatment, I desire again to refer to certain etiological facts which bear to a great extent upon the selection of remedies. I may be pardoned for calling attention to practical points which may appear unimportant to some ; but an experience gained from the management of a great many cases teaches me that they are to be care- fully considered in selecting a plan of treatment. These simple indica- tions, I am convinced, are too often overlooked even by painstaking and careful medical men. I allude to the necessity for discovering the excit- ing cause. I am every day made to feel that the idiopathic cases do not form so large a proportion as they were once thought to. AVith this be- lief I am satisfied that empiricism and routine management are bad methods. Any one who examines all his cases thoroughly will recognize the delicate shades in epilepsy, variations which are exhibited in other diseases presenting more pronounced and better defined symptoms ; con- sequently there are evidences of pathological action, which are not always grouped alike, and therefore all cases are not to be treated in the same manner. I ascribe the moderate success I have had in the management of this disease to the recognition of these difierences. Xot only may obstinate epilepsy result from masturbation, but it may be due to many diseases of women, and it is produced by eccentric irritations of various kinds, or by centric irritation, such as maybe asso- ciated with toxaemia. Sir Charles Locock ^ called attention to many cases he had treated where uterine irritation was the exciting cause; and I think others have had the same experience. In one of Locock's cases the patient was afiected particularly at the menstrual periods. Some of these peripheral causes are curious in the extreme. Through the kindness of Dr. Gibney, of New York, I was enabled to see a child who had accidentally injured her ear with her parasol, the brass tip of which remained for some time imbedded in the external auditory meatus. As a result, convulsions of an epileptic character were caused, and it was not until some time afterward that the foreign body was discovered and removed. In another case I treated, the epilepsy was unmistakably due to a bad habit the woman had of wearing a number of heavy garments about her hips, which produced some uterine change. When this condi- tion of affairs was noticed, and the skirts removed, she immediately re- covered. At the root of many epilepsies, as well as other neuroses, are reflex causes — the starting-point being the organs of digestion, or those contained in the pelvis. Of course the varieties of epilepsy of an idio- 1 Med. Times and Gazette, May 23, 1853. EPILEPSY. 405 pathic nature, or those caused by traumatism or organic disease, will defy the best efforts of the physicians. In prescribing for our patient there are five indications to observe : — 1. Removal of exciting causes, if possible. 2. The diminution of exaggerated reflex susceptibility of the medulla. 3. Equalization of cranial circulation. 4. Abortion of paroxysms. 5. Improvement of general condition. For the accomplishment of these, it is imperative that a judicious and discreet selection of drugs should be made ; and among those which are the most effective I may mention : — The Bromides : sodium, potassium, ammonium, calcium, lithium, iroa Chloral hydrate. Strychnine. Arsenic. Belladonna. Ergot. Amyl-nitrite. Digitalis. Mercury. Tri-nitro-glycerin. Cod-liver oil. I have not classified these remedies, as it is unnecessary to do so; but will now say a word in regard to their usefulness. No one drug can be declared a s]3ecific, as I am sorry to see has been done ; and we must not be too eager to accept the sanguine results of certain over-enthusiastic authorities, and be governed thereby. I allude more especially to the almost universal use of the bromides to the exclu- sion of everything else, and also to their employment in quantities which often ruin the patients, or, at any rate, produce a condition of diminished vitality, which is inconsistent with any hope of success. Radcliffe's^ idea in this respect is a good one : " There is reason to believe that the thera- peutics of convulsion must be based upon the notion that vital power has to be reinforced, and not upon the contrary opinion." What the proper dose is has not been clearly settled by any one. There are neurologists who believe in toxic doses, and there are others who prescribe quantities which are almost small enough to be inert. In England it has been the custom to prefer the small doses. I have seen the prescription of a very distinguished general practitioner, who some years ago thought five grains of the bromide of potassium a sufficient dose ; but this has now changed. Einger^ recommends from 30 to 60 grains in the day ; Rad- clifie,-^ 45 grains ; Russell Reynolds,* 30 to 90 grains ; Bartholow," 30 to 240 Handfield Jones'' remarks that there is a great difference in the tole- rance of individuals in regard to the bromides — some persons not being able to stand five grains, while others will not be afiected by doses of less than forty grains. ^ Pain, Epilepsy, and Paralysis, p. 215. 2 Handbook of Therapeutics, p. 92. " Op. cit., p. 202. * Op. cit., p. 323, vol. ii. 5 Materia Medica and Therapeutics, p. 371. fi Functional jS^ervous Diseases, p. 325. 406 BULBAR DISEASES. My own experience has taught me that the best effect can be gained by the repeated administration of sixty grains in the twenty-four hours. The larger doses produce rapid bromism, while the medium dose seems to be better api^ropriated, but will do just as much mischief in the way of bromism as the larger one, if given for a length of time. My records show me that the average time for development of symptoms of this kind is about three months, while amesthesia of the fauces is produced in a few weeks, or even a much shorter time ; and I agree with others that it is necessary to produce this condition before we can say that the medicine has produced its physiological effect. But when once reached, the further toxic action of the drug is deleterious instead of beneficial. Bi-own- Sequard considers the appearance of acne to be an indication that the medicine has begun to do its work, in which opinion he is joined by Dr. Putnam- Jacobi.' Voisin" considers the " point of saturation to be indi- cated by the anaesthesia of the pharynx and nares, so that in one case nausea is not produced by titillation with a spoon, and in the other sneez- ing and weeping do not follow the introduction of a straw into the nasal cavity." I should consider the latter a rather severe test. According to Danton,^ the bromides act as vascular medicaments, diminishing excito- motor power. They act on the unstriped muscular fibre, pi'oducing local anaemia, and moderating excitation resulting from temporary or perma- nent congestion. " They are agents that pass very rapidly into the blood (Ringer),* and consequently their effects are very immediate, and they accumulate till the point of saturation is reached before they are elimi- nated in anything like considerable amounts." We are all aware that repeated and large doses of these drugs are followed by a most disagree- able and pernicious state of affairs. Voisin* has referred to two forms of bromism, which he has divided, into the slow and rapid. In the first the complexion becomes muddy, the eyes sunken, sight and hearing poor, and memory obscure. The patient cannot write, and cannot express himself, as he forgets words ; there is tremulousness. In the other variety of the sloio form there is dementia, or delirium with manical outbursts. Ataxia is also a feature of this variety. In the rapid form — that with which we are most familiar — somnolence, headache, uncertain walk, difficulty o speech, loss of expression, " fishiness " of the eyes, drooling of saliva, etc. etc., are the ordinary symptoms. Various grades of toxaemia, or even a state which Voisin calls the " ca- chexie bromique," and which terminates in a typhoid condition, may result from a reckless use of this drug. As regards the variety of bromide, I think the sodic is the most reliable and stable, the potassic salt varying very much in strength. The others ^ Oral communication before Am. Neurological Association. - Voisin, Archiv. de Medecine, Jan. 1873. ■' Danlon, These de Paris, 1874. * Op. cit. p. 91. ^ Voisin, Arcliiv. de Medecine, Jan. 1873. EPILEPSY. 407 either have a tendency to deliquesce, or are expensive. It will be advis- able to keep the solution in a tight-stoppered bottle, and have fresh quan- tities put up constantly, as it is very apt to undergo changes — in which the bromine is evolved. And now a word regarding the time of adminis- tration. It has been shown repeatedly that these salts are much better absorbed when the stomach is empty. I have found also that a heavy dose at night is apt to do more good than if the amount prescribed is equally divided up through the day. In a great many patients I have found the attacks to occur at the waking hour, and I suppose this is due to the sudden change in the cerebral circulation. A mild diffusive stimulant has overcome this, and in many cases warded off the attack. I direct my patients who have their convulsion at this time to keep a glass or a small quantity of spts. ammonite aromaticus near at hand, to be taken before rising. Cold douches to the head are valuable. If the at- tacks be irregular, it will be found necessary to divide the dose. Analysis of Eleven Cases of Epilepsy. S. B. — Sodic bromide. P. B. — Potassic bromide. s Average o No. of s« Sex and Duration of attacks Maximum Minimum Diminu- Eemarks. C age. disease. before dose. dose tion. C I? 1 treatment. T Male, 15 Since birtli 1-2 weekly S. B. gr. XX. S. B. gr. xv. 2 in 8 weeks Weak intellect. t. i. d. t. i.d. 2 Male, 22 Two years 1-2 weekly S. B. gr. XV. 1 in 20 wk's Disease followed sunstroke ; treat- ment lasted three months. 3 Male, 25 One year 1 or more S. B. XXV., S.B. gr. ij. None in 8 Hard drinker. in week, P. B. gr. weeks. feeble intellect : sometimes XXX. potassium salt many in a day 1-2 weeklv, inert. 4 Female, 2 IS months Very small doses. None in 8 Fits followed den- tition ; rickety sometimes weeks. 3 in a day constitution. 5 Female, 18 One year 1 in week S. B. gr.Kxx Gr. XX. None in 4 weeks. Tuberculous dis- ease. 6 Male 18 Five years 4 in week S B _r Yv None from No affection of intellect. 5 weeks. 7 Female, 11 Five years 2-3 in week S.B. gr. xx.S. B. gr. XV. 1 in 5 w'ks Followed a blow ; subject to head- ache. 8 Female, 17 Several Sometimes'S. B. gr. xv. None after Hasbitten tongue months 4-5 daily treatment. 9 Male, 20 19 years 2-3 weekly S.B.gr.xI. S. B. gr. XV. No fits for 2 weeks. No aura. 10 Male, 13 Two years 3 weekly S. B. gr.xxv^S. B. gr. xv. I in 3 wks. Well developed disease, facies epilepticawell marked. 11 Male, 25 11 years lin2 weeks S. B. gr. XX. 1 in 5 w'ks. No fits since be- ginning of treat- ment. By this table it will be seen that from fifteen to twenty grains of the sodic salt were required to immediately decrease the number of attacks. The treatment of the disease in women should be directed as well to the pelvic organs. It will be found that the bromides will markedly affect the flow, and relieve the pain or uneasiness which is connected with the 408 BULBAR DISEASES. menstrual period. Locally I have found that cold applied for a few minutes daily over the ovaries will modify the attacks should they be connected with irritation of any of the pelvic viscera. The progress of the disease should be soon modified by the doses I have recommended; and it will be seen by the table condensed from that prepared by Dr. Hollis/ that even smaller doses modified or cured the majority of the cases he cites. At the Epileptic and Paralytic Hospital, where most of the cases are the very worst that can be collected as regards chronicity, I find that sixty grains a day will cut short the attacks of a great many pa- tients, and I have cured a number of private patients by this method. Dr. Hollis' cases were not selected, and are evidently hospital patients, like my own. On succeeding pages will be found two tables. In one are tabulated the interesting features of twelve cases of epilepsy. They are old hospital patients, and had applied for admission after outside treatment had been exhausted. Even here the bromides, in the doses I have given, seem to do much for the sufl:erers. Head-injury and actual insanity make the prognosis as bad as it well can be, and treatment is simply palliative. Large doses have aggravated many of those cases. The other observations are selected from my note-book, and are illus- trative of the efficacy of the dose I have advocated. Bromism occurred in spite of all I could do in most of them, though it was a mild form and under control. The patients were all of the better class, and of course had all the advantages of comfortable homes, attentive friends, substantial food and good air, although many of them were inclined to over eating, as in f;)ct all epileptics are. In this respect there is an advantage in favor of the poorer patients, who cannot obtain rich food. And now regarding the large doses. If the idea is thoroughly to ruin the patient's health, enfeeble his mind, or perhaps drive him to an asylum, the toxic administration may be indulged in. It is verytrue that some- times a rapid restoration may be brought about by "iron and quinine;" but there are many cases where the recovery is not quite so complete as one could wish for. Memory is enfeebled, and there is a cachexia which remains for an indefinite time. Adarker side of the picture is not always displayed when brilliant results are detailed. This is the list of demented and those that have died. Dr. Janeway was present at the autopsies of two patients who died bromiuized, for certainly the examina- tion disclosed no other cause of death. I myself have seen several demented cases, and I have no doubt others could tell the same story. I have used the bromides in combination with chloral hydrate, and have obtained the most excellent eflfects. Such good results as diminished condition of stupor and eruption, follow the administration of equal parts of chloral and the bromide of sodium. The bromides of ammonium and sodium with chloral as recommended by the N. Y. Therapeutical Society, may be employed. 1 British Medical Journal, Julv 1, 1876, p. 4. EPILEPSY. 409 < i ?' ~ ^ 1 - -- 1 1 I 1 1 1 1 -1 III llllllllllll ! 1 1 • X * x' — ^ ■ ^ z ^ \ ^ >< : i x' : : > X -=^ >5 t^' ffl « 1 3 H ■? ^ i 1 5) a 5 So 3j ° £c C- ^ fa ^ or j. CO 2-= ■Z = ^ £ Mill >>>■.— >-.>»>>>.>. g 1 5 « " S: 5: H .5 -S >. >. >> >. OOCCOCCCC ^- oj ^ g = =i =t :; o o e o o e. s. A ^ s. T. C/ o © tt o o >-.>>>> >i >» >1 O ;:= ■* SI t- I-l *- M Ol r-i »J IM IM H r- r^ N ?J r-( N CO QO C5 O i-i N 410 BULBAR DISEASES o 1^ a o 4/ > I i H 53 !N -= £ g££^ _-^.o o 5'= 3 t- M - C 1) O ' ;n S C C rs >. t> — 111 PI G. m. abou weekly ; p. 10 daily. o o ib < •ON I -> EPILEPSY. 411 Belladouna and its alkaloids are of great value when the seizures occur in the daytime, or are of the variety known as jJetit mal. I have injected the sulphate of atropia in ei gr. doses beneath the skin at the back of the neck with good effect, and have used it in the manner directed by Trousseau. In either way it should be administered until dryness of the throat is obtained, and should be given a patient trial. The property possessed by belladonna of blunting reflex susceptibility assures it a great advantage over other methods of treatment, when there are centres of irritation such as in gastric epilepsy. In ergot we have a remedy which controls the cranial circulation much more readily than any drug with which I am acquainted. As the object is to diminish the congestion at the floor of the fourth ventricle, its com- bination with the bromides greatly increases the action of the latter. Ergotin may be given alone in the form of Bonjean's capsules. To Tyrrell ^ belongs the credit of suggesting strychnine. He believes that this remedy controls excitation of the medulla oblongata. In one individual who averaged fifty-one attacks in a month, the number was reduced l)y the strychnine to eleven in two years. Handfield Jones does not favor the remedy, nor do others, although it has advocates in this country. In small doses it certainly does good ; but I have found that in larger doses than ^^ gr,, ter in die, it rather aggravates the disease. Arsenic is excellent, both for its anti-periodic and alterative action, and as an agent to relieve the acne. Clemens, of Frankfort, has lately advo- cated the bromide of arsenic, but in such small doses as to seem useless. He claims for it remarkable virtue when the disease depends upon idiocy, and appears in patients with deformity of the skull. He reports two cures. Dr. Hughes Bennet^ reports the results of the bromide- treatment in one hundred cases of epilepsy. In over sixty per cent, of the cases decided benefit resulted, the attacks being prevented or aborted. In about thirty- five per cent, there was bromism, and the remainder suffered from general enfeeblement of mind or body, without much benefit so far as the relief of the disease was concerned. Dr. Bennet's method of administration consisted of doses of thirty grains of the bromides of potassium and ammonium, in the proportion of two parts of the former to one of the latter, given with aromatic spirits of ammonia and water. The dose was always given when the stomach was empty. After two or three months the dose was diminished. Where there is an irregularity of heart action, sluggish circulation, blueness or duskiness of the skin, I think digitalis is indicated ; in fact, I generally use it in every chronic case. It is a drug well tolerated by epileptics, who can take it in surprisingly large dose^. An agent has been lately given to the profession which seemed all that ^ Med. Times and Gazette, May and August, 1867. ^ Br. Med. Journal, June 7, 1873, and Journal of Kervous and Mental Diseases, October, 1879, p. 770. 412 BULBAR DISEASES. Fas needed at first, but which I am convinced is very much over-estima- ted, except as an abortant. I speak of the arayl nitrite. Drs. Weir Mit- chell, Zeigler, and Alexander McBride, as well as several foreign writers, have praised it, and several cures have been reported. In epilepsy there seems to be a "habit (if I may use the expression) or tendency to period- icity. Amyl is well adapted to stop this, as is any other remedy of the same class. Crichton Browne alludes to the effects of this drug upon the status epilepticus. His patient had had a great succession of fits, and was at the point of death ; the pupils were contracted to an intense degree, pulse 116, temperature 102^, with stertorous breathing. Voluntary movements and yawning were caused by inhalation of the amyl nitrite, and the patient subsequently raised his head, looked about him, and re- covered. Dr. Browne relates ten other cases which were seen with Dr Mierson. Dr. C. Stecketec^ draws the following conclusions in regard to the action of this drug in epilepsy : — "It exerts an important influence where the epilepsy is due to or con- nected with cerebral auiemia, for the reason that it ' anticipates the attack when there are prodromata; cuts oflfthe attack when it appears; relieves symptoms due to interruiited innervation after the attack; and the attacks become less frequent.'" He also considers it injurious whei'e the attacks are due to cerebral hyperemia, for the reason that they last longer and become more frequent, and when either maniacal or convulsive, increase in intensity. My own experience wuth amyl nitrite has clearly settled in my mind the fact that it has great virtues in cutting short or averting attacks, but that it has no permanent influence. Whether we can or cannot make the delicate distinctions of Dr. Steketec, future clinical experiences I think must decide. Those who have used it say that it does good in a very lim- ited number of cases; and it is a diflicult task to decide which art to be benefited. I have tried it in every grade of epilepsy, and find in some of the worst cases, where the fits occur all through the day with very slight intervals, and even where there is time enough to be prepared, that it is often of no avail. It may be given inclosed in the little glass capsules invented by Dr. McBride, of New York, for hospital use, and for patients who are not intelligent, in alcoholic solution. 'Bourneville and d' Oilier have used the bromide of ethyl in epilepsy and hysteria, and have found that when it was inhaled during the tonic phase of the attack, it produced an abortion of the subsequent stages of the attack. My experience with the new anaesthetic given in solution in epilepsy was not encouraging — but it may be given by inhalation in place of amyl. ^Berland has used tartar emetic in doses sufficient to produce vomiting 1 Abstract of thesis in Chicago Journal of Nervous and Menta! Disease, April, 1874. p. 260. ■' Gaz. Med. de Paris, No. 35, 1880. ^ These de Paris, 1880. EPILEPSY. 413 with marked relief in cases of violent convulsive chorea, and it seems, worthy of trial in congestive epilepsy. I may be pardoned for bringing another renledy to the notice of the profession, and one that has never been used for this purpose. I allude to tri-nitro-glycerine. Its reputation is almost enough to intimidate the patient, but it is as powerful a medicinal agent as it is an explosive. The tenth part of a drop touched to the tongue is sufficient in a space of time which is almost inappreciable to produce a rapid cerebral hyperremia. The face is flushed, the eyes become bright, and the temporal vessels throb, while at the same time there are marked sensations of fulness. It produces more lasting congestion than doesamyl nitrite, is much safer, and I have found it to act better as an abortant than the latter. Any good pharmacist can prepare a solution containing one drop to ten of alcohol. This can be further diluted, so that ten drops of alcohol shall contain one- tenth of a drop of the nitro-glycerine solution. It may be kept safe in this way, for alcohol prevents its explosion. A dose of from a tenth to one drop of the decimal solution is sufficient in the majority of cases. Last of all, it seems almost unnecessary for me to direct attention to that most familiar remedy, cod-liver oil, which is so valuable in all ner- vous diseases. Anstie treated a number of cases by cod-liver oil alone, and cured seven out of twenty patients put upon this plan of treatment. In all cases I am convinced that it is a valuable remedy which is not appre- ciated as it should be. I have witnessed its great virtues when the bro- mide cachexia was profound, and believe that it should always be used in delicate subjects. Picrotoxin, a remedy recently brought forward, I have tried, and consider valueless. The subjects of diet and personal habits are very important ones — par- ticularly as the stomach is so often the seat of irritations which are trans- mitted to the over-active centres. Beyond the question of over-eating, it has been found that a vegetable diet is better suited to this class of patients. Mierson, in one of the volumes of the West Biding Rejoorts, publishes cases, and makes comparisons between those epileptics placed upon a meat and those upon a vegetable diet. The results pointed to the superiority of the latter. As the greater number of epileptics have inordinate appetites, the diet should be strictly regulated. It is a good plan, I think, to combine the remedies I have alluded to ; and I take the liberty of presenting a prescription I have used for several years : — R. Strychnise sulph. gr. j. Fl. ext. ergotse, ^'ss- Sol. potass, arsenit. 5ij- Sodii bromidi, ^iss. Tr. digitalis, Jiij- Aqu£e menth. pip. ad 5iv. — M. Sig. — A teaspoonful before eating, in a half tumblerful of water 41-4 BULBAR DISEASES. . If the attacks be the form known as petit mal, I think either ergot or belladonna are our best agents. With either form of treatment it may be found often necessary to 'use auxiliary general treatment. The syrup of the combined phosphates, or the syrup of the lacto-phosphate of lime, is a good adjunct; and salt baths, cold head douches, regular food, early hours, and the breaking off of bad habits, will often cure the disease, even Avhcn it has lasted many years. As a last resort, should continued medication prove useless, the actual cautery or a deep seton at the back of the neck will occasionally arrest these bad cases. A variety of other remedies have been suggested (and the list of drugs alone would fill several pages such as this), but as most of them have been found inefficacious, I do not think it worth while to further weary the patience of my readers. Galvanism I find to have but little value. BULBAR PARALYSIS. Synonyms. — Glosso-labio-laryngeal paralysis (Hammond) ; Glosso- laryngeal paralysis (Trousseau); Progressive bulbar paralysis (Erb). In the year 1841 Duchenne^ first called attention to a peculiar group of symptoms which were connected with progressive degeneration of the medulla oblongata ; and some years later Trousseau - noticed it in his ad- mirable lectures, and presented several cases reported by Davaine,'' long before Duchenne's observations were published, but which were before considered to be examples of double facial palsy. Hughlings Jackson,* Dumenil,^ Charcot,® and Joffroy, and lately Dowse," have contributed to the literature of the subject. Definition. — The condition under discussion may be described as a disease characterized by gradual loss of functions of parts supplied by the nerves taking their origin from the medulla, though the fifth nerve is rarely affected. It may be the result of morbid changes which are limited to the floor of the fourth ventricle ; or, this region may be the chance site of sclerosis, which affects other parts as well. Such may be the lesion, whether " pseudo-bulbar paralysis" (the result of arterial occlusion) sclerosis, or glosso-labio-laryngeal paralysis exists ; the special symptoms are alike, and they appear one after another as the different nerves are involved. 1 Op. cit., 2uie edit. ^ Lectures on Clinical Medicine, trans., vol. i. p. 908. 3 Quoted by Trousseau, vol. i. p. 909. * Philosoplueal Transactions, part i., 1868. * Gaz. Hebdomadaire, June, 1859, p. 390. * Archives, de Physiol., etc., torn, iii., 1870, p. 247. T Brit. Med. Jouto. Nov. 4 and 11, 1876. BULBAR PARALYSIS. 415 Symptoms. — The earliest expression of the disease is a certain loss of power of the lips ; the lower lip especially. If the individual attempts to whistle, his efforts maybe unsuccessful, and the lower lip hangs so that the mucous surface is largely exposed. The tongue next follows, and its protrusion by the patient is a matter of difficulty. The individual is un- able to bring the tip in contact with the roof of the mouth, and incompe- tent to use it in the formation of certain consonants (the Unguals). When he tries to speak or read aloud he finds great difficulty in pronouncing words containing the letters 1, n, c, d, g, h, j, t, w ; and in one of Trous- seau's cases the patient could not utter any letter but a. He may remain in this condition for some time— say for a year or two, when the tongue and lips become more extensively affected ; and not only are acts of a voluntary character impossible, but the automatic movements of the tongue are almost totally embarrassed. The use of this organ in the management of food during mastication and deglutition is much impaired, and particles of food bsoms lodged between the teeth and the gums and cheek. The patient's mouth is generally open, so that his teeth are exposed and from either side trickles a glairy stream of saliva. Next lie cannot articulate the labials, and consequently his speech becomes worse than ever. He wears an inane expression, and is apt to attract the atten- tion of people in the street by his open mouth and silly appearance. The condition of the tongue has been noted by Dowse; its papillse become atrophied, and the surface very smooth. I have noticed that there is no loss of the sense of taste at any time. The palate next becomes the seat of the paralysis, and the pharyngeal muscles are so weak that deglutition is at first difficult, and finally impossible. Fluids are especially troublesome to swallow, and are apt to be regurgitated through the nares, and the voice becomes nasal and metallic as the upper part of the vocal apparatus becomes involved. The facial expression, always a marked feature of the disease, is now very pitiable. The tongue lies in the bottom of the mouth utterly devoid of power, so that the patient cannot protrude it, and it becomes useless for all purposes. If the posterior wall of the pharynx be irritated, there is none of the reflex response which is so marked in the normal state, but only pain is produced. Such was the condition of affairs noticed in one of Dr. Dowsers patients. The epiglottis does not cover the larynx ; and there is a tendency to choking from the accidental introduction of food, so that eating becomes a dangerous undertaking. The voice grows very weak, and the sufferer can no longer even make the almost unintelligible sounds which charac- terized the early stages of his disease. His breathing now becomes very irregular, the inspirations are quite slow and shallow, and he sinks from sheer exhaustion due to insufficient nourishment and becomes amere wreck, dragging himself about, and look- ing forward to death as something which alone is to bring relief As the 416 BULBAR DISEASES. pneumogastric becomes more and more involved, the respiration undergoes changes which result in asphyxia. For some time before the eod, his sufferings grow intense. Mucus collects in the bronchi, which he is unable to remove by coughing, and he sits in his chair with a feeling of greater security than when lying down, for in the supine position the saliva finds its way into the larynx, and produces suffocation. Loss of consciousness or mental impair- ment is never a symptom of the disease unless it be of the complicated form. The following intei'esting case was reported recently by Dr. A. H. Smith,^ of this city: — The subject was a clergyman, aged sixty-one years. About fifteen years ago, after prolonged and severe exerci-e of the voice in preaching, he be- came hoarse, and ultimately his voice failed so that he could speak only in a whisper. After the lapse of a year he gradually regained the use of the larynx, but as he did so he became sensible of an imperfection in his enunciation of certain syllables, especially those containing the letters p, t, d, s, etc This difiiculty has increased until now the jDOwer of uttering the labial and lingual sounds is almost entirely lost. Later a difficulty in swallowing was gradually developed, which has reached such a degree that only ivarm Jiuids can be taken, and these with great care and hesitation, as they are apt to cause strangling, and to return through the nose. Mucus accumulates in the fauces, which he has great difficulty in getting rid of, and which causes a sense of strangu- lation. He finds that the movements of the tongue are very much restricted, and he has not the full control of his lips. His sight, taste, and smell are as perfect as is usual in persons of his age. The sense of touch, even in the paralyzed parts, is not impaired. He feels much less distress when the weather is warm, and dreads the approach of each winter. Such is the account which the patient — a very intelligent man — gave of himself. As to the objective appearances, the patient moved slowly and feebly, but this was evidently the result of mere debility. The next notable thing at a cursory glance was the expression of his mouth. The orbicularis muscle was entirely paralyzed, permitting the lower lip to fall avpay from the upper, and to become partly everted There was also relaxation and eversion of the upper lip from the same cause. The leva- tores menti and the deprcssores ang. oris were not involved iu the pa- ralysis, and by their aid the patient was able to bring the lips into contact ; but when so approximated they projected forward, leaving a space be- tween them and the teeth, and giving a very peculiar expression to the face. When the mouth was opened the movements of the tongue were ob- served to be very slow and very much restricted. The tip could not be turned upward to touch the roof of the m juth, nor backward beyond the bicuspid teeth. The tongue was not notably changed in shape or size. All the muscles of the soft palate, includiug the palato-pharyngi and palato-glossi, were paralyzed, so that when the head was thrown iMed. Kecord, Nov. 2t, 1877. BULBAR PARALYSIS. 417 backward the relaxed velum fell of its own weight against the posterior wall of the pharynx. The finger carried into the fauces produced scarcely any local reflex action, showing that the constrictors were complicated ; but sensation was perfect, and the reflex action of the stomach seemed unimpaired, efforts at vomiting being readily excited. There was a very profuse secretion of mucus from the larynx and pharynx, which was gotten rid of with the utmost diflGcalty. There being perfect inability to contract the cavity of the pharynx, the air which was forced from the larynx in the act of hawking escaped into a great loose bag, instead of into a narrow, firm passage, and thus it failed to drive the mucus before it. The paralysis of the soft palate added to the difficulty, for when by great labor a portion of mucus was coughed up into the back part of the mouth, the non-closure of the isthmus faucium permitted it to fall back again upon the larynx. Examination with the mirror showed that the laryngeal muscles re- tained their activity, and the cords, with the exception of slight hyperaj- mia, were normal. The respiratory muscles were as yet unimpaired. In this case it is not probable that the loss of voice, which occurred in the early stage of the disease, was owing to a central lesion, since, after a year had passed, the larynx gradually regained its power. Moreover, laryngeal paralysis of bulbar origin does not usually occur in this asso- ciation until after the paralysis of the lips, tongue, and soft palate has become well-marked. It is more than probable that the aphonia was the result of a catarrhal affection, and that if life continues long enough, there will be a return, but this time from advancing chano-e iu the me- dulla. ° _ The greater ease in swallowing imrm fluids is characteristic of dyspha- gia from_ almost any cause. Thus it is observed in both organic and spasmodic stricture of the oesophagus, and also when dysphagia results from the pressure of a tumor. Dowse ^ considers the disease to be either progressive, stationary, or re- trogressive, and if it were not for the single case of the last variety, which he publishes, I should not be prepared to accept the two latter divisions This he calls reflex bulbar paralysis. His patient, a woman aged 59, suf- fered from Bright's disease and inflammation of the maxillary and parotid glands. ^ After her recovery from the last-mentioned condition, there was paralysis of the hypoglossal, facial, and spinal accessory nerves, as well as the third division of the fifth. The vocal cords acted feebly, and she could scarce speak in a whisper, being able to pronounce only the liu- guals r and s, and could not protrude her tongue ; food lodged in the cheeks ; saliva dribbled from the mouth ; she was unable to blow out a candle, while deglutition was interfered with to some extent. Strange to say, there has been improvement. It would be well, however, if Dr. Dowse had allowed a longer time to elapse before coming to a conclusion in regard to the retrogressive character of the disease in this instance, for the parotitis may have been simply a coincidence. I am inclined to think that the history of any genuine case thus far reported has shown a ten- dency to progressive decline, which, though delayed in some instances, has nevertheless steadily advanced to a fatal termination. 1 Brit. Med. Journ., Nov. 11, 1876, p. 615. 27 ' 'f 418 BULBAR DISEASES. Causes. — The disease is one of middle age, and attacks men more often than women. It is usually the result of syphilis, and sometimes follows exposure and mental worry. Dowse considers the causes of the peripheral symptoms to be the following : — Direct. 1. Progressive interstitial neuritis. 2. Thrombosis. 3. Hemorrhage. ^ 4. Morbid growths. ^Rare. 5. Vascular spasm, j Indirect. 1. Reflex action from peripheral irritation. 2. Inhibition from shock to central cerebral ganglia. Morbid Anatomy and Pathology. — Trousseau's autopsies re- vealed induration of the medulla, atrophy of the roots of the hypoglossal and spinal accessory nerves, thickening, and gray discoloration of the dura mater on a level with the medulla, which extended as far down as the roots of the fourth cervical pair. " This thickening was due to a considerable increase in the amount of fibers of connective and fibro-elastic tissue, and seemed to result from a chronic congestive process, as shown by the great number of capillaries and of deposits of hsematin external to them. The motor nerve-roots of many cervical nerves were found thinner than they should be from disappearance of nerve-tubes. The fifth and glosso-pharyngeal nerve-roots were healthy, and the muscular tissue of the paralyzed parts was found to be normal." Dumenil published a case which was probably progressive atrophy ; but some of the symptoms were those of the disease under consideration. In this case there was extensive atrophy of the roots of the hypoglossal, pneumogastric, and facial nerves, as well as a great many other changes. Fox^ considers an absolute or partial disappearance of the nerve-tubes, with preservation of the neurilemma at the nerve-roots, to be a constant lesion; and Wilks^ found that the roots of the hypoglossal and spinal accessory nerves had undergone atrophy, and become reduced to " little thin gelatinous threads." Sclerosis may occasionally involve the medulla, and produce symptoms characteristic of loss of function in the nerves to which I have alluded. Charcot^ gives, among other cases, one that involved the medulla ex- tensively. A patient of his presented, besides the ordinary symptoms of disseminated sclerosis, three months afterward, evidences of invasion of the pneumogastric and hypoglossal nerve-roots. There were dyspnoea and dysphagia. The patient was obliged to eat more slowly ; and often- times the food was regurgitated through the nostrils. Death followed in about six weeks afterwards, and was preceded by asphyxia. ^ Op. cit., p. 234. 2 Guy's Hosp. Kep., vol. xv. ' Le90iis sur les maladies du srsteme nerveux, Paris, 1872-73. Premiere partie, p. 234. BULBAR PARALYSIS. 4l9 The autopsy revealed the following state of the nervous centres : A section made one centimetre below the protuberance, at the point of origin of the trigeminus, disclosed a point of sclerosis. Other transverse sec- tions were made at the smaller part of the olivary bodies, and a sclerosed patch was discovered. Another patch was seen at the root of the pneu- mogastric. Examination by the microscope revealed a number of broken nerve-tubes and broken-down cells at the nuclei of the hypoglossal, and traces of irritation in the white substance of Schwann in the pneumogas- tric fibers. The pharynx and larynx were healthy. The observations of Lockhart Clarke have shown the intimate rela- tionship of the nuclei of the important cranial nerves which become af- fected in bulbar paralysis. There is a set of nerve- cells common to these nerves, and disease of the nuclei of one nerve is very likely to extend to others of the group, so that ultimately there is a general invasion, which is bilateral and never one-sided. The destructive process is probably myelitis, as Leyden has suggested, and disappearance of the motor-cells is the direct cause of the paralysis. It is a curious fact that the sixth nerve invariably escapes when we remember that it arises from a common nucleus with the seventh, as demonstrated by Lockhart Clarke and Stilling. In regard to the partial paralysis of the facial as an early symptom, and the subsequent increase in the area paralyzed, we must remember Romberg's statement that in organic brain-disease the entire distribution is not affected, but that the fibers involved are those that supply the muscles of the upper lip and alse of the nose ; and this is an important point in the diagnosis from periphe- ral paralysis ; and Dowse calls to mind the fact that bilateral paralysis of the muscles supplied by the facial is connected with lesion at the root of the nerve. The aphonia may result, according to Dumenil, either from paralysis of the thoracic muscles, or those of the larynx. The ptyalism I am in- clined to ascribe, in the later stages, to paralysis of the chorda tympani, but agree with others who have observed it, that the accumulation of saliva in the first stage is due more to the patient's inability to swallow it than to anything else. Respiratory troubles may be due to paralysis of the pneumogastric and its motor, the spinal accessory. Dowse has divided the disease into three stages as regards the diffi- culty of swallowing, the first of which is connected with paralysis of the hypo-glossal; the second with paralysis of the motor branches of the glosso-pharyngeal ; and the third with paralysis of the spinal acces- sory. Voisin, in speaking of the alterations in speech, defines them into stut- tering, drawling, hesitation, jabbering, stammering, and quavering. The first three are due to lesions of the nerve-tracts which pass from the an- terior cortex to the medulla oblongata, and which traverse the corpora striata, crura cerebri, and pons, and are connected with disturbances of will. The other three have no such origin, but depend upon inco-ordina- tion of the muscles supplied by the hypoglossal, facial, and glosso-pharyn- geal nerves. 420 BULBAR DISEASES. Diagnosis. — Facial palsy, general paresis of the insane, progressive muscular atrophy and diphtheritic paralysis may suggest themselves, and some are rather difficult to exclude, among them tumor, which however is often attended by convulsive attacks : — 1. Facial palsy may be suggested, but as this disease is of sudden origin, and affects other muscles than those about the mouth, there need be no reason to confound it with bulbar paralysis. 2. The early symptoms of general paresis of the insane somewhat resemble the initial symptoms of the disease of which we are speaking. There is tremor of the tongue, however, in addition to the embarrass- ment of speech ; contracted pupils and subsequent psychical symptoms make the diagnosis clear. 3. Progressive muscular atrophy, rarely attacks the tongue primarily, and only one case has been reported (by Charcot) where there were any bulbar symptoms. The subsequent atrophy of other muscles will dispel any doubts the observer may have. The affection of the medulla is ordi- narily a final result of the extension of the central disease in progressive muscular atrophy. 4. Diphtheritic paralysis is symptomatized by initial paresis of the muscles of the pharynx, and the tongue is seldom involved. A previous history of diphtheria will confirm the cause of the paralysis, should there be a suspicion. Prognosis. — As I have said, Dowse believes that there are forms of the disease which may be cured, viz., the stationary and the retrogressive. I cannot believe that when once affected by inflammatory disease, such extensive alteration, and such decided symptoms as he mentions, can ever be removed. The histories of the cases reported by the several observers already mentioned certainly offer a gloomy prospect and little encouragement for the victim. The only case reported as actually cured was that of Cheadle,^ and from the pain, visual trouble, and unilateral paralysis, it is improbable that the case was one of genuine bulbar paralysis. Raynard^ reports a case of bulbar paralysis with violent heart dilata- tion, syncope and speedy death. The heart was found after death to be greatly increased in size, and though its valves were unaffected, there was very decided dilatation of all the cavities. Treatment. — Nothing has been done which has resulted in any de- cided improvement. I am sorry to say that electricity did no good in the one case I have treated, but Duchenne^ in several cases found that systematic faradisation greatly facilitated articulation and otherwise helped his cases. Erb and Benedikt were particularly successful. Dowse recommends cod-liver oil, iron, and phosphorus, but Erb does not believe in the latter. 1 Labio-glosso laryngeal Paralysis, St. George's Hosp. Eeports, vol. v., 1871, p. 123. 2 Quoted by Pitres in his Thesis, 1878. 'De I'electrisation, etc, 2d Ed. p. 649. CEREBRO-SPINAL MENINGITIS. 421 CHAPTEE XIY. CEREBRO-SPINAL DISEASES. CEREBRO-SPINAL MENINGITIS. Synonyms. — Spotted fever ; Meningite foudroyante ; Head pleu- risy ; Myelitis petechialis ; Cerebral or Cerebro-spinal typhus ; Menin- gite cerebro-spinale ; Fievre cerebro-spinale, etc. Definition. — A disease characterized by inflammation of the men-r inges of the brain and cord, symptomatized by pain, tetanic spasms, and herpetic eruptions, and occurring in an epidemic form. This most terrible disease has of late years received a great deal of at- tention at the hands of German and French writers. Niemeyer^ was one of the first of the former to direct attention to the disease ; while in France, Broussais and others wrote extensively. There is no doubt as to the antiquity of the disease, for among the writings of Hippocrates a nearly perfect description of the malady is to be found. In our own country the epidemic character of the affection was noted by several of the older authors, among them North ^ (1811), Gallup^ (1815), and Minor* (1823), and their contemporaries. Outbreaks occurred at Med- field, Mass., Litchfield Co., Conn., and at various points in the Eastern and Middle States during the early part of the present century. Clymer,* Jones,® and others have since written exhaustively on the subject. Cerebro-spinal meningitis is certainly an irregular disease ; it is not contagious, and is_ influenced seemingly in no way by climate. Symptoms. — The appearance of symptoms is usually quite sudden, and their course is remarkably rapid and ordinarily tends to a fatal termi- nation. In exceptional cases pain in the back, headache, vomiting, or malaise may constitute a premonitory stage, which lasts a few hours ; but usually there is no such delay. A severe rigor, an attack of vomiting which is followed by headache of an intense description, and an elevation in pulse and temperature mark the commencement of the trouble. The child may present these symptoms, and in addition another which is invariably pathognomonic. ^ Treatise referred to in Niemeyer's Text-Rook of Prac. Med., vol. ii., p. 218. 2 Treatise on a Malignant Epidemic, etc., 1811. * Sketches of Epidemical Diseases, etc., 1815. * Essays on Fevers and other Medical Subjects, Middleton, Conn., 1828. ° Aitken's Science and Pract. of Medicine, pp. 492-505, 3d Amer. edit. ^ Med. and Surg. Memoirs, pp. 412-507. 422 CEREBRO-SPINAL DISEASES, TJie head is drawn bachvards and downwards, and the muscles at the back of the neck are rif/idlj/ contracted. When the head is forced forward, or when the child bends forward to drink, the pain is greatly aggravated. At the same time the pupils are contracted. The child moans constantly, and is restless ; this is an early symptom, and may appear at the end of twenty-four hours, and be the first to attract our attention. Fi-. 59. (J. Lewis Smith.) The pulse is now quite rapid, and may beat 100 to 120 per minute. The pain meanwhile increases, and affects the head as well as the entire length of the spine, and is increased by pressure. Just as in other forms of meningitis, the movements made by the patient aggravate his suffer- ing, and he usually strives to keep quiet. He is conscious for the first two or three days should he live so long, but at the end of this time he loses his intelligence after first growing delirious. The pulse, tempera- ture, and respiration are increased. The former sometimes beats 130 per minute, while the thermometer may indicate an advance of 104°, but it usually remains at about 100°. At an early period crops of herpes ap- pear upon the face and limbs, and the skin is hypenesthetic, and the patient cannot bear handling. After the first ninety-six hours the con- vulsions succeed the primary rigidity. Opisthotonos or other tetanic con- tractions make their appearance. Stupor follows, and he dies in a condi- tion of coma ; and according to Niemeyer death takes place with symptoms of oedema of the lungs. The bowels are constipated during the entire disease, and during the later stages the jmtient has involuntary discharges of urine. The above description is of an ordinary case. There are great varia- tions, and either death may take place in a few hours, or there may be a tardy convalescence accompanied by structural changes of a very serious nature. The course of the disease may open with chill followed by rapid convulsions and coma, when the patient may die in less than twenty-four hours. In other cases, after the subsidence of the acute symptoms, which may last for a week or two, convalescence takes place, attended by headache CEREBRO-SPI^"AL MENINGITIS. 423 and muscular contractions, "wliicli continue for some time. Deafness very often results ; and I have several times met with total loss of vision, and paralysis of some of the facial muscles. In one case brought to me from the interior of the State, there was rigid contraction of the muscles at the back of the neck ; and in another, seen with Dr. F. H. Rankin, now of Newport, besides ptosis, and paralysis of the pharynx, there was an otor- rhoea with extensive middle-ear disease. This patient was quite an im- becile, intellectual impairment having begun after the subsidence of the acute stages. One of these chronic cases has been under observation, for several years, but I have been, unable to effect more than trifling improvement. Causes. — Epidemic cerebro-spinal meningitis seems to be much more common during cold weather, and is much oftener met with during infancy than at any other period of life. Adults are not exempt ; but the disease prefers the young. It is a disease, like typhus, which usually attacks the poor ; and bad ventilation and insufiicient food seem to prepare the way for epidemics. In the city of New York the first outbreak of the disease appeared in 1866 ; and subsided, to reappear, February, 1872. In the sparsely settled wards of the city (the 19th, 20th, 22d), where building was going on and fresh earth turned up, it seemed to prevail. There were 45 fatal cases during the winter quarter in these wards, while the entire number of deaths in New York during the same period from this cause was 108. During the spi'iug quarter there were 492 deaths, 148 being in these wards. It subsided in the spring of 1873, but reappeared during the autumn of that year. It would seem, from these statistics, that overcrowding had but little to do with the disease, but that bad drainage (this portion of the city being imperfectly drained) had undoubtedly some influence. Morbid Anatomy. — The meninges of the brain show evidences of intense hypersemia, the sinuses being distended with blood which slowly coagulates, and the dura mater is the seat of ecchymotic spots. There is usually a sero-purulent exudation beneath the arachnoid, and this is found at the base of the brain as well as in the ventricles. It may be recognized, also, in the different fissures and sulci. The spinal meninges are the seat of the same exudation, it being found beneath the dura, or between the arachnoid and the pia mater. All of the spinal membranes are vascular, and opaque in spots. The exudation appears to be confined to the poste- rior parts of the cord ; and usually, when infiltration in the cord has taken place, small elevations may be observed beneath the pia mater. Accord- ing to the German pathologists, the cervical portion of the pia mater is not commonly the seat of exudation. The membranes are often adherent, and patches of false membrane are visible, so that sometimes the sub-cere- bral nerve-trunks are bound together and connected by bridges of organ- ized lymph. The nervous tissue proper is extensively softened in rare cases- especially if the inflammatory action has been at all severe. Spots of localized softening are, however, not uncommonly observed. Diagnosis. — Cerebro-spinal meningitis sometimes resembles certain 424 CEREBRO-SPIXAL DISEASES. irregular forms of malignant malarial fever, on account of intermissions in the febrile state. This is the case more especially during convalescence, when the affection assumes a periodical character. The chill in cerebro- spinal meningitis is not so marked as in the true malarial affection, and contractions of the muscles are rare in any form of malarial trouble. The other points of difference may be thus summed up : — CEREBRO-SPINAL MENINGITIS. CONGESTIVE PERNICIOUS MALARIAL ^ . -1 FEVER. Bowels constipated. jS^ot usually so. Pulse and temperature do not suffer Both subject to great variations, feeble rapid variations. and irrej^ular (Jones). Temperature does not undergo periodi- Temperature undergoes decided peri- cal changes. odical changes. Face Hushed ; eruption. Complexion sallow. Delirium and coma not affected by large j^\i symptoms modified usually by nega- dosts of quinine. _ tiy^ treatment with quinine. Increase of fibrin, andj rapid coagula- tion of blood when drawn. A malignant typhus, or a masked variola, might counterfeit cerebro- spinal meningitis ; or, on the other hand, acro-uarcotic poisoning might simulate the affection. The presence of tetanic spasms of the post-cervical muscles is, however, so prominent a symptom that when it is absent the improbability of cerebro-spinal meningitis is considerable. Prognosis. — This disease, like other forms of meningitis, has a bad character. Death is generally the rule, recovery the exception. In the city of New York the total number of deaths from all causes was 29,084 during the twelve months ending Dec. 31, 1873. Of these, 9593 were placed under the head of zymotic diseases ; and the number of deaths due to cerebro-spinal meningitis was 290. Of these, 69 were under one year, and 164 under live years. Very few cases were over thirty. In the ma- jority of cases the disease runs its course in from 4 to 20 days. In fatal cases death occurs generally before the 12th day. Treatment. — In regard to treatment, little can be said that will be encouraging. The ordinary antiphlogistic treatment, consisting of ab- straction of the blood by leeches applied to the mastoid processes, and blad- ders of ice to the head, and large doses of calomel, according to some ob- servers, have cut short the disease, especially when these remedies were used at its commencement. The almost wonderful results that have fol- lowed the use of ergot in large doses suggest this remedy to us, and I have no doubt that it will prove to be very efficacious. Ziemssen recom- mends morphine, and has never observed any unpleasant effects following its employment. CEREBRO-SPINAL SCLEROSIS. Synonyms. — Sclerose en plaques disseminees (Charcot and Bourne- ville) ; Insular sclerosis (Moxon). Definition. — A disease of the human system, the essential lesions of which are patches of neuralgic degeueratiou irregularly scattered through CEPvEBRO-SPINAL SCLEROSIS. 425 the nervous substances of the brain and spinal cord, and involving chiefly the motor tracts. For a long time this disease was mistaken for paralysis agitans (Park- inson's disease), chorea, and other neuroses; and even after it had been shown to be a separate neurosis a certain amount of confusion existed in regard to its nomenclature and its position among the scleroses. Charcot and Moxon^ were the first to give it a distinct character. Symptoms. — We may divide the progress of the disease into three stages. 1st Stage. — The first symptom, which is common to several other neu- roses, is gradual loss of power in the lower limbs, which, by itself, does not attract attention to the grave nature of the disease in its iucipiency. With the weakness there is no atrophy and no loss of sensation, while reflex excitability is either normal or only slightly increased. The rec- tum is not afiected, nor is the bladder, and there is simply a paresis which lasts for a variable time, perhaps for two or three months, or for a much longer period. The partially paralyzed limbs become agitated by tremors, which are seen best when the patient takes some constrained position, or attempts to walk a straight line. He may have the gait of an ataxic, but generally the walk is more like that of a general paralytic, being charac- terized by weakness of the extremities. As the disease invades a higher portion of the cord, we will find tremor of the upper limbs and paralysis of the cranial nerves, indicated by symptoms I shall describe in speaking of the descending variety. I may allude, however, to a particular defect in articulation, the patient being unable to pronounce some of the labial consonants. 2d Stage. — Rigidity of the limbs supervenes, with various contractures of a spasmodic character, and exaggeration of the tremor. One of my patients died in her bed with her knees drawn up to her chin, her legs flexed on the thighs, and her arms drawn closely to her chest. It re- quired quite violent exertion for me to extend the limbs, and the tremor was markedly aggravated when I did so. Electro-muscular irritability is next greatly increased, and reflex excitability heightened. Epileptiform attack may now appear, as well as apoplectiform, and death may occur at this period from the invasion of some cerebral vessel and consequent cerebral hemorrhage. Zd Stage. — This stage is marked by rapid decline of the patient's strength. Incontinence of urine and feces, bedsores, and dementia follow, and, after other evidences of gradual wasting away, death may end the scene. The course of this form is : First, paresis of lower extremities and tremor ; second, contraction, and aggravation of tremor ; third, general dissolution. " 1st Stage of Descending Form : This is the condition of afiairs when ^ Eight cases of insular sclerosis of the brain and spinal cord, by W. Moxon, M. D., Guy's Hospital Eeports, vol. xx., 1875. 426 CEREBRO-SPINAL DISEASES. the cord is attacked secondarily. "When the disease begins in the brain, the early symptoms may be headache, convulsions, vertigo, or, what is more common, paralysis of some of the cranial nerves ; there may be ptosis, strabismus, loss of hearing, and facial paralysis, or troubles of speech and embarrassment in swallowing. The important symptom next in advance is the appearance of tremor, which is first seen in the tongue, which, when protruded, trembles visibly ; or it may affect the lips, as may be noticed when the patient speaks. The eyeballs oscillate (nystagmus), and the head may become agitated, and afterwards the upper extremities. A peculiarity characteristic of all forms of sclerosis is not absent here, viz., the aggravation of tremor by voluntary efforts made to control it, and its diminution during rest. If the individual attempts any complex action, he is utterly unable to complete it properly, for the movements increase until muscular control is entirely lost. I have alluded to the lost sense of location, which is also seen in advanced locomotor ataxia, and I may state that it is also a symptom of this form of sclerosis. 2d Stage : The limbs lose their power to a great extent as the disease advances, and permanent contractures of the upper and lower limbs, which by this time are affected, render the patient very uncomfortable. His forearms may be flexed, and the fingers are doubled up, as is the case in uncomplicated lateral sclerosis. The thighs are even flexed on the pelvis, and the legs may be as well. The knees are approximated quite forcibly, and it is often difficult to separate them. This stage may last for several years. 3d Stage : Meanwhile the tremor has continued, and increased in vio- lence ; but it may sometimes be stopped by flexing the great toe, just as Brown-Sequard has shown may be done in epilepsy. The bladder and rectum are now involved, and the patient suffers terribly from cystitis, and is prostrated by diarrhoea. Bedsores form, and he gradually sinks into a state which invariably has a fatal termination. In both varieties there is great difficulty in articulation, and disturbance of function in those organs supplied by the lower cranial nerves. The lower lip falls, and there is dribbling of saliva, while food often remains in the mouth wedged between the teeth and between the gums and cheek, and liquids find their way through the nostrils. Beyond slight irritability and rest- lessness, there are usually no mental symptoms at the outset, or until the fixed stage, when sometimes there is intellectual as well as physical de- cay ; but this is not the rule. A case which seems to be of great interest, because of the atrophy of the upper limbs, came under my notice two years ago. E. W., aged 37, salesman, no family history of nervous trouble. Father and mother alive ; nothing to account for his present condition. Five years ago he was employed in a drygoods store, and his attention was called to a slight weakness in his thumb and forefinger of the right hand when he used his scissors. There was subsequent tremor, which annoyod him excessively, and which subsequently became quite general. About the same time he was subject to very severe headache, vertigo, and some- CEREBRO-SPINAL SCLEROSIS. 427 times vomiting. The tremor meanwhile increased, ?nd ifc became so "s-io- lent when he attempted to execute some fatiguing act that he was forced to desist. He next noticed that his vision was beginning to be impair.ed, that he saw double, or that " mist floated before his eyes." The tremb- ling continued, and when he came to me I found his condition to be as follows : The patient is a tall man, of decidedly nervous temperament, quite feeble and emaciated, and very much depressed. Both arms are convulsed by tremors, but especially the right. The biceps and the ex- tensors of the hand are much atrophied, and there is great loss of power. He tells me that the tremor has been much more violent than it is now. The sensibility of the cutaneous surface is rather lowered, and there is a certain amount of analgesia, so that pins may be run into the dorsal aspect of the forearm without producing pain. He was able to press the fluid in the dynamometer up to 7.50 with the right, and to 17 with the left. There is still headache at times, and some dizziness. The left eye- lid seems to cover the eyeball more fully than the right, and the muscles of the left side of the face were trembling quite violently. When I told him to whistle, his lips trembled so much that he could not do so ; and when I requested him to repeat the line " Ben Battle was a solider bold," ('tutter) (hesitation) (slow) (explosion) (explosion)* he did it as follows : " Me-e-n m-m-m-etta was a s o o g a m-mold." His articulation was quite defective, and I had great difficulty in understand- ing him. His tongue trembled, and his lower lip seemed to sag and fall forwards, and he was obliged to wipe his mouth quite constantly, as there was a considerable escape of saliva. When I told him to hold his head in such a position that I might examine his eye with the ophthalmoscope, it shook to a great degree, and I had difiiculty in illuminating the retina. He says this is recent, and that his head was not affected by tremor until a month or two ago. His mind is clear, and his memory unimpaired. I have seen him but once, and there has been no advance in his condi- tion. The following case is reported by Bourneville : — ^ Rosine Spitale, 20 years old. At 17 years of age she was suddenly affected (after crossing a small stream and becoming chilled) with loss of power, first in the right lower extremity, and then in the left, and some time after the hands began to tremble. At 18 there was some subsequent improvement, but it was very slight. Soon afterwards menstruation ceased, and some time after this the symptoms reappeared. Hemiplegia occurred without loss of consciousness or convulsions, and the tongue and eyes were involved. The disturbances of sensation were moderate ; there Avas a certain amount of numbness in the lower limbs, and a sense of clum- siness of the tongue, with difficulty in articulation, and some diminution of mental power. At the beginning of 1853 the patient was well nourished. A half grain of strychnine daily has produced an amendment for ten or twelve days. Electrization produced movements in the lower limbs, and increased the trembling in the upper extremities. In the course of the month ihe paresis of the inferior extremities was nearly complete, the trembling of the eyes with dilatation of the pupils is quite pronounced, and the patient has become very stupid. * The intonation was very much like what we would expect to find in " cleft palate." 1 La Sclerose, etc., Paris, 1869, p. 92. 428 CEREBRO SPINAL DISEASES. January, 1854. The hands tremble less than they did. There are in- voluntary discharges of urine. Ergot 3'j per day has been used for several months. It acted once upon the sphincters, and seemed to improve the weakness of the limbs, for several movements were possible. Spring, 1854. Bedsore on sacrum. September. In a state of decline ; the bedsore has extended very rap- idly ; pain in the head ; pulse 136. October. Repeated rigors ; sensibility of the inferior limbs returned ; feebleness of the extensors of the back ; scoliosis toward the right ; the trembling in the extremities persists. November 1. Death, preceded by involvement of the muscles of the pharynx. Autopsy. — The gray matter is hard; the nervous substance in the neighborhood of the lateral ventricles and that of the protuberance were hard. We found gray nodules superficial and deep. The white substance had become hard in spots. Beneath the microscope the indurated nodules (white) consisted of a fibrous, moss-like, connective tissue ; the elements of the nervous matter had almost entirely disappeared ; and the white nodules were pressed beneath the surface of the cut. The spinal cord was indurated. The great vessels and viscera were healthy. Dr. Geo. S. Gerhard ^ has presented the following interesting case of this disease: — Samuel A., set. 57, a native of Ireland, and a blacksmith by trade, was admitted into the out-patient department of the Infirmary for Nervous Diseases on September 17, 1876, and gave the following history. His health had always been good until about seven years ago, when, after no known cause, he began to lose power in the legs. One year after this his arms grew weak, and he then observed for the first time that any move- ment of the upper or lower extremities was accompanied by tremor. At a somewhat later period his speech became affected. The weakness of his limbs and the trembling gradually increased, until finally, about four years ago, he was obliged to give up work. On admission there is decided loss of power in the upper and lower extremities, and upon his attempting to use either, a large and jerky tremor is developed. He walks with the assistance of a cane, but his movements are slow, and his feet clear the ground with much difficulty.' His grip, particularly that of the right hand, is feeble, squeezing the dynamometer with the former to 100"^ and with the latter to 110^. In the upper ex- tremities the trembling is especially well shown during the performance of an act requiring some little time for its execution, such as lifting a glass of water to tlie mouth. The tremor also involves the muscles of the head and trunk, but it ceases entirely when the patient is in a state of absolute repose. There is no muscular wasting, no loss of electrical response, and no disturbance of sensibility. His mental faculties are decidedly impaired, and his speech is thick and deliberate, there being a decided interval between each word. His eyesight is poor, and examination of the fundus reveals commencing atrophic changes, as shown by attenuation of the vessels and a general pallor of the optic disk ; there is also slight nystagmus. The unsteadiness of gait and the tremor are not increased by closure of the eyes. His urine ^ Philadelphia Medical Times, Xovember 11, 187^. CEEEBEO-SPINAL SCLEROSIS. 429 is in all respects normal, and he has no loss of control over the bladder or bowels. Causes. — Jaccoud is of the opinion that sclerosis occurs as a disease of childhood, or adult life up to 45 years, and that there is nothing to indi- cate the special liability of either sex ; whilst Charcot considers it a dis- ease which is much more common among females than males, and that it rarely appears after 40. Of six cases I have recorded their respective ages were 18, 26, 33, 37, 41, 46 ; four were males and two females. Of eighteen cases collected by Bourn eville fifteen were women and three men. In three of these the disease began between 36 and 40, three between 30 and 35, and the others between 15 and 30. Very little is known in re- gard to the etiology of sclerosis ; but " moist cold," emotional excitement, and venereal excesses are spoken of by the different Continental writers as causes. Bourneville found that the greater number of his cases died between 35 and 50, and that the disease appeared in most instances between the ages of 26 and 35. In one of my patients the disease began at the 5th year, in another at about the 18th year, and in the third and fourth at 32, and in the fifth and sixth between 35 and 40. Morbid Anatomy and Patholo^. — I have spoken in another chapter about the morbid appearances in sclerosis, and nothing remains to be said in regard to this particular form. It is only a question of loca- tion that concerns us, and after death we will probably find patches of tissue scattered through the brain and cOrd. The antero-lateral columns seem to be invaded in nearly all cases, and this would appear probable from the contractures. Diagnosis. — In the ascending form it must be remembered that the tremor follows the paresis, while the descending form is characterized by tremor as a primary affection, or at least before the muscular paresis of the extremities. Paralysis agitans may be confounded with the descend- ing form of the advanced disease ; the tremor in the former disease is continuous, and is often not aflfected by quieting infl.uence or sleep, but is not aggravated by efforts of the will. The early symptoms of this form may also point to progressive paralysis of the insane, and to intracranial tumors ; but the subsequent progress of the affection, the development of new symptoms, and the common absence of neuro-retinitis, are sufficient to remove any doubts as to its true nature. Prognosis. — Invariably bad. Treatment. — I know of no remedy that can reconstruct a degenera- tion of nerve-tissue which consists in proliferation of connective-tissue cells, and nerve-tube disappearance. Nitrate of silver, tribasic phosphate of silver, chloride of gold, galvanism, bichloride of mercury, and chloride of barium have been all used. It seems that only one chance may exist — the possibility of syphilis. If this be present, it is probable that spe- cific treatment will be successful. We are to improve the patient's gene- ral condition, and relieve his tremor either by conium or hyoscyamia, and make him as comfortable as possible. 430 CEREBRO-SPINAL DISEASES. ALCOHOLISM. ACUTE — CHRONIC. Synonyms. — Ebrietas, Alcoholismus, Delirium tremens; Mania a potu, Alcoolisme; Trunksacht; Chronic alcoholic intoxication (Reynolds). Definition. — A disease of the nervous system resulting either through direct action of alcohol upon its tissues, or through impairment of other organs which fail to remove eifete substances from the blood ; and symp- tomatized by mental aberration, and by various sensorial and motorial phenomena, usually the result of lowered functional activit}'. The immoderate use of alcoholic beverages is usually followed by the most deplorable consequences. Sad to say, this condition is too familiar to need any extended description, as far as the appearance of the patient is concerned ; but there are other features of the disease that need earnest and careful study. The effects of alcohol upon the human being may be said to be physio- logical and pathological. The sensorial alterations are much more inte- resting than the motorial, and of these we will speak in detail. The imbibition of a moderate amount of alcohol, as we know, is usually followed by a general feeling of comfort, a certain degree of exhilaration. The individual is no longer absorbed in himself. He is animated and gay, his ideas flow rapidly, and he becomes filled with greater energy and endurance. If the dose be increased, the mental functions become more active. He is excited and demonstrative, and either violent and noisy, or tender and maudlin, according to the thoughts which have most en- grossed his attention, or through the influence of temperament. Incohe- rence of speech and confusion of ideas succeed the ordinary mental ex- citement, and this may be followed by a condition of stupor, the individual becoming perfectly unconscious of injury, and unmindful of either bruises or cuts, or even severe burns. He may stagger and fall, and lie in some exposed place regardless of the blaze of the sun, the flies, and the noise. He has finally become reduced to what Magnan ' calls " la vie vegetative." He is " dead drunk." This deep alcoholic stupor may last for some time, and end the patient's career ; or he may become maniacal instead, or present the condition described by Percy ^ under the name ivresse con- vukive, in which, with clonic convulsions, he grows furiously maniacal, grinding his teeth, and cursing and menacing those about him. The maniacal attacks are no doubt influenced to some degree by the character of the illusions and hallucinations. ACUTE ALCOHOLISM. Symptoms. — The continued use of alcohol in excess for a week or two, such as occurs during an ordinary debauch, is very apt to lead to an ^ Kecherches sur les centres nerveux, p. 116. 2 '' Art. Ivresse Convulsive," Dictionnaire des Sciences MMicales, t. xxvi., p. 249. ALCOHOLISM, 431 attack of delirium tremens. This state of acute alcoholism may also occur should the patient, who has drunk not necessarily to intoxication, but to a degree almost approaching it, be deprived of his drink. One of the earliest indications of this state of alcoholism is a tremu- lousness or " shakiness," which is quite marked in the early part of the day, and is connected with nausea and want of appetite. The patient ia restless and irritable, sleeps poorly, and presents an appearance of dejec- tion and sadness. His eyes are red and watery, and his skin is of a muddy color. His features are drawn and haggard, and he is a wretched object indeed. The gastric irritability may be so great as to prevent any retention of food, and the simplest forms of nourishment are ejected by the stomach. Constipation is obstinate, and the urine is passed in small quantities and loaded with the urates, so that a dense brick-dust precipi- tate is found in the chamber. The attack is immediately preceded by great excitability, and by illusions and hallucinations, which grow very marked as the patient becomes noisy and violent. Magnan has graphi- cally described the different varieties of mental trouble. The patient may be sad and utterly dejected. He may imagine that he has committed some great crime ; that he has been sentenced to death ; that he is being executed ; and these delusions may markedly influence the character of his outward expression. In nearly every case there is some delusion of persecution of a horrible kind. The attack usually begins with halluci- nations of a visual character, in which snakes and other reptiles, devils, imps, gnomes, and goblins terrify the patient. In one instance which I remember, he was tortured by devils who held lighted candles, and were about to set his clothes on fire ; in another case the patient endeavored to escape a falling weight. The illusions are always followed by halluci- nations, and finally by delusions. The irritations of the organs of sense ai'e distorted so that the simplest and most common noises become changed by the patient's disordered imagination into the most terrible sounds. The cry of the vendor in the street is likened to the despairing shriek of a lost soul. The stroke of the clock, a funeral bell, and the voices of those in the room are supposed to be the savage yells of a howling mob. The objects which the patient sees are nearly always transformed into animals, which, controlled by no natural laws, run over the ceiling, or gallop through the air. Odors are reversed, and food is supposed to be poisoned. Animals run over the skin; sometimes they are rats or lizards; and at others he may call attention to the torture inflicted by thousands of needles or cutting instruments. Maniacal outbursts are the common feature of the attack, the patient seeming to possess herculean strength, and it is sometimes necessary to have six or eight strong men to prevent him from throwing himself out of the window, or committing some deed of violence. He may remain in this condition for several days at a time, during which period he neither sleeps nor eats. His eyes are bloodshot, and he sweats profusely. The pulse ^ is very rapid, small, and irritable, 1 The sphygmograph has been employed by Anstie in cases of delirium tremens, and the tracing obtained very closely resembles that of the typhoid fevers and in- flammation. It is of a marked dicrotic type. 4^-J CEREBEO-SPINAL DISEASES. and though the deep temperature may reach 102° or 103° F., the hands and feet are cold, and the i^alms and soles clammy. When recovery takes place, the first change for the better is sleep. The violent symptoms subside gradually in the reverse order of their appear- ance. He may awake, after fifteen or eighteen hours, irritable, but not much better ; or there may be a lesser degree of excitement, more sleep, and gradual improvement. In other cases death follows, there being a subsidence of the violent de- lirium, which changes its character and becomes muttering; when he relapses into a typhoid state, and gradually passes away. The tendency to the commission of deeds of violence is quite charac- teristic of acute alcoholism. Of 377 cases observed by Bouchereau and Magnan^ in the year 1870, twenty- four attempted to commit suicide, and nine attempts at homicide were made. These cases were seen under re- straint, but among the cases which occur outside of hospitals and asylums, the number is far greater, Laucei'eaux has described the features of acute absinthism, which, however, is rare in this country. He agrees with Magnan, that epileptic attacks exactly like those of the ordinary disease follow the immoderate use of absinthe. Several hours after the toxic dose of this liquor has been taken, the convulsions take place, and involve chiefly the muscles of the back and of the posterior part of the neck, so that a species of opisthotonus results. These tonic convulsions are followed by others of a clonic character, affecting chiefly the muscles of the face. There is frothing at the mouth and grinding of the teeth. The muscles of the body are also next in a state of clonic contraction. The actual attack lasts for an hour, and is not followed by coma. It is separated by inter- vals of comparative quiescence. The jjatient then falls asleep, and, after a variable time, awakens complaining of sensory disturbances. In an abstract of Lancereaux's article by Decaisne,^ an admirable de- scription of acute absinthism is given. He calls attention to the fact that the cry and coma are absent in absinthe epilepsy, and the attack is ii-re- gular, and resembles a convulsive attack of a hysterical character. CHRONIC ALCOHOLISM. Symptoms. — A much more grave condition of affairs follows the continued use of large quantities of alcohol, and no more hopeless disease exists than that of which we are about to speak. While in delirium tre- mens recovery may take place, followed by total reformation, without any serious damage to the nervous system, the more serious nerve-changes wrought by constant saturation can never be repaired, but tend to further degeneration and decay. Chronic alcoholism begins by a number of insidious alterations in the 1 Op. cit., p. 129. » Eevue des Sciences Med., No. 33, 1881, p. 231. ALCOHOLISM. 433 nervous substance, whereby its functional activity is embarrassed, and minor symptoms at first, and more grave ones afterwards, appear very gradually and progressively. The victim of chronic alcoholism may present the symptoms of tremor and loss of power of which I have before spoken. The tremor is rhyth- mical, and begins at first in the extremities, and afterwards involves the entire body. There seems to be an accompanying want of power, for he relaxes his hold upon any object he may grasp when his attention is di- verted. His morning dram involves an effort worthy of a better cause. He grasps the glass with both hands, fearing that he may spill even a single drop of the precious liquid, and carries it carefully to his mouth, clutching the rim of the glass between his teeth, oftentimes with sufficient force to bite out a piece. The lower extremities become involved, and the patient shuffles along in a clumsy manner, his feet being scarcely lifted from the ground. His dress becomes disorderly, and his habits are no longer characterized by neatness and tidiness. His facial muscles lose their play, and his countenance wears a wonderfully woebegone and sorrowful expression. He wanders wretchedly from one grog-shop to an- other ; eats sparingly, and rarely ever, uuless his worii-out stomach is stimulated by a dram. He loses flesh, and his clothes hang to his with- ered limbs like the vestment of a scarecrow. This is but the first step in the advancing disease. Memory becomes weakened, and forgetting even faces and names, he drops one by one his old friends, and sits in loneliness for hours at a time. The mind is utterly sapped, and he is reduced to a state of dementia, l^umerous grave changes occur in addition to these. Speech becomes thick and unintelligible. In the early stages there may be convulsions or attacks of delirium tremens ; but one of the most striking and serious expressions of the disease is the occurrence of paralysis; and there may be hemiplegia or paralysis of a local character, the third nerve becoming implicated, and ptosis resulting. The subject of chronic alcoholism is generally anaesthetic, and this to a marked degree. Not only is tactile sensibility impaired, so that he is unable to determine the nature of even a rough object, but he is uuafi'ected by extremes of temperature. In one case which I can recall, this was illustrated by the fact that in sitting before the fire he thrust his foot beneath the grate, and left it there for some time before his position was discovered by a member of the family. Hemi-an£ejthesia ^ is spoken of by some writers, but it is an extremely rare feature of the disease, and is pro- bably a late symptom resulting from organic changes on one side of the brain. An anaesthetic condition of the cornea has been alluded to. Convulsive seizures of difierent kinds are occasional evidences of the serious effects of alcohol. These may vary from simple spasm to a va- riety of convulsion which closely resembles a marked epileptic paroxysm. In fact the diagnosis is oftentimes very difficult. What I have said. about ^ Magnan con.siders that organic hemi-ansesthesia and general paresis are- quite common results of chronic alcoholism, op. cit., p. 134. 28 434 CEREBRO-SPINAL DISEASES. the mental condition in acute alcoholism may be now applied. The hal- lucinations and lighter forms of sensory and mental aberration exist at diffei'eut stages, but towards the end the condition is one of dementia of the most profound character, the patient being completely oblivious of the outside world, and of his duties to society. He is morally irresponsible, and the crimes he may commit are motiveless and dictated only by a dis- eased mind. Causes. — Chronic alcoholism follows the steady use of large quanti- ties of alcoholic liquors, but is rarely found among those who drink wine or malt liquor. The French, Italians, and Germans are, therefore, seldom affected in their own countries, especially outside of the large cities, where a very small amount of ardent spirits is taken. In England, Scotland, Ireland, and America the case is different, for in these countries there is no low-priced light beverage which takes the place of the wines and beer of the European Continent, which are drunk in preference to water. "Without entering into the discussion of the effects of alcohol upon other organs of the body than those of the nervous system, it may be said that the condition known as alcoholism springs from a protracted use of large quantities of strong liquor, so that the nervous substance is deprived of its normal nutrition, the blood being charged with effete substances which should be eliminated by the kidneys, lungs, and skin. Delirium tremens is due generally to the direct action of a large quan- tity of alcohol, which produces overwhelming toxic effects ; while chronic alcoholism implies a structural degenei'ation due to the continued action of the alcohol itself, and to the vitiated blood. Delirium tremens may occur either from a sudden cessation of indul- gence, or in the midst of a prolonged debauch, most commonly, however, the latter. In some persons elimination goes on so perfectly that large quantities of liquor may be taken and disposed of without any profound effect upon the nervous system being produced. These individuals may drink to a point much beyond moderation, and still suffer no marked in- convenience, the alcohol seemingly affecting some other organ, which may be either the liver or kidneys, so that cirrhosis or degeneration of other kinds may take the place of the cerebral trouble in the beginning. Males are much more often affected than females, as the statistics of Magnau show : — Acute alcoholism (D. T.) -j ^„_.. Subacute " {J^l™ Chronic " / 1870 11871 This fact has been confirmed by statistics collected by the Health De- partment of New York. During the year 1873, 45 deaths were reported from delirium tremens, but four of whom were females. It is probable that there were many more cases which were not reported as such. M. F. 35 2 42 216 51 159 47 126 11 90 14 ALCOHOLISM. 435 Women, however, though not so subject to chronic alcoholism as men, often drink to excess, and not rarely develop delirium tremens. This bad habit is confined chiefly to either extreme of society — the very lowest class, or the highest in the social scale. Among the latter the amount of pri- vate dram-drinking is astonishing ; and though the " skeleton in the closet " is carefully guarded by the friends of the patient, it is by no means uncommon for the physician to be called in to attend cases of de- lirium tremens in high life. Absinthe, which is extensively used in Paris, and is beginning to be introduced into this country, produces a terrible form of delirium tremens, in which mania is a marked feature ; and a form of epileptiform attack is also quite common. Alcoholism is much more often observed between the twentieth and the fiftieth year, and is very rare before that time. As to hereditary predisposition there is a great deal to be said, but when we attempt its consideration we depart from the immediate subject. Occupation and mental influences have much to do with the making of drunkards or hard drinkers. Barkeepers, and individuals exposed to se- vere weather, are commonly addicted to drink ; the one either feeling obliged to be convivial or indulging only because the liquor is so accessi- ble, and the other because he " needs something to keep out the cold." Mental depression, grief, and business worry are interesting in their social features, but do not strictly come within the scope of an article of this character. Morbid Anatomy and Pathology. — The prolonged use of alcohol is followed by marked changes in the structure of the nervous substance. In the early stages there may be found appearances which are ordinarily met with in uncomplicated cerebral congestion, viz., enlarged vessels , injected meninges, and effusions of serum. These may vary greatly in their extent and appearance, and may be associated with a fatty degenera- tion of the vascular walls, patches of softening, or even little foci of indu- ration. The disease leaves its traces most indelibly stamped as meningeal thickening and opalescence, and perhaps encysted collections of blood, which have been described in speaking of pachymeningitis. The sinuses are engorged, and the dura mater may be adherent to its underlying mem- branes ; or they, in turn, may be in such close contact in spots with the cortex that their removal necessitates the tearing out of patches of super- ficial gray substance. The convolutions will be found to be atrophied and reduced in size, and the ganglia at the base are often greatly softened. Many observers, among them Carlisle and Percy, have found alcohol in the fluids in the ventricles. Besides these intracranial changes, the liver, kidneys, and stomach present appearances with which all pathologists are familiar. The arteries throughout the body are found to have undergone atheromatous degeneration, and this is seen in the brain to a very decided degree. As to the condition alluded to by various observers, viz., th e mechanical change exerted directly by the contact of alcohol with the tis- sues, I think there has been much exaggeration. The sclerosis so often 436 CEEEBRO-SPINAL DISEASES. seen is much more probably the result of interstitial inflammatory change than a chemical transformation. The experiments made by Anstie,^ Magnan,^ Percy, Marcet,^ and Motet* settle with great certainty the pathological processes which follow the toxic administration of alcohol. Anstie took a full-grown dog weigh- ing 10 lb. 4 ozs., and injected 6 ozs. of mixed alcohol and water into the itomach at 1 P. M. No food had been taken for four hours previously. 1.4 P. M. Auimal obviously affected; staggers in walking, and fre- quently falls down. The hind quarters are weak, and skin of hind limbs insensitive. Resp. 24 ; circulation, 140. 1.6 P. M. Dog lies extended on the floor quite drowsy, but capable of being roused ; fore-limbs retain slight degree of voluntary power. Tongue protruded, and the dog " slavers " still. Skin about mouth amesthetic ; conjunctiva sensitive. 1.7.30, p. M. Animal falls on its side, comatose and snoring. Conjunc- tiva insensitive with other parts. Resp. 20 ; circulation, 184, tolerably strong. Ano-genital region was sensitive to painful impressions. Pupil strongly contracted at first, but became dilated at 1.25, little sensitive to light ; antesthesia remained ; eyes still insensitive ; continuous tremor of hind-legs began and continued for a short time. Respiration declined in frequency, and became gasping, and ceased at 3.5 P. M., two hours after the ingestion of the alcohol, the heart beating 64 per minute. It remained irritable for some minutes later. Much more complete and earlier coma followed the administration of larger doses. The continued toxic use of alcohol produces changes not only upon the nervous system directly, but secondarily through other organs which are primarily aSected. A large quantity of alcohol taken into the system in- duces pathological changes somewhat after the following manner : A certain portion, quite small in amount, is promptly excreted, and maybe detected in the breath, urine, bile, and sweat, while the greater proportion remains in the blood, greatly altering its character and inducing a large number of interesting changes. Lallemand, Marcet, and various experimenters have found that the excretions contained much pure alcohol, and others have detected, by the chromic acid test, traces of alcohol forty-eight hours after- wards. Anstie declares, however, that but the merest fraction of the amount taken is eliminated in its unchanged form. In this conclusion he differs from the authorities I have quoted. The alcohol remaining in the blood is partially eliminated in its decomposed state (carbonic oxide and water), while a certain quantity remains. The internal organs are con- gested, notably the liver, kidneys, and lungs, so that excretion is very slowly performed, and the urine voided is scanty in amount, devoid of the chlorides, and rich in urates. The blood circulates sluggishly, and 1 Stimulants and Narcotics, p. 335 et seq. ''■ Op. cit., p. 116. ' De la folic causee par I'abus des boissons alcooliques, these de Paris, 1847. * Considerations generales sur I'alcoolisme, et plus pardculierement des efl'ets tox- iques sur I'liomme par la liqueur d'absintlie, 1859. I ALCOHOLISM. 437 contains fat and sugar. I have also found sugar in the urine, which pro- bably resulted from irritation of the medulla as well as certain disturb- ances of kidney and liver function. The abundance of carbonic acid requires double duty upon the part of the lungs, and consequently respiration becomes labored and quickened. The natural oxidation of the blood is seriously embarrassed, and elimina- tion is retarded most seriously. The nervous system of course suffers from this change in its badly nour- ished state. Degeneration of the nervous elements follows, and interstitial thickening and medullary metamorphoses take place, so that the loss of function is very great. The pneumogastric being implicated, the lungs and other organs are not properly innervated, and many of the curious evidences of such disorder follow. This is illustrated by the tendency to pneumonia which often exists as a feature of alcoholism. The sympathetic system is of course implicated. The actual presence of alcohol is attended by vaso-motor paresis, and a number of vascular changes probably follow. It might be well, before closing, to refer to a condition of the cranial bones noted by Lancereaux and others, A hard- ening and thickening is due to nutritive changes, which Anstie thinks is not a true hypertrophy, as the original texture of the bone is lost. Prognosis. — A table prepared by Mr. ISTeilson from the Registrar- General's report shows that the probable duration of life in individuals who have reached the 20th, 30th, 40th, 50th, and 60th years, and who have been either temperate or intemperate, is about the following : — Having reached Has an average chance But the intemperate have an average chance the age of of still surviving of surviving only 20 44.21 years 15.53 years, or 35 per ct. of the duration of life of the general population. 30 36.48 " 13.80 " " 38 " 40 28.70 " 11.62 " " 40 50 21.2-5 " 10.86 " " 51 60 14.28 " 8.94 " " 63 " " " This applies only in a general way to the subject, but is significant in showing how greatly the alcoholic habit diminishes the patient's chances. In regard to the prognosis of the actual attack, there is rarely any rea- son to fear a fatal termination unless the patient has had a number of previous ones. Coma and convulsions should be looked upon with grave suspicion, as they greatly diminish the patient's tendency to recovery. Chronic alcoholism is more unfavorable. Should the patient survive his immediate nervous trouble, it is very likely that disease of some other organ will carry him off. Cirrhosis is the most common of these, and the patient's mental condition may be for some time aggravated by choles- tersemia. Much depends upon his ability to reform ; and no assurance can be given that he will recover until this is accomplished. Diagnosis. — The only diseases for which alcoholism maybe mistaken 438 CEREBRO-SPINAL DISEASES. are: 1. General paresis; 2. Sclerosis, and paralysis agitans; 3. Soften- ing ; 4. Dementia. 1. General paralysis differs from delirium tremens in the fact that in the former the delusions are always pleasurable and exalted. The general paralytic is the king, the capitalist, the ruler of the universe ; the alco- holic patient is depressed, dejected, and sad. These differences, taken into consideration with the fact that the patient suffers from anorexia, that his face is flushed, and the conjunctivae red, ought to settle the real nature of the trouble. Anstie^ alludes to the presence of acne as a pathognomonic sign. Chronic alcoholism may very closely resemble general paresis, but there is more proper dementia in the latter, 2. Sclerosis and paralysis agitans are sometimes confounded with chro- nic alcoholism when there is much disturbance of co-ordination. The tremor and inco-ordiuation are much greater during voluntary action, however, in the first conditions, and there is rarely any mental disturb- ance in either. 3. Softening resembles chronic alcoholism, but the paralysis and speech disturbance ai'e much more pronounced, there generally being aphasia, and the headache besides is quite different from that of alcohol- ism. 4. Senile dementia may make the diagnosis somewhat difficult. The previous history of the patient, however, will generally clear away any doubts that may arise. Treatment. — The physician's first attempt should be to prevent the patient from further indulging his de^jraved appetite. How this is to be accomplished depends very much upon his surroundings, temperament, and condition. If the attack arises during a debauch, I prefer to cut off at once the supply of alcohol, unless he is utterly prostrated. If the at- tack occurs after cessation, we may then give small quantities of stimu- lants, and " taper off." Should he be irritable and excited, immediate recourse to sedatives and hypnotics should be had. I have great faith in the bromides, lupulin, or simple remedies of this class. Fifteen or twenty grains of the bromide of calcium, given in a drachm of the tr. lupulin twice or three times a day, is often sufficient to quiet the nervous state. A good cathartic which shall increase the action of the liver, and hasten elimination of the alcohol, is an early form of treatment which is gene- rally recommended. Should the insomnia be troublesome or the delirium violent, we may administer either the bromides, or the mono-bromide of camphor, which I make the claim of being the first to use for this purpose. It may be given in pilular form, made up with confection of roses, in doses of five grains every hour until sleep is produced. The bromides of calcium or sodium in thirty grain doses every two hours sometimes succeed, or, better still, they may be combined with chloral hydrate, so that the patient shall take fifteen grains of each every two hours until the excitement subsides. Cannabis indica has enjoyed great ^ Article on Alcoholism, Keynolds's System, American Edition, vol. i. p. 677. I NICOTINISM. 439 popularity iu the treatment of this trouble, and should be given in doses of from one-half to one grain of the extract. Should the maniacal ex- citement be intense, I know of no better remedy than morphine adminis- tered hypodermically, but not by the mouth, as it may lie unabsorbed for some time with producing any effect ; and the physician may be tempted to give still more than the ordinary dose, when to his surprise absorption takes place, and its cumulative action follows. Digitalis has been recom- mended in large doses, and Anstie preferred the powder because the alco- hol of the tincture interfered with the proper action of the drug. I am inclined to think that the application of digitalis stupes to the lumbar region and the abdomen favors kidney action, and does more good than when the medicine is given by the mouth. It is of importance that the action of the skin and bowels should be increased. For the first object, small doses of tartar emetic assist the emunctory action of the skin, while the compound jalap powder induces copious and watery discharges from the bowels. Cold to the head, either by ice-bags or cloths wet with ice-water, blisters to the calves, and local abstraction of blood may be resorted to in violent cases. As to food : when the worn-out stomach refuses all ordinary articles of diet, it will rarely reject iced milk, which may be given in all cases. After a while soups, nutritious broths, or bouillon made from beef, or Valentine's beef juice, or Borden's extract of beef, either of which is preferable to the Liebig extract on account of the nauseous taste of the latter, may be given in liberal quantities. Small doses of carbonic acid, seltzer, or Apollinaris water, or coflfee may be administered before eating, and gently stimulate the stomach, in this respect taking the place of the drams. The patient's nausea may be corrected by the aromatic spirits of ammo- nia, or bismuth and morphine, the latter in very small doses. In chronic alcoholism the aim of the physician should be to restore the normal action of the viscera ; to stop the supply of drink ; and to freely administer the various preparations of iron, quinine, and phosphoric acid, as well as cod-liver oil. I have found that dialyzed iron is well borne by the irritable stomach, does not constipate,and is therefore an excellent remedy. This may be given with tr. digitalis and tr. nux vomica. NICOTINISM. "When the nervous system is subjected to the influence of tobacco in ex- cessive quantities a train of symptoms may be manifested indicating a con- dition of affairs that may ultimately assume a serious character. While I believe tobacco to be one of the most valuable articles of comfort we possess, I every day am made aware that in an insidious way it produces nervous disorders which are sometimes quite as formidable as those caused by alcohol. I have found in more than one case of general paresis that the immoderate use of tobacco, had, in those of unstable nervous tem- perament, all to do with the development of the disease. I have no in- tention, however, of entering into the discussion of its general bearings in relation to public health and the morals of the community, for these sub- 440 CEREBRO-SPINAL DISEASES. jects have been frequently discussed by popular reformers— and not always temperately or truthfully — but I will briefly call attention to the nervous expression of chronic tobacco poisoning. Symptoms. — The question of tolerance, in connection with physical development; the effect of the constant use of tobacco upon the nervous individual — the possessor of the insane neurosis, perhaps — enter largely into the genesis of nervous symptoms. In persons of full habit, of phlegmatic temperament, and fat-making tendency tobacco may be used in considerable quantities and quite con- stantly without other than trifling effect, and in the rheumatic diathesis it is positively beneficial. In the spare, nervous individual the case is different, and the careless and continuous use of tobacco often produces a train of motorial and sensorial symptoms of varying grades of gravity. Both the voluntary and involuntary muscles may be affected, and atonic action of the unstriped muscular fibre result in a variety of cardiac and digestive disturbances. The action upon the heart is decided, there being great feebleness and inequality of the pulse, and as the brain becomes the seat of chronic anaemia we find dizziness, headache and melancholia, besides a variety of light mental troubles. The muscular tissue of the stomach, intestines and lower bowel are enfeebled so that slow digestion and loose evacua- tions are consequent. The production of general muscular weakness is a very conspicuous manifestation of the depressed tone of the nerve centres. These may be ex- pressed either in tremor, slight paresis, or an epileptoid condition ; the tremor, however, is the most familiar of all disorders of motility. It may be unilateral, but is usually found on both sides, the upper ex- tremities being more often its seat than the lower, and like the same mo- torial disorder seen in alcoholism, and among opium eaters it may be overcome for the time by recourse to the cause. It is essentially the tremor of debility, and has no very regular character. If the smoker ex- tends his hand so that it is in a somewhat constrained position, he will notice that some fingers are more agitated tha n others, notably the second and third. An advanced grade of motor feebleness is expressed in paresis, but rarely by paralysis, so far as complete and diffused anaesthesia is con- cerned. Erb, under the head of toxic spinal paralysis, speaks of the influence of tobacco in its production, and says that it causes lasting paralysis when the toxic action is slow and repeated, and much more rapidly than when acute. There is usually diminution of electro-muscular contractility. Various other disorders of motility are shown in local spasms, and among them are painless facial twitchings and blepharo- spasm, which may be very distressing ; spasms of the limbs and starting during sleep. Not a small number of cases of chronic tobacco poisoning, as I have said, end in the direct production of serious organic disease of the brain, and symptoms in many respects similar to those of cerebral softening or general paresis will be expressed. The pupil presents no NICOTINISM. 441 constant appearance that may be considered important. Some authors, among them Taylor, and Woodman and Tidy hold that it is dilated in acute poisoning, while Pereira and Bartholow, say contracted, but in chronic nicotinism it is usually dilated. The urine is copious and loaded with earthy phosphates. Various dyssesthesia are common in chronic nicotinism. The patienfe calls attention to tinnitus, " tightness about the throat," " pains beneath the ears," as well as intercostal pains, coldness of the feet, crawling sensations, and a sense of feebleness, especially in the morning. Amaurosis is one of the indications of anaesthesia. ^Drysdale reported the cases of two young men who became amaurotic from the continued use of tobacco, in one case the man taking but half an ounce of tobacco a day. ^ Masselon in an admirable thesis refers to the production of color blindness, one of his patients being unable to tell a piece of silver from a piece of gold, and in all cases the patients seemed to lose the faculty of distinguishing yellow and red from other colors. ^Webster, in a very careful paper, has called attention to the amblyo- pia produced by tobacco, and fully believes that tobacco alone may give rise to this ocular trouble. In seven out of twenty cases he found inci- pient atrophy of the optic nerve. In 18 of Webster's cases alcohol and tobacco were used to excess, and in one case tobacco was used excessively from ten to fifteen years, and alcohol moderately, and an' occasional glass of gin was taken. In one case in which the amblyopia seemed to be wholly due to the abuse of tobacco, the vision rose from t^tt to 70 in each eye when the patient abstained from its use, and received appropri- ate treatment. Dr. Ely takes a more conservative view of tobacco j)oisoning as a cause of amblyopia. Cutaneous hyperathesia or anaesthesia are by no means rare symptoms of chronic tobacco poisoning. I have in patients repeatedly found anaes- thesia of the lips and tongue, and in one subject smell was abolished, and not restored until the patient was subjected to a course of strychnia. Tactile sense is sometimes blunted, and especially is such the case in the tips of the fingers. Neuralgic pains are by no means uncommon, and are perhaps among the early sensory troubles. These pains may counterfeit those of early locomotor ataxia, and create great misery. In other cases there may be cardiac neuralgia, resembling in many respects the pain of angina pectoris. So grave is this symptom that even medical men who smoke to excess often believe themselves to be the subjects of this affec- tion. Vague muscular pains, shortness of heart, and fatigue after slight exertion all come in for a share of our attention. The mental expressions of nicotinism are exceedingly variable, and may consist in the beginning simply of a change in the temper and dis- position, evinced by irritability, and accompanied by loss of memory, irresolution and hypochondriasis; or in a graver form we may find actual 1 British Medical Jonrnal, Sept. 5, 1874. 2 These de Paris, 1872. 3 Medical Eecord, Dec 11, 1880. 442 CEREBRO-SPINAL DISEASES. symptoms of insanity, illusions, hallucinations and delusions either insane or otherwise, attacks of extreme excitement amounting to mania, or per- haps mania itself. ^Backnill and Take speak of tobacco poisoning in the causation of insanity, and ' Kirkbride reported four cases of insanity due to tobacco. ^Skac reports a case of mania produced by tobacco, and Continental literature contains other observations. The skin is usually muddy in color, and the mucous membrane o f e tongue of an excessive smoker presents, according to some observers, the appearance as if it had been brushed over with nitrate of silver. Causes. — Tobacco, when used to excess, does far more harm in some ways than others ; and the purity of the substance and the method of its consumption greatly influence the troubles that may follow. * Anstie says : " There are a few whom no amount of care and skill exercised in taking the tobacco, nor any moderation in the dose used, can save from unmistakable poisoning whenever they indulge in it. These cases are rare, and they should be carefully separated from the evil results which are produced by mere unskillfulness in smoking." Chronic poisoning arises from certain bad habits, and these may be enumerated as : 1. Smoking when the stomach is empty. 2. Using several cigars in succes- sion. 3. Inhaling the smoke of cigars or cigarettes. 4. Smoking only a pipe in which the nicotine has collected. 5. Swallowing the saliva. Among smokers it is found that the nervous effects are more easily pro- duced in the early part of the day. It is difiicult to say just how much tobacco is harmful. In a case re- ported by ^Gmelin, seventeen or eighteen pipes were smoked in quick succession by two men with fatal results. The use of snuff by women in the manner known as " dipping," is hap- pily becoming rare in this country. I have seen several examples of this kind leading to chronic poisoning. A stick, tooth-brush, or some such article, is dipped in fine snuff, and the gums and inside of the mouth are rubbed therewith. The toxic effects of tobacco are produced in a short space of time and are said to be pleasurable. I have found this custom to be prevalent among prostitutes, but it is by no means confined to them. In Ihe case of a lady of refinement and social position, I found that a peculiar train of obstinate nervous symptoms were due to " snuff dipping," and search disclosed small parcels of snuft' under her pillow and beneath the mattrass of her bed. Cigarette-smoking, which has increased to an incredible extent of late in this country, is much more apt to give rise to nervous symptoms, be- cause of the tendency to almost constant indulgence, and the inhalation of the smoke. 1 Manual of Psychological Medicine, p. 100. 2 Annual Report of Philadelphia Hospital for the Insane, 1880. 3 Ed. Med. Journal, Jan., 1856. * Stimulants and Narcotics, p. 138. 5 Eeported by Woodman and Tidy, p. 379. NICOTINISM. 443 Pathology. — According to ^ Anstie, tobacco is a narcotic-stimulant, and he classes it with tea and coffee. The poisonous effects, as agreed by most authors, are excited in l^wo ways : 1st. In interfering with the pul- monary circulation, retention of carbonic acid gas, and blood-poisoning. 2. A direct influence from the nervous tissue itself. The motor-nerves seem to suffer abasement of function, though the muscular irritability is not disturbed. There seems to be some doubt as to the poisonous agent in tobacco. Vogel says that the toxic properties of tobacco-smoke are due to the pre- sence of sulphide and cyanide of ammonia. ^Eulenburg could not find a trace of nicotin (Woodman and Tidy), but he and Vohl believed the poi- sonous substance to be pyridin (C 5 H 5 N.) and parvolin (C 9 H 13 N.) ^ Huebel, however, has found the amount of nicotin in one cigar sufficient to produce convulsions and death in a frog. There is undoubtedly in tobacco-smoke a certain amount of nicotin and other alkaloids in combination with alkaline bases. In gouty subjects, therefore, the use of tobacco cannot fail to be beneficial, when smoked in moderation. In small quantities tobacco slightly exhilarates and increases the action of the heart, and one cigar may effect a prompt increase of thirty or forty pulse-beats — a secondary depression follows, however. ^Headland ascribes the comparatively light narcotic effect of tobacco to its prompt elimination by the kidneys, and says : " It is only not a poi- son because slowly taken into the system in small amounts and eliminated pari passu." In those individuals in whom, through disease of the ex- creting organs, the poisonous elements are not promptly removed, the production of nicotinism is much more prompt. The occurrence of ver- tigo is probably often due to a cumulative efiect which occasions cardiac weakness. The cerebral effects of prolonged nicotinism are occasioned by the continued malnutrition of the brain tissue. Prognosis and Treatment. — Nearly all the alarming symptoms can be immediately moderated or cut short by prompt discontinuance, and recourse to nux vomica or its alkaloid. The analysis of tobacco by ^Schlossing and others, with regard to the quantity of nicotine has some bearing upon the evil effects attending its immediate use. In 100 parts of Virginia tobacco Schlossing found 6.87 parts of nicotine In the same quantity of Kentucky tobacco there were 6.09 ; in French tobacco, 4.94 — 7 ; Maryland, 2.29 ; Havanna, less than 2. In dry snuff there is 2 per cent. ; in moist, 1.3. Those who use tobacco are rarely inclined to acknowledge its bad eflects but to attribute them to other causes ; but, as Taylor says, " The argument that cases cannot be adduced to show direct injury to health proves too much — for a similar observation may be made of the habit of opium-eating." ^ Stimulants and Narcotics, p. 100. 2 Viertljahrschrift f. Ger. Med. N. F. xiv., p. 249, and Woodman & Tidy, p. 379. 3 Centralblatt, Oct. 5, 1872. * Adion of medicines, p. 269. ^ Quoted by Taylor, p. 771- 444 CEREBRO-SPINAL DISEASES. For the person who presents decided nervous symptoms traceable to tobacco, no better treatment can be suggested than the continuous use of a tonic containing iron, quinine, and strychnine, — such, perhaps, as the following : R — Strychnine Sulphas, gr. i. Quinice Sulphas 5'' Tr. Ferri. Chloridi 5^"- Acidi Phosp. dil. ) ^-.. Syr. Limonis J '-' Sig. : — Oue teaspoonful in water thrice daily. Strychnine alone, in small, repeated doses, or perhaps combined with digitalis, is useful. In amblyopia many authors, among them Webster, recommend the hypodermic use of strychnine. From 1-60 to 1-24 gr. may be given at a dose. HYDROPHOBIA. Synonyms. — Rabies canina ; Paraphobia; Lyssaphobia (?). The name adopted to express that form of nervous trouble which some- times follows the bite of a rabid animal is an evident misnomer, as the definition of the term signifies " a dread of water." As this is but one symptom, and by no means a constant one, the first synonym is much more expressive and appropriate, and is in every way preferable to that in general use. Symptoms. — 1- Period of Incubation. — After the receipt of the bite, which may produce an extensive wound, or, as is the case sometimes, an insignificant scratch, a period of time extending from a few months to several years may elapse before the appearance of the second stage. The wound may heal by first intention, giving rise to no inconvenience, or there may be redness and neuralgic pain. A history of this kind is usu- ally given by the patient, and is based upon an exaggerated statement of the actual facts, which arises from a disordered imagination, while his story of the accident and of his subsequent symptoms is tinctured with a deci- ded flavor of romance. Nervous derangement dependent upon fear, di- gestive disorders, mental worry, and others of the same category, generally characterize this first stage. 2. Period of Invasion. — At the end of the period of incubation, the first alarming symptoms noticed are those connected with the cicatrix, which becomes painful aad tender, and at the same time there are pains which dart along the nerves in the vicinity. There are next generally headache and a sense of epigastric oppression, with constipation, broken sleep, and a feeling of general discomfort. At the end of two or three days, during which the patient suffers intensely, we may expect the appear- ance of the next stage. 3. The Period of Development. — With aggravation of the symptoms just enumerated, we find added thereto a sense of constriction about the throat, irregular and quickened respiration, rigidity of the muscles of the neck, discomfort in deglutition, and spasms, which begin in the muscles of HYDROPHOBIA. 445 the throat and back of the neck, and gradually invade those of the back. The spasms give rise to much pain, which is sometimes spinal and at others muscular. The patient is at this stage delirious and flighty, and gene- rally has delusions in which dogs play an important part. The difficulty of swallowing, which next follows, is not so great when solids are taken. Fluids, on the contrary, seem to produce an aggravation of the spasms, and the mere sound of splashing or trickling water will excite a convulsive seizure. To add to the sufferings of the patient, there is excessive thirst, which is very distressing. His face becomes dusky, and his eyes promi- nent and wild. He tosses from side to side if placed in bed, the saliva running from the angle of the mouth in a viscid stream. Towards the end of the disease this secretion becomes thicker and mixed with mucus, and it collects in the trachea and bronchi. These symptoms may last two or three days, while in the meantime the reflex excitability becomes so great as to precipitate a convulsion under the least stimulus. The pulse is rapid, the headache more severe, the air-passages become filled, and respiration is greatly interfered with. The convulsions are readily pro- duced by blowing upon the patient, or by jarring him, or even by slam- ming the door. At this stage he becomes partially unconscious, is quite delirious, and very much agitated. Previous to death there is a marked rise in the temperature, and in one case I saw, the history of which I shall presently relate, the temperature rose to 103°, and I believe there was even a subsequent rise. Death occurs in two or three days in most cases, but it may be delayed a day or two longer. Incontinence of urine and feces precedes the end ; the immediate cause of death being asphyxia from spasmodic stenosis of the larynx, or obstruction of the air-passages by mucus. I had the privilege of seeing one case at the request of Dr. Augustus Viele, of this city, which was subsequently reported by Dr. Hadden.^ Through the courtesy of Dr. Hadden and Deputy Coroner Leo, I was also enabled to observe the post-mortem appearances of the brain and cord. Dr. Hadden describes the case so minutely that I shall mainly use his own words. " On the 24th ultimo, at 8.30 P. M., I was called to attend a young man named Wm. McCormick, residing at No. 309 East 51st Street, a native of this city, aged 26 years, athletic in appearance, of usually good health, nervous temperament, and of moderately temperate habits ; by occupation a driver of an express-wagon. He was in bed, complaining of nervous- ness, soreness in his nock and throat, strange feelings of tightness around his chest. His countenance was anxious, pupils of his eyes were dilated, and his general appearance was like one who was in fear of impending danger, and not in extreme pain. He told me that his throat was so sore that he could not swallow anything — not even water. This, he thought, was due to some simple medicine he had taken, and not to any serious ailment. I noticed his throat was not swollen on the outside, and that his ^ Journal of Psychological Medicine, May, 1870, p. 80. 446 CEREBRO-SPINAL DISEASES. voice was whining, and unlike a person suffering from any ordinary sore- ness within. I, however, examined his throat within, but found nothing to account for this difficulty ; it was perfectly healthy in appearance. His pulse, respiration, and temperature were normal, excepting an occa- sional sigh. I observed, also, a little disposition to hack and spit, but in no way troublesome. He complained also of thirst, but said he could not drink, he knew, for the very sight of w'ater made him shudder. I told him his throat was not sore, and urged him to try. He assented, and water was accordingly brought, which, at sight, caused a violent spasm. He threw himself around in the bed, forward and backw^ard, and told the party to take it away at once, as it would kill him. He immediately af- terwards called for the goblet, and said he was very thirsty and must drink, seized it, and with a violent effort succeeded in taking a single swallow, which was followed by a severe convulsive shudder and contrac- tion of the muscles of the neck and chest." Dr. Hadden ascertained the fact that he had been bitten by a dog, and then inquired about the symp- toms antecedent to his visit. " Wednesday and the two preceding days he was complaiuing of general lassitude and nervousness ; had not been able to sleep at night ; was thirsty, and had drunk a great deal of water; had eaten but little ; appetite very poor, and on Wednesday afternoon he seemed to be growing worse. He went out upon the street, but soon re- turned, saying that it was very chilly, and he could not stand thQiair at all. While taking a cup of tea at 6 P. M. the same evening, he first showed signs of difficulty in swallowing. Shortly afterwards, as he was going to the kitchen, he was met by a draught of cold air, which so stag- gered him that he nearly fell ; he then went to bed, where I found him. After giving the necessary caution to the family, I ordered fifteen grains of bromide of potassium to be given every hour. I left, and returned at 10.30 p. M. . . . Found him in about the same condition I had left him, only his pulse was irregular, and his spasms more frequent. The saliva was a little more troublesome, and he also could not swallow without great difficulty. I was called again at 2.30 A. M., the messenger stating that the patient had become very violent, and that they were unable to restrain him. I went immediately. . . . Found him in a frightful state of excite- ment; had broken down the bed, and was struggling with his attendants to get at liberty. He was shouting and crying out to them to let him go, and called for water, which, when brought, he could not drink. His mind was clear, and he knew all those around him ; was spitting a viscid saliva, but was cai'eful not to spit upon any one, not even on his clothes. It was so abundant that his attendants were obliged to wipe it from his lips. Dr. Leavitt and myself, after viewing the case in all its aspects, concluded to inject in the tissues of the leg half a grain of morphine and one-sixty- fourth of a grain of atropine in solution, which was done at 3 A. M. by Dr. Leavitt. We carefully watched the effect till 3 30 A. M., when, his violence having in no way abated, another injection was given in the same part of three-eighths of a grain of morphine and one-eighth of a grain of atropine, which in some degree produced the characteristic effect of morphine, and very clearly the appearances of the atropine ; for, not- withstanding he was struggling violently, the saliva, which had been very troublesome, was completely dried up ; so much so that the patient re- marked that he was very thirsty, and his ' mouth felt as if he had been chewing a brick.' Fifteen drops of chloroform were then injected, with no effect whatever, unless to weaken his already weak and frequent pulse. HYDROPHOBIA. 447 At 4.15 A. M. three-eighths of a grain of morphine were a gain intro- duced under the skin without atropine. This quieted the patient, so that he was easily restrained, and he remained in this condition from 4.30 till 10 A, M., when the effects had so far passed off that the attendants were alarmed at his violence and the abundance of saliva that he was spitting from his mouth. At 10.15 A. M. three-eighths of a grain of morphine in solution were injected in the tissue of the thigh, which served to temper down the increasing violence of the spasms, but did not stop the flow of saliva. I accordingly, at 10.45 A. M., injected three-eighths of a grain of morphine and one-fortieth of a grain of atropine, which had the de- sired effect of producing the quieting effect of the morphine and the spe- cific effect of the atropia on the salivary glands. The poisonous effects of the morphine and atropia were at no time apparent. He died at 4.15 P. M. June 26, 1874, about twenty-four hours after the first spasm." I saw him at three o'clock on the afternoon of the 26th day, and found him lying upon the floor bound with twisted sheets, the ends of which were held by his attendants. He was very violent, and, though there were no very marked convulsions, he seemed to be quite rigid, and his forearms were flexed during most of the time. He was semi-comatose, and groaned occasionally, but took no notice of those about him, and did not speak. His respirations were quick, and there was a rattling sound produced in his throat with each expiration and in- spiration. A quantity of quite thick mucus and saliva was spat up dur- ing my visit, and there seemed to be a very free secretion of this sub- stance. The pupils were widely dilated, and as far as I could judge there was no marked elevation of temperature.^ Recent cases of hydrophobia have been reported by Francois,^ Ed- wards,^ Smith,* and Hanscom.^ The case of the latter is so interesting and so graphically detailed, that I shall take the liberty of giving it in full. On the morning of the 20th November a good-natured pet spaniel, which had never been known to snap at any one, suddenly and without any provocation sprang at his mistress. His master whipped him, and he was left in the cellar of the house until the time for his dinner. When eating it in the company of a pet cat, as he had been accustomed to, without ever having molested her, he suddenly seized the cat and threw her across the room. The owner reached out his hand to catch the dog, when the latter caught him tightly by the wrist and inflicted a deep wound, biting him three times; the skin became lacerated while making an effort to shake him off. It was supposed at the time that the dog was 1 In this case the newspapers were filled with sensational accoonts of the patient's illness, and an attempt was made to prove that the dog was not mad. It is needless to say that such was probably not the case, and it is to be regretted that the dog was never found. - Bost. Med. and Surg. Journal, May 17, 1877. Mbid., March 15, 1877. * Ibid. 5 Ibid., April 19, 1877. 448 CEREBRO-SPINAL DISEASES. irritable from the whipping which he had received in the morniug, and, as he expected another for snapping at the cat, defended himself by bit- ing. Half an hour after, the patient applied to me for treatment, and be- lieving it to be too late for incision or cauterization to be effective, and as there was no history of hydrophobia, I dressed the wound with a solution of carbolic acid. It healed readily, and the patient attended to his busi- ness as usual in four or five days. Soon after the infliction of the bite the dog disappeared and he did not return for thirty-six hours ; nothing could be ascertained of his whereabouts or of his behavior during that time. When he returned he was very much exhausted, and had the appearance of having been severely beaten. From what I can learn of those who saw him he gradually grew weaker, apparently losing the use of his legs, espe- cially the hind ones, which he would d rag after him. He died quietly, with his head in the lap of his mistress, without having had a convulsion, excessive flow of saliva, or tremors. On the 13th day of January (fifty- four days alter the injury), the patient bigan to have shooting pains in the forearm, but not especially localized. They did not radiate from the cicatrix, and there w'as no change in the appearance of the latter On the following day the pain had increased so much that he required one-sixtli of a grain of morphia to relieve him ; it was given subcutaneously, an I was repeated the next morning. After that there was very little pain in the arm, and no appreciable change in the pul.se or temperature. He was despondent, and stated on the morning of the loth that ' he felt sick and used up all over;' he was obliged to go to bed in the afternoon, and then for the first time began to have some difficulty in swallowing. This symp- tom was not manifested by an attempt to drink water, but during an effort to swallow some herb tea which he was accustomed to take when ill, and which he believed would relieve his bad feelings. There was no trismus ; he was quiet and inclined to d(,'ze. At 5 P. M. Dr. H. H. A. Beach saw the patient with me, and agreed that the history of the case in connection with the symptoms then existing indicated the probable development of hydrophobia, and an unfavorable prognosis was given to the patient's brother, who promised not to communicate it to the patient or his friends until the disease should be fully declared. His pulse at this time was 102, and the temperature in the axilla 102^ F , face flushed, tongue coated. The cicatrix presented no unusual appearance, nor was it tender. A dark room was agreeable to him, but on raising the curtains the light did not disturb him in the least. He was perfectly rational, and had some thirst, but no sore throat. He made an attempt to swallow a teaspoonful of milk, but was obliged to give it up from the moment that the fluid touched his lips. Immediately after this attempt unmistakable spasmodic contraction of muscles between the chin and sternum was observed. Mentally the patient was perfectly clear, and not disturbed by the unsuccessful attempt at swallowing fluids, but said he would try it again when he should be more thirsty. This symptom, excepting when he swallowed teaspoonful- doses of medicine, continued until his death. He was obliged to relieve his thirst by sucking ice and snow through a napkin. The air from a fan or from adjusting the bed-clothing caused a shudder. Occasional sighing was noticed after the second day ; it grew deeper and more fre- quent until the end. When disturbed from any cause, his respiration was of a spasmodic character, so much so at times as to interfere with his speech. On the following morning (the 16th) his pulse was 96, and mild de- HYDROPHOBIA. 449 lirium first developed ; this also continued until his death. He was easily controlled throughout the disease. He became very suspicious of the people about him, believing that they were attempting to make him the victim of practical jokes, then of being poisoned. One hallucination was continuous from the time that the delirium first developed : he thought that some one had thrown a dirty powder on him, and he was continually making efibrts to shake it off from himself and his clothing. He was also very cross and dictatorial, but showed no disposition to snap or bite. Between four and five P. M- on the 18th he began to have spasmodic contraction of the muscles of the chest, larynx, and throat; some of them lasted nearly a minute, and prevented him from taking an inspiration. He also had a profuse dischflrge of saliva sufiicient to wet his clothing through from his chin down to his hips. The spasmodic contractions con- cerned in respiration exhausted him rapidly, and he died quietly at 8.15, while sitting up in a chair. This position became necessary from the fact that he could not lie on his side, and if on his back the saliva accumulated so rapidly that it obstructed his respiration. For the last twenty minutes before his death there was no spasm. He lived five days after the first general symptom. At no time was he disturbed by the sound of ringing bells or running water. Morphia in one-fourth-grain doses, and chloral and bromide of potassium in fifteen-grain doses of each at the same time were given as needed. Ansesthetics were not required. At the solicita- tion of his friends he was allowed to take a j^ill, the prescription for which was said to be one hundred years old and to have cost originallv five hundred pounds. It had the reputation of curing and preventing many cases of the disease. ISTo change in his symptoms could be attributed to its action, nor could its composition be ascertained. It was given as a placebo, on the chances that an hysterical element existed in this case ; that whatever offered encouragement to the patient without the possi- bility of injury in his hopeless condition was justifiable, but so far as the evidence furnished by one case is of value its inefficacy was demonstrated. The permission of his friends for an autopsy could not be obtained. The particular symptoms of the disease which were not observed in the dog when seen might have existed during the thirty-six hours that he was absent. The proximity of the wound to the ulnar nerve and its character (punctured and lacerated) suggested the consideration of tetanus as an explanation of the symptoms ; the latter seemed to be fairly excluded, however, on the ground that delirium was continuous from the third day of the attack, and that at no time did trismus or any other form of tonic spasm exist ; the profuse discharge of saliva was also corroborative of this view. The unquestionable existence of repeated attacks of laryngeal spasm ; the fact that the symptoms developed after a considerable interval had elapsed from the date of the injury ; that for three hours previous to his death, and after he became wholly unconscious, marked spasms of the chest and throat occurred at intervals of from three to five minutes; that death occurred as a result and within five days following the development of symptoms characteristic of the disease, reasonably offset a theory that the hydrophobic symptoms were simulated by an hysterical man. In Smith's case the period of incubation was about two months, and the paroxysms were ushered in by vomiting, fear of water, and febrile symp- toms. On the third day of the disease he became delirious, and on the 29 450 CEREBKO-SPINAL DISEASES. fourth died. The sound made by the patient, which is so often compared to the bark of a dog, was likened by the author to that made by a croupy child. In Edwards's case, the period of incubation was about five months. The injury was insignificant,, but with the invasion of the disease there was pain in the cicatrix which extended up the arm. In this patient there was also dread of fluids, especially water. On the second day the convulsions began. The same day she spat up bloody mucus. At the end of sixty hours from the first local pain she died. Causes. — The circumstances which concern the etiology are still enshrouded in mystery. Some authors are of the opinion that rabies may be communicated by a dog that is not mad, and cases are brought forward to prove this theory. I cannot agree with this, for it seems to me highly improbable that there should be so few cases of this disease if the bite of a non-rabid animal can inoculate an individual. Bouley states that in no way can the disease be transmitted other than by inoculation with the saliva. In this statement he receives the endorsement of Magendie and others. Another point remains to be answered, and this is in regard to the trans- mission of virus from one person to another without the second person being bitten. Fleming has given an example which shows that this may take place. In the spring of the present year I was subpoenaed to serve as a jury- man in the case of a boy who had died of rabies. At about the same time another death occurred which the attending physician said was simply the result of fear, and not of hydrophobia. A careful inquiry and examination of witnesses revealed the following history, which I think proved beyond a doubt that the cause of death in both cases was the bite of a rabid cat. This cat had found her way into a stable on Thirty- fourth Street, and had bitten a horse. This horse afterwards died in con- vulsions, and from all I could learn the cause of death was hydrophobia. In an adjoing yard the cat bit one of the boys, who also died, and in a few days afterwards bit the other boy, whose inquest we attended. Both of these victims died within a short time of each other. In one of these cases there was but a slight scratch. Morbid Anatomy and Pathology. — Cliflfbrd Albutt,^ Meynert, Elder,'-' and others have made autopsies, and still there seems to be very little light thrown upon the pathogeny of the disease. Albutt found en- largement of vessels in the cerebral convolutions, pons, medulla, and spinal cord, and granular disintegration. Elder found absolutely nothing ; and the results of the search of Lockhart Clarke who examined parts of the brain, medulla, and cord, were equally negative. Kolesnikoff^ reported the appearance of the nervous centre in ten dogs that had died of hydrophobia. " The jDarts examined included the hemi- spheres, corpora striata, thalami optici, cornua ammonis, cerebellum, me- dulla oblongata, spinal cord, the sympathetic and vertebral ganglia. The * Med. Kecord, i. 22. - Britiph Med. Jour. vol. ii. 1874. 3 Centralblatt fiir Med. Wissen., No. 50, 1875. Abst. Phil. Med. Times, Feb. 5, 1876. HYDROPHOBIA. 451 most marked changes were observed in the two latter, and were as fol- lows: 1. The vessels were enlarged, choked with red blood-corpuscles; occasionally, extravasated red corpuscles and round indifferent elements (probably white corpuscles) were found in'the perivascular spaces. The walls of the vessels were here and there filled with hyaloid masses of various forms, which occasionally extended into the lumen of the vessels, and closed this as a thrombosis would. Not far from these masses collec- tions of white and red biood-corpuscles could be observed, the latter de- prived of color. They could be seen also in all stages of metamorphosis into hyaloid globules. 2. In the pericellular spaces of the nerve-cells could be observed collections of round indifferent elements, whose pene- tration, to the number of five to eight or even more, pressed out the pro- toplasm of the cells. This penetration of the elements spoken of was frequently sufficient to change the form of the nerve-cells, giving them at different-times a sac-formed, bulged, or flattened-out appearance. Fur- ther, the nucleus was sometimes pushed towards the periphery of the cell and surrounded by many round elements. In other cases, only groups of round (indifferent) bodies could be observed in place of the nerve-cells. In isolated nerve-cells the changes described could also be observed." The body of Dr. Hadden's patient was examined by the deputy coro- ner and several physicians, among whom were Drs. Clymer, Hammond, Cross and myself. The calvarium was removed, and great congestion of the meninges and brain was observed. The sinuses were much engorged, but there was very little effusion either upon the surface of the brain or in the ventricles. The lower surface of the brain appeared to be slightly softened in patches, but there was nothing else to attract attention, ex- cept it might perhaps have been a great hardness of the pituitary body. The internal viscera were all hyperaamic, but there was no other morbid apperances. The larynx and trachea were found to be very much in- jected, and the latter contained a quantity of frothy mucus. Dr. Willis has found the blood of persons who have died from this disease to be very fluid and of a dark color. Dr. Shattuck and Fitz ^ have published the notes of an interesting case of hydrophobia treated unsuccessfully by them. An immense amount of curare was given, about four grains within six hours, without any of the physiological effects being produced, though the drug was of good quality. Dr. Fitz's subsequent examination is of so much interest and so full that I present such parts of it as relate to the change in the nervous tissues : " While exposing the spine the surrounding tissue seemed to contain less fluid than usual. No abnormal appearances were observed in the membranes of the spinal cord, or upon the surface of sections made across the latter at intervals of an inch throughout its length. The calvaria was readily separated from the dura mater, both the bone and the membrane j)resenting no unusual appearances. The lon- gitudinal sinus contained a soft gelatinous clot, only partially filling the 1 Boston Medical and Surgical Journal, Aug. 28, 1878. 4o2 CEREBRO-SPI^'AL DISEASES. cavity. The pia mater -was occasionally spotted and streaked from fibrous thickening, and was unusually injected over the greater part of the convexity of the brain, the vessels being often varicose. The meshes contained a considerable excess of clear fluid, and the membrane was readily detached from the brain. On section of the brain no un- usual appearances were observed in the ventricles or cerebral substance beyond abundant puncta cruenta. The chief interest naturally centered in the possible condition of the nervous system, and the spinal cord, medulla oblongata, and portions of the cerebral convolutions were preserved in Midler's fluid for the purpose of microscopical examination. Positive results were obtained from the medulla alone ; it should be stated, however, that the cord- was perfectly hardened, so that the sections obtained from it were comparatively useless. The changes found in the medulla were ob- served throughout its length, and were most commonly met with in the posterior portion, especially in the immediate vicinity of the floor of the fourth ventricle. The alterations were most extreme in that part corres- ponding with the calamus scriptorius. The appearance most frequently met with was infiltration of the adventitia of the veins with small, round cells, both large and small veins being affected. So abundant was their distribution that upon longitudinal section the wall of the vessel seemed to be paved, as it were, with these cells. As a rule, the vessels thus modified were distended with blood, and it seemed probable that the ob- served changes were pathological, as the vessels in other parts of the medulla did not present such an appearance. The injection of the veins was so complete at times that their section was of a dark-brown color and quite opaque, the individual corpuscles being indistinct, and the condi- tion deserved to be spoken of as a thrombosis. It was evident from transverse sections that the different cells were not simply adherent to the inner surface of the vessel, but were actually within the wall, nor was there any evidence of an increase in the relative proportion of white to red blood-corpuscles. Another appearance often met with was that of haemorrhage. In general the extravasated blood was found within the perivascular, particu- larly venous, spaces. The sharply-defined outline of the corpuscles and the absence of granules of blood-pigment indicated that the hemorrhages were recent. Transverse sections of the injected vessel, with its wall in filtrated with round cells, and a perivascular accumulation of red blood- corpuscles, were often met with. In none of the sections were ruptures of the vessel wall seen. At times the wall was somewhat collapsed, the contents correspondingly less, while around the vessel a considerable hiemorrhage- was apparent. The hosmorrhages were usually limited to the perivasc- ular space, the blood rarely having made its way between the nerve fibres or into the gray matter. Finally, an appearance was sometimes met with which may be spoken of as a miliary abscess. Occasional minute agglomerations of indiffer- ent cells were seen, but their relation was such as to suggest their prob- HYDROPHOBIA. 453 able origin from sections througli limited portions of the infiltrated ad- ventitia already referred to. In two instances, however, actual abscesses were found, — one wifhin a convolution of the olivary nucleus, another in the immediate vicinity of a pigmented ganglion cell in the upper part of the medulla. The former was a larger, and it was found in a part where none of the cellular infiltration of the vessels already mentioned was observed. In brief, then, the alterations were a difiuse cellular infiltration of the adventitia of the veins, venous injection and thrombosis, perivenous hsemorrhages, and miliary abscesses." The question to be answered after all is, whether this affection is a pri- mary disorder of the nervous centres or whether it is the result of general blood-poisoning. I am inclined to accept the latter theory, as the array of facts is too meagre to permit any positive assertion as to its nervous ori- gin. Like other disorders, not essentially nervous, there is a period of in- oculation, or incubation, of invasion, and development. I think, then, that in this respect this disease, as well as tetanus, resembles closely some of the exanthemata. Diagnosis. — It is important to bear in mind the fact that a great many so-called cases of hydrophobia are not this disease at all, and that certain forms of hysteria bear to it a close resemblance. Fright may act so powerfully upon the nervous system that a train of symptoms -may be produced very much like those of the genuine affection. A case of this kind occurred at Bellevue Hospital a year or two ago, in which the symptoms counterfeited those of the real disease in every respect, and the patient finally died. It was found that the individual had not only never been bitten, but that he actually died of fear, his imagination having been stimulated by the sensational articles in the newspapers. Dr. J. W- S. Arnold, of the University, who examined the brain and cord, was unable to find the slightest indication of any morbid change. The only other conditions from which we may be required to make a differential diagnosis are tetanus. Calabar bean, and picrotoxin poisoning. In the former there are many points of resemblance, and occasionally a dread of liquids and a difiiculty in swallowing. In tetanus, however, the risus sardonicus is present, the spasms are tonic, and there is opisthotonos, and the mind is clear to the last. In poisoning by both agents, to which I have alluded, the rapidity of their action is conspicuous, and a dose of either would carry the patient off in a few hours, more or less. In picrotoxin and Calabar bean poi- soning, there are many of the symptoms of hydrophobia, such as clonic spasms, frothing, rise of temperature ; but no dread of water, nor delirium. Epilepsy may resemble hydrophobia, but it is only when the attacks are numerous and closely connected that such a mistake could possibly occur. Marbaix^ "gives a case of epileptiform convulsions more or less resem- bling hydrophobia, in a man who had been bitten four days before by a 1 Presse M6d. Beige, 1869, 237. 454 CEREBRO-SriJfAL. DISEASES. cat ; they were accompanied by delirium and hypersesthesia of the optic nerve, a stray light thrown across his eyes causing a convulsive attack. The shortness of the incubation, the blueness of the face, without the 'vultueuse' expression characteristic of hydrophobia, the delirium, and the melancholy, not exalted, condition, combined with a history of an epileptic attack a year before, prevented the case being looked upon as one of true hydrophobia." Prognosis. — In true hydrophobia it is very bad. I believe there never have been more than one or two genuine cures reported ; and if others have been claimed, it is probable that no rabies existed, but that the affection described was simply hysterical. The chance of inoculation seems to be a matter of interest, for of the reported cases in which indivi- duals have been bitten, it has been found that about two-thirds of them subsequently developed symptoms of rabies. Treatment. — We rarely see these patients until actual evidences of madness have appeared. If, however, we are fortunate enough to be called to the individual immediately after he has been bitten, we may either incise or cauterize the wound. It is well to ligate the limb as soon as possible, and then remove en masse the piece of the muscle which has been penetrated by the teeth of the rabid animal. Various writers re- commend the cupping-glass, which should be applied to the excised part till it abstracts several ounces of blood from the wound. A pencil of ni- trate of silver may be thrust into the punctures made by the teeth of the dog until they are well cauterized, and a strong solution (5ij~^j) should be applied afterwards by means of a piece of folded linen, which is to be covered by oil silk. I am convinced that no remedy can do good where the disease has al- ready appeared, except, perhaps, curare, which has been tried ; and in one case, where it was prescribed by Dr. Austin Flint, Sr., it is said to have saved the patient's life. The case must be desperate, however, when this powerful substance is resorted to, for its preparation is not always the same, and no two speci- mens are of the same strength. It has been injected hypodermically in doses of one grain. Oftenberg^ reports the cure of a girl of eighteen. She received at first hypodermic injections of morphine and chloroform, but there was no im- provement in her condition. Seven hypodermic injections, aggregating three grains of curare, were afterwards given in the course of six hours. The muscular disturbance subsided at once, and there was ultimate reco- very. The convulsions were succeeded by paralysis, which gradually disappeared. Hot baths have been recommended, but I cannot find that they have ever cured a case of this kind. HYSTERIA. Synonyms. — Hysterie (Fr.) Muttersucht (Ger.) Vapors. 1 Wien. Med. Presse, 1876, No. 1. HYSTERIA. 455 Definition. — It would be almost impossible to give a concise defini- tion of this most protean of nervous affections, for it simulates a multitude of organic and functional diseases so perfectl}^, that the task of considering it in any systematic manner would be attended with great difficulty. The nervous system in this respect is like the " general utility " actor. It plays the most varied parts. Sometimes we are presented with a hemi- plegia or paraplegia, and at others with contractures which seem to be the result of organic disease, so permanent and intractable do they appear. Convulsions, ansesthesia, urinary and other troubles of a more or less grave character, swell the list, until we are almost inclined to look upon it as a " disease of the Devil," and cease to wonder at the credulity and superstition of those who believe in demoniac possession and witch- craft. Confining ourselves as closely to the subject as possible, we con- clude that hysteria is a disease of an emotional character chiefly among women, in which the symptoms are rarely the same in any two instances, but among a large number of cases there can be noticed a certain simi- larity. Symptoms. — These symptoms may be grouped as sensorial, motorial, and visceral. Sensorial symptoms are of three kinds ; hypersesthetic, anaesthetic, and mental. Hypersesthesia, though much more common than anaesthesia, is not so marked. Large areas of hypereesthesia may be detected by careful examination, though the patient usually saves this trouble, for she calls attention to the weight of her clothes, the pressure of some fold of her underwear, or the contact of some very light substance which is pronounced unbearable. The external organs of generation are extremely sensitive, and the slightest touch of the finger or speculum pro- duces a spasm and great agony. Coition is impossible, and one patient called my attention to a horrible shooting pain which occurred whenever her husband approached her. Hypersesthesia about the nipples, at the end of the coccyx, and in other parts of the body, is alluded to by vari- ous writers. Charcot has directed attention to the prominence of these ; and Briquet has described fixed pains of the abdomen which he called ccelalgice, and of 450 cases he found 200 presenting this symptom. They were hypogastric and iliac, but more commonly the latter. These have sometimes been mistaken for the pain of peritonitis ; there is, however, no tenderness, but simply superficial elevation of sensibility. The pa- 1 tient often calls attention to vague pains in different parts of the body, of J a transitory, and sometimes permanent character. She complains of strong light and loud noises, and insists upon perfect quiet, although she will herself talk and cry in a very noisy manner. All of her pains are increased when her attention is concentrated upon them, but when her mind is diverted she will bear very rough treatment without complaint. Neuralgic pain, a familiar variety being the clavus hystericus, is a com- mon form of complaint. Various local pains are also experienced, and these, among others, include alterations in sensibility which simulate lum- bago ; indeed, a very constant hysterical complaint is backache, which the patient generally attributes to the kidneys. A most interesting form 456 CEREBRO-SPIN^AL DISBASES. of hysterical dyssesthesia has received mention from Skey, Paget, and others, and is very often mistaken for rheumatism. The joints are neither swollen nor red, however. ]M. Meyer,' in an interesting article upon the subject, gives the leading points in diagnosis as follows : " 1. The neu- ralgia is of a diurnal form entirely. 2. Light pressure of joints produces pain, but comparatively violent handling is not at all painfnl. 3. The temperature of the affected joint undergoes variations. 4. There is no loss of substance of the muscles of an unsound limb. 5. The cure is usually spontaneous." The mental disturbances are of the most interest- ing character, whether expressed by transient emotional excitement or apparent prolonged unconsciousness. Examples of the lighter grades are too familiar to need description, and it is only necessary to allude to the outbursts of immoderate laughter or crying which occur when there is no reason for either emotional elation or depression. Such individuals may indulge in laughter at church or at a funeral, and, while perfectly aware of the impropriety of their conduct, will be utterly unable to restrain themselves. Illusions, hallucinations, and even delusions are evidences of a very irritable condition of the nervous centres, as are ecstasy and mental excitement of various kinds, such as belief in impending calamity or death. The involuntary use of foul words and gestures, and a remarka- ble eccentricity of behavior, are additional suggestions of a disordered state of the emotions. Wynter,- in his excellent little book, thus alludes to a condition which, after all, is but a manifestation of hysteria. " There is a terrible stage of consciousness in which, unknown to any other human being, an individual keeps up as it were a terrible hand-to- hand conflict with herself when she is prompted by an inward voice to use disgusting words, which, in her sane moments, she loathes and abhors. These voices will sometimes suggest ideas which are diametrically opposed to the sober dictates of her conscience. In such conditions of mind, prayers are turned into curses, and the chastest into the most libidinous thoughts." ^ The will is quite weak, while the emotions, far from being held in abeyance to the extent which they are in health, respond to trivial ideational impressions. The hysterical person firmly believes herself to be the subject of various disorders of a greater or less serious character ; is hopeless ; believes in a speedy fatal termination of her imaginary trouble ; and can only be convinced of her mistake by fear of the reme- dy suggested, or by some strong appeal to her appetite or comfort. While in a state which may sometimes appal the observer, the patient declares her inability to walk. If, however, some powerful excitement be pro- duced, such as an alarm of fire, she quickly recovers the use of her legs. I have recently seen a most interesting case of hysterical torticollis, in ^ Berliner Klin. Woch., 1874, No. 26. - Borderland of Insanity, p. 3. 3 Hysterical girls and women occasionally evince a depraved appetite, eating all sorts of extraordinary things. The school-girl habit of eating slate-pencils is an ex- ample of this. I have personally observed this evidence of hysteria on many occa- sions. A young lady recently under treatment ate enormous quantities of nutmegs- The morbid appetite of pregnancy is probably an hysterical disorder. HYSTERIA. 457 whicli the patient refused to turn or raise her head. I quietly seated my- self at her other side, and engaged her attention so fully that after a while she turned her head and talked for some time ; and it was only when I referred to the subject of her troubles that she quickly resumed her original position, and I could not persuade her to change it. She may at times believe that she is deaf or dumb, and remain in such an uncom- fortable condition for years, punishing not only herself, but making all about her uncomfortable. One of the most striking mental characteristics of the hysterical woman is her utter want of confidence in herself. She relies upon all those about her, and goes to her physician at all hours and with no object in view except the need for sympathy. She often has an impending dread of some ca- lamity, and requires constant reassurance. If the physician could give her the belief that she could control her own emotions and conquer, much might be done. She even may know how unsubstantial are her symptoms — her paralysis, for instance, but she says " I cannot help it ; I have every desire to move my leg, or my arm, but I know that I cannot." Hysterical anaesthesia has received a great deal of attention of late years from the French observers, especially from Charcot, as well as Piorry and Gendrin. Briquet^ has found that this condition oc- curs more frequently on the left than upon the right side. It may be superficial or deep, even afiectiug the muscles and bones. Reynolds has found it limited often to the back of the hand or foot, or about the mouth and nose. The vaginal canal and the lining mucous membrane of the mouth are also places where there may be loss of sensation. Hysterical hemianaesthesia does not diflfer from that due to cerebral hemorrhage so far as the symptomatology is concerned. The same regions are affected and the same complicated amblyopia takes place. Taste and smell are unilaterally involved. Hysterical anaesthesia not rarely follows, or comes on during a convulsive attack, and lasts for a variable time. It may subside in a few hours, or continue for months at a time. During its existence the most violent stimuli will fail to restore sensibility ; and I have often used powerful counter-irritants, electricity, or even the hot iron, without any response whatever. The loss of sensation may extend more deeply, so that the underlying muscles may be utterly without sen- sation. This peculiarity probably explains the insusceptibility to pain spoken of by Carre de Montegeron. The Jansenists or Convulsionnaires " became so wrought up by religious excitement that they fell, twenty or more at a time, into violent coavul^ions, and demanded to be beaten with huge iron-shod clubs, in order to be relieved of an unbearable pressure upon the abdomen. One of the brothers Marion felt nothing of the thrusts made by a sharp-pointed knife against his abdomen." Not only may there be analgesia, but loss of appreciation of heat or cold, and the surface may become blanched and white, and the skin even bloodless. Brown-Sequard has demonstrated the absence of blood ; a fact ^ Traite Clinique et Therapeutique de I'Hysterie, Paris, 1859. 458 CEREBRO-SPINAL DISEASES. which has an historical interest in connection with the tests of the early- religious enthusiasts. Charcot alludes to the epidemic of St. Medard, when the cut of a sword failed to produce any flow of blood. The tem- perature of the anrcsthetic spot is sometimes lowered two or three degrees, and varies in different regions. There may be anresthesia of the mucous membranes of the mouth, the pharynx, and larynx ; or the organs of special sense may be implicated, and a resulting amaurosis, amblyopia, or deafness ensue. In a paper upon " Hysterical Affections of the Eye," by Dr. Geo. C. Harlan,^ of Philadelphia, attention is directed to retinal an- aesthesia and various hysterical disorders of an interesting character. " Almost any derangement of vision may be counterfeited. A little girl of eight years complained that every object that she looked at seemed covered with diagonal white lines, the direction of which she indicated with her finger. As the ophthalmoscope revealed a normal fundus, a favorable prognosis was given. This was made more positive the next day, when the white lines changed to blue, and was justified by the early disappearance of the difficulty. '' In the second class of cases we have more or less retinal anaesthesia, with anomalous and variable symptoms, changing, perhaps, at each ex- amination. " In the third class of cases the parts affected have been the retina, the muscle of accommodation, the external muscles of the eyeball, and the elevator of the upper eyelid. " It is not very uncommon to meet with patients who have apparently perfect eyes and full acuity of vision, but who say that the test letters be- come blurred and unrecognizable after they have looked at them for a few seconds. That this is due to an exhaustion of the sensibility of the retina which disables it from the sustained performance of its function, and not to an irregular action of the accomtaodation, is shown by the fact that it persists when the eye is fully under the effects of atroj^ia. As to color blindness in hysterical women, I think its importance has been exaggerated, and I have very rarely met with even the slightest affection of the color-sense, unless the hysteria has existed in connection with cerebral disease and herai anaesthesia. Taste and smell are sometimes impaired, so that there is a greater or less extensive loss or a perversion, the patient declaring that natural odors are reversed, or that articles of food are tasteless. The Motorial symptoms are numerous, and maybe either of a sthenic or asthenic character. The more simple include spasms, violent gesticulations, and contractures : the more obstinate, paralysis of either a hemiplegic, or paraplegic, or even a local form, and chorea and convulsions, as well as various kinds of muscular incoordination. The individual may assume the most painful positions, the limbs being rigidly flexed or extended, and the face distorted by grimaces of the most absurd description. Sometimes there is torticollis, or spasm of some small group of muscles, or the muscular 1 Phil. Med. and Surg. Eep., August 12, 1876. HYSTERIA. 459 rigidity may even amount to opisthotonos, pleurothotonos, or emprostho- tonos, and these forms of trouble are much more marked in conditions of hystero-epilepsy and hystero-catalepsy. The dependence of these motorial phenomena upon reflex excitement is their marked feature, slight peri- pheral irritations, uterine trouble, or sexual excitement of any kind, often being the origin of the affection. The pharynx, larynx, and not rarely the stomach are implicated, so that difficulty of swallowing, loss of speech, and vomiting are resulting phenomena. Hysterical attacks of a convulsive character are met with sometimes, when the jDatient is apparently unconscious, but is in reality not at all so. There is slow respiration, which is scarcely perceptible, and small weak pulse. The legs and arms may be wildly thrown about, or rigidly extended, and there may be opisthotonos, while the skin is livid, and may be bathed in perspiration. A lighter grade of attack is frequently seen, in which the patient, after a period of excitement, screams, and falls to the floor (being very careful not to hurt herself) ; her muscles become contracted ; she breathes heavily, froths at the mouth, talks incoherently, and berates those about her. She may cry, and in doing so sobs violently, sometimes catching her breath in an alarming manner, frightening her attendants and attracting sympathy. If left to herself and not noticed, she may fall asleep or gradually recover. The patient looks about the room during the attack, and is undoubtedly conscious of what transpires. One significant mark of hysteria, previously alluded to, is that, however much the patient throws herself about, she is always careful not to do her- self injury. Pomme^ was among the first to describe hysterical contrac- tures, and later Gorget related a case of hysterical flexion of the thigh upon the pelvis which was supposed to be due to coxalgia. In hemiplegic contractures the upper limb may be drawn in to the trunk, the forearm is flexed at a right angle, the thumb is bent so that the point is buried in the palm of the hand, and it is covered by the other fingers. According to Strauss,^ extension of the upper limbs is quite rare. The lower limb is extended, so that the foot presents the appearance of talipes equiuus, the toes having a claw-like apj)earance. The thigh is extended on the pelvis, and the whole limb is adducted. Hysterical contractures of a permanent character may affect the body, either laterally or below the waist, or but one member may be involved. Charcot^ relates a case in which the left leg was firmly extended. The foot presented the deformity of talipes varus, and the limb was very rigid, so that, by lifting it, the body could be moved without bending the knee. The contracture could be overcome by chloroform, but returned when its effects had disappeared. In this case the limb was agitated by a tremor, or " tremulation convulsive," as this author calls the movement. These hysterical contractures often last for years, and are cured spontaneously. Skey * relates a case which is quite interesting. ^ Traits des Affections Vaporeuses. '■^ Op. cit., p. 307. * Des Contractures, Paris, 1875. * Hysteria, etc, London, 1866. 460 CEREBRO-8PINAL DISEASES. " In the year 1864 a young lady of 16 years of age was placed under my care under the following circumstances : For eight months prior to her visit to me, she had been suffering from inversion of the left foot, which was so twisted as to bring the point of the foot to the opposite ankle ; in fact, at nearly a right angle with the foot of the opposite side. Her family consulted a surgeon of much experience in the treatment of distortion, and of orthopaedic notoriety. The case was considered as an example of an ordinary distortion, and the foot was placed in a very ela- borately made foot-splint, by the force of which it was made to approach a parallel relation to the opposite side ; but it was an approach only, for no mechanism could retain it in a perfect position, the toes yet to some degree pointing inwards. A month elapsed, and the disease continued unchanged. A second orthopaedic authority was then consulted in con- junction with the first, and as no new light was thrown on the disease by the combined opinions of the two, the same principle of treatment was recommended to be continued, and the mechanism was yet somewhat more elaborated, and thus the eighth month of the young lady's life passed away, during which no constitutional treatment was resorted to, and loss of exercise, for she walked, it was almost unnecessary to say, with great difficulty." Skey examined the foot, and arrived at the conclusion that the inver- sion was too great to be due to the muscles alone, and discovered that those of the whole limb were involved ; that the disease had appeared suddenly in a girl of 15 years, who was otherwise well and strong, and in whom there was no indication of acute local disease. The apparatus was removed ; a hearty diet, with tonics, was ordered ; she was told to walk ; and at the end of six months was invited to a ball, her foot being still deformed. She accepted an invitation to dance, and remained standing throughout the entire evening. She had been sud- denly cured. Hemiplegia and paraplegia of an hysterical character are sometimes met with, as well as local paralysis, but the face is rarely affected in hysterical hemiparesis, and the tongue never so. The walk is quite different from that of organic hemiplegia, and the foot is simply dragged along and not swung, and there is an absence of that helplessness which is so characteristic of the seri- ous trouble. Electric sensibility and contractility are not usually affected, though the former may be occasionally impaired. The cure is spontaneous, and there is never atrophy or anj'^ of the peculiar tissue changes of neuritis which generally follow hemiplegia from cerebral dis- eases. Paraplegia of the hysterical variety is rarely attended by any urinary or rectal trouble, and never by incontinence, and the muscles are well nourished and respond to electric stimulation. Some voluntary motion is possible in the recumbent position, and it is only when the patient walks that she shows her loss of power. Reynolds states that a peculiarity of the disease, which is familiar to all, is the fact that no amount of help can keep the patient from staggering or falling ; she may be supported by strong anus, but she sinks to the ground, not, however, falling entirely, but regaining her position by a voluntary effort. The patellar tendon-reflex is usually increased upon the paralyzed HYSTERIA. 461 side ill hysterical hemiplegia. I have never found it to be diminished, but care should be taken to define the line between the paralysis, due to ravelitis, with hysterical symptoms, and the hysteria, in which there is paralysis. I have referred to the former cases in a previous article. The visceral troubles are a host in themselves. Not only may the patient complain of unbearable pains situated in the liver, stomach, and other organs, but there may be urinary affections of considerable impor- tance. Two varieties of hysterical urinary derangement are spoken of by Charcot, one beiug ischuria, and the other a complete suppression, which he has called oligurie. In both cases the urinary passages are per- fectly normal ; in the first there is simple retention of urine in the bladder ; and for a long time (amounting even to months or years) it will be found necessary to use a catheter. Laycock^ has called attention to this state of afiairs, which lasts some- times twenty-four or thirty-six hours, during the menstrual epoch. Charcot has found the condition to last even longer— sometimes for seve- ral days. This suppression of urine is occasionally accompanied by vomiting, and the presence of urea has actually been discovered in the vomited substances. This has been explained by the experiment of Brown-Secjuard, w^ho found that after certain forms of mutilation cai*- bonate of ammonia or free urea was found in the intestines of animals, which settled the fact that there was a " supplementary elimination." This same condition of afiairs is not unusual in renal disease, and the odor of the breath and sweat is decidedly uriniferous. Vomiting of fecal matter is a rare symptom. There is in the majority of cases a decided increase in the amount of urine voided. It is of a very light color, quite limpid, and of low specific gravity, and is sometimes discharged during the convulsive seizure. Digestive disturbances, accompanied by eructa- tions of wind, borborygmi, epigastric pain, and loss of appetite, are pre- sent in most cases. Abstinence from food and continued unconsciousness need hardly be alluded to in this chapter. Cases of this kind derive sensational impor- tance from newspaper description, and from their very hysterical nature suggest fraud and deception. The case of Louise Lateau, as well as others, has been cleverly investigated, and is doubtless familiar to my readers. The history of this class of cases furnishes us with many exam- ples, some of which are quite ancient. Senneratus^ writes of three individuals who fasted almost two years, and " yet, though lean, were in good health." Upon the authority of Schenck,^ we are informed that "Katherine Binder, a native of the upper Palatinate in Germany, was said to receive no other nourishment than air for more than nine years. John Caffimer, in the year of our Lord 1585, commanded her to be watched by a Minis- ter of State, Ecclesiastic and two Licentiates in Physic, but they could 1 Treatise on the Xervous Diseases of Women, London, 1340, p. 229. 2 Prax Med., p. 212. ^ Obs. 1. 3, p. 306. 462 CEREBRO-SPINAL DISEASES. make no discovery of her beiug an impostor, and therefore reported it to be miraculous." A symptom which I am inclined to think very common, but which is not generally considered so, is the globus hystericus. The patient calls at- tention to a " lump which rises in her throat." It is probably nothing more than a spasmodic contraction of the muscles of the pharynx or oeso- phagus, or in other cases a morbid, sensory distui'bance. It " rises " from the epigastrium, and is attended by dyspnoea and difficulty in deglutition. In some cases obstinate vomiting, which is readily excited by such slight agencies as a hand laid upon the surface of the body, or the administra- tion of a very small amount of food, is a formidable symptom, and unless corrected the patient may become speedily exhausted. In one case which I saw at the request of Dr. Austin Flint, this condition had lasted for seve- ral years, and was not relieved by any medication, but was for a time stopped by pressure made over the left ovary. The disease among males is of interest because of its rarity. A case presented by Bonnemaison,' of Toulouse, may be cited : — The patient was a man aged 72. The brother of the patient was a hypochondriac; and his mother, who died at the age of 81, suffered from various forms of nervous disturbance, analogous to those of her hysterical son, after reaching her 76th year. The attacks in the case of Dr. Bonne- maison's patient came on three or four times in the twenty-four hours ; ushered in, when occurring during the night, by nightmare; when in the day, by various sensations, and usually by pain in the ei^igastric region. An aura proceeding from this point traveled along the sternum to the throat, and thence to the mouth and tongue, and other regions of the body, the muscles of the parts affected by this sensation being thrown into violent, rapid, and unaccountable convulsive action. The patient uttered strange cries and yells, or repeated the same words over and over again with extreme rapidity. At times the tongue would be smacked violently against the roof of the mouth, the cheeks spasmodically puffed out with the action of blowing or whistling, and the jaws snapped violently toge- ther, without, however, biting the tongue. The arms were moved rhythmi- cally together with the action of flying, or drumming, or playing the piano. Sometimes the lower limbs shook violently, or executed the movements of dancing. The attacks bore a strong resemblance to those of the " convulsionnaires " of St. Medard, or the rhythmic chorea of the epidemics of Louviers, Toulouse, and Morziac. The disturbance of the voluntary muscles might be accompanied by spasm of the involuntary mu-cles also, or the latter might form the chief phenomena of the parox- ysm, consisting in hiccup, eructations, sighs, and borborygmi. During the whole of the attack the hyperiesthesia of the skin was excessive, especially at the forehead, epigastric region, and sternum ; there was no loss of consciousness. The attack ended either wi^h a copious flow of limpid urine, or a discharge of tears. There was never any pain or sensation referable to the generative organs, nor anything whatever in the history of the symptoms indicative of their implication in any way whatever. The same absence of any pathological condition of the organs ^ Archives Generales de M6d., Jan., 1875. Abst. in Med. News, Oct. 1875. HYSTERIA. 463 of generation has been observed in cases of male hysteria observed by others. Children are not exempt from hysterical troubles, and much of the perversity of young children will often be found to be of this character. If this fact was recognized, a great deal of the suffering in after life might be prevented. Many of Briquet's cases began before the twelfth year, and it will ba found that even before puberty the tendency to this trouble may be often recognized. Dr. Jacobi,^ whose careful investigations of the nervous diseases of young children have furnished us with striking facts, looks upon hysteria as an extremely common trouble among young children, connected often with masturbation even in infants of two or three years. Jacobi refers to the tables of Briquet, Amann, and others, to show that hysteria is found frequently before adolescence. Of Amann's cases, 16 of 268 cases were between 8 and 10 years; of those of Althaus — 820 — seventy-one were be- fore the tenth year. Landouzy collected 303 cases, 48 of whom were between the tenth and fifteenth years. Causes. — Hysteria is most decidedly an affection of women, and is connected in many instances with some sexual or uterine derangement. Among men hysteria is far le«s rare, I think, than it is supposed to be, but with them the hysterical trouble is of a lighter grade, and it is un- usual for examples either of ansesthesia, convulsions, or contractures to be witnessed. As a rule, the hysterical man possesses a smooth face, slen- der figure, soft falsetto voice, large thyroid cartilages, small hands, and tapering fingers, and sometimes large mammse. His genital organs are poorly developed, and his manners are mincing and effeminate. Hysteri- cal phenomena are, however, not uncommonly presented by stalwart men. Among women this approach to the appearance and behavior of the other sex is inconsistent with the development of hysteria. Women with bushy eyebrows, coarse hair, perhaps a slight moustache, angular build, narrow hips, and coarse voices are seldom hysterical. They are " strong-minded," rarely emotional, and inclined to look upon the hysterical trouble of their weak sisters with something like contempt. Reynolds aptly says : " Some women are as little likely to become hysterical as some men are to fall pregnant." It might be added : and as their chances to conceive are diminished. Hysteria is of much more common appearance among spinsters and single women, and is far from being rare among old maids who marry late in life. A case of this kind fell under my observation some years ago. An examination revealed an undeveloped uterus ; and from the nuptial night dated a series of ner- vous symptoms of a grave hysterical character. The uterine irritability which is connected with the pregnant state between the ages of thirty and 1 On Masturbation and Hysteria in Young Children, by A. Jacobi. Am. Jour, of Obstetrics, etc., vols. viii. and ix., 1876. 464 CEREBRO-SPIKAL DISEASES. forty is apt to produce a profound impression upon the nervous system. Among married women with impotent mates, or among tliose who have, on the other hand, suffered through the lust, inconsideration, and brutalitv of husbands of another kind, the disease is not uncommon. The puerperal state, lactation, and the cessation of the catamenia favor its development. I have lately treated a number of cases of a class which I am sure is familiar to most medical men, especially to those who devote the greater part of their time to the study of nervous disease. I allude to certain ill-defined hysterical conditions that are connected with or follow the pu- erperal state. These cases do not come under the head of puerperal mania, which is a common and well-recognized form of insanity, but are difficult of description and classification, because of their irregularity. The patients I have seen have all been urcemic at some time during preg- nancy, not to the extent which is accompanied by convulsions or other grave symptoms, but the blood-poisoning was much more extensive than it usually is. Barker thinks that albuminuria is not the cause of puerpe- ral mania, but, when found, is merely a coincidence. In the cases I allude to it was always present, and seemed to be the cause. I have seen the same symptoms expressed, though in a less marked degree, in patients who were suffering from chronic nephritis, and where the puerperal state had nothing to do with the history.* In the spring of 1875 Mrs. C came to my office with her husband. I found her to be an amiable, well-educated woman of thirty-two years of age ; her manner was cheery and agreeable, and there was no evidence of mental trouble. Three months before this she had been delivered of a child at full term, which was born dead. X. week after her milk " dried up." The last months of her pregnancy were attended by evidences of urtemia, marked ana-sarca, clouded urine excreted in small quantity, but no convulsions or mania. Mrs. C.'s previous history was uneventful. There was absolutely no hereditary predisposition to insanity, and her mind was perfectly clear during pregnancy. She was antemic, and complained of dizziness, palpitation, gastric dis- turbance, vertical headache, loss of memory, ringing in the ears, etc. She passed her urine at the time of her visit in normal amounts, and it did not contain albumen. Her complexion was pale, and her pupils were dilated. A very slight blueness of the skin was apparent, but was confined to the hands. The lips had not lost their lines of expression, which is generally the case in melancholia, and they were not swollen. She was inclined to sleep. Considering that the symptoms indicated '• cerebral ansemia," I began with iron, phos^^horus, and other remedies of the same kind. Two days after this visit she again appeared at my office, looking much agitated, and saying that she had come for " protection from herself." She had been tempted to get up from her bed and cut her throat with her husi)and's razors. She was perfectly cognizant of her condition, and was aware of the fearful nature of the act she was tempted to perform. After a talk of half an hour, she left me, feeling settled, and without the desire. ^ Bost<'n Med. and Surg. Journ., June 15, 1876. HYSTERIA. 465 On another occasion she came to see me, as "she had the feeling again." She had taken her sister's baby in her lap, and while it was there she ''suddenly felt like throwing it on the floor" with all her force. At another time she was prompted to run the blade of a pair of scissors into the fontanelle. These impulses would recur every week or so, when she always came to see me, and would sit a few minutes, talk upon other sub- jects, and rise to go, saying : " Now, doctor, the feeling has passed off" Not at this time, nor at any other, were there delusions of any kind. Under treatment she improved in general health, and her nervous symp- toms disappeared. Her last morbid impulse occurred during the fourth month after treat- ment. One evening, with her husband and brother, she went upon the house-top to see a fire. While there the old feeling returned, and she would have thrown herself from the roof, had she not been prevented. This was the last and most serious expression of the disease. Since that, time she has not had a return, and says she is perfectly well. A second case I lately saw was attended by slight though perfectly de- fined mental changes. The patient was a young married woman of twenty-four years. For some time before parturition and during her pregnancy there was kidney trouble. Before her labor she was a loving and devoted wife, but shortly after lost all of her amiability, and treated her husband and mother with marked coolness, and sometimes with de- cided rudeness. A month after delivery she took a deep interest in re- ligious matters, and carried the observance of her religious duties to such a pass as to be disagreeable to all about her. She did eccentric things, such as getting up at night, going down to the piano in the drawing-room, and singing hymns. When reminded of the unseasonableness of the hour, she would return to her bed, first shutting the hymn-book in a mechanical manner. I saw her in this condition, and found a state closely bordering on mel- ancholia, though there was no mental depression, no anxious facies, no sighing, no hopelessness. A p^^rsistent use of agents which would restore the action of the kidneys, combined with fresh air and a well-regulated diet, did her much good. After a few weeks the patient slept well, and the mental irritability gradually disaj^peared. In both of these cases there were symptoms which were not those of insanity. In Case I. the patient was able to reason, and had full con- sciousness of her infirmity ; so that she had the power to seek the society of others when she felt the impulse. There was the absence of all physi- cal signs of insanity, except the coloration of the skin. In the second case, the short duration of the mental trouble, and its subsidence with improvement of the kidney difficulty, proved it to be a functional de- rangement. As regards age, pronounced hysteria rarely begins before the twelfth year; it generally takes its origin at the time of puberty, and from this pe- riod may continue through life. It not rarely begins after marriage, or sometimes not until after the menopause, but this is exceptional. In males it begins in middle life, though I have seen the affection among boys. Hys- teria is not necessarily a disease of the well-to-do, though indolent habits and luxurious living favor its development ; but it frequently appears among 30 466 CEREBRO-SPINAL DISEASES. overworked shop-girls who are compelled to stand for many hours during the day. The follies of fashionable life have much to do with the pro- duction of a morbid performance of functions of the nervous system. Continued rounds of dissipation, parties and balls which do away with sleep, together with excitement and late suppers, days of idleness spent in reading sensational novels and eating improper food, or tippling liqueurs, especially favor the development of this morbid state. This mode of life, when kept up for some time, especially when the menstrual periods are disregarded, brings about a condition of ei'ethism which expresses itself in the symptoms I have named. Dysmenorrhoea may be attended by attacks, and so may menorrhagia, but many cases occur even when there is no disturbance of menstrual function. Abnormalities of the posi- tion of the uterus, and excessive sexual excitement, whether from mas- turbation or coition, have decided etiological bearing, while warm weather favors the development of attacks. Mental worry, emotional excitement, an attack of illness, and a number of influences of the same kind all act as exciting causes. Morbid Anatomy and Pathology. — Accidental lesions are some- times found, but so irregular is their character that they are valueless as indications. As to the pathology of the affection, very little can be said in addition to what has already been stated in speaking of the symptoms. Hysteria may be said to be a very near relation to insanity, and one writer even con- siders it a form of insanity ; but I should be loath to believe that so many people are actually insane. Hysteria is rather a mental inco-ordinatiou. Emotional exaltation, conuected with liveliness of ideation and with feeble volition, and a, paralysis of judgment, may be said to be the mental condition of an hysterical patient. The balance is lost ; and when the emotional side has full play, all the reflex and sensational functions are active and unchecked, while it is only with difliculty that the governing side to which belong volitional and intellectual control is made to counter- act the other. This is only brought about by the most powerful agencies, and sometimes these are inefficient. If the reader will consult an article by Lauder Brunton,^ in one of the West Riding Reports, he will find some excellent diagrams which illustrate the mechanism of the nervous centres in the physiology of inhibition. I have slightly modified the chart of this author by introducing another centre. Let Fig. 60 represent the arrangement of nerve centres concerned in the performance of the functions of the cerebro-spinal system. I. indi- cates the centre of ideation, E. an emotional centre, W. a will centre, M. a motor centre innervating ; M (a muscle), v (a vessel), and G (a gland). S. is a sensory centre, and P. the origin of an external impression. The connecting lines are efferent and afferent nerves. It will be seen that I is in centrifugal communication with W, with M, S, and with E. So that ideas which are evolved without external stimulus may find motor expres- ^ West Riding Lunatic Asylum Reports, vol. iv. p. 179. HYSTERIA. 467 sion either in a voluntary or involuntary manner ; may affect the emo- tional centre, or may be stimulated by impressions received either from that centre or from S. External impressions may be transmitted from P either to S, to E, or to M ; in one case being perceived and transmitted to a higher centre, or being converted into a reflex action. E is affected by S and by I, and in turn influences M and I, and to a slight degree W ; or on the other hand may be controlled by W. In the normal state we may roughly suppose the proportions of these areas to be represented in the right-hand diagram. In the hysterical state their relative (left-hand diagram) size is greatly altered ; E gains in size, and W is very much diminished. The relative size of the communicating tracts also under- goes modification. Though this explanation is decidedly rough and super- ficial, I trust it will give the reader a better idea of the pathology of this affection than would any extended written description. Fig. 60. The Pathology of Hysteria. Diagnosis. — As hysteria may counterfeit nearly every known symptom, it will be seen that the task of making a diagnosis is not always an easy matter. If, however, we consider that the symptoms are generally presented in a group, which is decidedly irregular and its elements inharmonious, and that the patient is on the alert in regard to all that goes on about her ; that she has a fear of severe treatment ; that the use of chloroform will certainly overcome the contractures ; and that the cure is generally sudden, there is not much chance for mistake. Besides, there is never any evidence of gross organic change, the muscles only losing their fulness from inaction. Jannet^ says that the difference between hysteria and epilepsy, with which it is often confounded, can be detected by the thermometer, there being no change in the former trouble. ^ De r hyslerie chez 1' homme, Thise de Paris, 1880. 468 CEREBRO-SPINAL DISEASES. Prognosis. — If the individaal has suffered for a great length of time, and especially if there be confirmed uterine or ovarian disease, the chances of entire recovery will be extremely bad. The disease is not only discouraging in the way of treatment, but annoying to the friends, and far more disa- greeable to the physician, who receives very little for his pains but abuse and want of appreciation. Some cases may be easily cured, and these are among young people. Much, however, depends upon treatment. Dr. Mitchell has known of three deaths from hysteria, and all three were abrupt, and one was due to acute congestion of the kidneys. In two cases that have fallen under my notice, death has taken place in an en- tirely unexpected way. In one patient there was intense cerebral cedema, and the other, seen by Dr. Ball at my request, rapidly developed uraemic symptoms and died comatose, her death being preceded a few hours by hemiplegia. Treatment. — The history of the treatment of hysteria is curious in the extreme. Going back to the middle ages we find numerous examples of miraculous cures, which were undoubtedly of an hysterical character. Scheie de Vere, in his little work entitled " Modern Magic," thus speaks of a favorite mode of treatment which has been followed by the Zouave Jacob and many others in modern times : — " The imposition of hands for the purpose of performing miraculous cures has been practised from time immemorial ; Chaldees and Brahmins alike using it in cases of malignant disease. The kings of England and of France, and even the counts of Hapsburg in Germany, have been reputed to be able to cure goitres by the touch of their hands. The idea seems to have originated in the high North, King Olave the Saint being reported by Snorre Sturlesou as having performed the ceremony. From thence, no doubt, it was carried to England, where the Confessor seems to have been the first to cure goitres." " In more recent times a prince, Hohenlohe, in Germany, claimed to have performed many miraculous cures, beginning with Princess Schwar- zenberg, whom he commanded in the name of Christ to be well again. Many of his patients, however, were only cured for the moment. When their faith, excited to the utmost, cooled down again, their infirmities returned. Still there remain facts enough in his life to establish the marvellous power of his strong wnll, when brought to bear upon peculiarly receptive imaginations and aided by earnest prayer." Several years ago an individual named Newton went about the country. It was his custom to hire a large hall and extensively advertise. Upon the day appointed he would meet the lame, halt, and blind, and after powerful exhortations and prayers, tell them to form in line and pass one by one before him. The emotional excitement and eager anticipation were sufiicient in some instances to divert the hysterical patients who chanced to be among the number, so that in many instances there were spontaneous cures, the lame dropping their crutches, and starting off at a lively gait, and the blind recovering their sight. Beard, in a paper upon "Mental Therapeutics," recently called HYSTERIA. 469 attention to some experiments he had been making. In many in- stances of functional disease, he assured the patients that their recovery would take place in some very short time, and found that at the time specified they returned completely cured. This procedure in cases of hysteria is of great value. I have repeatedly stopped an hysterical attack by a douche of cold water or by the exhibition of the cautery. Oftentimes, after the patient has been pleaded with, threatened, and dosed to no effect, a sudden fright or a sharp word or two will do more for her than anything else ; but the physician's demeanor to his patient should always be characterized by firmness and dignity, and not by harsh- ness or undue severity. It is a difficult matter to meet the peculiar manifestation of disordered mental expression in hysteria, for, as we all know, its phases are nume- rous. No two cases of hysteria are exactly alike, and consequently no two can be treated in the same way. A scolding occasionally does good, as I have just said ; but in other cases it would aggravate the patient's condition. We cannot treat the hysterical woman in a trouble-saving and careless way ; and though many medical men hold that a sharp word or the direct appeal to the common sense, which is, however, absent here, is all that is required, it will be found that such a course is by no means a wise one to always follow. In many cases it is not best to tell the woman that she is " not to give way," or that she is " not to disgrace herself," for she is unable at once to use her will to overcome all the indirect agencies at work which are acting upon her disordered brain. It is better to gain her confidence, and make her gradually exert her will in new channels by the performance of some act which requires the use of physical force, and this form of exercise may be prescribed by the physician. As to medication, we may make use of the motor-depressants, bromide of sodium, hyoscyamus ; or the mono-bromide of camphor in doses of three grains every hour, till quiet is obtained ; the spts. etheris co., chloroform or chloral, and valerian, or its compound, valerianate of zinc. The ob- stinate vomiting is occasionally stopped by hypodermic injections of mor- phine ; and a belladonna plaster over the irritable ovary will often prove to be an excellent form of treatment. All sources of reflex irritation should be removed as soon as possible, and uterine congestion overcome by leeching the cervix uteri, or hot douches. When there is much irrita- bility of the pelvic organs, I would suggest a combination of tr. cannabis indicus, and bromide of ammonia, with mucilage as a menstruum. For the anaesthesia and paralysis, strychnia and electricity are the best remedies of which I know, the latter being employed in its induced form, and the electric brush applied upon a dry surface. General treatment of a tonic character should be used when it is possible ; and iron, in com- bination with phosphorus or phosphoric acid, cod-liver oil, and sea-baths, together with local treatment. Local disease should be promptly eradi- cated if possible, uterine versions or flexions righted, and the menstrual function restored to its regular character. In those bed-ridden cases which are so discouraging and trying, we may use Weir Mitchell's treat- 470 CEREBRO-8PINAL DISEASES. ment. A patient may lie in bed leading a very irregulai* life, and doing just about what she chooses, without improving in the least; while, if her room be well lighted, her diet changed, and her muscular tone kept up, a cure may be often wrought. I am not inclined to place any faith in the wonderful accounts of " me- talo-therapy " as used in these cases, and in several experiments I have made I have come to the conclusion that the possible increase in sensi- tiveness came entirely from the warmth of the metal applied or the irrita- tion of the foreign body. If the skin of a perfectly healthy person be subjected to slight rubbing or pressure, and a point be applied, he will feel the application much more acutely than in other parts in the vicinity. For acute paroxysms of hysteria, we may use large enemata containing assafcBtida, and if a suppository of this drug in combination with bella- donna is inserted every night, a constant influence upon the patient is kept up which is very beneficial. HYSTERO-EPILEPSY. This interesting variety of nervous trouble has received a great deal of attention from Charcot,^ Dunant," Dubois, and Bourneville, as well as from many other writers, some of whom did not recognize its distinct character until after Charcot's valuable investigations had been announced. Tissot* says that "the hysterical attack sometimes resembles epilepsy, so much so as to have received the name epileptiform hysteria, but the attack nevertheless does not possess the true character of epilepsy." Others, among whom are Briquet,* Landouzy, and Saunders, have also described the condition. Upon the authority of Charcot,' the combinations of epilepsy and hys- teria take place under the following different circumstances : — 1. a. Epilepsy being the primary disease, upon which hysteria is en- grafted, under the influence of emotional causes or at the time of puberty. b. After marriage (vide Landouzy's Case), the epilepsy having always existed. After connection, the hysterical feature of the attack is de- veloped. In this case the hysterical character of the epilepsy subsided when sexual excitement was interrupted by pregnancy. 2. The hysteria being primary, the epilepsy is added thereto. A rare condition. 3. Convulsive hysteria coexisting with petit-mal. 4. An epileptic attack, followed by hysterical contractures, anaesthe- sia, etc- I have observed a form which slightly differs from any of the above. The patient, an epileptic, was seized occasionally with hystero-epileptic attacks during the menstrual periods, and at other times there was un- * Lepons sur les Maladies du Systenie Nerveux, part i., Paris, 1872. * De I'Hyst^ro-^pilepsie. ^ Maladies des Nerfs, quoted by Charcot. * Op. cit. 5 Op. cit., p. 324. HYSTERO-EPILEPSY. 471 complicated epilepsy. She has had epilepsy since the fifth year, when she was frightened by her mother, who threatened to beat her. Symptoms. — In an excellent pictorial work published by Bourne- ville and Regnard, the admirable clinical assistants of Charcot, a num- ber of plates are given, some of which I have reproduced with an ab- stract of the description by the authors. ^" The prodromal features of an hystero-epileptic attack are ovarian hypersesthesia, the globus hystericus, cardiac palpitation, constriction about the neck, noises in the ears, violent beating of the temporal arteries, obscure vision, etc. The immediate attack is ushered in by irregular respiration, oppression and dyspnoea, awkwardness of speech, amounting to embarrassment, of which the following example, which occurred in one of our author's cases, may be presented. After the prodromal symptoms described above, the patient, with hesitation and difficulty, enunciated the words : " J'ai . . . I'a . . . respiration . . . . dif . . ficile . . . se . . ne . . . . serai .... pas . , . . malade . . . afin . . . de . . . pas . . . avoir . . . de nitrite d'amyle," in the way they are written. Some tumultuous heaving of the belly then follows, the eyelids palpitate rapidly, the look becomes fixed, the pupils dilated, the gaze is fixed upon some object above, then she loses consciousness. (Fig. 61.) Tonic Phase. — {Bourneville). The actual attack is characterized by an initial stage (the tonic phase) of tonic convulsion. The entire body becomes rigid, the arms being usually stretched out, and the hands are turned in ; there is a movement of circumduction of the hands and forearms, the arms being drawn across the body, and the back of the hands brought together, so that the knuckles are approximated (see Fig. 61). The inferior extremities 'are stretched out, and drawn apart, the feet being in the position of equinus varus, but in other cases the feet may overlap each other, the toes being 1 See author's review of Bouraeville and Eegaard's work, Am, Jour, Med, Science, July, 1879. 472 CEREB PvO-SPINAL DISEASES. strongly flexed. The face is contorted and suffused with blood, and the mouth is often widely opened, or in some cases tightly shut, the lips being compressed over the teeth. Respiration is suspended, the pulse is with difficulty perceived, and the belly is immobile and contracted. The next phase is that characterized by tetaniform and clonic spasms, the head, which was drawn downwards and to one side, or backwards, returns to its normal position, the facial muscles become seized with clonic spasms, and the eyelids are opened and shut violently but somewhat slowly. A stertorous phase supervenes, the face becomes covered with large drops of sweat, the respiration grows noisy and violent, and there is frothing at the mouth. A period of repose then follows, when the respiration appears regular ; there are movements of swallowing, abdominal gurglings are heard, and undulations of the abdominal walls become apparent. The clonic phase, \ih.\c\i has been described as the " stage of contortion," is expressed in two ways, which sometimes succeed each other in the same attack. 1. In clonic movements of the limbs and head, which is rolled from side to side. The face is red and engorged with blood, the neck is stiff, and the arms are stretched out and contracted, and after a time the patient falls violently to the bed, arising and falling again several dif- ferent times. At the same time the rigidity of the arms disappears, little by little. 2. " The mouth is widely opened, the tongue is protruded ; she moves rapidly to the side of the bed crying oh ! oh ! (oite ! one !) The body becomes curved in opisthotonos. She rests on the back of the head and feet, her hair is dishevelled, the legs are convulsed and agitated by alter- nate movements of flexion and extension." (See Fig 62). A new period of repose follows. By far the most intere-tiug phase of the disorder now makes its ap- pearance, viz., the period of delirium. In Bourneville's patients, and in fact those of other observers, the incidents of the previous life figure conspicuously in the delirium, and though there is a tendency to the for- mation of causeless hallucination of the horrible kind, in which reptiles, and such small animals as rats and cats figure at some stage, there is an old impression which serves as a field for the development of a delirium which is exhibited by gesticulations and facial expressions of fear, ecstasy, auger, mockery, erotism, and grief. The patient at this stage a sumes an attitude and expression indicative of her emotional condition. She may remain lying upon the bed, her body inclined to one side, her arms resting by her side, her face upturned and wearing a beseeching look, which constitutes the " Attitude Passi- onelle" of Appeal. At another time she clasps her hands, sits up, turns her face upwards, and gives expression to words of supplication, such as these ; " Tu ne veux plus ? Encore . . ! " this being the " Sujjpli- cation Amoreuse." At other times the patient lies upon her back, her arms crossed over her breast, and her f ice wreathed with a most sensuous smile (erotisme). The variations of the delirium do not seem to b^ at all regular in. HYSTEKO-EPILEPSY 473 their mode of appearance or constancy, but there is a general similarity in the form of emotional excitement and method of expression, and from an inspection of either of the cases, it ^vould appear that for several days at a time there were convulsive attacks followed by delirium, in which scorn, mockery, fear, amorous ecstasy, subsequent repose, and either a re- turn of the delirium, or fresh convulsions, occurred. Phase of Opisthotonos. — {^Bournevllle). There may be fifteen or twenty attacks in twenty-four hours, or even many more, and some of these are aborted or irregular, at such times the only manifestations being those of a purely psychical nature ; the syn- copal attacks being examples of this kind. In rare cases the clonic phase (or period of the grand movements) is followed directly by the extension of the arms at right angles from the body, so that an appearance is pre- sented which has been called Crucifiement, or the position of crucifixion. This is usually associated with the portrayal of various ecstatic states, which are termed by Bourneville beatitude, etc. The first of these is most strikingly portrayed in the plate which is here reproduced. (See Fig. 6-3). An occasional feature of one of Bourneville's cases was the complication of chorea, which was manifested at diflerent times in the course of the dis- ease. It was of a rhythmic character, and involved the entire body, so that the trunk was drawn backwards and forwards, the forearms were flexed and extended, the hands were pronated and supinated alternately, and the legs and thighs flexed and extended, the right eyelid became closed, and the muscles of the right side of the neck were convulsed. This occurred in paroxysms, and was modified under ovarian pressure, the movements becoming less violent, and finally ceasing. When the compression was suspended, the movements began aueAV, and a violent contraction of the right arm and leg, which had lasted during the maintenance of pressure, disappeared. Ether was given, and again the movements were suspended, but a fresh contraction of the limbs of the right side took place. In one or other of these cases hemiansesthesia and ovarian hypersesthesia 474 CEREBRO-SPINAL DISEASES. were observed from time to time. Contraction of various organs was quite frequent, and was sometimes provoked by ovarian pressure, as in the case just detailed, and different visual disorders, such as amaurosis and disordered color sense, were discovered, while hallucinations of vision were prominent in both eases." Beatitude. — (Boumeville.) The following cases were my own : — Case I. — A. P., set. 18, since the beginning of the menstrual epoch, has suffered from her present form of hystero-epileptic attacks, which have come on generally just after the cessation of the catamenial period. She has been very irregular, and has suffered from amenorrhoea, but there is no uterine disease that I can discover. This amenorrhoea has amounted to an entire cessation of the menstrual flow for several mouths at a time, during which she would have her attacks. Some of these attacks were like that I shall presently describe, and lasted for several days. There was no succession of attacks, but usually several severe but distinct epi- leptic seizures, and afterwards an hystero-epileptiform paroxysm. She had been in the Epileptic Hospital for some time, and had given a great deal of trouble by her irritability and mischief-making propensities. Her attacks at the hospital were three in number during one year, each of them lasting from two to three days at a time, during which there was suppression of urine, vomiting, and hemiauiesthesia, which in one instance was on the right and twice on the left side. Her most pronounced attack occurred while she was staying at her mother's house, where I was summoned to see her. This was on the 14th of March, 1877, when her mother came to my office, and told me that her daughter had been ill since the preceding Thursday ; that she had HYSTEEO-EPILEPSY. 475 gone with her sister to see a friend ; and that while there she had been seized with a severe fit, and could not go home until the next day (March 9). She said that on her return her daughter complained of headache, pain in the back, over the ovaries, and abdominal discomfort, and as the time for her menses had come, she gave her a pill of aloe s and myrrh on Saturday, and another on Sunday night, with no result, and a warm hip-bath on Monday. (She had not menstruated since December 1876.) On Monday she had several severe epileptic fits, with frothing at the mouth, during which she bit her tongue, and went to bed, where she remained until I saw her. I went to the house, and found that she had been seemingly unconscious since Monday night, that she had been *' frothing at the mouth" since that time, and that on Tuesday she began to mutter and talk to herself ; that she had had hallucinations Fig. 64. Hystero-Epilepsy. and delusions, some of them of a painful character, believing that she had been followed by a nurse from the hospital, whose intention was to kill her. When her mother entered the room, she berated her soundly, and was quite abusive, indulging in obscene language. I found her lying upon the bed, lightly covered by a sheet. The mus- cles of her back were rigidly contracted, so that her position was one of opisthotonos ; her head was turned to one side, and her tongue was pro- truded. Her eyes were open, and the pupils widely dilated, and insen- sible to light. Her expression was blank, and she was apparently un- mindful of her surroundings. Her arms were drawn over her chest, and_ her forearms slightly flexed and crossing each other. Her thumbs were bent in, and covered by her other fingers, which were rigidly flexed. Her pulse was 124; temperature, 101.2°; respiration, 33. She was muttering to herself a disconnected string of words without any mean- ing, and continued them during my visit. She had not eaten for twenty- four hours, and I ordered milk and chloral hydrate in twenty-grain doses, to be forced into her mouth if she did not open it of her own ac- cord. On my return the next morning, the mother told me that she had had delusions during the night, and had cursed those of her family who ven- tured to approach her. I found that the rigidity of the previous day had become less marked, but that her right hand and forearm were beneath the lower part of her back. The right corner of her mouth was drawn downwards, and her eyes were still open, and the cornese ansesthetic. 476 CEaEBRO-SPINAL DISEASES. She did not kaow m3. Terap3rature 100^ ; pulse lOS ; respiration 28. On the folltnviu^ m )rning Dr. Charles E Lockw )od of this city went with 013 to see her. She was then much better, and was less rigid, but the right haul was tightly clenched, and no persuasion would induce her to open it. Her toes were also flexed, and her right foot presented the appearance called by Charcot, ' le pied bot hysterique." Her corne?e were sensitive, and lier pupils less dilated. There was some rolling of the eyeballs from side to side, and patient occasionally sighed. Her pulse was now only 96, and was small and irritable; the temperature was 99^. When sharply spoken to, she said •' Doctor," and relapsed into a state of stupidity, turning her head from right to left, and staring at the ceiling. She occasionally moved her tongue, as if her mouth -was dry. Dr. Lockwood suggested the experiment of frightening her, and .so we threatened the use of the cautery, the mention of which first brought forth remonstrance and afterwards a reply to our questions. Her mother stated that she had not passed urine for several days. I did not find a distended bladder, but when the catheter was introduced, it brought away about half a pint of light-colored urine. This suppres- sion of urine continued for several days.^ She aro.se from her bed the day after this last visit, and her menses appeared. Daring the next three or four days there was slight hemiantesthesia of the right side. Case II. —A young lady, 19 years old, had been my patient for nearly a year, during which she had had on an average about one attack of haut mal in a week. Her epilepsy dated from the ninth year, and was not dependent upon any discoverable cause. At all times she is irritable, pettish, and techy, an 1 leads a very irregular life. There was nothing remarkable about her attacks ; they were not very violent, nor were they connected with any hysterical manife.station. There was rarely any coma ; but the attacks were more severe about the time of the menstrual discharge, which was never abundant. On September 12, 1876, I was telegraphed for to see the patient. The day before my arrival, without any premonitions, she had had an attack very much like all the others, but instead of falling asleep sh-3 remained convulsed, and apparently un- conscious. She vomited two or three times, and became quite cyanotic ; so the local physician was sent for. He found it impossible at first to open her mouth to remove the substance which had collected thorein and distended the cheeks, and it was only when he was assisted by others that he could do so. She was placed in bed, and remained in this state, the eyeballs rolling from side to side, the body drawn slightly to the right -side, and the hands clinched. She bacam 3 delirious during the night, and had delusions of a lively kind, like those of a patient with delirium tremens. Oatbursts of hysterical laughter and jactitations of the limbs fjUowed in the morning, and then she became quiet, but the muscles were somewhat rigid. I arrived at about 2 P. M., and found her lying upon the bed with open eyes and meaningless stare. Her right hand was rigidly abducted, and the bed-clothes were tightly gra-^ped in her hand. The head was drawn so that the chin was approximated somewhat to the chest. The teeth were set together, and there was som3 grinding of the molars. She breathel noisily, there bsing an accam illation of mucus in the throat. Temperature 10[).2' ; pulse 86. Tne pupils were dilated, ^ It is probable that this uriaarj derangemeat was of the form called bj Charcot oliguria. • HYSTERO-EPILEPSY. 477 and seemingly unaffected by light. Pressure upon the right ovary caused her to shrink somewhat. Her abdomen was distended by flatus. During the night she became somewhat relaxed, and muttered unintel- ligibly, but in a petulant tone. She fell into an apparent sleep about 5 A. M., her respiration being natural. She awoke at about 5 P. M. of the same day (the third), and though somewhat fatigued, arose and went about. She was not hemiansesthetic, but ischuria lasted for several days. An inspection of the cases of Charcot and others will enable the reader to detect certain symptoms which are alike in all the patients. Case III. — Reported by Charcot. Marc , 23. Hystero-epilepsy dated from the 16th year; attended by hemiansesthesia and hemijmresis of left side. Daltonism of left eye ; frequent vomiting. Attack preced- ed by an aura and pain in left ovary. Attacks included three stages : a. Tetaniform contraction, epileptiform convulsions, h. Violent movement of trunk and lower extremities (period of contortion). Silly and discon- nected talking. Patient appeared to be semi-delirious, c. Laughing fits; attacks stopped by ovarian compression. Case IV. — Charcot. Cot., 21 years. Hysteria dated from the 15th year, and followed cruel treatment at the hands of her father, when she took to drink and became a prostitute. Local symptoms are : right hemi- ansesthesia, ovarian pain, permanent, and tremulation of the right lower extremity. Convulsions followed ovarian pain ; they are tonic, and she bit her tongue and frothed at the mouth. The second period followed at once, and was marked. The attack often terminated by movements of the pelvis, laryngeal constriction, crying attack, passage of large quantities of urine. Ovarian pressure moderated attack, but did not ar- rest it. Case V. — Charcot. Legr. Genevieve, 28. Hysteria dated from puberty. Permanent local symptoms ; left hemiansesthesia, ovarian pain, and mental peculiarities (bizarre). Aura quite marked, and so are cardiac palpitation and head symptoms ; attack may be divided into three stages : a. Epileptiform convulsion, frothing at the mouth, and stertor. b. Movement of limbs and body, c Period of delirium, dur- ing which she detailed the events of her life. Occasionally last stage would be characterized by hallucinations, when she would see crows, ser- pents, etc. She would at other times dance. Ovarian pressure arrested attack. Case VI. — Charcot. Ler., 48 years. Attacks date from early life, when she was frightened by a dog, and by the sight of the body of a wo- man who had been assassinated. Local symptoms : hemiansesthesia of ovary ; paresis and contractures of the upper and lower right extremi- ties, and occasionally the left. Attacks begin by ovarian aura, followed by epileptiform and tetaniform convulsions, after which she assumed the most trying postures. At the time of the attack she falls into a delirium, during which she indulges in furious invectives, crying to imaginary persons : " Villains, robbers, brigands ! fire, fire ! Oh the dogs ! oh, I'm bitten !" these being suggested by memories of her childish fears. When the convulsive part of the attack is terminated, there follow : 1. Hallu- cination of sight, the patient seeing skeletons, frightful animals, spectres, etc. ; 2. A paralysis of the bladder ; 3. A paralysis of the pharynx ; 4. Finally, a more or less permanent contracture of the tongue. These last 478 CEEEBRO-SPINAL DISEASES. symptoms remain for several days, during whicli it is necessary to feed the patient with a stomach pump, and then draw off her urine. Two cases, reported some years ago,' resemble the more modern hys- tero-epilepsy so closely that I am inclined to infer that they were attacks of this disease. Case VII. — Arguinosa's Case. "Woman, twenty years. Epileptiform convulsions first showed themselves during infancy, in consequence of head injury. They reappeared at puberty. While residing in the house of Dr. Arguinosa she complained of ovarian pains. The precursory signs of an epileptic attack soon showed themselves, and, on, returning from a walk, " she had scarcely time to throw herself on a bed before she lost both sensation and motion. The skin was hot, respiration loud, pupil immovable, eyelids closed convulsively, limbs flexible, while the lips were convulsively moved, or else a sardonic smile sat upon them. Bleeding was about to be practised, when, all of a sudden, after some horripilations, the skin bscame cold and colorless, the pulse and respiration were sus- pended, and the patient appeared dead." Cold affusion to the head seemed to produce an effect. The respiration then became agitated, the pulse strong, and violent convulsions, with tetanic rigidity (pleurosthotonos) set in. She became angry and irritable, screamed out. Noises in the room, light, and the steps of persons around her were sufficient to " draw her from her attacks of delirium." She had a presentiment of sudden death. " Two days following there were the same alternatives, the delirium occurring less frequently, and lasting a shorter time ; she slept but little that night (the 4th) ; the next day the only symptoms noticed were aver- sion to water, light and air, with the pain of stomach previously com- plained of. On the sixth day she asked for a bath, and the opium which she took in the evening. A stool brought on strong convulsions and noisy delirium. The women who were attending to her believing her to be possessed by the devil, sprinkled her with holy water, which increased her furious cries and bizarre contortions. The following night was dread- ful ; the mouth full of foam, the eyes injected, and the delirium almost continuous. About ten in the morning immoderate laughter succeeded the previous symptoms. She ultimately died." Case VIII. — Ward's case. Mary P., aged 13. Measles at age of 7, and has ever since been subject to cough and pain in the side. About one year ago she had her first epileptic fit, during which she attempted to bite and scratch the bystanders. She was not insensible, but delirious. The attacks came on at intervals for a fortnight afterwards, and they be- came much worse at the end of this time. Her arms were extended and rigid, and the fingers clenched. At other times she struggled violently, and the abdomen became swelled. She never became unconscious. Her disposition was changed, for she grew exceedingly mischievous between the attacks, developing a propensity for climbing trees and playing the hoyden. Ovarian pain sometimes The attack is occasionally finished by a fit of laughter. The so-called hysterogenic zones have been described by Richer^ Char- * Forbes Winslow's Psychological Journal, vol. ii. ^Etudes cliniques sur I'Hystero-epilepsie, etc., Paris, 1881. CATALEPSY. 479 cot and Mills ^ tlie latter having written a most valuable article upon hystero-epilepsy which will be found to be very complete. These zones consist of limited cutaneous districts which, when subjected to pressure, electric excitation, blistering or hot or cold stimulation, are likely to give rise to, or on the other haad, modify or stop an attack of hystero-epilepsy. These are bi-lateral, and are situated above and below the mammse, over the ovaries, beneath the axillee, over the ilia, over the seventh cervical spine and the upper dorsal region. The form of excitation varies greatly, whether the patient's surface is or is not hypersesthetic or ansesthetic, or in proportion to the severity and kind of impression. Occasionally, as has been ascertained, the excitation of these regions during an attack may modify the character of the delusions during the stage of delirium. The so-called erotogenetic zones of certain French writers include these as well as other spots — the palmar surface, the back of the neck, and the eyelids — which, when irritated during an attack are followed by changes in the character of the delirium, the patient indulging in erotic fancies. In simple hysteria, pressure or irritation of these spots may give rise to various dysjesthesise. Charcot holds that a very important diagnostic sign is the reduced tem- perature. In epilepsy the temperature may even rise to 107.6"^ F., while that of the hystero-epileptic rarely attains a height of 100° F. In the cases I have alluded to. Case I. presented all the prominent symptoms by him enumerated, and still the temperature was quite high. Treatment. — Nitrite of amyl has been recommended by the French authorities for the suppression of the attack. I would recommend nitro- glycerine for the same purpose, in doses of tn. v. of the solution spoken of on a previous page. It is of great importance that the pelvic organs be looked after. Dislocation of the ovaries, uterine flexion, or troubles of a like kind, will often be found to have much to do with the genesis of hystero-epilepsy. CATALEPSY. Definition. — A disease closely allied to hysteria, of extreme rarity, and characterized by a condition of muscular contraction and semi-rigid- ity, so that the limbs may be placed in constrained and awkward posi- tions, and remain so for some time. It is attended by loss of consciousness, and cutaneous anaesthesia. Symptoms. — The disease, like epilepsy, is characterized by attacks separated by intervals of greater or less duration, during which periods the patient is usually in apparent good health. After such prodromata as malaise, vertigo, headache, or functional tre- mor, the individual will suddenly be seized. He may be talking or eat- ing, when the particular act is arrested, the mouth remaining open, or the hand half raised. The muscles become rigid, but the limb may be moved by the physician or bystander, and if placed in a new position, no matter 1 American Journal of Med. Sciences, Oct., 1881, p. 392. 480 CEREBRO-SPINAL DISEASES. \ how awkward it will remain so fixed until the muscles are fatigued, when it drops. Individuals are reported to have remained for even an hour or two with legs or arras extended ; and in one case I saw the pa- tient remained for half an hour with the right arm extended in a straight line from his shoulder, and the other extended above the head. The position was subsequently changed. The peculiar semi-rigidity of the muscles has gained for it the ndnne fiexlbllltas cerea, on account of a " wax- like " mobility; and there is none of the pronounced stiffness, or, on the other hand, limpness of the limbs, that usually attends the unconscious state. The surface of the body becomes quite cool ; the pupils are dilated ; respiration is shallow and scarcely perceptible; and it is sometimes difficult to find the pulse, which grows thready, but nevertheless preserves its regularity. The skin is anaesthetic to an astonishing degree. Needles may be thrust into the tissues without the knowledge of the individual, and pinching, slapping, or other forms of cutaneous stimulation, produce no expression of pain. In a case of hystero-catalepsy, seen with Dr. D. B. St. John Roosa, I repeatedly thrust pins into the arms and legs of a young woman and waV^hed attentively for some sign, but her expression was immobile and tranquil. It is stated that the electro-muscular contractility is not affected, but reflex excitability seems to be diminished or lost entirely, so that some- times it is almost impossible to determine whether the patient is alive or dead. The so-called trance states are examples of this kind, and cata- lepsy has undoubtedly led to burial alive in many instances. The ordinary attacks usually subside in a few hours, the rigidity grow- ing less marked, and consciousness gradually returning. The attacks, as a rule, follow each other in a series, and then comes an interval of normal health. In this mode of appearance and behaviour, the disease has been likened by Eulenburg to neuralgia. " Strictly speaking, it is rather a cycle of attacks quickly following one another ; " and there are remis- sions characterized by a temporary return of consciousness, and then a fresh relapse, which evidently follows some internal irritation. In rare cases there is a sudden return of consciousness and an ability to perform volun- tary acts. The urine and feces are rarely passed in an involuntary manner. Unless the disease be due to malaria, it becomes chronic, and continues for years. If it is due to malarial poisoning, it usually assumes a regular periodic character, and is amenable to treatment. Causes. — Like many other neuroses, such as hysteria, epilepsy, and those of this class, mental excitement plays no mean part in the etiology of catalepsy. Fright, and other forms of emotional excitement enter into its causation. Injury and malaria may also be mentioned, while mastur- bation, venery, and intestinal worms are spoken of by writers generally. Jaccoud considers it to be a result or accompaniment of certain forms of melancholia (Melancholia attonita), and ecstacy. It appears as if it were more common in early life, and children are therefore nearly always the victims. Antemic girls, or boys especially CATALEPSY. 481 "who study too constantly, are affected more often than those of adult life. Nearly all writers agree that the female is more subject to the disease than the male, and probably the delicate organization of the sexual apparatus has much to do with this. Hereditary influences seem to play a part in the etiology only so far as the general neurotic tendency is concerned. Families in which there is epilepsy, neuralgia, or insanity sometimes include cataleptic members. I have never heard, and I can find no re- cord, of transmitted catalepsy. Morbid Anatomy and Pathology. — Besides the autopsies made by Calmeil and other older writers, which, by the way, throw very little light upon the question of pathology, Schwartz made one autopsy, and Lasegue two, but nothing was found by the latter observer. Schwartz^ mentions the case of a boy "who, after an injury, had at first attacks resembling chorea, later cataleptico-tetanic attacks, and after two years died from anaemia and marasmus. There was found in this case, besides a serous effusion in the arachnoid, a softening of the corpus striatum and optic thalamus, on the left side; along the posterior surface of the spinal cord, from the cervical to the lumbar enlargement, was a brownish-red, jelly-like mass, arranged in groups, covering the dura mater. The spinal cord seemed healthy. (There was no microscopic examination.)" Catalepsy, which is associated with many other interesting perversions of consciousness such as somnambulism, stigmatization, etc., has received a great deal of attention, not only from the laity, but from scientific men of all ages. It is not my purpose to enter extensively into the consideration of these various curious states. The lighter forms, such as the "catalepsie passagere" of Lasegue,^ have been induced, by mesmerists and others, by passing the hand over the face or body, or by closing the eyelids. The same condition may be induced by looking fixedly at some bright object held close to the face. A remarkable experiment of a popular nature, which I have repeatedly performed myself, is a curious instance of the susceptibility of certain animals to influences of this kind. If a lobster be placed head downwards, and gentle scratching of the back is made, it will become perfectly quiet, no matter how pugnacious it has been before, and will remain in this position for some time. The general opinion in regard to the pathology of the affection is that the peculiar muscular condition is due to an increased muscular tone, which probably depends upon impaired voluntary control, so that the muscles respond to trivial irritation reflected upon the spinal ganglion cells. Volition is checked just as it is in hysteria; and when we consider the theory of " expectant attention," advanced by Carpenter, the genesis of some forms of catalepsy is easily explained. These are the varieties in ^ Quoted by Eulenburg in Ziemssen's Encyclopaedia, vol. xiv., translation. 2 Archives Gen. de Med., 1865. 31 482 CEREBRO-SPIKAL DISEASES. ■which the individual becomes cataleptic when influenced by another. The time has not yet come for the admission of mooted subjects like trance and double consciousness into text-books for students ; I therefore await the further development of the subject, which at present is in a chaotic state of confusion. Diagnosis. — The waxy flexibility, which is pathognomonic, is not a feature of any other disease, and this, taken in connection with the loss of consciousness and ansesthesia, makes the diagnosis a matter of certainty. The only point which should interest us is the possibility of simulation. Numerous instances of so-called stigmatization come under this head. There is abundant opportunity for detection, however ; and electricity, mental influence, and strong cutaneous revulsives are recommended should •we suspect malingering. Prognosis. — When the cause is emotional, or when there is a malarial influence, the individual's chances are remarkably good. It is only when the disease appears in a subject of very marked nervous temperament that there is any reason to give a bad prognosis, and such cases are chro- nic. A fatal termination is a very remote possibility. Treatment. — Electricity in its induced form seems to be indicated for the abortion or relief of the paroxysm, and amyl nitrite may be re- commended for the same purpose. Should there be malarial influences, quinine, arsenic, or iron are of course in order. Curare, bleeding, and many other forms of treatment have been useless. In the transitory affection (catalepsie passagere) cold water douches, or diff'usible stimulants, are resorted to. The cataleptic and hystero-epileptic conditions are often attended by very great flatus, and when this is removed the patient quite often immediately recovers. An ounce or so of the tincture of assafoetida may be put in a quart of hot water and the woman is to be given an enema therewith, a folded napkin being held by the nurse over the anus. In other cases the rectal tube, such as is used by Emmet, may be tried. I would strongly discountenance a modern operation for the removal of the ovaries. I have seen one case where this was tried. The result was death within three or four days. There are so many causes that may enter into the production of catalepsy that it seems an unwarrantable assumption to fix upon the ovaries as the offending organs.^ 1 The Principles and Practice of Gynsecology, 1st Ed., p. 201. CHOEEA. 483 CHAPTER XV. CEREBRO-SPINAL DISEASES (Contintjed.) CHOREA. Synonyms. — St. Vitus's dance ; St. Jolin's dance ; ^ Paralysis vacil- lans ; Tarantismus ; Choree ; Veitz tanz, etc. Definition. — Chorea is a disease characterized by involuntary and disorderly movements of the muscles, is unattended by loss of conscious- ness and cutaneous sensibility, and may be connected with paresis of cer- tain groups of muscles, or those of one side of the body. As early as the fifteenth century, a species of religious delusion appeared in Southern and Middle Europe, in an epidemic form, and was connected with certain saltatory and muscular phenomena, which gained for it the name of St. Vitus's dance. This is described by various writers as a condition of religious excite- ment characterized by gesticulation, contortions of the body, and leaping, while the patient generally screamed or howled like an animal. This peculiar state was supposed by the older writers to be demoniac possession, and many victims were made to undergo the ordeal, or were put to death by the sword, or burnt at the stake. Under the influence of their condi- tion they sought the shrine of St. Vitus, which was situated in a small chapel near Zabern. Here they were cured by the priests, who sang masses and removed the disorder.^ Various epidemics appeared subsequently, but the disease gradually became divested of its noisy character. In Italy a dancing disease, sup- posed to be due to the bite of the spider, and which received the name of tarantism, made its appearance in the early part of the sixteenth century, while at the same time, a peculiar outbreak occurred at Amsterdam, where seventy children of the Orphan Asylum became possessed. They climbed the walls, swallowed needles, hairs, pieces of glass, and other in- digestible substances, and " distorted their features and limbs in a fearful manner."^ At other places the same thing occurred, and until the end of the seven- teenth century, when there was some decrease in superstition, instances of this kind of chronic disorder were common. ^ For a most entertaining description of this affection read Hecker's Epidemics of the Middle Ages, third edition, Sydenham Society's Transactions. ^Eeynolds's System of Medicine, vol. ii. ^ Scheie de Vere's " Modern Magic," p. 357. 484 CEREBRO-SPINAL DISEASES. Symptoms. — The beginning of a simple case of chorea may be the following: The patient, a boy of ten years, who attends school, becomes irritable, loses appetite, and does not care to go out and play with his fellows. He becomes pale and thin, and sits by himself In a little while some movement of the hand or fingers, some twitching of the face, or dragging of one foot when he walks, attracts the attention of parent or teacher. He may be punished, with the idea that such movements are the result of bad habits or viciousuess, but it does no good, and probably increases the trouble. These jactitations cease at night, when he rests un- easily, and is disturbed by bad dreams. This is the condition in which we find the patient. What is the course of the disease? If he is neglected, it will not be long before the convulsive movements become general. The feet may drag along as if paralyzed, and such is the case. He will be unable to button his clothing, or attend to his little wants, and may need the careful and constant attention of his friends. The vocal cords may be affected, and there is as a result a certain aphonia, so that phonationis husky and subdued. Inco-ordination of the lips and tongue gives rise to difficulties in articulation, which are quite distressing, the words being " snapped " and cut short. Mitchell uses the term " habit chorea " for a light form of the trouble, which consists perhaps only of some repeated grimace, or shrugging of the shoulders. The symptoms are worthy of separate consideration, and we will pro- ceed to discuss them in their order of importance. 1. Motility} — The spasms, as I have said, are clonic, and are more often unilateral than bilateral. The right hand is usually affected first, then the leg of the same side may follow, and finally the other side may be implicated, so that the movements are general. The arm is usually involved before the face, though in several of my personal cases the first symptom noticed was a slight twitching about the mouth, and an awkward ^ In an excellent report of 80 cases of Chorea,* made by Dr. G. S. Gerhard, of the Philadelphia Orthopsedic Hospital and Infirmary for Nervous Diseases, the following points were observed : — Movement. — In 27 cases, general. II " '' but marked on right side. 10 " " " " left " 32 " unilateral, 20 on right, 12 on left side. In a certain number of these cases the movements shifted to the other side. Paralysis. — Partial paralysis noted in 17 cases. Loss of power in 10 instances confined to right side, in 7 to left. Age. — Under 10 years, 28 cases, 9 m., 19 fern. From 10 to 20 " 52 " 18 " 3-4 " Total, 80 " 27 " 53 " Cure in 56 cases, improvement or '' result unknown " in 24 cases. * Amer. Journ. of the Medical Sciences. CHOREA. 485 tendency manifested by the child to open the mouth and draw its breath while speaking. In another, the little boy first attracted the notice of his mother by movements of the alse of the nose. I do not think that the movements in chorea are always increased by the efibrt of the will to stop them, as is the case in sclei'osis, in which disease the tremors are exaggerated by any voluntary attempt of the individual at control ; and I have often been led to suppose that chorea might be divided into two varieties, viz., one in which the movements are increased with the exercise of the will, the other when they are most violent in a state of rest. The movements of the hands are characteristic, I think. There is a prehensile movement of the fingers and a rubbing of the ball of the thumb and ends of the fingers. There is swinging of the arm, and a shrugging of the shoulder, as if the patient had on large or uncomfortable underclothing. There is a trivial point which may perhaps be of interest, and I only mention it because it is unique. I allude to the habit which these little patients have of rubbing the seam of the trowsers leg by the hand which is afiected, for these movements often go on most actively when the arm hangs by the side, and when the attention is not directed to it. In other diseases just such " little straws " will once in a while give a serviceable hint; for instance, in commencing paresis of any kind of the lower limbs. If we examine the tip of the shoe, we will find the sole to be worn down on one side of the body. In locomotor ataxia we will find a reduction of the heel. "When these little patients are worried or embarrassed, the movements are greatly increased, and this is one of the strong features of diseases of this kind. I have at present a patient at the Hospital who is almost quiet when in the presence of people he has been associated with for some time, but every new face seems to excite him to such a degree as immediately to give rise to the most violent movements. The loss of power, which is very often a phenomenon of chorea, is nearly always one-sided, and when it exists to a marked degree, may greatly affect the patient's walk, so that he drags his foot in a helpless manner. Handfield Jones thinks that the want of power is a constant feature of the disease. Such paresis is extremely variable, however, in its extent. Muscular exertion is distressing, and he may not have the power to perform some of the least fatiguing actions of daily life without great prostration. The muscles that are most paralyzed are always those which have been the seat of the most violent spasm. Sensation. — There may be pain in the wrists if the spasms are severe, or the skin may be ansesthetic ; such loss of sensation being confined to the whole paralyzed side, or to a single limb. Mental Condition. — Irritability of temper and emotional excitement are present from the beginning, and the child is restless, sleeps lightly and is tortured by bad dreams. Study or mental application is an impos- sibility, and spells of crying are quite familiar evidence of the disease, 486 CEREBRO-SPINAL DISEASES. especially in the earlier stages. Chorea may exist iu a very severe form ■when there is a grave exciting cause ; and the convulsive movements may be so violent as to render it necessary to bind or hold the patient in bed. At the request of Dx\ J. P. P. White, of IS ew York, I saw with him a case of this kind. The little girl, who was about ten years of age, had arrived in New York after a sea-voyage, during which the symptoms began. We found her agitated by violent spasms of all four extremities, which had lasted for several days, and it required constant watching to keep her from throwing herself out of bed. They ceased partially during sleep, but this needed repose was denied her to a great extent. Her skin was hot, and her pulse bounding and full. She was perfectly couscivus, but com- plained of pain in the wrists. I inferred, from the general character of the convulsions, their constancy and violence, and from other symptoms, that there was some form of eccentric irritation ; and an anthelmintic ad- ministered by Dr. White brought away a tapeworm several yards long. The movements disappeared in a very short time. The urine had been found by Walshe and Bence Jones to be of much higher specific gravity than in health, and to contain an excess of urea. It may vary from 1030 to 1040, and is loaded with the oxalates and lithates. Another form has been described which is characterized by paroxysms, during which the patient may perform the strangest antics. Her condi- tion before and after the attack is one of quietude, but without warning she becomes agitated by spasms, rolls on the floor, jumps in the air, or rushes about the room. Wood reports a case of this kind, in which the patient, a young married woman who had been slightly ill for some time, developed this paroxysmal variety. " The paroxysms themselves were not always of the same kind. At one time she would be violently and rapidly, hurled from side to side in the chair in which she might happen to be sitting, or else, suddenly gaining her feet, she would go on jump- ing or stamping for a while ; or, she would rush around and around the room, and would rap with her hands each article of furniture which lay in her course ; or she would spring aloft many times in succession and strike the ceiling with the palm of her hand, so that it became ne- cessary to remove some nails and hooks which had done her an injury ; or she would dance upon one leg with the foot of the other leg in her hand." A professional friend has recently informed me of a case of this kind which came to his knowledge, in which the woman was affected very much in the same way as the patient of Mr. Wood, and that on one occasion she created great commotion by attempting to climb one of the stanchions in the cabin of a steamboat. These cases are so rare, however, that they only deserve to be men- tioned en 2iassant as examples of the irregularity of the disease, and are somewhat like the original dances of St. Vitus and St. John. CHOREA. 487 The following case illustrates a very curious phenomenon of motility which I lately noticed : The patient, a boy of ten years, was brought to me by his father for treatment, after having been seen by many practitioners, who did not agree in regard to his condition. I saw that his movements were choreic. Questioning revealed the fact that he had never been a strong child, but had always been disposed to nervous troubles ; even the exanthematous fevers, which, like other children, he had had, were generally connected with stupor, and other evidence of susceptibility of the nervous fsubstance to blood-poison. He never had any rheumatic or cardiac affections, and I could hear nothing to indicate valvular trouble. The heart-sounds were sharp and quick, however. Four years ago he began to decline, became weak and anaemic, was irritable, moody, and bad-tempered. His appetite was capricious, and he preferred sweets to other food. In the summer of 1872 the movements in the hands and arms began, and soon became gen- eral. His rest was uncomfortable, and he started up in his sleep and cried out. When I saw him four months ago he was a pitiable object. His movements were general. He was unable to hold anything, and was powerless to perform any voluntary actions except those of a gross kind. He could not unbutton his clothing or put on his cap ; his mother even had difficulty in making him walk. Variety of Movement. — Head was violently agitated, there being con- tractions of the sterno-cleido-mastoideus. He " sucked in his cheeks," and pursed up his mouth, smacking the lips. Other facial contortions were violent. He winced spasmodically, and there was constant motion of the eyeballs. The arms were in constant motion, but the right was not affected so much as the left. The right arm and hand were slightly paretic, and he was able to force the column of fluid in the fluid dynamometer up to 16°, which is equal to 15 lbs. pressure to the square inch. The left forced it up to 18°. The legs. The right leg was also slightly paretic. The toe of the shoe was worn down to some degree, althouglx the walk was not noticeably affected. There was an uneasy rolling of the pelvis when he sat down, and the legs were not entirely under his control. There was pain in the wrists and ankles. Under proper management of his diet he gradually improved, and at the last visit was nearly well. I noticed then for the first time the following peculiar state of affairs. When sitting in front of me, I told him to raise his hands, one after the other. The right hand he raised promptly, but the left he could not, unless he took hold of the wrist with the other hand, and lifted it. This condition struck me as remarkable, especially as he had to repeat the process of aiding with the right hand. The left hand and forearm might be paretic. There was no loss of electro-muscular contractility, however, but, if anything, it was increased. The muscular power, tested by the dynamometer, was found to be even better than in the other hand. There was no atrophy. With these facts in view, it seemed improbable that this should be the cause. It was found that when the other hand ivcis held down, the boy was able to lift his left hand untssiited, and even to raise a dumb-bell loeighing 10 lbs., but as soon as the other hand luas released he ivas unable to re- peat it. 488 CEBEBRO-SPINAL DISEASES. To determine whether this was the result of any bad habit, I ascertained from the father that his son had never used one hand to lift the other till a few weeks ago. In adult life forms of chorea are met with which in nearly every respect resemble those of infancy. Sometimes pregnancy is the cause, and in other cases prolonged emotional excitement, and more especially grief, are in some way connected with the development of the disease. My case-book contains the records of several of these examples, and their form is usually of that kind which is known as hemichorea, and very often seems to be dependent upon some true organic lesion. In this form the exercise of the will to stop the movements is generally provocative of a decided increase in their violence. The patient is unable to carry food to his mouth, to manage his clothing, or to perform any little acts of necessity. He fears to make any attempts in the presence of other people, and this is especially the case before strangers. I have already alluded to one instance of this kind. In another patient the mere sugges- tion of meeting a new physician was sufficient to aggravate her convulsive movements. The chorea occurring during pregnancy generally disappears before parturition, and Jaccoud considers that it may lead to miscarriage, and he has found the mortality greater than in any other form. I am not disposed to agree with him as to the serious character of the disorder. An instructive case of this disease is subjoined : — Mary K., set. 24, entered the Epileptic and Paralytic Hospital July 10th, 1877. She is of nervous temperament, and gives a family history of nervous disease. Her sister has epilepsy, and a brother has infantile paralysis. Up to the fifth day of June, 1877, she was perfectly well. While in bed she was awakened by a storm at about 3 A. M-, and was greatly frightened by the loud claps of thunder and the vivid lightning. She arose and fell to the floor, where she lay for some time, crying, but found no difficulty in arising, there being no paralysis. The next day she felt "a cramp " in the left side, and the leg and arm were spasmodi- cally contracted, and afterwards began to twitch. There is no profound loss of power whatever, but some slight paresis of the left side, and a de- cided hyperiesthesia of this part of the body. The left upper and lower extremities were convulsed by choreiform movements, the hand being more agitated than the leg. The strength of grip is decidedly weakened, and she is only able to force the fluid index in the dynamometer up to 8°, while with the other hand she raised it to 14°. There is some dragging of the foot when she walks. She does not sleep, but requires chloral and other hypnotics. She is in her seventh month of pregnancy, and it was decided not best to try any very active treatment. Arsenic was given, however, in the form of five-minim doses of Fowler's solution, and she became more quiet under its use. At no time has she shown any indica- tion of impending abortion, and though feeble and anaemic, she is able to go about and enjoy herself in a limited way. Aug. 25. Fowler's solution increased, so that she takes rrix, t. i. d. Movements somewhat lighter. Sept. 20. Gave birth to a healthy boy after a sliort labor. CHOREA. 489 Oct. 10. Cured. Discharged. There "was no special temperature variations at any time. A case of interest is that of — Lena C, ast. 44 ; Germany ; married. Her mother had chorea at the same age. About four years ago, without any appreciable cause, convul- sive movements of the whole body began. These were not general at first, and were limited only to the upper extremities. The movements are bilateral, and agitate the hands more than any other part. The facial muscles are slightly affected, and there is a jerking upwards of the corners of the mouth, more especially on the right side. The movements are neither aggravated nor controlled by the will, but cease during sleep. Her cutane- ous sensibility is in no way affected, and her sight and hearing are both good. She has a strange habit of clutching her dress in front, probably to steady her hands, and when spoken to she seems greatly disconcerted and moves more than ever. June 25. Fl. ext. conii, TIX xl, t. i. d. ordered by visiting physician. 2Qth. Ko marked toxic effects of the drug apparent, except dilatation of the pupils ; and the patient says that there is a " complete lightness of the body," and that "she could fly-" Some improvement in movements. With a strong voluntary effort the movements are stopped for a time. July 10. Great improvement ; patient can hold her arms quite steadily. Discharged at her own request Dec. 15, 1875. She re-entered Dec. 22, 18.75. I found the patient in probably the same state in which she first came into the hospital. She is a spare, tall woman, very restless and emotional. She cannot express herself at all, for when she attempts to speak the tongue refuses to do its part in arti- culation, and the result is the utterance of ill-arranged sounds, which are not properly formed into words. She smacks her lips, and " clicks " her tongue against the roof of the mouth, and the sounds which come forth are tremulous and agitated, and just such as one would expect to hear from a person who was agitated by some great fear. The contortions of the arms are very violent and irregular, and almost defy description. The body seems to twist upon the pelvis ; the arms are thrown backwards and forwards, and the hands and fingers are constantly working. She seems to have no volitional control over her limbs, and has very little muscular force. She walks without any apparent embarrassment, but when seated the movements in the lower extremities are more active than when she stands up. She was somewhai analgesic, as was demonstrated by pinching. Treatmeat with strychnine considerably moderates the violence of the spasmodic movements. Chorea may often present a periodic character, especially if malaria enters into its causation. The tendency to relapse is quite a striking feature, and, in many cases which I have seen, it appeared either during the early fall or spring, and reappeared the following season. ^ Weir Mitchell, who has presented some very interesting facts regarding the re- currence of chorea -of 80 cases collected by Dr. Gerhard, 25 had attacks before — some of them several times. I have two patients now under treatment who have had attacks every spring for the past four years, but in these as well as other cases I find 1 Treatise upon Diseases of the ]S'ervous System, especially of Women. Phila., 1881. 490 CEREBRO-SPINAL DISEASES. the disease diminishes in violence, and the attack in duration, as it is re- peated. Mitchell has observed cases in which the recurrence of attacks was irregular, a year or two having intervened between them, and such is my experience. Chorea may be accompanied by other nervous troubles, or exist in an uncomplicated form as a result of debility arising from repeated nervous exhaustion or fresh eccentric causes. In one case I found it to appear as soon as cold weather came, and at the same time an extensive eczema upon the calves of the legs and scalp was developed. This disappeared, together with the movements, under the use of arsenic and oil, but both reappeared the following winter. Dr. E. Frankel has reported a similar case, and I have no doubt there are others who have had a like experi- ence. The disease usually wears itself out in a short time, the tendency to relapse rarely lasting after puberty ; and if a cure can be effected, the maintenance of a high standard of general health and certain precautions as to overwork or study prevent a return. Causes. — Various writers agree that the disease is confined to the period between the third and fourteenth years, and this has been my ex- perience. I do not know of a case under three years, but others have seen the disease in younger children. Watson limits the time at which chorea may appear to the period between the first and second dentitions; and Hillier of Great Ormond Street Children's Hospital, has given a table, which is referred to by Radcliffe. He found that of 422 cases at the above institution, 104 were between the ages of ten and twelve. Niemeyer believes the malady to be very rare before the sixth year and after the fifteenth. Girls seem to be more often affected than boys, for what reason I cannot say, except that it may be the more delicate organization of the former, and the preparative changes going on before menstruation. Mitchell has gone to great trouble to collect statistics showing the in- fluence of season and meteorological changes. He finds that March and April are the two mouths in which the attacks are more frequent, con- firming the observations of other writers; and that the rise and fall of the line of humidity and temperature play a decided aggravating or modify- ing influence. Mitchell also has ascertained that chorea is very rare among the blacks. When the disease appears after puberty, it generally takes an eccentric form, or it may be due to central organic changes, or fol- low hemiplegia. This latter form, denominated by Mitchell post-para- lytic chorea, has already been described. In chorea there is a general derangement of the digestive organs and loss of appetite and constipation and palpitation are quite common alterations of function met with in these cases. In the anaemic patients, and they are generally all so, there is often an aortic murmur, and the skin is pale and cool. The existence of cardiac disease or the previous history of rheumatism is considered* by many authors to have much to do with the causation of the disease. Romberg, Hughes, and West, besides many others, have so CHOREA. 491 decided ; and when we consider the pathology of chorea, it will ap- pear to us very reasonable. Of 104 cases of chorea at Guy's Hospital, but 15 of the number were free from any indication of cardiac or rheuma- tic difficulties. The disease often follows scarlatina or other zymotic febriculas, or takes its origin from an attack of acute rheumatism, or whooping-cough. It may result, and generally does, from some directly exciting causes, such as over study, bad air, or food, worms, or sudden fright. My recent investigations in regard to the occurrence of the disease among school children revealed the astounding fact that over twenty per cent, of young school children of the public schools of New York were affected with choreic affections of greater or less gravity.^ West expresses it as his opinion, that over-study is a common cause, and my investigations are sufficient to prove this. Many cases are supposed to result from association of unaffected chil- dren with those who are the subjects of chorea. Niemeyer alludes to the prevalence of this " mimetic form " among boarding-school pupils. This view has been very popular with the laity, and I am convinced has some importance, still, I cannot but think that the influence of example has been grossly exaggerated. Malaria seems to play a decided part in the etiology of the disease. This was pointed out by Kinnicutt, who reported some interesting cases in which the movements were aggravated at certain hours on alternate days, and were characterized by something like periodicity. Morbid Anatomy and Pathology. — Comparatively few cases of fatal chorea have been reported. Twenty-two of these are brought for- ward by Dr. Dickinson, whose excellent article upon the pathology of chorea deserves the attention of every student of neurology. One case has been reported by Ellischer,^ which is instructive, as it exhibits changes in the nerve-trunks ; and Ogle,^ Kirkes/ Hughes,^ Romberg," and See ', have made autopsies in other cases. The connection between disease of the heart and the neurosis under consideration has been studied perhaps most extensively on account of the occurrence of rheu- matism and valvular trouble as a complication in many of the cases. In Dickinson's cases the heart was found to be healthy in five ; in the remaining seventeen the following lesions were observed : — Eecent vegetations on mitral valves only, seven. " " " " with old thickening, .... one. ^ Am. Psychological Journal, Feb. 1876. A number of papers containing questions were sent to the public school teacher.^ of this city. In most instances the answers were intelligent and satisfactory. The cases alluded to above varied from movement of the hands and twitching of the facial muscles to general movements which attracted the attention, of visitors. 2 Archiv. fiir Path. Anat., etc, Bd. Ixi. 3 Brit, and For. Med.-Chir. Review, January, 1868 ; Med Times and Gaz., 1S66. ^London Med. Gazette, 1850; Med. Times and Gaz., 1863. * Guy's Hospital Reports, vol. iv., 1846. 6 Op. cit. 'Referred to by Ziemssen. 492 CEREBRO-SPIXAL DISEASES. Recent vegetations on mitral and aortic valves, one. Recent vegetation^' on mitral and aortic valves, with pericardial adhesions, two. Recent vegetations on mitral and tricuspid valves, one. Recent vegetations on mitral and tricuspid valves, with pericar- dial adhesions one. Recent vegetations on mitral and aortic valves, with recent peri- carditis, ." two. Recent vegetations on mitial valves, with old pericardial adhesions, one. Of the patients affected with recent endocarditis, the chorea in 6 ori- ginated from rheumatism, in 2 from mental causes, in 3 from uterine, in 1 from rheumatic and uterine, in 2 from mental and uterine, and in 3 from unknown causes ; thus showing the connection between the rheu- matic origin and the cardiac changes. The brain and cord were affected in 11 cases, there being congestion, softening, and appearances similar to those noted by the other observers I have mentioned. In one of his cases (No. V.) he made very thorough microscopical examinations, and I present his account of the appearances noted : " Sub- sequently sections from almost every region of the brain were examined microscopically. They were in most instances natural, the nerve-cells invariably s^, save some injection of the vessels, not enough to be de- cidedly morbid ; though the veins were much distended, in particular about the dentate bodies of the cerebellum, the vessels and their canals were normal. There was no extravasation, effusion, or erosion. Two situations, however, were remarkable exceptions to these statements. In the deeper white matter of one of the cerebral convolutions were many conspicuous spots, which consisted of accumulations of crystals of hcema- tine mingled with indefinite debris, probably of nervous origin, swelling the canals around the arteries which still remained distended with blood. " The other region referred to as the seat of significant change is that of the corpora striata. These bodies were more minutely injected than the rest of the brain. The capillaries, as well as the larger vessels of both classes, being packed with blood-corpuscles and numerous spots, striking objects under the microscope, were closely set in their substance. These consisted each of an artery in section, empty, crumpled and col- lapsed, and surrounded by a mass of globular debris, which had been formed at the expense of the surrounding tissue. They had evidently been produced by a solution or destruction of tissue around the vessel consequent upon effusion from it, the result of injection which had now ceased to exist. In time these mixed effects of extravasation and disin- tegration would have disappeared and left mere vacuities. "The spinal cord displayed loaded vessels and eroded fissures, such as were seen in every other instance examined. In addition to these com- mon changes, the gray matter had undergone extensive transformation of the kind to which the term sclerosis has been given. This was slight in the cervical region — extreme throughout the dorsal — absent from the CHOREA. 493 lumbar. The change was confined to the gray matter, which it affected on the same side of the cord nearly symmetrically. In the dorsal region it involved at least a third of the gray matter as seen in section ; the affected portions on each side being adjacent to the attachment of the transverse commissure, and at the root of each posterior horn. In the cervical region, though the change was less extensive, its position was the same. The altered gray substance had been converted into a wool-like entanglement of curving areolar fibers, among which nerve-fibers could be sometimes traced, especially near the edges, but from which all other nerve-elements had disappeared, leaving a mere confusion of connective tissue. The nuclei proper to the healthy structure were present, but had undergone no increase, nor was there any other evidence of fibroid or connective new growth. The change seemed to consist essentially of a destruction and removal of the nervous elements, their fibroid skeleton only remaining." A fatal case of chorea was reported by Dr. Jas. H. Hutchinson.^ The heart was found affected, the aortic valves incompetent, the leaflets being "swollen and softened," and the aor.a was atheromatous above the sinus of Valsalva. Ellischer,^ who made an autopsy, found that the vascular changes in the brain were marked, the wails of the vessels being changed, and the surface covered by dark granules. In certain places the calibre of the vessels was narrowed, and there was an accumulation of blood-corpuscles, and consequent effusion of the watery parts of the blood. Some of the vessels contained coagula. The connective tissue about these vessels was thickened and increased in size, and contained yellow pigment and granulated nuclei. The large ganglionic cells in the brain were filled with pigment, and the cell contents much changed. Sections of motor nerves exhibited red patches and destruction of nerve-fibers. These changes show, then, great vascular alteration, and degeneration of nor- mal nerve-tissue. In regard to the pathology there is much dispute, some observers con- sidering it to be but a functional condition, while others are well satisfied as to its organic nature. The original observations of Kirkes first demonstrated the relation be- tween chorea and rheumatism. Ogle contends that this relationship (or at least the evidences of rheumatismal causation in the brain, such as emboli) is only demonstrated by fatal cases. He considers the excess of fibrin in the blood to be only the result of the same influence that pro- duces the chorea, and that the blood state, instead of being a cause, may be a consequence of chorea, the result of tissue metamorphosis due to ex- cessive muscular action. He raises a question as to the disappearance of the movements, and considers this condition of affairs incompatible with organic lesions. This 1 Phila. Med. Times, August 5, 1876. 2 Op. cit. 494 CEREBRO-SPINAL DISEASES. objection, however, seems to lack force when we remember that in aggra- vated cases the movements do not stop during sleep. Another fact is to be considered, and this is the tendency' to relapse which the simplest cases present. The embolic theory has been advanced by nearly every investigator, and its strongest supporters are Broadbent, Hughliugs Jackson, and Bas- tian. The original investigations of Kirkes served as a basis for this new theory. He found that particles of fi brine were washed into the cerebral vessels. Hughlings Jackson located the place of final deposit in the gray matter of the convolutions in the neighborhood which is supplied by the middle cerebral artery. Jackson very cogently considers the signifi- cance of its one-sided character as compared with hemiplegia from embo- lism, and has since brought up the question of involvement of the mus- cles more concerned in special voluntary acts, which are likewise conspi- cuously affected in certain forms of hemiplegia and epilepsy, with cortical degeneration Against this theory, some writers have raised the question in regard to the existence of the hemichorea on the same side of the body as that of the brain where the lesion is found, and contend that there must be crossed action. The recent and conclusive investigations of Flechsig al- luded to in other parts of this book, show however, that total decussation does not take place in the medulla. Dupuy and Brown-Sequard have made experiments which prove that such a condition of aft'airs may exist, and I have myself done the same thing. Since my experiments, I have heard of a case, related by Dr. Walter Hay, of Chicago, in which post-mortem, examination revealed a cerebral hemorrhage on the side of the hemiplegia. In one of these experiments made by Dr. F. H. Rankin and myself upon a monkey, electrical irritation (galvanic) of the white matter just beneath the cortex of the upper part of the left ascending parietal con- volution produced convulsions in both extremities of the same side. The views of Jackson now seem to warrant the supposition that in a very large number of cases, in those especially in which no j^ost-mortem appearances were found ; or at least have not been hitherto looked for in the region of the cortical motor centres where they might have existed unrecognized ; that the motor area of the cortex is primarily in fault. In some cases we are furnished with startling proofs of this. A woman who recently died at the Hospital for Epileptics and Para- lytics, and who was in my ward for a number of years, presented the most aggravated symptoms of chorea I have ever seen. Her disease had lasted for twenty or thirty years, and before her death there were decided mental disturbances which occasionally burst out in attacks of mania. Her whole body seemed to be affected, for every limb was agitated by cho- reic twitchings. She sat usually upon a low chair, her body bent for- ward, her arms extended, and her fingers spasmodically working. Her head w^as in a constant state of movement, and her li]3s and facial muscles were implicated as well. She could not talk distinctly, but her utter- CHOREA. 495 ances were explosive and rapid. There never had been any paralysis, but after death the important cortical motor centres oti both sides were found to be the seat of atrophy. In this case, which probably re- sembles others of the same class, the destruction of certain psycho- motor cortical centres does not result in paralysis, but a loss of governing control upon the part of the upper gray matter, while the lower motor ganglia act independently and inharmoniously in the inner- vation of the muscular system. Broadbent localizes the lesions entirely within the corpus striatum. He also calls attention to the existence of peripheral irritation, shock, and various causes which may produce a depraved functional condition. Bastian adopts the theory that the emboli consist of masses of agglome- rated white corpuscles, and that the location of the lesion is in the corpus striatum. Dickinson is disposed to regard the chorea as the result of rheumatism rather than of endocarditis, and considers the central condition one of hypersemia of the nervous centres, '' not due to any mechanical mischance, but produced by causes mainly of two kinds : one a morbid, probably a humeral, influence which may affect the nervous centres as it affects other organs and tissues ; the other, irritation in some mode, usually mental, but sometimes what is called reflex, which especially belongs to and dis- turbs the nervous system, and afiects persons difierently according to the inherent mobility of their nature." In regard to localization he agrees in the main with the other observ- ers. " The spots of perivascular change are widely scattered throughout that large region which lies iuferiorly to the cerebral convolutions be- tween the corpora striata and the lower end of the cord ; the district of the motor and sensory as distinguished from the mental functions." It seems, then, that the quality of the lesion is only disputed. I am strongly inclined to accept the embolic theoiy, not only because the pare- sis of the limb may precede any muscular movements, but because lesions in or about the corpora striata, which produce hemiplegia, may also give rise to choreic movements, but I believe that the motor zone of the cortes is often at first the seat of pathological changes. Diagnosis. — The movements of chorea must be difierentiated from those of sclerosis and paralysis agitans. This will not be a difficult task, as the peculiarity of the choreic movement is the jerh, while the tremor of the other affection is rhythmical and usually fine, and varies under certain circumstances. The rapid recovery should also be an element in the di- agnosis. That chorea may result in some secondary disease, such as softening or meningitis, is well settled ; and in these cases it will be necessary to take into account the character of all the new symptoms, and the history of the old ones. The exceptional forms of the disease may be mistaken for hysterical troubles, and then the diagnosis will be difiicult. It must be borne in mind, however, that this mistake can be made only in adult cases. The 496 CEREBRO-SPINAL DISEASES. paralysis of chorea may be differentiated from true cerebral or spinal pa- ralysis by its gradual development, and by the age of the individual, as these two forms are quite rare iu infancy. Choreic movements usually stop at night, and the exceptions to the rule of quiescence during sleep include those in which the patients have "dreams of movement," such as were alluded to by Marshall Hall. Prognosis. — Chorea is an affection which may very often disappear, without any treatment whatever, in from six weeks to four months; but there are very likely to be relapses. If properly treated, the movements should disappear in from six weeks to two months, or even in a shorter time. If the disease appears after puberty, the prognosis is unfavorable, and all we can do in some cases is to moderate its violence. There is a tendency to recovery in other cases, among them those of pregnancy. Death is a very unusual termination, and it rarely occurs as a result of the disease itself, but rather of some cardiac complication. Treatment. — Internal remedies : Strychnia ; arsenic ; iron in its various forms (bromide, carbonate, etc.) ; phosphorus and cod-liver oil. External remedies : Cold to spine — ice, ether spray, and cold douche ; Russian or Turkish baths ; and salt baths. Rest, diet, and fresh air. Some of these may be combined with good effect. The plan of treat- ment I generally employ is the following: Should the child be "run down," as is generally the case, I begin with some preparation of iron, and administer at the same time cod-liver oil. As regards special treat- ment, I find strychnine serviceable, carried up to the point where stiffness of the sural muscles is arrived at. Next to this stands arsenic. It must be given in large doses ; but when we find that digestive troubles are produced very quickly by this drug, strychnia may be substituted. In some cases, when gastritis is produced, we may use the arsenic in the form of Fowlers solution hypodermically, and larger doses may be ad- ministered in this way. Cold to the spine cannot be overestimated as a plan of treatment. We may either use the ether spray, which was first suggested for use in this disease by Subet^ki, of Warsaw, in 1866, or apply ice-bags every day, allowing them to stay on about ten minutes. Perroud, who has used the ether spray, makes applications from four to eight minutes in duration every day. Of thirty-five cases I have treated in this way (I mean with the ether spray), from fifteen to twenty appli- cations produced permanent benefit ; and here I would say that the spray should be directed chiefly to the upper part of the cord, over the upper cervical vertebrae. Eserine has been recommended, and Bouchut has given the results of 437 cases, 205 of whom took it in pilular form, and 232 hypodermically. The average dose was from two to five milli- grammes. He obtained temporary benefit, which seemed to wear off; but when the drug was repeatedly administered, he accomplished many cures. He reports twenty-three cures by an average of seven injections. It is a dangerous remedy, however, and produces severe gastric symptoms. The salts of zinc have occasionally proved valuable in cases of this dis- ease ; and conium is occasionally eflBcacious, but its effects are tempora- CHOREA. 497 ry ; but I prefer the remedies I have mentioned. I have found phospho- rus, with cod-liver oil, to be a most valuable curative agent, and in cases where everything else failed it has succeeded. This seems reasonable, when we consider how much impaired must be the nutrition of the nerv- ous matter. Da Costa^ and Mills,^ of Philadelphia, have used the bromide of iron ; but the latter has had very successful results. In twelve patients to whom he administered the drug, there was no improvement after its use. Dr. Mills says : " It was usually given in plain syrup and water, com- mencing with five grains three times daily, as recommended, and rapidly increasing the dose to twenty. The treatment was continued from two to four weeks. Twenty grains very generally caused vomiting. It seems to be a remedy which quickly irritates the intestinal tract." Oulment and Laurent recommended hyoscyamin in doses of one-six- tieth of a grain, in pill form, at first twice daily, and afterwards more frequently. Amelioration is said to begin in eight or nine days for a child. I have administered hyoscyamin to a number of cases with great benefit. It is, however, a most dangerous remedy, and the commencing dose should not be more than sho of a grain, to be increased if dryness of the mouth and dizziness are not too great. Should the presence of worms be suspected, we may either use an injection of quassia and carbolic acid solution (gtt. X — Oj) after each stool, or pursue the ordinary santonine . treatment. The use of ferruginous tonics is generally indicated, and those should be selected which are best assimilated and which tax digestion the least. I would therefore recommend either the carbonate of iron, or dyalized iron. The addition of digitalis seems to increase their good effects quite materially. Chalybeate waters are useful, and sulphur baths are recommended by Baudelocque and others. Trousseau recommends morphine and strychnine, but I have never seen any good results follow the use of the former ; of the virtues of the latter I have already spoken. H. C. Wood recommends a tincture made from the fresh leaves of the skunk-cabbage, with which he has had some success. Electricity I have no faith in, except, perhaps, when the so-called " general electrization " is used as a cutaneous and muscular stimulant. Benedikt has cured many cases by galvanism; but, as far as I can learn, his results are exceptional. There are instances where nothing does good. It is well to put the patients in a dark room, and keep them perfectly quiet. We will be often astonished at the result. There are little things that must be watched. The diet, above all things, should be regulated with judgment. Plenty of fresh air and sleep come next, and absolute mental rest must be enforced. The school-books and the school-room are to be parted from,, and agreeable diversions planned. An excellent auxiliary to our medi- cation is the salt-bath. A handful of rock-salt in the water, and the ener- 1 Med. and Surg. Eeporter, Jan. 30, 1875. 2 Phila. Med. Timea, Sept. 25, 1875. 32 498 CEREBRO-SPINAL DISEASES. getic use of the rough towel, will infuse a tone and vigor that will soon become apparent. In conclusion, I must say that decided medication is useless in these patients if their personal habits are not looked after. PAKALYSIS AGITANS. Synonyms. — Shaking palsy ; Parkinson's ^ disease ; Trembling palsy ; Tremblement senile; Chorea senile; Chorea festinans. It is unfortunate that so much confusion exists in regard to the proper classification of this tremor of old age. It has been and is to this day confounded with cerebro-spinal sclerosis. I shall speak of it as a disease of advanced life, symptomatized by paresis, involving usually the upper extremities, with tremor which is not increased by voluntary muscular action. This tremor rarely affects the muscles of the face, except in advanced stages of the disease, and is accompanied by festination, and in certain cases by bending of the body forwards, and inclination of the chin forwards and downwards. Symptoms. — The extremities first become the seat of tremor, the fin- gers being agitated in the beginning; the hand is next involved, and after- ward the arm. This tremor is bilateral, and it may not make further advances for some time, but ultimately the head, and other limbs are included. The tremor may involve one hand before the other, or the leg of the same side may be next affected, then the leg of the other side, and next the opposite arm. After a variable time, extending from one to ten • years, a species of muscular rigidity takes place, so that the head is drawn down, and ultimately the body is bent and the head is thrust forwards, or the chin is drawn down to the breast. The forearms and hands are flexed, and the arms may be drawn to the side of the body. The constant move- ments may produce an actual abrasion of the skin by friction of the elbows or hands, should the muscular contraction bring them in contact with the body. Any attempt at locomotion is attended by what has been called " festination." The patient may rise slowly from his seat, and perhaps in the early stages walk, slowly though awkwardly, by taking long strides, but^when the muscles of the back lose their power, and the body pitches forward, the patient's attempts to preserve his equilibrium result in a shuffling gait, and finally he is compelled to run and gladly clutches the nearest chair or support to avoid falling. The voice is weak and the speech broken and abrupt, and the form of interruption has been compared by Charcot "to that which affects a novice in equitation when his horse begins to trot." This interruption is caused by the violence of the muscular movements. The patient pitches his voice when he begins to speak, and never changes the tone until he has finished, so that his phonation is decidedly monotonous. He is greatly fatigued by the constant muscular movements, and is restless and inclined to seek new positions which may give him ease. A disagreeable symptom is the occurrence of cramps of temporary duration, which are more com- ^ Essay on Shaking Palsy, London, 1817. PARALYSIS AGITANS. 499 mon during the day. During the tremor the fingers or toes may be rigidly flexed or extended. The face is utterly devoid of expression, but the mind is never impaired, and there are no affections of the organs of special sense. The tremor in the beginning ceases at night, but in the established form it is present at all times. The termination of the disease may be in death through exhaustion or complicating diseases, such as pneumonia, which carried off three cases reported by Trousseau. The functions of the bladder and rectum are not usually involved, except when the disease has become confirmed. In one case Topinard found sugar in the urine, but it is hardly necessary to say that this circumstance is exceptional. After suffering for a number of years the patient is finally obliged to seek his bed, sloughs form over the sacrum, and he gradually sinks, the tremor, perhaps, moderating slightly before death. The following interesting case is one that illustrates the course of the disease perfectly : — Mr. M., the patient, during his early years led an active life, and after following the occupation of a peddler gradually worked his way up to prosperity. For-years he went about the streets of New York carrying, many hours in the day, a heavy pack upon his back, and during this time he suffered many privations of food, rest, and sleep, and was exposed to the elements, after going home wet and cold. About fifteen years ago he first noticed the appearance of his present disease. He is a stout man of large frame, and about 70 years old. The trembling began after slight exertion, and continued for some time. It became more pronounced and constant during the next two or three years, and he was unable to un- button his clothing, feed himself, or use his hands. His general health did not seemingly suffer, but he was " nervous" and depressed, and fully aware of his pitiable state. He did not tremble so much when lying down, but when he moved about or assumed the erect position the hands shook and the head shook constantly from side to side. The movements always stopped at night, but it was some time before he could sleep. He gradu- ally lost power; the right arm losing strength primarily, and afterwards the left. Coincident with the loss of power there was tremor. When I saw him two years ago, I found him seated in a chair in which he had difficulty in keeping his place. His upper extremities and head were chiefly affected. The head was inclined forwards, and was constantly agitated by movements of a rhythmical character, which did not appear to be increased or diminished by any act of volition. He could not raise his chin, but looked up at me when I entered the room with his son. When asked a question, he answered in a tremulous voice, speaking as would one who was chilled. His body was curved forwards, and his arms were semi- flexed, the elbows being drawn to the chest; and forcible or voluntary extension was impossible. There was no atrophy of the muscles of the arms or forearms, and no d-^cided loss of sensation. The hands were agi- tated by the same rhythmical tremors as the head. When he was lifted up he could not walk, and would have pitched forward if not held. In this position I noticed that the knees were also affected by the tremor. His bladder and rectum did not seem to be involved, at least not as a result of the disease, for beyond symptoms of enlarged prostate he suffered no impairment of function. For the past two years he has needed powerful 500 CEREBRO-SPINAL DISEASES. opiates to procure sleep, the movements continuing unless they are given. He swallows with difficulty, and there is a drain of saliva from the corner of his mouth. As far as I can learn there have heen no disorders of the organs of special sense, and certainly there are now none. His mind seems to be somewhat affected, as he is irritable and silly, and his memory is deficient. It may be stated that the affection may exist in a modified form (Par- kinson's disease; and that tremor alone may be the only symptom. Festination and rigidity are by no means constant expressions of the affection. Causes — Nothing is known in regard to the causes of paralysis agi- tans. It has followed mental distress, or has been preceded by neuralgia and rheumatism, but these seem to be connected with so many nervous diseases that it is difficult to say just how much they have to do with the etiology of paralysis agitans. I have seen several cases, and in none of them was there any history of predisposing or exciting causes. We know that the disease is rare before the fortieth year, and that the male sex is more often affected than the other sex. Morbid Anatomy and Pathology. — Handfield Jones ^ holds to the doctrine that the affection is purely of a functional character while others believe it to be a multiple cerebral sclerosis. In an excellent re- view of the recent writings of Charcot and Moxon, which has appeared lately, the reviewer says : " There is a certain satiric humor in Professor Charcot's notice of the morbid anatomy of paralysis agitans. He divides the autopsies hitherto made into three groups. In the first group nothing at all was found. The second group comprises cases of supposed paraly- sis agitans, which Prof. Charcot considers were in reality sclerosis ; and the third group contains the case of Parkinson subsequently mentioned, and a similar case by Oppolzer, which is treated with similar distrust. There are, however, other cases on record which give much more satis- factory results. Leyden has reported one in which the agitation was limited to the right arm, and a sarcoma the size of a large nut was found in the optic thalamus of the opposite side. Murchison and Cayley have reported a case in which very definite changes, partly of sclerosis and pai'tly of cell growth, were found in the cord ; but as in this case the symptoms are described but very briefly, it is possible that Prof. Charcot would place it in his second group. Joffroy, however, took especial care to investigate this point, as to whether the cases were really paralysis agitans or insular sclerosis, and he states that two out of his three cases were clearly paralysis agitans. In these two cases there was exuberant growth of the epithelium of the central canal and of the nuclei around. In the third case, which seems not to have been a very doubtful one, there was in addition a sclerosed patch in the medulla." ^ The pathology of tremor is still so imperfectly understood, and there is 1 Functional Nervous Diseases, p. 382. ■^ Brit, and For. Med.-Chir. Rev., Oct. 1875. PARALYSIS AGITANS. 501 SO much to be said, that it would involve a mucli more protracted consi- deration than the size of this book will permit. We may, however, con- sider some of the physiological conditions of muscles which, when dis- turbed, result in the pathological state known as tremor. The variation or interruption of any compound entity is followed by an inharmonious relation of its parts ; thus a musical sound is the result of a number of more or less rapid vibrations and waves, their number influencing pitch. If a catgut string in a state of tension is twanged, vibrations are induced and a musical tone is produced ; but if a stick be loosely held against the string, without actual pressure being made, the vibrations will be interrupted, and a discordant noise will be the result of such contact. It has been demonstrated that a visible muscular con- traction is, after all, the result of an incredible number of smaller con- tractions, which cannot be seen with the naked eye, but may easily be appreciated with the aid of the myographium or some other registering instrument. Upon faradizing a muscle this may be experimentally de- monstrated. Shorts breaks are followed by visible contractions of the muscle and movements of the limb ; but if by a proper current-breaker this interruption be repeated many hundred times a minute, the intervals will be so short that, though an immense number of rapid contractions take place, there is but one grand contraction of the muscle which is ap- preciable. In the physiological state this co-ordination (if I may use the word) of the minor contractions is so perfect that the mu?cular movements are steady and separated by regular intervals ; but when the rhythm is lost, or the harmony destroyed, the smaller contractions will be separated by intervals of sufficient length to be seen, and tremor results, the degree of tremor being proportionate to the length of the interval. The filaments of a tired muscle, the motor centres being worn out, do not contract evenly ; so, as a consequence, there is a visible tremulous- ness. In functional tremor, such as characterizes the disease in question, this is undoubtedly the pathological condition. Diagnosis. — The treatment of cerebro-spinal sclerosis may be mis- taken for that of paralysis agitans. Let us compare the points of dif- ference : — PARALYSIS AGITANS. CEREBRO-SPINAL SCXEROSIS. Tremor continues, but not increased by Tremor subsides during repose, and is voluntary efforts. always aggravated by volitional attempts at control. Tremor regular and '' fine.'' Tremor '' coarse.'' Facial muscles unaffected. Usually cranial nerve paralysis, or tre- mor of facial muscles. Kuns forward to preserve balance. Only staggers wben walking is at- tempted. Speech slow, or affected by violence of Speech-defects those which arise from muscular movements. paralysis. A disease of old age, or advanced Usually a disease which appears before life. middle age. 502 CEREBR0-8PINAL DISEASES. Mercurial tremor, lead tremor, and alcoholic tremor sometimes resem- ble that of the disease in question ; the former is, however, more violent in the morning ; the tremor from lead is attended usually by colic and other symptoms of plumb ism ; while no doubt need arise in regard to the third, which is attended by evidences of alcoholism. Post- paralytic cho- rea may be excluded by the history of hemiplegia or some other equally prominent organic condition, and the tremor is aggravated by voluntary efforts. A functional tremor of a very light grade, which is simply a personal peculiarity, is met with sometimes, and should not be magnified to the dignity of a disease. This may affect several members of the same family, as is the case in one example of which I know. The head of the family is a vestryman of a church, and in passing the plate he sometimes is obliged to exercise the utmost self-control to prevent the contents from being thrown out, and more than once this infirmity has given rise to in- sinuations concerning his habits. His two children, both very young and healthy people, are affected by the same tremor. In such a ease the trou- ble does not increase with time, and there are none of the other progres- sive signs of the true affection. Prognosis. — The course of paralysis agitans is decidedly progressive, though very gradual, and the individual may live for ten, twenty, or even thirty years after the appearance of the tremor. When death takes place, it is in nine cases out of ten the result of some other disease. I am con- vinced that genuine paralysis agitans is never cured, though it may be relieved ; and it is highly important to distinguish simple functional tremor, which is not uncommon, from the disease under consideration. This func- tional disorder is amenable to treatment. Treatment. — Handheld Jones ^ considers that nothing can be done for the disease among very old people when it has become decidedly chronic. He has used electricity, conium, and a variety of remedies. " The general tenor of experience in this and in kindred disorders is to the effect : (1) that the main indication is to nourish and support the fail- ing power of the nervous centres affected ; (2) that this is best accom- plished by remedies drawn from the class of sedatives, or by the milder tonics. Henbane, conium, chloral, subcataueous opiates, bromide of po- tassium, belladonna, hypophosphites, or phosphorus, cod-liver oil, carbon- ate of iron, and sulphuret of potassium baths, with electricity in one or other of its three forms, appear to me the most hopeful remedies. But steady persistence in appropriate treatment is doubtless essential, and the want of this may account for many failures. Trousseau's adage should be borne in mind, ' A longue maladie, longue traitement.' " He refers to a cure reported by another observer. The patient was a woman, eighty years old, in whom the disease followed severe labor; and she was ultimately unable to carry trays or heavy loads. Thefaradic cur- rent used several times effected the disappearance of the tremor. I am 1 Brit. Med. Journal, March 8, 1873. EXOPHTHALMIC GOITRE. 503 inclined, however, to consider this case one of functional tremor, and not of the grave variety I have described. I have used conium with good results, and find that it relieves the pa- tient, but after the use of the drug has been discontinued for a few weeks, the tremor is pretty sure to reappear. It should be given in doses of the fluid extract of from n^^ v-^L viij thrice daily. Hyoscyamin, a remedy that possesses virtues second to none as a de- presso-motor, is worthy of a trial in this affection, although in chronic cases its good effects are rarely more than temporary. Elliotson^ has cured a case by the carbonate of iron iu large doses, and strychnine has been suggested, but it is doubtful whether it does any real good. Galvanization of the spine, one pole placed over the spine, and the other as near as possible to the point of exit of the spinal nerves, has been advised ; and in some instances it has improved, if it has not cured, the affection. EXOPHTHALMIC GOITRE. Synonyms. — Basedow's disease; Graves' disease; Exophthalmic cachectique ; Cardiogmus strumosus. This interesting disease has received but little attention until within a few years, and it is only lately that it has been considered as a neurosis. Definition. — Exophthalmic goitre is a disease connected with vascu- lar excitement and circulatory disturbance ; there is not only enlargement of the thyroid gland, but an excessive engorgement of the intra-orbital vefcsels, so that the eyeballs are pressed forward, giving rise to a hideous deformity. Symptoms. — The first symptoms of the disease are generally indi- cated by violent action of the heart, and great acceleration in the circu- lation; and with this there is hypersemia of the cerebral vessels. Pal- pitation and pain over the left side of the chest, shortness of breath, and flushing of the face are other symptoms of this early stage. This early vascular disturbance is, perhaps, the first .evidence of the disease noticed by the patient, but the enlargement of the thyroid gland may have been progressing for some time. There may be other early symptoms which appear with increased growth of the goitre, and protrusion of the eye- balls. These are falling out of the hair of the eyebrows, as well as the eyelashes. The heart's action is violent throughout the disease, and the pulse may beat from 120 to 140 per minute ; while the temperature is one or two degrees higher than the normal standard. There is nearly always a sys- tolic bruit and a carotid murmur. The hand, when placed over the goitre, may receive a peculiar sensation, which is produced by the agi- tation of the thyroid by the rapidly circulating blood in the enlarged vessels. ^ Quoted by Jaccoud, op. cit., vol. i., p. 427. 504 CEREBRO-SPINAL DISEASES. Although the disease begins suddenly in some instances, it is usually of slow development, and, according to Eulenburg, there may be hysterical manifestations before the pulse acceleration manifests itself. I have my- self noticed that the patients then seen were emotional and easily excited. Digestion is nearly always impaired, and there may he some diarrhoea or attacks of vomiting ; while sleep is troubled, and the patient suffers greatly for want of rest. His appearance is unmistakable. One or both eyes are prominent, and uncovered by the lids ; and the sclerotic is ex- posed above the cornea to a great extent. The patient is hypermetropic, and suffers considerably from conjunctivitis produced by the irritation of foreign bodies which lodge there. There is rarely any visual disturbance, although troubles of accom- modation are met with ; and there are no changes to be observed in the retina. Dr. Yeo reports two very valuable cases, which are presented in admi- rable shape in a late number of the British Medical Journal} In one of these there was exophthalmos of the left eye only, the goitre being on the right side. The second case was thus described by Dr. Yeo : " The patient is a young single woman, 23 years of age, robust and strong-looking. She shows no signs of the pronounced cachexia (phthisi- cal) so evident in the other patient. But she is especially interesting now, as being also the subject of unilateral exophthalmos. In her case the right eye only is prominent. There is very little, if any, enlargement of the thyroid, but there is constant palpitation. The pulse has varied during the time she has been under observation from 116 to 140. She comes of a healthy family, and has always had good health till lately. She first noticed the prominence of the right eye about a year ago. All this time she has been feeling nervous and excitable. She came to King's College Hospital about nine mouths ago complaining of pains in the back of the head and palpitation. She stated, also, that she suffered frequently from ' bilious attacks,' attacks of vomiting which would last a whole day, after which her throat would get very large. She complained, also, of frequent profuse perspirations coming on twice and three times a day, sometimes without any cause and sometimes on the slightest exertion. The hands and feet are always perspiring, and her hair is sometimes wringing wet" She is easily fatigued, has lost her appetite, and is much thinner than she used to be. She suffers much from dysmenorrhoea, and all her symptoms are worse at her periods. She says her throat was much more enlarged nine months ago than it is now. There may be double exophthalmos or single, but the double affection of the eyes is the rule in the great proportion of cases. In some cases it is absent entirely, and of 58 cases reported by Von Dusch it was absent in four. The eyeball may be pressed back, as the vascular cushion behind is 1 March 17, 1877. EXOPHTHALMIC GOITRE. 505 soft and yielding; and a peculiar thrill is felt. An " arcus senilis" has repeatedly been observed by Bartholow/ who first called attention to this change, and by others afterward, among them Thomas.''' Von Graefe was the first to allude to the peculiar behavior of the upper lid, Fig. 65. Dr. Yeo's Case of Exophthalmic Goitre. which, as Eulenburg expresses it, " loses its power to move in harmony with the eyeball in the act of looking up or down." Irritability of tem- per, hysteria, laryngeal trouble, and difficulty of breathing are symptoms which are to be noticed, and towards the end this respiratory embarrass- ment becomes quite distressing. The patient is generally badly nourished, and we may have added to the symptoms already described, many of those of general ansemia. The skin of the whole body may sometimes be of a much darker hue than it is in a condition of health, and some discoloration of that covering ^ Chicago Journal of Nervous and Mental Diseases, July, 1875. ^ Richmond and Louisville Med. Journ., Nov. 1876. 506 CEKEBRO-SPIXAL DISEASES. the forehead is often noticed. This discoloration resembles a brown stain, and it has been spoken of as " bronze skin " by some writers. Raynaud' has called attention to the connection between this stain, or vitiligo, and exophthalmic goitre. He gives "five cases of exophthalmic goitre, culled from various sources, in the course of which patches of vitiligo appeared on various parts of the body. Beyond the observation that vitiligo is more common in men than in women, except when congenital, that it attacks by preference persons of dark complexion, that it is sometimes, though rarely, hereditary, and has a certain analogy to Addison's disease, viewed as an imperfect vitiligo, little has been made out with regard to its pathology. Mr. Hutchinson has pointed out that although no known cachexia appears to set up a predisposition to the affection, the symmetry of the cutaneous patches is suggestive of some pre-existing general fault of the circulatory or nervous systems, and is opposed to the hypothesis of a parasitic origin. Without offering any explanation of the coexistence of vitiligo with exophthalmic goitre. Dr. Raynaud thinks that the coinci- dence should not be allowed to pass unnoticed." The connection of urticaria ha.s been pointed out by Bulkley, who reports two cases of the disease. One of these is presented : — " Mrs. — , aged 45, was delicate and sickly when a child. Was married at 18 years of age, but separated from her husband after 4 months ; she had a miscarriage at 3 months, and has never been completely well since. She is of full habit ; bowels and menses regular; tongue coated; pulse 84, weak ; has had chronic rheumatism. "The history of the Graves' disease dates back a number of years — at least five years previous to my seeing her. This diagnosis was made by a prominent oculist whom she consulted about the projection of her left eye. She has been treated much of the time ineffectually by various physicians, remaining with each long enough only to experience more or less benefit, and then changing. The eyes exhibit clearly the peculiar appearance of patients with exophthalmic goitre, the left one being more strikingly prominent, and being of but little service fur vision, she soon losing control of it. The other phenomena of the disease have been present for some years — irregularity of the heart's action, and at times severe palpitation, and enlargement of the thyroid ; but this is not so very marked. " Five years before coming to me she experienced a severe nervous shock, and dates her skin trouble from that period. She states that she has not perspired since. She began then to have 'a fine rash and redness all over the body,' and itching. This continued about the same, ofi* and on, for four years, when, after being weak and exhausted, and having various hysterical difficulties, the itching became more general, and an eruption corresponding to that now existing appeared. Lumps would foi-m on the forehead and on various parts of the body ; sometimes the face and head would appear greatly swollen. " When first seen she was in a pitiable state of nervous anxiety ; the itching of the feet and toes and sometimes of other parts of the body she ^ Archives Gen., June, 1875 ; and London Me 1. Record, Sept. 15, 1875. EXOPHTHALMIC GOITRE. 507 described as agony. At the first visit there was not so much to be seen on the skin, but there were a few urticarial blotches on various parts of the body and limbs. While under observation, however, she had several acute attacks of skin trouble, all of the same sort. On one occasion she woke with the upper lip greatly swollen, and with swellings on various parts of the body. On the following day, when seen, the whole face was swollen and puffy ; on the middle of the forehead there was a large erythe- matous lump, also one beneath the right eye, and smaller ones about the face. The hands were swollen ; on the right hand, near the little finger, there was an erythematous patch, somewhat swollen and with two small vesicles on it. There were also various erythematous and urticarial blotches about both hands and wrists ; and on the back of the left hand, near the thumb, there was a red spot with the skin broken, as if the seat of a former vesicle. The whole surface cf the skin burned as if scalded or scratched ; there was no pain on deep pressure. On another occasion, a day or two after there had been, according to her statement, numerous swellings on various parts of the body, the remains of several were visible on the right cheek, and on the arms there were numerous stains, some of them quite dark, as if the parts had been bruised — the remains of the lumps ; the hands and arms were manifestly swollen, and there were urticarial wheals on the limbs and body." The following case is one of unilateral thyroid enlargement, with double exophthalmos : — Mrs. L. B., 28, U. S. ; milliner. Was always well until eight years ago, when her present difficulty began. She was them living in New York, and actively employed. At this time she noticed the growth of a goitre upon the right side of the neck, which pulsated violently when she was excited or over-fatigued. She then flushed easily, and often had headaches, which were quite intense. These she has now, and her pain is of the congestive variety, and diffused. She presented herself at the out-patient department of the New York Hospital, complaining of a pain just beneath the border of the last rib on the left side, which was quite constant, but not increased by pressure, or by taking a long breath, or after eating. The pain was most severe in the morning, and seemed to move off towards night. Her heart seemed healthy, so far as valvular lesions were concerned, for no abnormal murmur was present ; but there was great rapidity of action, the pulse-beats varying from 106-120 per minute. The pulse was also quite bounding, and full. The carotids pulsated quite strongly, and there was a very marked venous thrill perceptible in the jugulars. Upon the right side of the neck, just above the sterno-clavicu- lar articulation, and extending laterally, there was a tumor measuring 2i inches in length, and about 2 inches in breadth. The marked pulsa- tion of this growth led Dr. Slaughter and myself to suppose at first that it was an aneurism, but we were unable to reduce it by pressure, or to diminish its size by compression of the carotid ; and there was no history of injury. The peculiar movement was due to the pulsation of the carotid upon which it rested above, and laterally passed the right jugular vein, which was also agitated by the transmitted pulsation of the carotid. When the hand was placed upon the enlargement there was perceived an unduiatory or "purring" movement. No bruit was heard with the stetho- scope, but the tracheal sound was readily perceived. This growth under- 508 CEREBRO-SPINAL DISEASES. went variation in its size. Cold weather seemed to influence it in this way, and stimulants, or other ascciicies which increased the blood pressure, materially modified its size. The face was puffed, bloated, and red, and the eyeballs were somewhat prominent, while the pupils were dilated, and the irides rather sluggish. She was not hypermetropic, and there were no other defects noticed. By steady pressure I was enabled to perceive the " cushion feeling" alluded to by medical writers who have observed this disease. Her companions twitted her in regard to her fixed stare, which resulted from the exophthalmos. Her ankles and feet were cedematous, and pitted deeply on pressure. Her urinary organs seemed to be in order, and there were no indications of renal disease. She has noticed at times patches of rusty discoloration which appeared about her neck and upon the left side of her face. These lasted for several days, and then faded away. She has had several minor symptoms, such as nose-bleed, which occurs even now, every two or three weeks. Her menses are scant, but there is apparently no uterine disease. Her digestion is feeble, and she is slightly constipated. M- — Ext. ergotte fl. 5j, t. i. d. Causes. — The disease is one of adult life, and there are about twice as many females as males affected. But few cases have been reported in which the disease appeared before puberty. Devol saw a case, the pa- tient being a girl of two and one-half years. It is connected, in some cases, with metrorrhagia, or hcemorrhoidal bleeding, or in others with heart disease; but though many authors consider anaemia to be an im- portant cause, others are doubtful. Examples of traumatic origin have been noted by Begbie^ and Von Graefe,^ and others have been apparently of idiopathic origin. The case of the first followed injury to the occiput. Morbid Anatomy and Pathology. — The observations of those who have made autopsies, differ greatly. Morel Mackenzie found soften- ing of the corpora quadrigemina and the posterior part of the medulla. The heart was not much affected, there being only slight atheromatous deposits on the mitral and aortic valves, with thinness. Other observers have found hypertrophy of the heart and insufficiency of its valves, but in other cases there were no heart lesions whatever. The thyroid gland has been found to contain enlarged vessels, and the orbits an increased quantity of fatty tissue. In one of Begbie's cases there was sinking of the eyeballs in the orbital cavities after death. Much discussion has taken place in regard to the pathology of the af- fection, but recent investigations point to the nervous origin of the dis- ease. The cervical sympathetic has been found to be altered, and numer- ous instances of the change have been brought forward by Recklinghausen,' Trousseau,* Archibald,^ and others. In eight cases of exophthalmic goitre, referred to by Arnozan,® there was degeneration of the cervical sympa- ^ Edinburgh Med. Journal, February, 1849. 2 Arohiv. fiir Oplithal., 1857. ' Deutsche Klinik, 1863. * Trousseau and Peter, Gaz. Hebdom., 1864. 5 Med. Times and Gaz., 1865. « Op. cit. EXOPHTHALMIC GOITRE. 509 thetic in all; but in four other cases no such lesion was discoverable. In ^Ebstein's case, as well as those of ^ Keith and Knight/ the sympa- thetic was involved alone, and more often on both sides. Notwithstanding this explanation (the sympathetic origin), others contend that it is a dis- ease of the brain ; and still another theory is accepted by those who con- sider it a cardiac disease per se. The nervous origin seems to me to be that which is most acceptable. Not only does the use of galvanic treat- ment, which cures the disease, suggest the neurotic character of the affec- tion, but the hysterical phenomena mentioned by Basedow, and noticed frequently by others, are certainly significant. ^ We may, I think, consider the disease to be dependent upon an affec- tion of both the sympathetic and spinal accessory nerves. The condition of the vessels of the thyroid gland and those of the orbit, the flushing of the face, and general disturbance of digestion, are probably due to the al- tered function of the first-mentioned nerve, and the heart excitement is a consequence of deficient innervation of the accessories. Diagnosis.— There need be no mistake made in the diagnosis of this affection from simple goitre, and after this is accomplished there is nothing else suggested. An inspection of the enlarged thyroid, and the protruding eyeballs, and the detection of the vascular excitement, are sufficient to enable us to say that the case is one of exophthalmic goitre. Prognosis.— A cure is recorded by Cheadle,* another by Mackenzie, who also reported a death. Bartholow* has cured three patients ; Dr. J.' P. Thomas,^ of Kentucky details a very interesting case which ended fatally in five years. Very little can be said in regard to the character of the disease, but it his been cured in certain instances in a year or two. It may last for several years, however, and is essentially a chronic affec- tion. Trousseau, Charcot, and Corlieu* report cures, in which pregnancy, uterine hemorrhage, or some such complications occurred during the dis- ease, influencing its disappearance. Of course, the existence of organic cardiac disease gives the affection a very serious character. Treatment.— Galvanism, it seems, has succeeded admirably, and Bar- tholow has cured three cases by this agent. 'Eulenburg treated exoph- thalmic goitre, as early as 1867, very successfully, and Meyer and Chvostek obtained the most happy results. Eulenburg recommends very mild gal- vanic currents, and he uses from 6-8 elements. I have used the current from 10-15 Leclanche cells, the water column being employed to regu- late the same. ^ Quoted bj Eulenburg. 2 Medical Times and Gazette, Nov. 11, 1865. * Boston Med. and Surgical Journal, April 19, 1868. * St. George's Hospital Eeports, vol. iv., 1869. * Eichmond and Louisville Med. Journal, 1877. fi Rep. by Jaccoud, vol. i., p. 672, 2d edition. ^ Cyclopaedia of Practical Medicine, vol. xiv., p. 102, Am. trans, 510 CEREBRO-SPINAL DISEASES. Roth ' reports a case of exophthalmic goitre, the patient being a woman fifty years of age, her menopause having taken place six years before. She became debilitated, suffered from palpitation and sweating at night, and afterwards there was gradual enlargement of the thyroid gland and protrusion of the eyeballs. The pulse was 120, and the temperature normal. It was impossible for her to close her eyelids. The exophthal- mos was greater on the left side, and the thyroid was more enlarged on the opposite side. Galvanism was used, the positive pole being placed on the upper part of the sternum and the negative on the superior cervical ganglion. On the right side ten cells produced no sensation, but on the left, six were sufficient to produce burning. The current was also passed through the back. The night-sweats and palpitation diminished, and she grew stronger. At the end of a month she had gained two pounds in weight, but the reduction in size only occurred in the left exophthalmos and left portion of the thyroid. Chalybeate preparations, digitalis, ergot, and cod-liver oil are all excel- lent remedies. Since the appearance of the first edition of this book I have cured one case by ergot, and greatly helped another by the con- tinued administration of the Syrup of hydroiodic acid in doses 3i--^ss thrice daily. If galvanism be used, we should bring the sympathetic nerve under its influence by placing one pole (the positive) at the angle of the lower jaw, and apply the negative over the epigastrium or the thyroid. 1 Wien. Med. Presse, 1875, No. 30. NEURALGIA. 511 CHAPTER XVI. DISEASES OF THE PERIPHERAL NERVES. NEURALGIA. Synonyms. — (See special varieties.) Definition. — Neuralgia may be defined as " a disease of the nervous system, manifesting itself by pains which in the majority of cases are unilateral, and which appear to follow accurately the course of particular nerves, and ramify sometimes into a few, sometimes into all, the terminal branches of those nerves."^ Neuralgia is essentially the result of lowered vitality, and is never a consequence of any sthenic condition. This is proved by the circum- stances under which it occurs ; it taking its origin from general debility, rheumatism, syphillis, or malaria, or some other disease which produces a cachexia. Anstie very justly considers that it is the first expression of a condition which later on becomes paralysis — one being a partial dis- turbance, or cutting off of the nervous supply ; and the other a complete interruption of the nervous force; and it is a familiar fact that neuralgia very often precedes loss of power in parts supplied by an affected nerve. Neuralgia is, then, a disease in which pain is the prominent symptom, and with which circulatory, trophic, and motorial disturbances may be connected. Pain. — Neuralgic pain is quite distinct from that of any other disease. It is not at all like that of neuritis, which is constant and aggravated by pressure, but it is paroxysmal, and is characterized by a stage of increas- ing intensity and rapid recurrence, and by a second stage of " wearing out " or subsidence. It appears suddenly, disappears, and returns, being broken by a period of rest. These breaks or intervals of remission become shorter as the attack increases in severity, until the pain seem,s almost continuous. When the climax is reached, the intervals grow in length, and the pain diminishes in severity, and finally subsides. Re- peated neuralgic attacks leave the nerve in a hypersesthetic condition, so that at particular points it is tender and sensitive to pressure. These foci of exalted sensation have been called by Valleix^ "les points douleureux," and correspond to the points of emergence of the nerve from its foramen, or at a point when it passes from a deep to a superficial course. The terminal ends of nerves are much more often the seat of this tenderness than any other part. The external ramifications of the supra- orbital branch of the fifth or the small filaments of other nerves — the 1 Anstie, Neuralgia, etc., p. 14. -Traits des Nevralgies, Paris, 1841. 512 DISEASES OF THE PERIPHERAL NERVES. ulnar aud radial for instance — are not rarely painful to pressure. These painful points are met with frequently in cases of facial neuralgia. A gentleman who consulted me some time ago presented this indication of facial neuralgia, there being several hyperaesthetic spots in the roof of his mouth, aud his gums on one side were exquisitely tender. Circulatory dkturbancei, of a quite marked character, are pronounced features of the neuralgic attack. The pulse at first is irritable, small and quite rapid. A species of fluttering palpitation is also present, and the surface is pale and cool. In the later stages of the attack, after the pain has grown decided, the face becomes flushed ; the pulse soft, full, and quite bounding ; and the eyes may be suffused and bloodshot, should the attack be one of facial neuralgia. During this stage, and after the subsidence of the pain, the patient may sweat profusely. Trophic Disturbances. — These may be connected with the acute pa- roxsyms, or may result from repeated attacks. Among the former may be pemphigus, and herpetic and bullous eruptions; and among the latter, loss of teeth or hair, or alteration in the coloring matter of the hair, atrophy of muscular tissue, and various cutaneous changes. Charcot and Weir Mitchell, as well as various writers upon dermatology, have called at- tention to the connection of aggravated neuralgic pain, with various cutaneous diseases. The most striking of these neurotic skin diseases is herpes zoster, in which eruptions of a vesicular character, a cluster of patches are found here and there along the course of the affected nerve. The pain precedes the appearance of the eruption, and may con- tinue during its existence, and for some time after, or there may remain a pruritus, limited to the parts which have been the seat of eruption. The neurotic character of this complication may be proved by its very rapid disappearance after galvanization of the affected nerves, or admin- istration of large doses of quinine.^ The other trophic alterations, which are secondary, will be considered at a later period. Motility. — Connected with some forms of neuralgia are certain condi- tions of spasm. In form of facial neuralgia which has been known as tic epileptiform or tic douloureux, tonic spasm of the eyelid or of the masseter muscles is present as a decided symptom. Convulsive move- ments of the legs, due to spasms of the flexors, have also been observed in sciatica by Anstie; but in cases in which I have noticed this symptom, it seemed rather a result of excessive pain, and an effort upon the part of the patient to relax the pressure upon the affected nerve. Local spasms are quite common ; and the muscles of the face, of the trunk or limbs, and the vomiting of sick headache, are varieties of spasmodic action which may be cited as examples of this kind. In a case lately under treatment, I have been reminded of a condition which I have several times observed — a species of heart pain resembling that of angina pec- ' A form of skin disease lately denominated pompholyx by Dr. A. R. Robinson, of New York, is an example of a neurosLs of this kind. NEURALGIA. 518 toris, and connected with facial neuralgia. With this pain there would be spasmodic contraction of the muscles of the thorax. Mitchell ^ " has encountered from time to time certain forms of neuralgia, accompanied by muscular spasms and extravasations of blood in the affected part. He relates three cases, all occurring in females, and explains the circum- scribed hemorrhages by nutritive changes in the walls of the vessels, occasioned by conditions of the nervous system analogous to atrophic changes in the skin and nails in nervous diseases." Valleix has divided the neuralgias into the superficial and the visceral, and classifies them as follows : — A. Superficial. 1. Neuralgia of the fifth nerve (trifacial or trigeminal neuralgia ) 2. Cervico-occipital. 3. Cervico-brachial. 4. Intercostal. 5. Lumbo-abdominaL 6. Crural. 7. Sciatica. B. Visceral, 1. Uterine or ovarian neuralgia. 2. Neuralgia of the urethra. 3. " " bladder. 4. " " rectum, 5. " " testis. 6. Hepatic neuralgia. 7. Neuralgia of the heart. 8. " " stomach. 9. Laryngeal and pharyngeal neuralgia. Among the first group the most important is neuralgia of the fifth nerve, which may also exist with a motor complication, as tic epileptiform, or with gastric complications, as migraine or " sick headache." FACIAL NEURALGIA. Synonyms. — Face-ache ; Fothergill's face-ache ; Prosopalgia ; Tri- geminal neuralgia ; Tic douloureux ; Migraine y Sick headache. The supra-orbital branch may be alone afiected, and the pain confined to the brow and top of the head, or it may be quite generally difinsed over the face and head, the three branches being involved. The first division of the nerves is, however, the most common seat of neuralgia ; but it i& not unusual for an attack to begin above, and finally extend to all of the- divisions of the nerve on one side. Migraine, or " sick headache," presents the following features : The at- tack may be preceded by some chilliness, pallor, and uneasiness, and is ^ American Joura. of Med. Sci. Iviii. Id. 33 514 DISEASES OF THE PERIPHERAL NERVES. ushered in by a twiuge of pain, which begins just above the eye on one side, and radiates over the head. The pain is often erroneously referred by the patient to both sides of the head, when, in reality, but one-half is affected. Deep-seated orbital pain, photophobia, hemiopia and nausea, with an irritable, thready pulse, and increase of pain, immediately usher in the attack, which rapidly increases in severity ; the pulse after a while losing its asthenic character, and becoming full and bounding. The pa- tient's face becomes flushed, and his skin red and sweaty, and in rare cases the sweating is confined to one side of the face. The paroxysms of pain, which at first were separated by intervals of relief, next become al- most continuous, but after a time, during which the patient may feel like vomiting, they become less severe, and finally, after his stomach has been emptied, may disappear altogether. The features of an attack of this kind are too familiar to need elaboration. The following case will serve as an illustration: — Mrs. Gr. is a delicate, hysterical woman, who devotes most of her time to duties of society. Her domestic affairs are Avorrying, and the constant excitement of entertaining, late hours, and the management of several unruly children, have so worn upon her that now, at the end of the winter, she is ansemic, " run down," and suffers from want of appetite, insomnia, and general debility. About twice a week, at irregular times, she suffers in the beginning from light pains, radiating from the right eye, and over the head, which become quite severe, and increase during the next hour or two. She usually becomes cold, and bundles herself up in shawls and wraps. Her eyelids feel heavy, and the " skin covering " her " face feels as if it were drawn tightly." She is nervous and irritable, and cannot bear the presence of her children, and is sometimes so depressed that she bursts into tears. She has a vague dread of some trouble, the character of which she does not know. The pain increases in severity, and becomes almost unbearable. Her eyes are hot, and " it seems as if a peg was be- ing driven in from behind." Her face becomes very hot, and her tem- poral vessels throb. The slightest step she may take in walking so jars her head that it gives rise to intense pain. She " feels as if" her " heail would split open." She cannot look out of the window, but lies upon ht r bed, and buries her face in the pillows. Nothing seems to relieve her. She may lie so for hours, panting for breath, and pressing her aching heaJ. After a variable time, sometimes two hours, sometimes a day, the pain is diminished somewhat, and she becomes nauseated ; not because food lies undigested, for she has taken none for some time, but the vomiting is of a purely cerebral character. She attempts to vomit, but cannot bring up anything. The effort at retching jars her body, and increases the pain After this state of affairs has lasted for some little time, she becomes ex- hausted, and falls back upon the bed, sweating profusely. The pain grow very much less severe, is dull and throbbing, and finally she sinks into ; deep sleep, from which she awakens somewhat relieved. The variations in pain and circumstances which give rise to the disease have led different observers to apply such names as " rheumatic," " hys terical," " sympathetic," " organic," "syphilitic," and " clavus." Thest terms have little value, and it seems that a nomenclature based upon th( NEURALGIA. 515 anatomical situation of the neuralgia is all that is needed, and it certainly would do away with much confusion. Facial neuralgia, unless it be due to temporary exciting causes which may be readily removed, is rather an obstinate affection. It may take a periodic character, especially if it be connected with malaria ; or it may be more intense at night, should it be of syphilitic origin. The true attack rarely lasts beyond a few hours, but attacks. (especially of tic-douloureux) may be so frequent as to become almost continuous. The tendency is, I think, for the disease to become firmly rooted, and to increase in severity. If there be a rheumatic, mala- rial, or ansemic form, there is no reason why the disease should not subside when these morbid conditions are removed. As to clavus, in which the pain is compared to that which would probably follow the driving of nails through the skull, it may be said that this is an hysterical condition, and the patients' descriptions are based upon the workings of a disordered imagination. There' are very few cases of facial neuralgia in which all the branches may not be involved at some time or other. If the neuralgia be confined more particularly to the first and second branches of the fifth, the temples and forehead, upper eyelid, root of the nose, and the orbits will be the points at which the pain will be the most severe. Toothache, above and below, will indicate involvement of the middle and lower branches, and if the lingualis be affected, which it quite rarely is, the tongue will be the seat of the violent pain. The painful pointy are to be found principally over the supra-orbital notch, the infra-orbital foramen, the " malar point,'' or in the roof of the mouth, over the mental foramen, and in front of the ear. During the attack it is not uncommon to find hypersecretion of sa- liva, that fluid passing from the angle of the mouth in great quantity, and when the supra-orbital and infra-orbital branches are involved there may be a corresponding profuse lachrymation.^ Erb ^ has called attention to the occasional increase of secretion from the nasal mucous membrane. This has been referred by Vulpian to irritation of one of the spheno- palatine ganglia. The patient is nearly always excited and irritable, and if the paroxysms be of frequent occurrence he suffers from insomnia, and is entirely unfitted for his daily occupations. It must not be supposed that the vomiting of migraine has any direct connection with the condi- tion of digestion. The attacks are, however, aggravated by the presence of undigested food in the stomach. The deep neuralgias of this nerve are very obstinate, and often beyond the reach of any treatment. This is notably the case when the superior maxillary or its orbital branches are affected. The ocular symptoms are then of the most formidable description, and life to the patient is a burden indeed. The following is one of the most inveterate cases of neuralgia of this kind I have ever observed. The patient's trouble began in 1863, while 1 Sometimes there is spasmodic closure of the orifice of the lachrymal duct. ^ Ziemssen's Cyclopaedia, vol. ii. 516 DISEASES OF THE PERIPHERAL NERVES. at school, and then affected the superior maxillary and infra-orbital branches of the fifth nerve. His sufferings were intense, and after trying almost all forms of treatment, and consulting medical men in Europe and in this country, he consented to subject himself to an opera- tion for exsection. The history he brings, which was taken by the house surgeon. Dr. Peale, of Chicago, details the surgical procedures under- taken. " Patient has for a long time suffered from neuralgia of supra- and infra-orbital nerves, and the superior trochlear nerve. Prior to this he had a closure of the lachrymal ducts of both sides. He had been in Central America, where he was exposed to severe forms of malaria. About two years ago, Dr. Strawbridge, of Philadelphia, cut off the supra- orbital nerves at their point of exit from the supra-orbital foramen. In either eye there is loss of accommodation, and a high degree of hyper- metropia. Prof Holme.?, of this city, atter an ophthalmoscopic examina- tion, told him that the veins of the retina were diminished in size. He still suffers intensely with the infra-orbital nerves, and comes in de- siring to have them excised. He receives 3? grs. morphia, hypodermi- cally, each day. Dec. 18, 1876. An incision made downward from the location of each infra-orbital foramen to the length of one inch through the tissues of the cheek, the nerves raised on a blunt hook, stretched well out, and chipped off at their point of exit. Ether used as the amesthetic, collodion and silk sutures to approximate the edges of the incision. I'^th. Patient suffering from intense pain referred to outer edge of right lower eyelid. 23(/. Considerable cellular inflammation of right side of neck and face. 2%th. Considerable discharge of pus from incision on right side of face ; swelling very much diminished. 29■ Surgical Experiences, London, 1865, p. 205. 2 Practitioner, .June, July, and August, 1873. 5 Op. cit. * Lancet, March 27, 1869. * Op. cit., p. 302. 586 DISEASES OF THE PERIPHERAL NERVES. they refrained from their work. Two were improved, but upon begin- ning the pursuit of tbeir calling bad relapses. The remainder were of the paralytic variety, and have been for some time under treatment. Treatment. — Rest and electricity are the means at our command. A galvanic current is found to be the most beneficial, and the electrodes should be so small as to include but one muscle at a time in the circuit. The current must be mild, or it will only aggravate the disease. Besides this application to special muscles, one pole may be placed at the nape of the neck, and the other to the muscles of the hand and forearm. A. W., aged 38. The patient had followed the occupation of clerk for several years, and had assiduously worked at his desk for many hours in the day. Two weeks before I saw him he noticed an impairment in his writing power, and this consisted in an inability to write without the occurrence of a convulsive contraction of the extensors of his right fore- arm, by which the pen flew from the paper. This did not occur at the moment of writing, but after a few words had been finished. He tried to keep the hand steady by the influence of the will, but all his efforts were ineffectual. When he attempted to hold the point of any small ob- ject, such as a stick or pencil, against the surface, the same spasm would occur. There was no wasting of the muscles, pain, or other symptom. I determined to try galvanism combined with manual exercise, and the internal application of strychnia in doses of ^ith of a grain. Galvaniza- tion of the flexors of the forearm and of the small muscles of the hand was made, and, at the same time, the positive pole was held for a few minutes at the nape of the neck. He was directed to procure the rounds of a chair with which to exercise. Galvanization was persevered in, although the progress was very slow. At first he could not write more than two words (almost illegibly) ; but as he grew better, these spasms disappeared. Three seances a week kept up for a period of about three months effect- ed such an improved condition that he was finally discharged at the end of that time. Strychnia and iron, or conium, are remedies which may be used in conjunction. The ether spray apparatus does great good, and I have occasionally benefited my patients by fastening the hand in an immova- ble apparatus or sjDlint. Absolute cessation of the particular work which gave rise to the malady is to be inskted upon, and no benefit will result from any form of treatment unless this command of the physician is r espected. When the patient attempts writing anew he should provide himself with a pen having a cork holder, and this may be purchased from any good stationer. He should change his system of penmanship and acquire the so-called free hand style, in which the fingers are engaged only in holding the jjen, and the other motions are performed by the muscles of the forearm. The attempt at " shading " the lines should not be made but he should endeavor to adopt the round hand and avoid "pot hooks" and "up and down" strokes as much as possible. GESOPHAGISMUS. 587 Sea air, salt baths, and a change of habits and scene are all fraught ■with benefit. I do not consider tenotomy advisable except in extreme instances. GESOPHAGISMUS. A comparatively rare neurosis often met with among women consists in a spasmodic contraction of the oesophagus. It is usually hysteroid in character, or may be the reflex result of a simple stomatitis, beginning, perhaps, in a trivial irritation of the food passage ; and giving the indivi- dual little annoyance at first, it may develop into a condition causing great misery and sufifering from dysphagia, so that she may be unable to swallow anything but fluids, and these in small quantities, and most easily when they are warm. " Tightness of the throat," the globus hystericus and, more or less, hypersesthesia, may be symptoms which precede or accompany the trouble. There is emotional derangement as well, and the patient weeps and is de- spondent. The symptoms of spinal irritation may or not be manifested, and there is usually some spinal tenderness. A patient sent to me by Dr. Cohen, of Philadelphia, had suffered for several years, and I have exa- mined other patients who have suffered even longer. The discomfort at- tending the local trouble affects the general condition, and malnutrition from insufficient food and sleeplessness reduce the patient in every way. An examination, by means of an olive-pointed bougie, will immediately apprise us of the cause of the annoyance, and among hysterical women, who complain of their inability to swallow, we will often find, by local examination, that there is a true oesophageal spasm, which is sufficient to account for the subjective expressions some of us are inclined to disre- gard. I have met with subjects who complained of a spasm of the upper part of the pharynx with sharp pain, and in several instances have traced its origin to the immoderate use of tobacco. Treatment. — The affection is a troublesome and persistent one. Galvanization of the sympathetic ; local treatment by bougies and ether spray to the back of the neck are important external remedies ; while we may give internally, hysocyamia or any of the anti-spasmodics before alluded to. THE END. INDEX ABORTED epilepsy, 390 Abscess of cerebellum, 229 Absence of blood in cutaneous vessels in hysteria, 457 of "tendon reflex" in locomotor ataxia, 322 Abstinence from food in hysteria, 461 Abuse of bromides in epilepsy, 408 Active cerebral hypersemia, 76 Acute alcoholism, 430 cerebral anaemia, 127 cerebritis, 165 myelitis, 265 softening, 164 Acute ascending paralysis, 275 synonyms of, 275 definition of, 275 symptoms of, 275 causes of, 276 pathology of, 276 diagnosis of, 277 prognosis and treatment of, 277 Acute cerebral meningitis, 48 symptoms of, 48 causes of, 49 pathology and morbid anatomy of, 50 prognosis and treatment of, 54 Acute granular (tubercular meningitis), 58 symptoms of, 58 Acute and chronic spinal meningitis, 236 symptoms of, 236 causes of, 240 morbid anatomy of, 241 prognosis of, 242 treatment of, 243 Adult spinal paralysis, 287 ^jEsthesiometer, the, 25 Sieveking's, 26 Affections of the organs of speech in cho- rea, 484 Agraphia, 183 Albuminuric aphasia, 198 Alcohol in urine, means of detecting, 437 in ventricular fluid, 435 Alcoholism, 430 acute, 430 Alcoholism (continued) causes of, 434 chronic, 432 definition of, 430 diagnosis of, 437 hallucinations in, 431 morbid anatomy and pathology of, 435 prognosis of, 437 symptoms of, 430 treatment of, 438 Amblyopia as a symptom of brain tumor, 209 Amidon on tetanus, 378 Aneemia, cerebral, 127 spinal, 259 Anesthesia, 542 causes of, 542 diagnosis and prognosis of, 544 of fifth nerve, 543 hysterical, 457 of radial nerve, 449 symptoms of, 542 treatment of, 544 Angular gyrus, functions of, 194 Aneurism of cerebellum, 229 miliary, 113 Antero-lateral amyotrophic sclerosis, 342 causes of, 345 diagnosis of, 346 morbid anatomy of, 345 prognosis of, 346 symptoms of, 342 synonyms of, 342 treatment of, 346 Antero-spinal paralysis of adults, 287 causes of, 291 definition of, 287 diagnosis of, 292 morbid anatomy and pa- thology of, 292 prognosis of, 292 symptoms of, 287 synonyms of, 287 treatment of, 294 of infants, 277 589 590 INDEX. Antero-spinal paralysis (continued) causes of, 281 definition of, 277 deformities in, 279 diagnosis of, 285 electricity in, 285 morbid anatomy and pa- thology of, 282 muscular tissue, changes in, 284 prognosis of, 285 Sinkler'e cases of, 278 symptoms of, 278 synonyms of, 277 treatment of, 285 Aphasia, 179 children, of, 194 definition of, 179 diagnosis of, 195 history of, 180 infantile, 194 location of speech centre in, 186 Lordat on, 182 medico-legal study of, 197 of Dr. Allin, 193 synonyms of, 179 treatment of, 199 with left sided paralysis, 189 Apoplexy, 90 Apparatus, electrical, 34 for the treatment of nervous diseases, 34 Arthropathies in locomotor ataxia, 325 Ascending degeneration of posterior col- umns, 341 Asemasia, 179 Asphyxie locale, 544 Atheromatous changes in vessels, 113 Athetosis, 99 Atrophy, partial facial, 308 causes of, 310 diagnosis of, 310 Draper's case of, 308 pathology of, 310 prognosis of, 310 synonyms of, 308 symptoms of, 308 treatment of, 311 of cerebellum, 225 progressive muscular, 295 Auditory vertigo, 139 causes of, 141 definition of, 139 diagnosis of, 143 pathology of, 141 Auditory vertigo (continued) synonyms of, 139 treatment of, 143 Auditory epilepsy, 400 Automatic man, the, 390 BASEDOW'S disease, 503 Basilar meningitis, 58 Bed-sores, 268 Bell's paralysis, 549 Benzine cautery, the, 37 Bilateral facial paralysis, 549 Blanching of fingers, 544 Bloodletting in apoplexy, 123 Blue line, the, 566 Bone changes in posterior spinal sclerosis, 325 Brain, inflammation of, 164 red softening of, 170 syphilitic disease of, 173 tumors, 205 choked disk a symptom of, 208 diagnosis of, 219 localization of, 220 morbid anatomy of, 211 prognosis, 222 symptoms of, 205 treatment of, 223 Brittle ness of bones in locomotor ataxia, 326 Bromides in epilepsy, 405 Bulbar diseases, 384 paralysis, 414 causes of, 418 diagnosis of, 420 morbid anatomy and pathology of, 418 prognosis of, 420 progressive variety of, 417 reflex variety of, 417 stationary variety of, 417 symptoms of, 415 synonyms of, 414 treatment of, 420 CANCEROUS growths in brain, 212 Case of cerebellar tremor, 227 of Dr. Allin, 193 of post-paralytic chorea, 98 Catalepsy, 479 causes of, 480 definition of, 479 diagnosis of, 482 flexibilitas cerea in, 480 induced in animals, 482 INDEX. 591 Catalepsy (continued) malarial, 480 morbid anatomy and pathology of, 481 prognosis of, 482 symptoms of, 479 treatment of, 482 Catlin's observations, 527 Cauteries, 36 author's, 36 glass rod, 36 Guerard's, 37 Pacquelin's, 37 Central neuritis, 208 spinal hemorrhage, 251 Centre, auditory, 194 Cerebral anjemia, symptomatic, 127 causes of, 130 chronic, 128 definition of, 127 infantile, 129 morbid anatomy and pathology of, 132 . prognosis of, 135 symptoms of, 128 synonyms of, 127 treatment of, 135 congestion, 76 hemorrhage, 90 attacks of, without loss of con- sciousness, 94 causes of, 101 condition of eyes in, 93 conjugate deviation of eyes in, 93 definition of, 90 diagnosis of, 115 morbid anatomy and pathology of, 104 post-paralytic states in, 98 prodromata of, 90 prognosis of, 119 psychical disturbance in, 92 residual paralysis in, 95 respiratory disturbance in, 93 seat of, 115 symptoms of, 90 tendon reflex in, 100 time of attack of, 103 treatment of, 122 hypersemia, symptomatic, 76 causes of, 77 definition of, 76 diagnosis of, 86 morbid anatomy of, 85 pathology of, 83 Cerebral hyperaemia, symptomatic, {con- tinued). prognosis of, 88 symptoms of, 77 synonyms of, 77 treatment of, 88 meninges, diseases of, 38 meningitis, acute, 48 causes of, 49 diagnosis of, 50 pathology and morbid ana- tomy of, 50 prognosis of, 54 symptoms of, 48 treatment of, 54 chronic, 71 treatment of, 75 pachymeningitis, 38 acute, symptoms of, 40 chronic, causes of, 43 morbid anatomy and patho- logy of, 43 osseous plates in, 43 prognosis of, 44 symptoms of, 40 treatment of, 44 with hsematoma, 44 case of, 46 causes of, 45 formation of cysts in, 45 morbid anatomy and pa- thology of, 45 prognosis, of, 48 symptoms of, 44 treatment of, 48 rheumatism, 55 sclerosis, 199 causes of, 203 definition of, 199 difi'used, 199 diagnosis of, 204 prognosis of, 204 symptoms of, 200 synonyms of, 199 treatment of, 204 softening, 164 acute, 165 causes of, 167 diagnosis of, 168 morbid anatomy and pa- thology of, 167 prognosis of, 169 symptoms of, 165 treatment of, 169 chronic, 170 592 INDEX. Cerebral softening, chronic, {continued) causes of, 173 definition of, 170 diagnosis of, 177 morbid anatomy and pa- thology of, 174 prognosis of, 178 8}'raptoms of, 170 treatment of, 179 classification of, 161 definition of, 164 thermometry, 23 tumors, Gragset's classification of, 211 localization of, 220 Cerebellum, tumors of, 225 softening of, 229 abscess of, 229 atrophy of, 225 tumors of, 226 hemorrhage of, 225 Cerebellar disease, 223 diagnosis of, 234 prognosis of, 234 treatment of, 235 Cerebritis, 165 Cerebro-spinal diseases, 421 meningitis, 421 retraction of head in, 422 Cerebrum and cerebellum, diseases of, 76 Cervical pachymeningitis, 238 Cervico-brachial neuralgia, 519 Cervico-occipital neuralgia, 518 Character of the deposit in so-called tubercular meningitis, 66 Charcot on reduced temperature in hys- tero-epilepsy, 479 Chloral-bromide treatment in epilepsy, 408 Choked disk, 208 . Chorea, 483 adult, 488 among school children, 491 causes of, 490 definition of, 483 dependent upon tapeworm, 486 diagnosis of, 495 embolic theory of, 491 epidemic, 483 ether spray in treatment of, 496 heart lesions of, 492 irregular forms of, 486 hyoscyamia in, 497 malarial, 491 m6rbid anatomy and pathologv of, 491 Chorea (continued) of pregnancy, 488 post-paralytic, 98 prognosis of, 496 rare among negroes, 490 symptoms of, 484 synonyms of, 483 treatment, 496 with eczema, 490 Chronic cerebral pachymeningitis with haematoma, 44 myelitis, 269 Circulation of brain, Duret on, 111 alcoholism, 432 Clavus hystericus, 455 Color blindness, 441 Columns of Gall, sclerosis of, 341 Condition of organs of generation in hys- teria, 455 Congestion, cerebral, 76 spinal, 255 Congestive pernicious fever, its resem- blance to cerebro-spinal meningitis, 424 Constriction band, the, 269 Contractions, fibrillary, 296 of muscles in cerebro-spinal menin- gitis, 422 Contractures in antero-lateral sclerosis, 342 in hemiplegia, 98 in infantile paralysis, 279 in hysteria, 459 Contusions and punctured wounds as causes of paralysis, 555 Convulsion as symptom of brain tumor, 205 Corpuscles, Gluge's, 175 Cramp, dancer's, 582 telegrapher's, 582 writer's, 582 professional, 582 causes of, 584 diagnosis of, 585 pathology of, 584 " Crises gastriques," 328 Cross paralysis, 115 Crum-Brown's experiments, 140 Cutaneous eruptions iii locomotor ataxia 325 Cutaneous eruptions in neuritis, 539 DA COSTA on cerebral rheumatism, 50 Decubitus paralysis, 557 Decussation of optic fibres, 209 Delirium tremens, 430 INDEX.- 593 Depraved appetite m hysteria, 456 Diathetic growths, 212 Diphtheritic paralysis, 562 Diseases of cerebral meninges, 38 of cerebrum and cerebellum, 76 of lateral columns, Si? Dislocation as a cause of paralysis, 555 Disseminated sclerosis, 424 Division of a nerve trunk as a cause of paralysis, 560 Dorsal-clonus, 350 Douleureux, tic, 513 Dynamometer, 28 Mathieu's, 29 the author's, 30 ECHOLALIA, 196 Eczema with chorea, 490 Education of right side of brain, 199 Electrical apparatus, 34 Embolism, 154 of the cerebral vessels, 154 causes of, 157 diagnosis of, 158 morbid anatomy and pa- thology of, 161 prognosis of, 163 symptoms of, 154 treatment of, 163 Endemic tetanus, 374 Endoarteritis, syphilitic, 177 Epidemic chorea, 483 Epilepsy, 384 aborted, 390 . abuse of bromides in, 406 age in causation of, 393 auditory, 400 Brown-Sequard's experiments in, 398 causes of, 393 condition of pupils in, 392-403 definition of, 384 diagnosis of, 402 dislocation of bones in, 388 experimental production of, 398 grave attacks of, 385 heredity in, 394 history of, 384 hystero, 470 induration of cornua ammonis, 396 irregular attacks of, 390 Jackson on,, 399 light attacks of, 389 " masked, 390 morbid anatomy and pathology of, 396 38 Epilepsy (continued) nocturnal, 388 prognosis of, 403 responsibility in, 392 symptoms of, 385 synonyms of, 384 syphilitic, 403 temperature influences in, 394 tongue biting in, 387 treatment of, 404 warnings in, 385 Epileptiform tic, 513 hj^steria, 470 Equilibrium, sense of, the, 334 Erotogenetic zones, 479 with locomotor ataxra- 325 Essential paralysis, 287 Etat crible, the, 85 Examination of pupils, 33 post-mortem, 18 Exhaustion simulating acute tubercular meningitis, 70 Exophthalmic goitre, 503 causes of, 508 definition of, 503 diagnosis of, 509 morbid anatomy and pathologv of, 508 prognosis of, 509 symptoms of, 503 synonyms of, 503 treatment of, 509 skin changes in, 506 FACIAL neuralgia, 513 ^ : ' paralysis, 549 • causes of, 550 diagnosis of, 552 electricity in, 553 pathology of, 551 prognosis of, 553 symptoms of, 549 , synonyms of, 540 c 'treatment of, 553 wire hook in treatment of, 553 spasm without pain, 556 Faradic apparatus, 34 Fibrillary contractions, 296 Flechsig's investigations, 361 Flexibilitas cerea, 480 Function of angular gyrus, 194 Functional disease of lateral columns, 354 &ALVANIO batteries, 34 General paresis, false, 173 694 INDEX. Gibney on traumatic causation of spinal irritation, 259 Glass rod cautery, 36 Gliomata of brain, 213 Globus hystericus, the, 462 Gluge's corpuscles, 175 Goitre, exophthalmic, 503 Grasset's classifica ion of brain tumors, 211 Graves' disease, 503 GrifBn on spinal irritation, 259 HARDENING fluids, 20 Hemiplegia, 95 hysterical, 458 Hemorrhage, cerebral, flO .meningeal, 115 spinal, 251 , .cerebellar, 225 Hejedity. in pseudo-hypertrophic paraly- sis, 3}7 High tempe^atjure in tetanus, 372 Hints in regard to methods of examina- tion and study, 17 Holland on leeching, 54 Hydrobromic acid, 89 Hydroiodic acid in gotit.re, 510 Hydromyelia, 360 Hydrophobia, 444 causes of, 450 curare in, 454 diagnosis of, 453 Dr. Hadden's case of, 445 morbid anatomy and pathology of, 450 prognosis of, 454 symptoms of, 444 eynoayms of, 444 treatment of, 454 Hysteria, 454 causes of, 463 definition of, 454 diagnosis of, 467 in children, 463 morbid anatomy and pathology of, 466 : prognosis of, 468 symptoms of, 455 treatment of, 468 Hysterical .ajisegtheBia, 45.7 .ataxia, 337 contracture, 459 eye troubles, 458 hemiplegia, 460 paraplegia, 458 spasmodic spinal paralysis, 355 Hystero-epilepsy, 470 symptoms of, 471 treatment, 479 INFANTILE hemiplegia, 277 hysteria, 463 paralysis, 277 spasmodic paralysis, 353 Inflammation of spinal cord, 265 Instruments used for the diagnosis of nervous diseases, 22 Intra-cranial vessels, embolism of, 145 Intra-vesical troubles in myelitis, 265 Irritation, spinal, 259 cause of, 261 diagnosis of, 263 morbid anatomy and ipathology of, 262 prognosis and treatment of, 265 TACKSON on epilepsy, 399 LATERAL columns, hysterical disease of, 355 Lateral sclerosis of the spinal cord, 347 ■ diagnosis of, 368 '. morbid anatomy of, 360 prognosis of, 368 symptoms of, 347 synonyms of, 347 treatment of, 369 .Lead poisoning, 566 causes of, 568 diagnosis of, 572 morbid aaatomy and pathology of, 571 prognosis of, 572 synonyms of, -566 treatment of, 572 Lesions in epilepsy, 397 Local paralysis, 548 Localization of tumors, 220 of cerebellar disease, 233 of cerebral hemorrhage, 104 Locomotor ataxia, 321 hysterical, 337 nyrAIN en griffe, 296 Male hysteria, 462 Mastodynia, 523 Meniere's disease, 139 Meningeal hemorrhage, 115 Meningitis, acute and chronic spinal, 236 symptoms of, 236 granular, 58 INDEX, 595 Meningitis {continued} cerebro-spinal, 421 causes of, 423 definition of, 42t diagnosis of, 423 morbid anatomy and pathology of, 423 prognosis of, 424 symptoms of, 421 synonyms of, 421 treatment of, 424 chronic cerebral, 71 causes of, 74 diagnosis of, 74 morbid anatomy and pa- thology of, 74 prognosis of, 75 symptoms of, 71 treatment of, 75 of the aged, 57 rheumatic, 55 senile, 57 tubercular (granular), 58 basal, 58 causes of, 63 development of, 63 diagnosis of, 68 morbid anatomy and pathology of, 65 prognosis of, 68 symptoms of, 58 treatment of, 70 tubercular deposits in, 65 vertical, 63 Meningo-cerebritis, 165 Mental changes in locomotor ataxia, 327 Migraine, 513 Miliary aneurisms, 113 Mimetic chorea, 483 Morbid impulses in hysteria, 456 Mortality in tubercular meningitis, 64 Mottled skin in pseudo-hypertrophic pa- ralysis, 312 Multiple embolism, 161 Muscular rheumatism, 541 Myelitis, 265 causes of, 270 chronic, 269 diagnosis of, 272 ■ morbid anatomy and pathology of, 271 prognosis of, 274 symptoms of, 269 treatment of, 274 vesical troubles in, 268 NEEVES, tumors of, 547 Nerve-stretching, 534, 541 Neuralgia, age and sex in causation of 524 association with epilepsy, 524 bad teeth as a cause of, 526 causes of, 524 cervico-occipital, 518 brachial, 519 circulatory disturbances in, 512 clavus, 515 coarse and fine varieties of, 531 crural, 522 definition of, 511 diagnosis of, 528 electricity in treatment of, 584 excision of supra-orbital in, 516 facial, 513 influence of temperature in, 527 intercostal, 520 inveterate, an, case of, 529 morbid anatomy of, 528 nerve areas in, 532 nerve section in, 516 of testis, 523 ovarian, 523 prognosis of, 529 renal, 523 sciatic, 520 syphilitic, 525 treatment of, 531 trigeminal, 513 , trophic disturbances in, 512 urethral, 523 Granville's apparatus in, 528 visceral, 522 Neuritis, 538 causes of, 540 morbid anatomy and pathology of, 540 nerve section in, 541 stretching in, 541 prognosis of, 541 symptoms of, 538 treatment of, 541 trophic changes in, 538 Neuromata, sarcomatous, 547 treatment of, 547 Nicotinism, 439 causes of, 442 prognosis and treatment of, 443 • symptoms of, 440 Nystagmus, 189 596 I K D E X . OCCLUSION of intracranial vessels, 145 Occupation, and its relation to cere- bral hyperjEmia, 81 Ocular trouble witb brain tumor, 208 in locomotor ataxia, 323 CEsophagisraus, 587 Ophthalmoscope, the, 30 Opisthotonos, 371 Organs of speech, affection of in chorea, 484 PACHYMENI'nGITIS as a result of injury, 38 cerebral, 33 spinal, causes of, 238 diagnosis of, 243 morbid anatomy and pathology of, 241 prognosis of, 242 , s3'mptoms of, 236 treatment of, 243. with hsematoma, 44 Painters' colic, 566 Palsy, Scrivener's, 582 shaking, 498 wasting, 295 Paralysis, adult spinal, 287 acute ascending, 275 after dislocation, 555 agitans, 498 case of, 499 causes of, 500 diagnosis of, 501 morbid anatomy and pathology of, 500 prognosis of, 502 symptoms of, 49.S synonyms of, 498 treatment of, 502. antero-spinal, of infancj", 277 bulbar, 414 cross, 115 Cruveilhier's, 295 diphtheritic, 562 causes of, 564 diagnosis of, 565 morbid anatomy and pathology of, 564 prognosis of, 565 sj^mptoms of, 562 treatment of, 565 facial, 549 from pressure of forceps, 556 heat in the treatment of, 126 Paralysis [continued) hysterical, 160 local, 548 of sphincters, 268 pseudo-hypertrophic, 311 residual, 95 temporary spinal, 291 traumatic, 555 Paralytic chorea, 485 Paraplegia, 267 hysterical, 460 Paresis, general, 173 Parkinson's disease, 498 Partial celebral ansmia, 145 Partial facial atrophy, 308 Passive cerebral hyperasmia, 77 Percussion hammer, 33 Percuteur, the, 535 Perivascular spaces, the, 86 Petrina on localization, 220 Pleurodynia, 520 Pleurosthotonos, 371 Poisoning, lead, 566 Posterior spinal sclerosis, 321 ascending and descending, 322 causes of, 329 diagnosis of, 336 morbid anatomy and patho- logy of, 330 neuralgia in, 321 periods of improvement in, 339 prognosis of, 338 state of mind in, 327 symptoms of, 321 synonyms of, 321 treatment of, 339 Posthemiplegic disorders of movement, 98 Post-paralytic chorea, 98 Primary and compensatory contractions in paralysis, 279 Primary degeneration of lateral columns, 356 Prodromata of infantile palsy, 277 Professional ciamp, 582 muscular atrophy, 486 Prognosis in syphilitic brain disease, 179 Progressive muscular atrophy, 295 causes of, 299 definition of, 295 diagnosis of, 304 history of, 295 morbid anatomy and patho- logy of, 301 INDEX. 597 Progressive muscular atrophy {continued) prognosis of. 307 ' • resembling lead palsy, 304 skin changes in, 299 symptoms of, 295 synoDj-ms of, 295 treatment of, 307 Progressive Paresis and locomotor ataxia, 326 Pseudo-hypertrophic muscular paralysis, 311 cases of, 271 causes of, 317 diagnosis of, 319 heredity in, 317 lordosis in, 315 pathology and morbid ana- tomy of, 318 prognosis of, 320 symptoms of, 311 synonyms of, 311 treatment of, 320 Puerperal embolism, 158 hysteria, 464 "p ABIES canina, 444 JAi Red softening, 170 Pk,eflex spasm, 577 P.,etraction of head in cerebro-spinal me- ningitis, 422 Rheumatic meningitis, 55 Risus sardonicus, 370 Romberg on delayed transmission of pain- ful impressions, 269 Rubber muscle, the, 35 SCIATICA, 520 Sclerosis, antero-lateral, 342 cerebral, 199 diffused, 200 of columns of Goll, S41 cerebro-spinal, 424 causes of, 425' diagnosis of, 429 morbid anatomy and pathology of, 429 prognosis of, 429 symptoms of, 425 synonyms of, 424 treatment of, 429 disseminated, 424 lateral, 317 deformity of feet in, 357 posterior-spinal, 321 Sclerose en plaques, 424 Scrivener's palsy, 582 Seat of cerebral hemorrhage, 115 Secondarj' degeneration of lateral col- umns, 99 Senile meningitis, 57 Seventh nerve, paralysis of, 549 Shaking palsy, 498 Sieveking's sesthesiometer, 22 Sleep not necessarily due to cerebral anae- mia, 134 Softening after vascular plugging, 145 cerebral, 164 cerebellar, 229 not necessarily an inflammatory pro- cess, 164 of posterior columns in tetanus, 378 Spaces, the perivascular, 86 Spasm, facial, without pain, 576 from genital irritation, 577 functional, 576 with voluntary movements, 576 pathology of, 579 reflex, 577 treatment of, 579 Spasmodic spinal paralysis, 356 Spinal anaemia, so called, 259 Gibney on traumatic causation of 259 Griffin on, 259 congestion, 255 symptoms of, 259 hemorrhage, 251 causes of, 252 diagnosis of, 254 morbid anatomy and pathology of, 253 prognosis of, 254 symptoms of, 251 synonyms, 251 treatment of, 254 hyperemia, subacute, 256 causes of, 256 diagnosis of, 257 morbid anatomy and patho- logy of, 257 prognosis of, 258 symptoms of, 256 treatment of, 258 irritation, 259 causes of, 261 diagnosis of, 263 morbid anatomy and pathology of, 262 prognosis of, 263 symptoms of, 259 598 INDEX. Spinal irritation (continued) treatment of, 263 meninges, diseases of, 236 meningitis, acute and chronic, 236 pachymeningitis, 238 causes of, 240 symptoms of, 238 paralysis, temporary, 251 tumor, 245 causes of, 250 diagnosis of, 250 morbid anatomy and pathology of, 250 prognosis of, 250 symptoms o-f, 245 treatment of, 251 varieties of, 245 Spotted fever, 421 Staining solutions, 21 Sthenic cerebral hyperjemia, 77 Stomachic vertigo, 138 St. Vitias' dance, 483 Sulphur baths in, locomotor ataxia, 340 Syncope, 127 Syphilis of the brain, 173, 179 Syphilitic encepbalopathie, 177 " epileps}'', 403 " myelitis, 270 " neuralgia, 5.25 " pachymeningitis, 41 TABES dorsalis, 321 Tache cerebrale, 61 Tarantism, 484 Temporary spinal paralysis,. 291 Tendon-reflex, absent, 322 in lateral sclerosis, 358 method of testing, 34 Tetanoid paraplegia, 356 Tetanus, 370 allied to strychnia poisoning, 379 causes of, 373 curare in, 382 chloral h3'drate in, .382 definition of, 370 diagnosis of, 380 endemic, 374 morbid anatomy and pathology of, 377 nascentium, 373 on Long Island, 374 pleurosthotonos in, 371 prognosis of, 381 risus sardonicus in, 370 softening of posterior columns in, 378 statistics of, 374 symptoms of, 370 Tetanus (continued) synonyms of, 370 rise of temperature in,' 372 treatment of, 381 urine in, 372 Tetany, 576 The epileptic zone, 398 Theory of sleep, 134 Thermometer, the, 22 Thermometry, cerebral, 23 Thrombosis, 145 of cerebral arteries, 146 causes of, 149 diagnosis of, 151 morbid anatomy and patho- logy of, 149 treatment of, 151 of sinuses and veins, 151 after aural disease, 153 Tic douleureaux, 513 Tobacco amblyopia, 441 Tonga, 536 Torticollis, 578 Transposition in aphasia, 183 Traumatic paralysis, 555 diagnosis of, 559 prognosis of, 559 treatment of, 560 Treatment of bed-sores, 274 Tremor, 17 functional, 576 Tri-nitro glycerine, 413 Trismus nascentium, 373 Trophic changes in traumatic paralysis, 560 Tumors of brain, 205 of cerebellum, 226 of nerves, 546 spinal, 245 UNILATERAL tremor as a result of localized meningitis, 50 Urine in tetanus, 372 VARIATIONS of temperature in cere- bral hemorrhage, 94 Vertigo, 139 " stomachic, 138 Visual word centre, 194 WIRE hook in treatment of facial paralysis, 553 Writer's cramp, 582 Wasting palsy, 295 ZONE, the epileptic, 398 hysterogenetic, 478 HENRY C. LEA'S SON & CO.'S (LATE HEI^RT C. LEA) OF MEDICAL AND SUEGICAL PUBLICATIONS, In asking the attention of the profession to the works advertised in the following pages, the publishers would state that no pains are spared to secure a continuance ot the confidence earned for the publications of the house by their careful selection and accuracy and finish of execution. The large numher of inquiries received from the prof ession for a finer class of bind- ings than is usually placed on medical books has induced us to put certain of our andard publications in half Russia, and that the groiving taste may be encouraged, the prices have been fixed at so small an advance over the cost of sheep, as to place it toithin the means of all to possess a library that shall have attractions as well for the eye as for the mind of the reading practitioner. The printed prices are those at which books can generally be supplied by book- sellers throughout the United States, who can readily procure for their customers any works not kept in stock. Where access to bookstores is not convenient, books will be sent by mail post-paid on receipt of the price, and as the limit of mailable weiglit has been removed, no difficulty will be experienced in obtaining through the post-office any work in this catalogue. No risks, however, are assumed either on the money or on the books, and no publications but our own are supplied, so that gentlemen will in most cases find it more convenient to deal with the nearest bookseller. HENRY C. LEA'S SON & CO. Nos. 706 and 708 Saxsom St., Philadelphia, November, ISSl. INCREASED INDUCEMENT FOR SUBSCRIBERS TO THE AMERICAX JOURNAL OE THE MEDICAL SCIENCES. TWO MEDICAL JOURNALS, containing nearly 2000 LAEGE PAGES, Free of Postage, for FIVE DOLLAES Per Annum. TERMS I'OB 1881. The Amekican Journal of the Medical Sciences, published ] Five Dollars quarterly (11.50 pages per annum), with V per annum, The Medical News and Abstract, monthly (768 pp. per annum), ] in advance. SEPAIiATE SVBSCRIPTIONS TO The American Journal of the Medical Sciences, -when not paid for in advance, Five Dollars. The Medical News and Abstract, free of postage, in advance, Two Dollars and a Half. *^* Advance paying subscribers can obtain at the close of the year cloth covers, gilt-lettered, for each volume of the Journal (two annually), and of the News and Abstract (one annually), free by mail, by remitting ten cents for each cover. It will thus be seen that for the moderate sum of Five Dollars in advance, the. subscriber will receive, free of postage, the equivalent of four large octavo volumes, stored with the choicest matter, original and selected, that can be furnished by the medical literature of both hemispheres. Thus taken together, the "Journal" and the "News and Abstract" combine the advantages of the elaborate preparation that can be devoted to the Quarterly with the prompt conveyance of intelligence by the Monthly; while, the whole being under a single editorial supervision, the sub- scriber is secured against the duplication of matter inevitable when periodicals from different sources are taken together. The periodicals thus offered at this unprecedented rate are universally known for 2 Henkt C. Lea's Son & Co.'s Publications — (Am. Journ. Med. Set.). their high professional standing. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, Edited by I. MINIS HAYS, M.D., for more than half a century has maintained its position in the front rank of the medical literature of the world. Cordially supported by the profession of America, it circulates -wherever the language is read, and is universally regarded as the national exponent of American medicine — a position to which it is entitled by the distinguished names from every section of the Union wliich are to be found among its collaborators.* It is issued quarterly, in January, April, July, and October, each number containing about three hundred octavo pages, appropriately illustrated wherever necessary. A lar"e portion of this space is devoted to Original Communications, embracing papers from the most eminent members of the profession throughout the country. Following this is the Revikw Depaktment, containing extended reviews by com- petent writers of prominent new works and topics ol the day, together with numerous slaborate Analytical and Bibliographical Notices, giving a fairly complete survey of iiedical literature. Then follows the Quarterly Summary of Improvements akd Discoveries IN THE Medical Sciences, classified and arranged under different heads, and furn- ishing a digest of medical progress, abroad and at home. Thus during the year 1880 the "Journal" contained 67 Original Communications, mostly elaborate in character, 170 Reviews and Bibliographical Notices, and 147 articles in the Quarterly Summaries, illustrated with 47 wood engravings. That the efforts thus made to maintain the high reputation of the "Journal" are successful, is shown by the position accorded to it in both America and Europe as tlie leading organ of medical progress: — This is universally acknowledged as the leading | The Philadelphia Medical and Physical Journal Aiiieiicau Journal, and has been conducted by Dr. i issued its first niuiiber in 1820, and, after a brilliant Hays alone uutil 1809, when his son was associaied career,: was succeeded in 1S27 by the American ■wiih him. We quite agiee -with the critic, lliat this ! Journal -ol the Medical Sciences, a periodical of jiurual is second to none iu ihe language, and cheer- world- 'wide»reputation ; the ablest and one of the fully accord to it the first place, for nowhere shall oldesfperiodicalsin the world — a journal which has we find more able and more impartial criticism, and ■ an unsullied record. — Gross's History of Amtrican nowhere such a repertory of able original articles Indeed, now that the "British and Foreign Medico- C'h;rurgical Review" has terminated its career, the Au.erican Journal stauds without a rival. — London Mtd. Times and Gazette, Hov. 24, 1S77. The best medical journal on the continent. — Bos- i.toit Med. and Surg. Journal, April, 1879. The present number of the American Journal is .-tafi exceedingly good one, and gives every promi.se . of maintaining the well-earned reputation of the Med. Literature. 1S76. The best'medical'journaleverpublished in Europe or America. — Va. Med. Monthly, May, 1879. It is universally acknowledged to be the leading American medical journal, and, in oui opinion, is second to none in the language. — Boston Med. and Surg. Jottrnal, Oct. 1877. This is the medical journalof our country to which the American physician abrond will point with the greatest satisfaction, as rellectibg tlie state of medi- ra-.'iew. Our venerable contemporary has our best ' l^^ culture in his country For a great many years • wishes, and we can only e.xpre.ss the hope that U I jj j,^^ ^^^^^ jj^g medium through which our ablest ii.iiy continue Us work with as much vigor and ex- I ,jy,.ijgjg ^.^^^ ^^.^^^ known their discoveries and , ceU«ace lor the next filty years as it bas exhibited kbgervations.-^ddres.s of L. P. TnndM, M.O., be- . in the pi,st..— London Lar.cet, Nov. 24, 1877. [y.„^g j7Uernational Med. Congress, Sept. 1S76. And that it was specifically included in the award of a medal of merit to the Pub- Clishers in the Vienna Exhibition in 1873. The subscription price of the "American Journal of the Medical Sciences" has never been raised during its long career. It is still Five Dollars per annum ; ..and when paid for in advance, the subscriber receives in addition the "Medical Newsaj^d Abstract," making in all nearly 2000 large octavo pages per annum, free .of postage. 11. THE MEDICAL NEWS AND ABSTRACT. Thirty-^ight years ago the "Medical Nev^s" was commenced as a monthly to convey to the subscribers of the "American Journal" the clinical instruction and * Commnuic»tv*i.us are invited from gentlemen in all parts of the country. Articles inserted by the Editor are lib.fi!;>i.Ui; paid for by the publishers. Henry C. Lea's Son & Co.'s Publications — (Am. Journ. Med. Sci.). 3 current information which could not be accommodated in the Quarterly. It consisted of sixteen pages of such matter, together with sixteen more known as the Library Department and devoted to the publishing of books. With the increased progress of science, however, this was found insufficient, and some years since another periodical, known as the "Monthly Abstract," was started, and was furnished at a moderate price to subscribers to the "American Journal." These two monthlies have been consolidated, under the title of "The Medical News and Abstract," and are furnished free of charge in connection with the "American Journal." The "News AND Abstract" consists of 64 pages monthly, in a neat cover. It contains a Clinical Department in which will be continued the series of Original American Clinical Lectures, by gentlemen of the highest reputation through- out the United States, together with a choice selection of foreign Lectures and Hospital Notes and Gleanings. 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In this effort to furnish so large an amount of practical information at a price so un- precedentedly low, and thus place it within the reach of every member of the profes- sion, the publishers confidently anticipate the friendly aid of all who feel an interest in the dissemination of sound medical literature. They trust, especially, that the sub- scribers to the "American Medical Journal," wiU call the attention of their acquaintances to the advantages thus offered, and that they will be sustained in the endeavor to permanently establish medical periodical literature on a footing of cheap- ness never heretofore attempted. PEEMIUM rOK OBTAINING NEW SUBSOEIBEES TO THE "JOUENAL." Anv gentleman who will remit the amount for two subscriptions for 1881, one of which at least must be for a new subscriber, will receive as a premium, free by mail, a copy of any one of the following recent works : — " Seiler on the Throat" (see p. 19), "Barnes's Manual of Midwifery" (see p. 24), "Browne on the Use of the Ophthalmoscope" (see p. 29), "Flint's Essays on Conservative Medicine" (see p. 15), "Sturges's Clinical Medicine" (seep. 15), "Tanner's Clinical Manual" (seep. 5), "West on Nervous Disorders of Children" (see p. 21). %* Gentlemen desiring to avail themselves of the advantages thus offered will da; well to forward their subscriptions at an early day, in order to insure the receipt of' complete sets for the year 1881. 1^ The safest mode of remittance is by bank cheek or postal money order,, drawn to the order of the undersigned. Where these are not accessible, remlttances-for the "Journal" maybe made at the risk of the publishers, by forwarding in registered Henry C. Lea's Son & Co., Nos. 706 and 708 Sansom St., Phila., Ea. Henry C. Lea's Son & Co.'s Publications — {Dictionaries). nUNGLISON {ROBLEF), M.D., "^"^ Late Professor of Institutes of Mi-Aicine in Jefferson Medical College, Philadelphia. MEDICAL LEXICON; A Dictionary op Medical Science: Con- taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, Pathology, Hygiene, Therapeutics. Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Jurisprudence and Dentistry. Notices of Climate and of Mineral Waters ; Formulae for Officinal, Empirical and Dietetic Preparations; with the Accentuation and Etymology of the Terms, and the French and other Synonymes ; so a.< to con.stitute a French as- well as English Medical Lexicon. A New Edition. Thoroughly Revi.«ed, and very greatly Mod- ified and Augmented. By Richard J. 1>cn6liso>'. M.I). In one very large and hand- some royal octavo volume of over 1100 pages. Cloth, $6 50 ; leather, raised bands, $7 50 ; half Russia, $8. {Lately Issued.) The object of the author from the outset has not been to make the work a mere lexicon or dictionary of terms, but to afford, undereach, a condensed view of its various medical relations, and thus to render the work an epitome of the existing condition of medical science. Starting with this view, the immense demand which has existed for the work has enabled him, in repeated rev^isions,to augment its completeness and usefulness, until at length it has attained the position' of a recognized and standard authority wherever the language is spoken. Special pains have been taken in the preparation of the present edition to maintain this en- viable reputation During the ten years which have elapsed since the Inst revision, the additions to the nomenclature of the medical sciences have been greater than perhaps in any similar period of the past, and up to the time of his death the author labored a.ssiduously to incorporate every- thing requiring the attention of the student or practitioner. Since then, the editor has been equally industrious, so that the additions to the vocabulary are more numerous than in any pre- vious revision. Especial attention has been bestowed on the accentuation, which will be found marked on every word. The typigraphical arrangement has been much improved, rendering reference much more easy, and every care has been taken with the mechanical execution. The work has been printed on new type, small but exceedingly clear, with an enlarged page, so that the additions have been incorporated with an increase of but little over a hundred pages, and the volume now contains the matter of at least four ordinary octavos. A bouk well known to our reader.-*, and of which i jiay [;afely confirm the hope ventured by the editor every American ought to be proud. When the learned "that the work, which posses?e.c.an» The ortQer 1 appendix, renders this the most practical and flods in It the necessary ffnide in making dissec- , . • i i,i . « • j . nous ju 11 luc uc c J j> „i,,„,^_ „„ „;„„.„ comp ete treatise available to American students, tions' a verv comp^eheD^lve chapter on minute v ^ j • .. v. • u . ■ . iiuuo, a .C.J V y .„,K...„„„ .1 ,„„„!,, i,ir„ ^„ who find in It a comprehensive chapter on minne anatomy : and about all that can be taught him on u . n .i . v . u. i anaiom/ , auu a ,„„_. ~»,ii.» .v,l lut.o, in anatomy, about all that can be taught on general general and special anatomy while the latter, in ' ". ,., .. . °. . , , eueiai auu oyc „/,.'., „,„,^<.i r,„ini r,f aud special anatomy, while its treatment of each treatment ot each return irom a surgical point ol ■ . *^ . . i - . * . . .\_ » ireaimcui 1.1 CO, s j !.,;„„ .,xfr u^M^n region, from a surgical point of view, in the valu- iluable iidditionof Mr. Holden, „.»„'„,;„„ ^„ w,*„„,^^„ ;„ oii ,i,o, ;^;ii v,„ =o.„„_ view, and in the val will find all that will be essential to him in his practice —..Veii! Remed-es, Aug 1S7S. This work Is as near perfection as one could pos- sibly or reasonably expect any book intended as a able section by Mr. Holden, is all that will be essen- tial to them in practice. — Ohio Medical Recorder, Aug 1S78. It is difficult to speak in moderate terms of this text-book or a genera) reference book on anatomy ] new edition of " Gray." It seems to be as nearly to be. The American publisher deserves the thanks perfect as it is possible to make a book devoted to of the profession for appending the recent work of any branch of medical science. The labors of the Mr. Holden, '• irtrirfrnflfrfc*, J)f«d!cai<7?irfS'»r^ica/," ' eminent men who have successively revised the which has already been commended as a separate ' eight editions through which it has passed, wonld book. The latter work — treating of topographical seem to leave nothing for fntnre editors to do. The anatomy— has become an essential to the library of I addition of Holden's " Landmarks" will make it as every intelligent practitioner. We know of no indispensable to the practitioner of medicine and book that can take its place, written as It is by a 1 gnrgery as it has been heretofore to the student. As most distinguished anatomist. It would be simply regards completeness, ease of reference, utility, a waste of words to say anything further in praise beauty, and cheapness, it has no rival. No stu- of Gray's Anatomy, the text-book in almost every ; dent should enter a medical school without it ; no medical college in this country, and the daily refer- I physician can afford to have it absent from hia ence book of every practitioner who has occasion i library. — St. Louis Clin. Record, Sept. 1S78. Also for sale separate — TTOLDEN {LUTHER), F.R.C.S., J- J- Surgenn toSt. Bartholomew' s and the Foundling Ho.'ipitnls. LANDMARKS, MEDICAL AND SURGICAL. Second American, from the Latest Revised English Edition, with additions by W. W. Keen, M.D., Prof, of Artistic Anatomy in the Penna. Academy of the Fine Arts, formerly Lecturer on Anat- omy in the Phila. School of Anatomy. In one handsome 12mo. volume, of about 140 pages. Cloth, $1.00. {Just Ready.) TIE ATE (CHRISTOPHER), F.R.C.S., ''-'- Teacher of Operative Surgery in University College, London. PRACTICAL ANATOMY: A Manual of Dissections. From the Second revised and improved London edition. Edited, with additions, by W. W. Keen, M. D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia. In one handsome royal 12 mo. volume of 578 pages, with 24 7iIlustration8. Cloth, $3 50 ; leather, $4 00. Henry C. Lea's Son & Co.'s Publications — (Anatomy). 7 A LLEN (HARRISON), M.D. ^1 Profesior of Physiology in the Univ. of Pa. A SYSTEM OF HUMAN ANATOMY: INCLUDING ITS MEDICAL and Surgical Relations. For the Use of Practitioners and Studentsof Medicine. With iin Introductory Chapter on Histology. ByE.O. Shakespeare, M D., Ophthalmologistto the Phila. Hosp. In one large and. handsome quarto volume, with several hundred original illustrations on lithographic plates, and numerous wood-cuts In the text. (Shortly.) In this elaborate work, which has been inactive preparation for several years, the author has Bought to give, not only the details of descriptive anatomy in a clearand condensed form, but also the practical applications of the science to medicine and surgery. The work thus has claims upon the attention of the general practitioner, as well as of the student, enabling him not only to re- fresh his recollections of the dissecting room, but also to recognize thesignificance of allvaria- tions from normal conditions. The marked utility of the object thus sought by the author is self-evident, and his long experience and assiduous devotion to its thorough development are a sufBcient guarantee of the manner in which his aims have been carried out. No pains have been spared with the illustrations. Those of normal anatomy are from original dissections, drawn on stone by Mr. Hermann Faber, with the name of every part clearly engraved upon the figure after the manner of " Holden" and " Gray, " and in every typographical detail it will be the effort of the publishers to render the volume worthy of the very distinguished position which is anticipated for it. PILIS {GEORGE VINER). -*-^ Emeritus Professor nf Anatomy in University College, London. DEMONSTRATIONS OP ANATOMY; Being a Guide to the Know- ledge of the Human Body by Dissection. By George Vtner Ellis, Emeritus Professor of Anatomy in University College, London. From the Eighth and Revised London Edition. In one very handsome octavo volume of over 700 pages, with 266 illustrations. Cloth, $4.25 I leather, $6.25. {Lately Issued.) This work has long been known in England as the leading authority on practical anatomy, and the favorite guide in the dissecting-room, as is attested by the numerous editions through which it has passed. In the last revision, which has just appeared in London, the accomplished author has sought to bring it on a level with the most recent advances of science by making the necessary changes in his account of the microscopic structure of the different organs, as devel- oped by the latest researches in textural anatomy. Ellis's Demonstrations is the favorite text-book ] its leadership over the English manuals upon dis- of the English student of anatomy. In passing secting. — Phila. Med. Times, May 24, 1879. through eight editions it has been so revised and 1 adapted to the needs of the student that it would i -^^ a dissector, or a work to have in hand and seem that it had almost reached perfection in this ' studied while one is engaged in dissecting, we re- special line. The descriptions are clear, and the : S'^''^ *' as the very best work extant, which is cer- methods of pursuing anatomical investigations are ' tainly saying a very great deal. As a text-book to given with such detail that the book is honestly entitled to its name. — St. Louis Clinical Record, June, 1879. The success of this old manual seems to be as well deserved in the present as in the past volumes. The book seems destined to maintain yet for years be studied in the dissecting-room, it is superior to any of the works upon a-tmiomj .— Cincinnati Med. News, May 21, 1879. We most unreservedly recommend it to every practitioner of medicine who can possibly get it. Va. Med. Monthly, June, 1879. w JLSON (ERASMUS), F.R.S. A SYSTEM OF HUMAN ANATOMY, General and SpeciaL Edited by W. H. GoBEECHT, M.D., Professor of General and Surgical Anatomy in the Medical Col- lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In one large and handsome octavo volume, of over 600 pages ; cloth, $4 ; leather, $6. gMITE {HENRY H.), M.D., and JJORNER { WILLIAM E.),M.D., Prof .of Surgery inthe Univ. of Penna.,&c. Late Prof, of Anatomy in the Univ. ofPenna. AN ANATOMICAL ATLAS ; Illustrative of the Structure of the Human Body. In one volume, large imperial octavo, cloth, with about six hundred and fifty beautiful figures. $4 50. CHAFER {ED WARD ALBERT), M.D., Assistant Profetsor of Physiology in University College, London. A COURSE OF PRACTICAL HISTOLOGY: Being an Introduction to the Use of the Microscope. In one handsome royal 12mo. volume of 304 pages, with numerous illustrations: cloth, $2 00. (Lately Issued.) s HOENER'S SPECIAL ANATOMY AND HISTOL- , for their Pass Examination. With engravings on 06T. Eighth edition, extensively revised and ; wood. In one handsome royal 12mo. volume, modified- In 2 vols. 8vo., of over 1000 pages, { Cloth, $2 2,5. with .320 wood-cuts : cloth, $6 00 ! CLELAND'S DIRECTORY FOR THE DISSECTION SHARPEY AND QUAIN'S HUMAN ANATOMY.! OF THE HUMAN BODY. In one small volume Revised, by Joseph Leidt, M.D.,Prof of Aaat. in Duiv. of Penn. In two octavo vols, of about 1300 pages, with .511 illustrations Cloth, $6 00. BELLAMYS STUDENT'S GUIDE TO SURGICAL ANATOMY : A Text-book for Students preparing royal 12mo. of 132 pages: eloth *1 25. HAKTSHORNE'S HANDBOOK OF ANATOMY AND PHYSIOLOGY. Second edition, revised. In one royal 12mo. vol., with 220 woodcuts; cloth *1 75. Henry C. Lea's Son & Co.'s Publications — (Physiology). fkALTON {J. C), M.D., •*-f Professor of Physiology in the College of Physicians and Surgeons, New Torl(,&e. A TREATISE ON HUMAN PHYSIOLOGY. Designed for the use of students and Practitioners of Medicine. Seventh edition, thoroughly revised and rewrit- ten, with about three hundred and sixty illustrations on wood. In one very beautiful octavo volume, of about 900 pages. {Neaiiy Ready.) A few notices of the previous edition are appe Prof. Dalton ha.s discu.s.'ied conflictiuf^ theories and conclusions regarding phyfiiological quustious with a fairnes.s, a fulness, and a concisenes.s which lend fresh- ness and vigor to the entire book. But his discussions have been so guarded by a refusal of admission to those speculative and theoretical explanations, which at best exist in the mindsof observers themselves as only pro- babilities, that none of his readers need be led into grave errors while making them a study .—TAe Medical /Jecord, Feb. 19, 1876. For clearness and perspicuity, Daltoii's Physiology commended itself to tlie student years ago, and was a pleasant relief from the verbose productions which it supplanted. Physiology has, however, made many ad- vances since then— and while the style has been pre- served intact, the work in the present edition has been brought up fully abreastof the times. Thenew chemical nolation and nomenclature have also been introduced into the present edition. Notwithstanding the multi- nded. plicity of text-books on physiology, this will lose none of its old time popularity. The mechanical execution of the work is all that could be desired. — Petiinsular Journal of Mexlicine, Dec. 1875. This popular text-book on physiology comes to us in i ts sixth edition with the addition of about fifty per cent, of new matter, chiefly in the departments of patho- logical chemistry and the nervous system, where the principal advances have been realized. With so tho- rough revision and additions, that keep the work well up to the times, its continued popularity may be confi- dently predicted, notwithstanding the competition it may encounter. The publisher's work is admirably done. — St. Louis Med. and Surg. Journ., "Dec. 1875. The revision ofthis great work has,brought it forward with the physiological advances of thed.ay, and renders it, as it has ever been, the finest work for studenlses- tant. — JVashville Journ.of Med. and Surg., Jan. 1876. pARPENTER ( WILLIAM B.), M. D., F. R. S., F.O.S., F.L.S., v^* Registrar to University of London, etc PRINCIPLES OF HUMAN PHYSIOLOGY; Edited by HenryPower, M.B. Lond., F.R.C.S., Examiner in Natural Sciences, University of Oxford. Anew American from the Eighth Revised and Enlarged English Edition, with Notes and Addi- tions, by Francis G. Smith, M.D., Professor ol thelnstitutescf Medicinein the Univer- sity of Pennsylvania, etc. In one very large andhandsome octavo volume, of 1083 pages, with two plates and 373 engs. on wood. Cloth, $5 50 ; leather, $6 50; half Russia, $7. We have been agreeably surprised to And the vol- 1 new a year or two ago, looks now as if it had been a nnie so complete in regard to the structure and func- tions of the nervous system in all its relations, a subject that, in many respects, is one of the most diffi- cult of all, in the whole range of physiology, upon which to produce a full and satisfactory treatise of the class to which the one before us belongs. The additions by the American editor give to the work as it is a considerable value beyond that of the last English edition. In conclusion, we can give our cor- dial recommendation to the work as it now appears. The editors have, with their additions to the only work on physiology in our language that, in the full- est sense of the word, is the production of a philo.so- pher as well as a physiologist, brought it up as fully as could be expected, if not desired, to the standard of our knowledge of its subject at the present day. It will deservedly maintain the place it has always Had iu the favor of the medical profession. — Journ. of Nervons and Mental Disease, April, 1877. Suchenormousadvances havereceutlybeenmadein our physiological knowledge, that what was perfectly received and established fact for years. In this ency- clopaedic way it is unrivalled. Here, as it seems to us, is the great value of the book; one is safe in sending a student to it for information on almost any given subject, perfectly certain of the fulness of information it will convey, and well satisfied of the accuracy with which it will there be found stated. — London Med. Times and Gazette, Feb. 17, 1877. Themeritsof "Carpenter's Physiology" are so widely known and appreciated that we need only allude briefly to thefact that in thelatest edition vvillbefound a com- prehensive embodiment of the results of recent physio- logical investigation. Care has been taken to preserve the practical character of the original work. In fact the entire work has been brought up to date, and bears evidence of the amount of labor that has been bestowed upon it by its ilistinguishod editor, Mr. Henry Power. The American editor has made the latest additions, in order fully to cover the time that has elapsed since the last English edition.— iV. y. Med. Journal, Ja.n.lSI't . fpOSTER {MICHAEL), M.D., F.R.S., J- Prof, of Physiology in Cambridge Univ., England TEXT-BOOK OF PHYSIOLOGY. Second American from tlie Latest English Edition. Edited, with Extensive Notes and Additions, bv Edwaud T. Reichert, M.D., Late Demonstrator of Experimental Therapeutics in the liniv. of Penna. In one handsome royal 12mo. volume of about 1000 pages, with 260 illustrations. Cloth, $3 25 ; leather, $3 75. {J7ist Ready.) In the prep:>ration of a second American edition of Mr. Foster's Physiology, the editor has endeavored to render it more than ever acceptable to the student as a clear and comprehensive text book, presenting the science in its latest developments. The original work being an e.x- position of abstract physiology without any reference to the details of physiological anatomy, it seemed desirable to introduce some account of structure, in order to render more intellii^i'- ble to the student the views and theories of the science. This the editor has added in°as concise a manner as possible; and in aid of this end has freely introduced illustration's Irom recognized authorities. LEHMANK'S MANUAL OF CHEMICAL PHTSIOL-i LEHMANN'SPHTSIOLOGICALCHEMISTRY Com- "*^7; ..J-'i^"^^''^®'^ /'''r^"" ^^^ German, with Notes ] plete in two large octavo volumes of 1200 papes, andAdditions, by J. Cheston Morris, M.D. Will with 200 illustrations; cloth $6 illustrations on wood. In one octavo volume of i ' 336 pages. Cloth, $2 25. Henry C. Lea's Son & Co.'s Publications— (C^emtsi!r?/). A TTFIELD {JOHN), Ph.D., ■^^ Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, &c . CHEMISTRY, GENERAL, MEDICAL AND PHARMACEUTICAL; Including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, and their Application to Medicine and Pharmacy. Eighth edition, revised by the author. In one handsome royal 12mo. volume of 700 pages, with illustrations. Cloth, $2 50 ; leather, $3 00. {Now Ready.) We have repeatedly expressed our favorable opinion of this work, and on the appearance of a new edition of it, little remains for us to say, ex- cept that we expect this eighth edition to "he as indispensable to us as the seventh and previous editions have been. While the general plan and arrangement have been adhered to, new matte of chemistry in all the medical colleges in the United States. The present edition contains such alterations and additions as seemed necessary for the demonstration of the latest developments of chemical principles, and the latest applications of chemistry to pharmacy. It is scarcely necessary for lis to say that it exhibits chemistry in its pre- has been added covering the observations made | sent advanced state. — Oincinnati Medical News, since the former edition. The present differs from April, 1S79. the preceding one chiefly in these alterations and | The popularity which this work has enjoyed is in about ten pages of useful tables added in the owing to the original and clear disposition of the appendix. -4m. Jonrn. of Pharmacy, May, 1879. ! facts of the science, the accuracy of the details, and A standard work like Attiield's Chemistry need i the omission of much which freights many treatises only be mentioned by its name, without further heavily without briugingcorrespondinginstruction comments. The present edition contains such al- to the reader. Dr. Attfield writes for students, and terations and additions as seemed necessary for i primarily for medical students; he always has an the demonstration of the latest developments of' eye to the pharmacopoeia and its officinal prepara- chemical principles, and the latest applications of tions; and he is continually putting the matter in chemistry to pharmacy. The author has bestowed the text so that it responds to the questions with arduous labor on the revision, and the extent of which each section is provided. Thus the student the information thus introduced may be estimated learns easily, and can always refresh and test his from the fact that the index contains three hun- , knowledge. — Med. andSurg. Reporter, A-pTill9,'79. dred new references relating to additional mater- : -vye noticed onlv about two vears and a half ago M f^'-q^^^* * ^^^''^^'^'' "''^'^ Chemical Gazette, the publication of the preceding edition, and re- May, lb/9. 1 marked upon the exceptionally valuable character This very popular and meritorious work has j of the work. The work now iocludes the whole of now reached its eighth edition, which fact speaks the chemistry of the pharmacopoeia of the United in the highest terms in commendation of its excel- States, Great Britain, and India. — New Rem,edie8, lence. It has now become the principal text-book i May, 1879. o REENE [WILLIAM H.), M.D., Deraonstmtor of Chemistry in Med. Bept., TTniv. of Penna,. A MANUAL OF MEDICAL CHEMISTRY. For the Use of Students. Based upon Bowman'.s Medical Chemistry. In one royal 12mo. volume of 312 pages With illustrations. Cloth, SI 75. {Now Ready.) It is well written, and gives the latest views on I The -little work before us is oue which we think vital chemistry, a subject with which most physi- will be studied with pleasure and profit. The de- dans are not sufficiently familiar. To those who scriptions, though brief, are clear, and in most cases may wish to improve their knowledge in that direc- sufficient for the purpose. This book will, in nearly tion, we can heartily recommend this work as being all cases, meet general approval. — Am. Journ. of worthy ofacarefulperusal. — Phila. Med. and Surg. Pharmacy, April, 1880. Reporter, April 2i, 1880. I ffLASSEN {ALEXANDER), ^-^ Professor in the RoyaJ Polytechnic School, Aix-la-Chapelle. ELEMENTARY QUANTITATIVE ANALYSIS. Translated with notes and additions by Edgar F. S-MITH, Ph.D., Assistant Prof, of Chemistry in the Towne Scientific School, Univ. of Penna. In one handsome royal 12mo. volume, of 324 pages, with illustrations ; cloth, $2 00. {Lately Issued.) It is probably the best manual of an elementary ] advancing to the analysis of minerals and such pro- nature extant, insomuch as its methods are the best, ducts us are met with in applied chemistry. It is It teaches by examples, commencing with single ' an indispecsable book for students in chemistry.—" determinations, followed by separations, and then , Boston Journ. of Qhernistry, Oct. 1878. riALLO WAY {ROBERT), F.C.S., ^-^ Prof, of Applied Ohemi-i-try in the Royal College of Science for Ireland, etc. A MANUAL OF QUALITATIVE ANALYSIS. From the Fifth Lon- don Edition. In one neat royal 12mo. volume, with illustrations ; cloth, $2 75. T?EMSEN{IRA), M.D., Ph.D., Professor of Cherai-itry in the Johns Hopkins University, Baltimore. PRINCIPLES OF THEORETICAL CHKMISTRY, with special reference to the Constitution of Chemical Compounds. In one handsome royal 12mo. vol. of over 232 pages: cloth, $1 50. BOWMAN'S INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANALYSIS. Sixth American, from the Sixth and revised London edi- tion. With numerous illustrations. In one neat vol., royal 12mo., cloth, $2 25. WOHLER AND FITTIG'S OUTLINES OF ORGANIC CHEMISTRY. Tran.slated,with additions, from the Eighth German Edition. By Ira Remsex. M D., Ph D., Prof, of Chemistry and Physics in Williams College, Mass. In one volume, royal 12mo. of 550 pp., cloth, $3. 10 Henry C. Lea's Son & Co.'s Publications — {Chemistry). pOWNES [GEORGE), Ph.D. A MANUAL OF ELEMENTARY CHEMISTRY; Theoretical and Practical. Revised and corrected by Henry Watts, B. A., F R.S., author of "A Diction- ary of Chemistry," etc. With a colored plate, and one hundred and seventy -seven illus- trations. A new American, from the Twelfth and enlarged London edition. Edited by Robert Bridges, M.D. In one larpe royal 12mo. volume, of over 1000 pages; cloth, $2 75 ; leather, $3 25. (Lately Issued.) This work, inorganic and organic, is complete in one convenient volume. In its earliest editions it was fully up to the latest advancements and theo- ries of that time. In its present form, it presents, in a remarkably convenient and satisfactory raan- nt-r, the principles and leading facts of the chemistry of to-driy. Concerning the manner in which the various bubjects are treated, much deserves to be said, and mostly, loo, in praise of thK book. A re- view of such a work as FouniKs's Chewi-itry within the limits of a book-notice for a medical weekly is simply out of the question. — Cineinnnti Lancet and Clinic, D^c. 14, 1S78. When we state that, in our opinion, the present edition sustains in every respect the high reputation which its predecessors have acquired and euj.)yed, we express therewith our full belief in its intrinsic value as a text-book and work of reference. — Am. Journ. of Pharm., Aug. 1878. The conscientious care which has been bestowed upon it by the American and English editors renders It still, perhaps, the best book for the student and the practitioner who would keep alive the acquisitions of his student days. It has, indeed, reached a some- what formidable magnitude with its more than a thousand pages, but with less than this no fair repre- sentation of chemistry as ii now is can be given. The type is small but very clear, and the sections are very lucidly arranged to facilitate study and reference. — Mud and Surg. Rf-portfr, Aug 3, 1878. The work is too well known to American students to need any extended notice; suffice it to say that the re vi>ion by the English editor has been faithfully done, and that Professor Bridges has added some fresh and valuable matter, especially in the inor- ganic chemistry. Th.e book has always been a fa,- vorite in this country, and in its new shape bids fair to retain all its former prestige. — Boston Jour, of Chemistry, Aug. IS78. It will be entirely unnecessary for us to make any remarks relating to the general characterof Fownes' Manual. For over twenty years it has held the fore- most place as a text-book, and the elaborate and thorough revisions which have been made from time to timeleavelittlechance for any wideawaherival to step before it. — Canadian Pharm. Jour., Aug. 1878. As a manual of chemistry it is without a superior in the language. — Md. Med. Jour., Aug. 1878. B LOXAM {G.L.), Profenaor of Chemistry in King'' s College, London. CHEMISTRY, INORGANIC AND ORGANIC. Prom the Second Lon- don Edition. In one very handsome octavo volume, of 700 pages, with about 300 illus- trations. Cloth, $4 00 ; leather, $5 00. We havein this work a complete and most excel- lent text-book for the use of schools, and can heart- ily recommend it as such. — Boston Med. and Surg. Journ., May 28, 1874. Theabovelsthe titleof a work which we can most conscientiously recommend to students of chemis- try. It is as easy as a work on chemistry could be made, at thesame time that it presentsa full account of thatscience as it now stands. We have spoken of the work as admirably adapted to the wants of students ; it is quite as well suited to the require- ments of practitioners who wish to review their chemistry, or have occasion to refresh their memo- ries on any point relating to It. In a word, it is a book to be read by all who wish to know what is thechemistry of the preaentday. — American Prac- titioner, Nov. 18T3. It would be difiBcult for a practical chemist and teacher to find any material fault with this most ad- mirable treatise The author has given ns almost a cyclopaedia within the limits of a convenient volume, and has done so without penning the useless para- graphs too commonly making up a great pan of the bulk of many cumbrous works. The progressive scientist is not disappointed when he looks for the record of new and valuable processes and discover- ies, while the cautious conservati»'e doe.s not find its pages monopolized by uncertain theories and specu- larions. A peculiar point of excellence is the crys- tallized form of expression in which great truths are expressed in very short paragraphs. One is surprised at the brief space allotted to an important topic, and yet, after reading it, he feels that little, if any more should have been said. Altogether, it is seldom yoa see a text-book so nearly faultless. — Cincinnati Lancet, Nov. 1873. rfLOWES {FRANK), D.Sc. London. ^^ Senior Science- Mn. iter at the HighSchool, Newcastle-under-Lyme, etc. AN ELEMENTARY TREATISE ON PRACTIC \L CHEMISTRY AND QUALITATIVE INORGANIC ANALYSIS. Specially adapted for Use in the Laboratories of Schools and Colleges and by Beginners. Second American from the Third and Revised English Edition. In one very handsome royal 12mo. volume of 372 pages, with 47 illustrations. Cloth, $2 50. {Just Ready.) This is a valuable work for those about to com- mence chemistry, the more so as by its use they are simultaneously acquainted with the manipulation of chemical analysis, a method which is the most valuable to impart a thor^'^ugh knowle,cr,c /^no if „«►*>,= „,...=.» ;..„„,-., ,v i I'ernaps one, ii not the most important book upon pharmacy which has appeared in the English lan- thas effected it constitutes, as now presented, a com- pendium of the science and artindi.-pensable to the pharmacist, and of the utmost value to everv practitioner of medicine desirous of fainiliarizing side^^VIhe w^t^rTnd tre°fa"ctshows"us tYatVrealiy himself with the pharmaceutical preparation of the nsefnl work nev^rbor-omo^ m»rpl^ in.ci ; n u= f, ' / guage has emanated from the transatlantic press. "Parrish's Pharmacy'- is a well-known work on this articles which he prescribes for his patieuts. eago Hed. tTotirn., July, 1S74. -Chi- useful work ueverbecomes merely local in its fame. Thanks to the judicious editing of Mr. Wiegand, the posthumous edition of "Parrish" has been saved to The work is eminently praotical, and has the rare the public with all the mature experience of its an- merit of being readable and interesting, while it pre- thor. and perhaps none the worse for a dash of neTr serves astrictly sciemificcharacter- The whole work blood. — Lond. Pharrn. Journal, Oct. 17, 1874. reflects the greatest credit on author, editor, and pub- , QRIFFITH (ROBERT E.), M.D. A UNIVERSAL FORMULARY, Containing the Methods of Prepar- ing and Administering Officinal and other Medicines. The whole adapted to Physiciars and Pharmaceutists. Third edition, thoroughly revised, with numerous additions, Idt Jons M. Maisch, Professor of Materia Medieain the Philadelphia College of Pharmacy. In one large and handsome octavo volume of abrut 800 pages. Cloth, $4 50 ; leather, %b 50. A more complete formulary than itis in its pres mitted to memory by every student of medicine ent form the pharmacist or physician could hardly ' As a help to phy.sicians it will be found inv«lniible, desire To the first some such work is indispen-a and doubtless will make its way into libraries no- ble, and it is hardly less essential to the practitionei already supplied with a standard work of the kind, who compounds his own medicines. Much of what — The American Practitioner ,Loms-<;iUe, July, "!4. is eoataiaed in the introduction ought to be com- i F ^ARQUHARSON [ROBERT), M.D. , Ler^turer on Materia Medica at St. Mary's Hospital Medical School. A GUIDE TO THERAPEUTICS AND MATERIA MEDICA. Se- eond American edition, revised by the Pharmacopoeia. By Frank Woodbuet pages: cloth, $2.25. {Lately Issued.) The appearance of a new edition of this conve- nient and handy book in less than two years may certainly be taken as an indication of its useful- ness. Its convenient arrangement, and its terse- ness, and, at the same time, completeness of the information given, make it a handy book of refer- ence. — Am. Journ of Pharrna.cy, June. 1S79. This work contains in moderate compass such well-dieested facts concerning the pbysiologTcal and therapeutical action of reiredies as are reason- ably established up to the present time. By a con- venient arrangement the correspondire effects of each article in health and disease are presented in parallel columns, not only rendering reference easier but also impressing the facts more strongly nrion the mind of the reader. The book has been adapted to the wants of the American student, and Author. Enlarged and adapted to the U. S. , M.D. In one neat royal 12mo. volume of 498 copious notes have beenintrodnced, embodying the latesf revision of the Pharmacopceia, together wi h the antidotes to the more prominent poisons, and Buchofthe newer remedial a sen ts as ."eemed neces- sary ro the completeness of the work. Tables of weights and measures, and a good alphabetical in- dex end the volume. — Druggists'' Circular and Chemical Qazette. June, 1879. ! It is a pleasure to think that the rapidity with which a second edition is demanded may be taken as an indication that the sense of appreciation of the value of reliable information reearding the use of remedies i- not entirely overwhelmed in the cultiva- tion of pathologicalstudies, ebaracreristicof the pre- sent day. This work certainly merits the success it has so quickly achieved. — New Remedies, July, '79. CHRISTISOX'SDISPEN'SATORT. With copiousad- ditions. and 213 large wood engravings By R E'*LESFiEi.D Griffith, II. D. One vol. Svo., pp. 1000 cloth, *4 00. ;aEPEXTEK'6 prize ESSAY ON THE USE OF Alcoholic LiQroKS in Health and Disease. JJew edition, with a Preface by D. F. Coxdie. M D., and explanations of scientifirwords. In oneneatl 2inOi volume, pp. 17S, cloth, 60 cents. 12 Henry C. Lea's Son & Co.'s Publications — (^Mat. Med. and Therap.). fJTJLLE {ALFRED), M.D., LL.D., and JlfAJSCH (JOHN M.), Ph.D., f^ Prof .of Theory 'ind Practic of Medicine -^'-*- Prof.ofMnt.MeA.andBot.inPhila. and of Clinical Med. in Univ. of Pa. Coll. Phnrmncy, Secy, to the American Pharmace^tiical AD-fociation. THE NATIONAL DISPENSATORY: Contaiuinjr the Natural History, Chemistry, Pharmacy, ActionF and Uses of Medicines, includin<^ those recognized in the Pharmacopoeias of the United St^ites, Great Britain and Germany, with numer- ous references to the French Codex. Second edition, thoroutrhly revised, with numerous additions. In one very handsome octavo volume of 1692 paEces.wlth 239 illustrations. Extra cloth, $6 75; leather, raised bands, $7 50; half Russia, raised bands and open back, $8 25. {Now Ready.) Preface to the Second Edition. The demand which has exhausted in a few months an unusually large edition of the National Dispensatory is doubly gratifying to the authors, as showing that tley were correct in thinking that the want of such a work was felt by the medical and pharmaceutical professions, and that their efforts to supply that want have been acceptable. This appreciation of their labors has stimulated them in the revision to render the volume more worthy of the very marked faTor ■with which it has been received. The first edition of a work of i=uch magnitude must necessarily be more or less imperfect; and though but little that is new and important has been brought to light in the short interval since its publication, yet the length of time during which it was passing through the press rendered the earlier portions more in arrears than the la-er. The opportunity for a revision has enabled the authors to scrutinize the work as a whole, and to introduce alterations and additions wherever there has seemed to be occasion for improve- ment or greater completeness. The principal changes to be noted are the introduction of seve- ral drufs under separate headings, and of a large number of drugs, chemicals ^nd pharma- ceutical preparations classified as allied drugs and preparations under the heading of more important or better known articles : these additions comprise in part nearly the entire German Pharmacopoeia and numerous articles from the French Codex. All new investigations which came to the authors" notice up to the time of public.Ttion have received due consideration. The series of illustrations has undergone a corresponding thorough revision. A number have been added, and still more have been substituted for such as were deemed less satisfactory. The new matter embraced in the text is equal to nearly one hmdred pages of the first edition. Considerable as are these changes as a whole, they have been accommodated by an enlargement of the page without increasing unduly the size of the volume. While numerous additions have been made to the sections which relate to the physiological action of medicines and their use in the treatment of disea=e, great care has been taken to make them as concise as was possible without rendering them incomplete or obscure. The doses have been expressed in the terms both of troy weight and of the metrical system, for the purpose of making those who employ the Dispensatory familiar with the latter, and paving the way for its introduction into general use. The Therapeutical Index has been extended by about 2250 new references, making the total number in the present edition about 6000. The articles there enumerated as remedies for particular diseases are not only those which, in the authors' opinion, are curative, or even beneficial, but those also which have at any time been employed on the ground of popular belief or professional authority. It is often of as much consequence to be acquainted with the worthlessness of certain medicines or with the narrow limits of their power, as to know the well attested virtues of others and the conditions under which they are displayed. An additional value posse.-sed by such an Index is, that it contains the elements of a natural classification of medicines, founded upon an analysis of the results of experience, which is the only safe guide in the treatment of disease. This evidence of success, seldom paralleled, keep the work up to the time. — ^Vew fier/iedie*, Not. shows clearly how well the authors have met the 1S79. existing needs of the pharmaeeutical and medical ^i,,-, j^ ^ ^^^^ ^o^^ t^^ t^o of the ab]e.et writer? on professions. Gr.itifying as it must be to them, they materia me.lica in America The authors have pro- have embraced the opportunity offered for a thor- ^^^^.^ ^ work which, for accuracy and comprt-hensive- ongh revision of the whole work, striving to em- ness, is unsurpas-^ed bv any work on the subject. There brace within it all that might have been omitted in j^ ^^ ^ook in the EnzUsh laneuatre \ANVIER [L.], J-ii Prof inthe O'lllegeof Fi-amee. MANUAL OF PATHOLOGICAL HISTOLOGY. Tmn slated, with Notes and Additions, by E. 0. Shakespeare, M.D., Pathologist and Ophthalmic Surgeon to Philada. Hospital, Lecturer on Refrpction and Operative Ophthiillnic Surgery in Univ. of Penna., and by Henry C. Simes. M D., Demonstratrr of Pathological Histology in the Univ. of Pa. In one very handsome octavo volume of over 700 pages, with over 350 illustrations. Cloth, S6 50; leather, $6 50 ; half Russia, %T, (Jhtst Ready.) We have no hesitation in cordially recommending the Eaglish translation ofCornil & Ranvier's -'Pa- thological Histology" as the best work of the kind in any language, and as giving to its readers a trustworthy guide in obtainiog a broad and solid i^asis for the appreciation of the practical bearings of pathological anatomy. — A'ln. Journ. of Med. Sciences, Aoril, 1880. This important work, in its American dress, is a welcome offering to all students of the subjects which it treats. The great mass of material is arringed naturally and comprehensively. The clj-ssifieation of tumors is clear and full, so far as the subject idmits of definition, and this one chap- ter is worth the price of the book. The illustra- tions are copious and well chosen. "Without the slightest hesitation, the translators deserve honest thanks for placing this indispensable work in the hands of American students. — Phila. Med. Times, April 24, 18^0 This volume we cordially eommead to theprofes- sion. It will prove a valuable, almost necessary, addition to the libraries of j-tudents who are to he physicians, a ad to the libraries of staden's who are physicians.— ulrnerican Praeiiifianer, Jnne, 18S0. 14 Henry C. Lea's Son & Co.'s Publications — {Pathology^ etc.). PENWICK {SAMUEL), M.D., -*■ Ansistant Phi/.iici'in to the. Londnn ffnxpital. THE STUDENT'S GUIDE TO MEDICAL DIAGNOSIS. From the Third Revised and Enlarged English Edition. With eighty-four illnstrations on wood. In one very handsome volnme, royal 12mo. , cloth, $2 25. (Lately Issued.) flREEN [T. HENRY), M.D., ^-* Kecturer on Pnlholngy and MnrhUI Anatomy nt Chnring-CroxD Hospital Medical School, etc. PATHOLOGY AND MORBID ANATOMY. Fourth American, from the Fifth Enl.arged and Revised English Edition. In one very h.indsome octavo Tolnme of about 350 pages, with 1.38 fine engravings; cloth, $2 25. (Just Ready.) Extract from the Author'.s Preface. In preparing the fifth edition of ray Te.xt-bnnk on Pathology and Morbid Anatomy, I have ag.iin added much new matter, with the object of making the work a more complete guide for the student. All the chiipter.« have been carefully revised, some :ilteration,s b.ave been made in the arrangement of the work, and an addition has been made to the number of wood-cuts. The new wood cuts, as in previous editions, have been drawn by M.-. CoUings from my own micro- scopical preparations. We have long considered this the best guide yet bnon thorouebly revised, and mnch new raatier p-esentei to the student for the identification of va- has been ?dded. To the physician as a guide in rions morbid tissues. We have found it more satis- diagnosis, we recoininend this volnme. — Phy.tioian factory than any other. The present edition has and Surgeon, May, ISSl. DRISTOWE [JOHN SYER), M.D., F.R.C.P., JL? Phynician and .Toint Lecturer on Medicine , St T^omax's Hnxpital. A TREATISE ON THE PRACTICE OF MEDICINE. Second American edition, revised by the Author. Edited, with Additions, by James H. IIutch- issoN, M .D., Physician to the Penna. Hospital. In one handsome octavo volume of nearly 1200 pnges. With illustrations. Cloth, $5 00 j leather, $6 00; half Russia, $6 60. {Kow Ready.) The second edition of tliis excellent work, like the | The views of the author are expressed with preci- first, has received the benefit of Dr. Hutchinson's ! sion and sufficient promptness to impress the sindeut aunotHtions, by which the phases of disease which with the weight of his authority; and should the are peculiar to this country are indicated, and thus medical professor differ c)u any subject from his doc- a treatise which was intended for British practi- trine, he will need to find strong arguments to carry tioners and students is made more practically nst:fnl on this side of tbe water. We see no reason to modify the high opinion previously expressed with regard to Dr. Bristowe's \Tork, except by ad- and has obtained so high a positioa amongst mod- , xiille Journ. of Med. and Surg , Feb. 1S81. ern treatises on medicine, that it is hardly neces "Flint's Practice" is recognized to be a standard saryto do more than annoance the pubUcation of I t..,,- , V- T ,, •<='^^S"'-^'^ )■'' o« a sv^uuara this fifth edition. All who perase it mu.t be «truck ^ i"-? 'V^,« "i ^'^l ':*°^ "I""" the prmcples and the by the exteosive research which has been under- ^r^^^"'^ «f medicine wherever the Enf?l,sh language taken in the revision of this edition, combined with mncb original thonght. There is hardly a subject which does not receive fresh illastratiou and discus- Mon, openins; up new lines of inqnii-y which had not been thonght of when the previous edition appeared. We cannot ennclU'de this notice without expressing our admiration of this volume, which is certainly one of the standard text-books on medicine, and we practice of medicine wherever the English language is read. The opinions everywhere reveal the man of extensive experience, diUsent study, calm jadg- raeat, and unbiassed criticism. The work thnuld be in the hands of every practitioner. — New York Med. Record, Feb. 26, ISSl. The style and chanicrer of this work are too well known to the profession fo reqnire an introduction. For a number of years thi« volume has occupied a may safely affirm that, taken altogether, it exhibits leading position as a text-book in the majority of a fuller and wider acquaintance with recent patho logical inquiry than any similar work with which we are acquainted, whilst at the same time it shows its author to be possessed of the rare faculties of clear exposition, thoughtful discrimination, and sound judgment. — Lond^oa Lancet, July %i, ISSl. Practically, this edition is a new work; for so many additions and changes have been made that one well acquainted with previous editions would medical schools, and the high position accoriled to it in the past is a guarantee of a hearty welcome in this new edition. The book may be said to represent the present state of the science of medicine as now understood and taua;ht. Ills a safe guide lo students and practitioners of medicine. — Maryland Medical Journal. March 1, 1881. The author has, in this edition, revised and re- written a great oart and made it accord with the hardly recognize this as an old friend. The size of more advanced ideas which have been developed the volumeis somewhat increased. An entire new within the past few years. He is the more fitted to section and several new chapters have been added. : is complete in Its special design, and yet 80 condensed, that he can by its aid, keep up with the lectures on practice without neglecting other branches. It will not escipe the notice of the practitioner that such a work is most valuable in culling points in diagnosis and treatment in the in- tervals between the daily rounds of visits, since he can in a few minutes refresh his memory, or learn the litest advance in the treatment of disease* which demand his instant a'tention. — Cincinnati Lancet and aUnic, Oct. 25, 1879. The eminent teacher who has written the volume ttnder consileratioo h. s recognized the needs of the American profession, and thf result is all that we could wish. The style in which it i- written is peculiarly the author's; it is clear and forcible, and marked by those characteristics which have ren- dered him one of the best writers and teachers this country has ever produced. We have not space for so full a consideration of this remarkable work as we would desire. — St. Louis Clin. Record, Oct. 1S~9. It is here that the skill and learning of the great clinician are displayed He has given us a store- house of medical knowledge, excellent for the stu- dent, convenient for the practitioner, the result of a long life of the most faithful clinical work, collect- ed by an energy as vigilant and systematic as un- tiring, and weighed by a judgment no less clear than his observation is e\.06e.—Archiveg of Medi- cine, Dec. 1879 To give an adequate and useful con»pectus of the extensive field of modern clinical medicine is a task of no ordinary difficulty; but to accomplish this consistently, with brevity and clearness, the diff^r^nt subjects and their several parts receiving the atten- tion which, relatively to tlieir importance, medical opinion claims for them, is still mo re difficult. Ttjis task we feel bound to gay has been executed wi*h more than partial success by Dr Flint, whose name is already familiar to students of advanced medicine DF THE SAME AUTHOR. ESSAYS ON CONSERVATIVE MEDICINE AND KINDRED TOPICS. In one very handsome royal 12rao. volume. Cloth, $1 38, {Just Issued.) DAVIS'S CLINICAL LECTURES ON VARIOUS i STURGES'S INTRODUCTION TO THE STUDY OF IMPORTANT DISEASES; being a collection of the Clinical Lectures delivered in the Medical Wards of iMercy Hospi.al, Chicago. Edited by Frank H Davis, M.D. Second edition, enlarged. In one handsome royal I2aio. volume. Cloth, $1 75. CLINICAL MEDICINE. Beinga Guide to the In vestigation of Disease. In one handsome 12mo. volume, cloth, $1 25. 16 Henry C. Lea's Son & Co.'s PrBLicATiONs — (Practice of Medicine). pTCHAFDSOX{BEXJ. W.). JI.D., F.R.S.. M.A., LL.D., F.S.A., -*-^ FeUoW'^/th'- Royal college of Phytioians, London. PREVENTIVE MEDICIXE. In one octavo volume of about 500 pages. {Shortly.) pfARTSHORNE {HENRY). M.D., •*-*■ Prrifffssor "f Hygicntin fhn Uniw.rfdttj of Pennsylvania ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDI- CINE. A hanrly book for Students and Practitioners Fifth edition, thoroughly re- vised and rewritten. With 140 illustrations. In one handsome royal 12mo. volume, of about 600 pages. {In Press.) The very great success which has exhansted four large editions of thi.s work shows that the author has sucjeeded in supplying a want felt by a large portion of the profession. It has also enabled him in successive revisions to perfect the details of his plan, and to render the work still aiore worthy of the favor with which it has been received. In the present edition several hundred brief additions h:ive been made, a number of new su'-jects have been written upon, especially in connection with the Pathology of tbe Nervous System, the illustrations have been considerably increased, and a large number of new and carefully selected formulae for the admi- 1 istration of medicines have been introduced. An account is given, also, in this edition for th^ first time, of the method of prescribing according to the metrical system, and a section is added U; on Eyesight, its Examination and Correction. In pre.=enting this edition, therefore, the pub- lishers feel that it is in every way worthy a continuance of the favor hitherto accorded this work. VrrOODBURY (FRAiVK). M.D.. '' Phi/sicirrn to the Oermnn Hrnpital, PA'7 fladelphia, late Chief Assist, to Med. Clinic, Jeff. College Unspitnl, etc. A HANDBOOK OF THE PRINCIPLES AND PRACTICE OF Medicine ; for the use of Students and Practitioners. In one neat volume, royal 12mo., with illustrations. {In Press.) JPOTHERGILL {J. MILNER),M.D. Ediv., M.R.C.P. Loud., ■'- Asst. Phyf:. to the. West Lond Eogp. .- A-i-it. Phyx. to the City of Lond. Ho.':p..etc. THE PRACTITIONER'S HANDBOOK OF TREATMENT; Or, the Principles of Therapeutics. Second edition, revised and enlarged. In one very neat octavo volume of about 650 pages. Cloth, $4 00; very handsome half Russia, $5 60. (Just Ready.) The junior members of the profession will find in , cated physician for his efforts toward rationalizing it a work that should not only be read, but care- , the treatment of diseases upon ihe scientific basis fully studied. It will assist them in the proper ; of physiology. Every chapter, every line, has the selectioQ and combination of therapeutical agens impress of a master band, and while the work is best adapted to each case and coudition, and enable thoroughly scientific in --very particular, it presents them to prescribe iDtelliaently und in balkier volarat-s, and and does not lack in informatioa that wili meet the becau^^e in its arrangement and complete index, it is wants of esperienoed and older men. — Phila. Med. unusnally convenient for quick reference in any Tirnes, Jan. 4, 1S79. ; emergency that may come upon thebasy practitioner. This is <»Be rf tbe really useful books. It is attrac- | ~^- ^- ^^- -^""'"a-. Jan- 1879. TTTA TSON (THOMAS), M.D., §-c. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- vised andcElargedEngli.^h edition. Edited, with additions, and several hundred illustrn- tione.hy Henry H.\rtshorse, M.D., Professor of Hygiene in the University of Penn- sylvania. In two large and handsome 8vo. vols. Cloth, $9 00; leather, $1100. WILLIAMS'S PULMONARY CONSUMPTION; its | a'ALSHEON THE DISEASESOF THEHE.'iRT AND Nature, Varieties and Treatment. WiibanAn-' GREAT VESSELS. Third .^Vmerican Edition. In alysis of One Thousand Cases to exemplify its | 1 vol. Svo., 42ri pp., cloth, $3 00. duration. In one neat «etavo volume of about i sMITH ON CONSUMPTION ; ITS EARLTAND BE- 3.50 pages ; el«th, *2 .10. MEDIABLE STAGES. 1 vol. Kvc.pp. 2.'<4. «2 25. 3LADE ON DIPHTHERIA; its Nature and Treat- ! ppLLER ON DISE.\SES OF THE LUNGS AND AIR- m-nt.with an iccountof the History of Its Pre-j pass.\GES. Th^ir Pat hologv.Phvsical Diagnosis, valeucein various Coantrie> Second and revised' Svmptoios and Treatment. From the Second and edmon. In one aeatroyall2mo. volume, cloth, revised English edition. In one handsome octavo *^ ■^- 1 volume of about oOO pages : cloth, $3 50. Henry C. Lea's Son & Co.'s Vv^-licatiot^ss— (Practice of Iledicine). IT J?EYNOLDS [J. RUSSELL). M.D., -*-*' Prnf. of the Principles and, Practice of Medicine in Univ. College, London. A SYSTEM OF MRDFnNE wtth Notes and \ddittons by Ht=:nrt H arts- HORNE, M.D., late Professor of Hygiene in the University of Penna. In three Inrge and hnndsome octavo volumes, containing 3052 closely printed double-columned pages, with numerous illustrations. Sold onlyhysiibscri-ption. Price per vol., in cloth, S5.00 ; in sheep, S6.00 : half Russia, raised bands, $6.50. Per set in cloth, $15 ; sheep, §18 ; half Russia, $19.50 Volume I. {just ready) contains Geneeal Diseases and Diseases of the Nervous System. Volume II. {jxist ready) contains Diseases of Respiratory and Circulatory SYSTEsrs. Volume III. {just ready) contains Diseases of the Digestive and Blood Glandular Systems, of the Urinary Organs, of the Female Reproductive System, and of the Cutaneous System. Reynolds's System of Medicine, recently completed, has acquired, since the first appearance of the first volume, the well-deserved reputation of being the work in which modern British medicine is presented in its fullest and most practical form. This could scarce be otherwise in view of the fact that it is the result of the collaboration of the leading minds of the profession, each subject being treated by some gentleman who is regarded as its highest authority — as for instance. Diseases of the Bladder by Sir Henry Thompson, Malpositions of the Uterus by Graily Hewitt, Insanity by Henry Maudsley, Consumption by J. Hughes Bennet, Dis- eases of the Spine by Char-les Bland Radclifpe, Pericarditis by Francis Sibson, Alcoholism by Francis E. Anstie, Renal Affections by William Roberts, Asthma by Hyde ^-'alter, Cerebral Affections by H Charlton Bastian, Gout and Rheumatism by Alfred Baring Gar- rod, Constitutional Syphilis by Jonathan Hutchinson, Diseases of the Stomach by M'^ilson Fox, Diseases of the Skin by Balmanno Squire, Affections of the Larynx by Morell Mac- kenzie, Diseases of the Rectum by Blizard CaRLiNG, Diabetes by Lauder Brunton, Intes- tinal Diseases by John Syer Bristowe, Catalepsy and Somnambulism by Thomas King Cham- bers, Apoplexy by J. Hughlings Jackson, Angina Pectoris by Professor Gairdner, Emphy- sema of the Lungs by Sir William Jenner, etc etc. All the leading schools in Great Britain have contributed their best men in generous rivalry, to build up this monument of medical sci- ence. St. Bartholomew's, Guy's, St Thomas's, University College, St. Mary's, in London, while the Edinburgh, Glasgow, and Manchester schools are equally well represented, the Army Medical School at Netley, the military and naval services, and the public health boards. That a work conceived in such a spirir, and carried out under such auspices should prove an indispensable treasury of facts and experience, suited to the daily wants of the practitioner, was inevitable, and the success which it has enjoyed in England, and the reputation which it has acquired on this side of the Atlantic, have sealed it with the approbation of the two pre-eminently practical nations. Its large size and high price having kept it beyond the reach of many practitioners in this country who desire to possess it, a demand has arisen for an edition at a price which shall ren- der it iiccessible to all. To meet this demand the present edition has been undertaken. The five volumes and five thousard pages of the original have, bj' toe use of a smaller type and double columns, been compres,-ed into three volumes of over three thousand pages, clearly and hand- somely printed, and ofi"ered at a price which renders it one of the cheapest works ever presented to the American profession. But not only is the Americ.in edition more convenient and lower priced than the English; it is also better and more complete. Some years having elapsed since the appearance of a portion of the work, additions are required to bring up the subjects to the existing condition of science. Some diseases, also, which are comparatively unimportant in England, require more elaborate treatment to adapt the articles devoted to them to the wants of the American physi- cian ; and there are points on which the received practice in this country differs from that adopted abroad. The supplying of these deficiencies has been undertaken by Henry Harts- HORNE, M.D., late Professor of Hygiene in the University of Pennsylvania, who has endeavored to render the work fully up to the day, and as useful to the American physician as it has proved to be to his English brethren. The number of illustrations has also been largely increased, and no effort spared to render the typographical execution unexceptionable in every respect. Really too much praise can scarcely be givea to this noble book. It is a cyclopeedia of medicine written by .some of the best men of Europe. It is full of usefal information such as one finds frequent need of in one's daily work As a book of reference it is invaluable. It is up with the times. It is clear and concentrated in ^tyle, and its form is worthy of its famous publisher. — Louisville Med. News, Jan. 31,1SS0. "Reynolds' System of Medicine" is ju=tly con- sidered the most popular woTk on the principles and practice of medicine in the English language. The contributors to this work are gentlemen of well- known reputation on both sides of the Atlantic subjects with which he should be familiar. — Gail- lard's Med. Journ., Feb. 18S0. There is no medical work which we have in times past more frequently and fully consulted whea per- plexed by doubts as to treatment, or by having un- usual or apparently inexplicable symptoms pre- sented to us than "Reynolds' System of Medicine." Among its contributors are gentlemen who are as well known by reputation upon this side of the Atlantic as in Great Britain, and whose right to speak with authority upon the subjects about which they have writteu, is recognized the world over. They have evidently striven to make their es.^ays as practical as possible, and while these are Each geurleman has striven to make his part of the ' sufficiently full to entitle them to the name of work as practical as pos-ible. and the inforiiiatioa \ monographs, they are not loaded down with such contained is such as is needed by the busy practi- I an amount of detail as to render them wearisome tiouev. — St. Louis Med. and Surg. Journ., J a,n.' 80. 1 to the general reader. In a word, they contain just I tha' kind of information which the busy practitioner Dr. Hartshorne has made ample additions and frequeotly finds himself in need of. In order that revisions, all of which give increased value to the i any deficiencies may be supplied, the publishers volume, and render it more useful to the Ameri- have committed the preparation of the book for the can practitioner. There is no volume in English , press to Dr. Henry Hartshorne, whose judicious medical literature more valuable, and every pur- ! notesdistribnted throughout the volume afi'ord abun- chaser will, on becoming familiar with it, congrat- > dant evidence of the thoroughness of the revision to niate himsfilf on the posspssiop of this vast store- ! which he hassubjected it. — Am. Jour. Med. Sciences, house of information, in. regard to so many of the ( Jan. 18S0. 18 Henry C. Lea's Son & Co.'s Publications — (Kerv. Dis , <&c.). B ARTHOLOW (ROBERTS), AM.. M.D.. LL.D. Prof. cfMnte.ria Medica nvd Oone.rnl ThTapeutics in the Jef Mfd. CoH of Phila , etc. A PRACTICAL TPvEATISE OX ELECTRICITY IX ITS APPLL CATION TO MEDICINE. In one very handsome 8vo. volume of about 270 pages, with 98 illustrations. Cloth, $2 60. {Just re.1 practitioner for the use of medical practitioners. No claim is made on the ground of pure science. It is believed, however, that the work makes an adequate presentation of the subject, regarding electricity as a remedial agent — as one of the means employed for the treat- ment and cure of disease. .So far as we know, the need of a clear, fimple, I practitioners. From this standpoint the work ia nntechDical, reliable, concise, and modern treatise | worthy of the careful study of all who desire to 'Q- np'in the tuhject of medical electricity is only cup- 1 vestigaie this subject for parely practical purposes, plied by the volume under consideralion. It is not This work rneetf a want of very many students and too much to say that, if availed of. it will render medical practitioners. Wb greatly err if it be not accessible to a vast number of niembers of the pro- I gladly welcomed by thera. The author, from his fes>ion a therapeutic agent of the greatest value, but \ long experience as a practitioner, is admirably fitted which has heretofore been practically of no use , to perfurm the task of writing a work of this kind whatever to them. — Maryland Med. Journal, June i for this special class of men. — Detroit Lancet, June, 1, ISSl. 18S1. We have not yet come across a book that can com- ] ^his book is expressive of careful research and a pare with this in clearness and simplicity of state ment. We have for a long lime needed a text-book on medical electricity, conden. 11, ISSl. lif ITCH ELL (S. WEIR). M.D.. •i-'-L Phyn. to Orfhopcedic Hospital nndthe Infirmary fnr Dt's.o/thf yrvous System, Phila., etc. etc. LECTURES OX DISEASES OF THE XERVOUS SYSTEM, ESPECIALLY IN WOMEN. In one very handsome 12mo. volume of about 250 pages, with five lithographic plates. Cloth, $1 75 (Just Ready ) The life-!ong devotion of ibe author to the subjects discussed in this volume has rendered it eir.inently c'esir^ble that the results of his labors should be embodied for the benefit of those who may experience the difficulties connected with the treatment of this class of disease. Many of these lectures are fresh studies of hysterical affections; others treat ot the modifica- tions his views have undergone in regard to certain forms of trentment, while, throughout the whole work, he has been careful to keep in view the practical le.^sons of his cases. It is a record of a number of very remarkable , ordinarily rich in acute observation and sound in- cases, with acute analyses and discussions, clinical, Eiruclion. The repuiation of the author is a t;car- physioli gical, and therapeutical It Is a hook to aolee of that, and no reai er will be disappointed. whi<"h the physician mepting wi h a new hysterical Nor can too mnch be sai'' in praise of the admirab e experience, or in doubt whether hia new experience syle of hio m- dical writings, and each of these ler- is hysterical, may well turn with a well-grounded tures reads with the flr,i«hed grace of a polished hi pe of finding a parallelism ; it will be a new ex- essay. Indeed, the book through on t is sO fascinatins; perience, indeed, if no similar one is here recorded a one that it cmld not fail to be read entire oy evei y — Phila. Med. Times, June 4, 1«S1. ' one who bfgins its pages. —Phila. Med. and Sv-rg. The nnmeof the author is sufficient guarantee that ; Ji'V'ri'r, May 7, ISSl. these topics are ably and appreciatively disrns^ed; The book thronehont is not only intensely enfer- sutfice.i to say that the principles of treatment, both taiainit. but it contains a large anion nt of rare and hygienic and therapeut c are clearly ludicaied. valuable information. Dr Mi chell has re^ordM The articles being in the form of ehnical lectures, ^ot onlv the resul-s of his most carefn' observat-on, abound ,n Illustrative cases, and are much ea-ier b„, has'added to the knowledge of the .subjects trea'- reading than a syjiemstic treatise on the same ed by his original investigation and p.actical study. top^cs.-ColUge and Clinual Record, May 15, 1^81. ^ The book is one we can commend to all of our read- It is needless to say that these lecinreg are extra- i era — Maryland Med. Journal, May 1, 1881. fjAMJLTO.y {ALLAN MrLANE). M.D., •'■■'■ Attending Physician at the Hoepitn) for Epileptic* and Paralytics. BlackwelVs Island, N. 7., and nt the Out- I'atienlK' Df^parlm^'nt of the New York HotpUnl. NERVOUS DISEASES; THEIR DESCRIPTIOXAXDTREATMEXT. Second edition, thoroughly revised and rewritten. In one handsome octavo volume of about 600 pages, with nuicerous illustrations. (/« Press.) Henry C. Lea's Son & Co.'s Publications— (Dzs. of the SMn,&G.). 19 MORRIS (MALCOLM), M.D., ■J-'J- Joint Lecturer on Dermatology, St. Mary's Hospital Med. School. SKIN DISEASES, Including their Definitions, Symptoms, Diagnosis, Prognosis, Morbid Anatomy and Treatment. A Manual for Students and Practitioners. In one 12mo. volume of over 300 pages. With illustrations. Cloth, $1 75. (NowReady.) To physicians who would like to know something about skin diseases, so that when a patient present)- bimseif for relief they can make a correct diagnosis and prescribe a rational trea'ment, we unhesitatingly recommend this little book of Dr. Morris. The affec- tions of the skin are described in a terse, Incid man- ner, and their several characteristics so plainly set foi'th that diagnosis will be easy. The treatment in each case is such as the experience of the most eminent dermatologists advise. — Cincinnati Medi- cal News, April, ISSO. This is emphatically a learner's book ; for we can safely say, so far as our judgment goes, that in the whole range of medical liieraiure of a like scope there is no book which for clearness of expression, and methodical arrangemeut is better adapted to beginner. — Si. Louis Courier of Medicine, April, 1880. The author of this manual has evidently a full and intimate acquaintance with the literature of derma- tology, and with the most recent developments and appliances of cutaneons medicine. He has produced a plain, practical book, by aid of which, who so chooses may triin his eye to the recoguiiion of light but significant differences. The descriptions are neither too vaa;ue nor over-refined ; the direc- tions for treatment are clear and succinct. — London Brain, April, 1880 The author's task has been well done and has pro- duced one of the best recent works upon the difBcnU subject of which it treats ; there is no work published which gives a better view of the elementary facts F' promote a rational conception of dermatology, a and nriaciples of dermatology.— jVe?.£) OcZeans ilfetti branch confessedly difficult and perplexing to the | cal and Surgical Journal, April, 1880. 'OX ( TILBVRF), M.D., F.R.C.P., and T. C. FOX, B.A., M.R.C.S., Physician to the Department /or Skin Di.teases, Univer.iity College Hospital. EPITOME OF SKIN DISEASES. WITH FORMULA. For Stu- DENTS AND Practitionkrs. Second edition, thoroughly revised and greatly enlarged. In one very handsome 12mo. volume of 216 pages. Cloth, $1 38. 'C^LINT [A USTIN) , M.D., •*• Professor of the Principles and Practice of Medicine in Bellevue Hospital Med. College, N. T. A MANUAL OP PEPvCUSSION AND AUSCULTATION; of the Physical Diagno.»is of Diseases of the Lungs and Heart, and of Thoracic Aneurism. Second edition. In one handsome royal 12mo. volume: cloth, $1 63. (Just Ready.) The little work before us has already become a | author has for miny yearx given, in connection with standard one, and has become extensively adopted | practical instruction in auscultation and percussion, as a te.xt-book. There is certainly none better. If I to private classes, composed of medical students and contains the substance of the lessons which the 1 practitioners. — Cineiftraaii .Med. iVews, Feb. 1880. »r THE SAME AUTHOR. PHTHISIS: ITS MORBID ANATOMY, ETIOLOGY, SYMPTOM- ATIC EVENTS AND COMPLICATIONS, FATALITY AND PROGNOSIS, TREAT MENT AND PHYSICAL DIAGNOSIS; in a series of Clinical Studies. By Austin Flint, M.D. , Prof, of the Principles and Practice of Medicine in Bellevue Hospital Med. College, New York. In one handsome octavo volume : $3 50. 1>F THE SAME AUTHOR. A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged edition. In one octavo volume of 550 pages, with a plate, cloth, §4. ■DT THE SAME AUTHOR. A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume of 595 pages, cloth, $4 50. jyRO WN [LENNOX), F.R.G.S. Ed., -*-' Senior Surgeon to the Ci'ntral London Throat and Ear Hospital, etc. THE THROAT AND ITS DISEASES. Second American, from the Second English Edition, thoroughly revised. With one hundred Typical Illustr:itions in colors, and fifty wood engravings, designed and executed by the author. In one very handsome imperial octavo volume of over 350 pages. (^Preparing. ) ^EILER (CARL), M.D., ^ Lecturer on Laryngoscopy at the Univ. of Penna., Chief of the Throat Dispensary at the Univ. Hospital, Phila., etc. HANDBOOK OF DIAGNOSIS AND TREATMENT OF DISEASES OF THE THROAT AND NASAL CAVITIES. In one handsome royal 12mo. volume, of 156 pages, with 35 illustrations ; cloth, $1. (Lately Issued.) We most heartily commend this book as showing , A convenient little handbook, clear, concise, and sound judgment in practice, and perfect familiarity * accurate in its method, and admirably fulfilling its with the literature of tlie specialty it so ably epi- i purpo.se of bringing the subject of which it treats tomizns,.— Philada. Mtd. Times, July 5, IS79. within the comprehension of the general practi- I tioner. — N O. Med. Jour., June, 1879. CLINICAL OBSERVATIONS ON PCNCTIONAL ) HILLIER'S HANDBOOK OF SKIN DISEASES, for NERVOUS DISORDERS B v 0. Handfieli) Jones Students and I'ractitioners. Second Am Ed In M.D., Physician to St. Mary's Hospital, &c. Sec- i one royal 12mo.vol. of 358 pp. With illustrations. Otld America p Edition. I n one hd udsome ociav( t Cloth, $2 25. ▼(jlnmeof 3-18 pageb,cloth,$3 23. 1 20 Henry C. Lea's Son & Co.'s Publications — ( Venereal Diseases, &c.). jyUMSTEAD {FREEMAN J.), M.D..LL.D., ^-^ Lnte Profe.sitor of Venereal Dixea.iea at the Col. of Phy.i and Surg.. New York, Ac. THE PATHOLOGY AND TREATMENT OF VENEREAL PIS- EASES. Including the resultsof recent investigations upon the subject. Fourth Edition, revised and iarg'-ly rewritten with the co-operation of R. W. Taylor, M.D., of New York, Prof, of Dermatology in the Univ. of Vt. In one large and handsome octavo volume of 8.'?5 pages, with 138 illustrations. Cloth, $4 75 ; leather, $5 75; half Russia, $6 25. (Now Ready.) VTe have to congratulate onr conntrymen upon i will more than repay him for the outlay. — Archives the truly valuable addition which they have made i of Medicine, April, 18=^0. to American literature. The careful esiiraate of the value of the volume, which we have made, justifies as in declaring that this is the best treatise on venereal diseases in the English laugnage. and we might add, if there is a better in any other tongue we cannot name it; there are certainly no books in which the student or the general practitioner can find snch an excellent ri-^nmi of the literature of any topic, and such practical suggestions regarding the treatment of the various complications of every venereal disease. We take pleasure in repeating that we believe this to be the best treatise on vene- real disease in the English language, and we con- gratulate the authors upon their brilliant addition to American medical literature. — Ohiiagii Med. Jour- nal and Examiner, February, ISSO. This now classical work on venereal disease comes to us in its fourth ed.tion rewritten, enlarged, and materially improved in every way. Dr. Taylor, as we had everv reason to expect, has performed this part of his work with uuusual excellence. We feel that what has been written has done but scanty jus- tice to the merits of thi'- truly great treatise.— Sf. Louis Couri^r of Medicine, Feb. 18S0 We find that we have here practically a new book —that the statement of the title-page, as to the fact that it has been largely rewritten, is a safficieatly modest announcement for the important changes in the text, .\fter a thorough examination of the pre- sent edition, we can assert confidently that the enor- mous labor w* have described has been here most , . . , . , , ,, . , faithfully and conscientiously performed. — Amer. It IS, without exception, the most valuable single i jpurn. Med. Sci , Jan. ISSO work on all branches of the subject of which it treats I ' . . \ in iiny language. The pathology is sound, the work ,." '^ one of the best general treatises on venereal is, at the same time, iu the highest degree practical, diseases with which we are acquainted, and is espe- and the hints that ha will get from it for the man- cially to be recommended as a guide to the treatment agement of any one case, at all obscure or obstinate, '^^ syphilis.— I,o?uio» Practitioner, March, 18S0. fyROSS {SAMUEL W.), A.M., M.D., ^-^ Lecturer on Genilo-Urina-y and Venereal Di.ien.^en in the .Tefer.ion yfedicnl College, Pkila. A PRACTICAL TREATISE ON I.MPOTENCE, STERILITY A'^D ALLIED DISORDERS OF THE MALE SEXUAL OKG.XN.-^. In one very hand some octavo volume of 1 74 pages, with 16 illustrations. Cloth, $1 50. (Just Ready.) EXTRACT FROM TH"? AI^THOR's PREFACK. "My aim has been tosupply, in a compact form, practical and strictly scientific information, especially adapted to the wants of the general practitioner, in regard to a class of common and grave disorders, upon the correction of which so much of human happiness depends. In the ehiipter on Sterility, the abnormtil conditions of the semen and the cttuses which deprive it of its fecundating properties are fully considered — a portion of the work intended to supplement the subject of sterility in the female. From answers to letters addressed to many of the most prominent writers in this country on gynteoology, I find that, with few exceptions, the womivn aliine commands attention in unfruitful marriages. The importance of e.xamining the husband before subjecting the wife to operation will be best appreciated when I state that he is, as a rule, at fault in at least one example in every .'ix." /1ULLERIER (J.), and '-' Surgeon to the Hdpiial du Midi. I? DMS TEA D [FREEMAN J.), -*-' Profexsor of Venereal Di.ie(rjie.}!2 .'lO. A TREATISE ON FEVER. By Robert D. Lto.vs, K.C.C. In one octavo volume of 362 pages, cloth «2 2.'). HILL ON SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. In one handsome octavo volume; cloth i(3 3.T. SMITH'S PRACTICAL TREATISE ON THE WAST- ING DISEASES OF INFANCY AND CHiLDH-iOD. Second American, from the Second revised and enlarged English edition. In one handsome octn.- vo volume, cloth . *2 .SO LA ROCHE ON PNEUMONIA. 1 Tol. 8vo., cloth, of 500 pages. Price, $3 00. Henry C. Lea's Son & Co.'s Publications — (Dis. of Children, So.). 21 ^MITH{J. LEWIS), M.D., Clinical Professor of Diseases of Ohildren in the Bellemie Hospital Med. College, N. T. A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fifth Edition, thoroughly revised and rewritten. In one handsome oc- tavo volume of 836 pages, with illustrations. Cloth, $4 50; leather, $5 50; very hand- some half Ru.=sia, raised bands, $6. (Just Ready.) The opportunity afforded the author bj' the call for a new edition of his treatise on the Diseases of Children has been taken advantage of to render the volume in every respect worthy a contin- uance of the profession's confidence with which it has been favored in the past. Many portions of the work have been entirely rewritten, several additional diseases treated of, and much new matter introduced : but by the employment of a more condensed style of letter, the size of the work has not been materially enlarged. It will be observed that the very moderate price of the previous edition has not been increased. ^EATING [JOHN M.), M.D., Lecturer on the Visen.ses of Children nt the University of Pennsylva.nia, etc. THE MOTHER'S GUIDE IN THE MANAGEMENT AND FEED- ING OF INFANTS. In one handsome 12mo. vol. of 118 pages. Cloth, $1 00. (Nmv Ready. ) The title of this little book is well chosen, and Dr. Keating has written a work which should be read, and it.s precepts followed by every iuielligent rno- ther in tbi.s country. It is free from all technical terms, the language is clear and distinct, and so structing them on the subjects here dwelt so thor- oughly and practically upon. Dr. Keating has writ- ten a practical book, has carefully avoided unne- cessary repetition, and, I think, successfully ia- strncted the mother in such details of the treatment carefully written that it caunol fail to become popu- of her child as devolve upon her; he has studiously lar. It has always been a mooted question how far omitted giving prescriptions, and instructs the mo- it is well to instruct the public, but works like this ther when to call upon the doctor, as his duties are one will aid the physician immensely, for it saves totally distinct from hers. — American Journal of the time he is constantly giving his patients in in- Obstetrics, October, ISSl. WrEST {CHARLES), M.D., Physician to the Hospital for Sick Children, London, &c. LECTURES ON THE DISEASES OF INFANCY AND CHILD- HOOD. Fifth American from the Sixth revised and enlarged English edition. In one large and handsome octavo volume of 678 pages. Cloth, $4 50 ; leather, $5 50. ^r THE SAME AUTHOR. ( Lately Issued.) ON SOME DISORDERS OF THE NERYOUS SYSTEM IN CHILD- HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of London, in March, 1871. In one volume small 12mo., eloth, $1 00. Dr THE SAMS AUTHOR. LECTURES ON THE DISEASES OF WOMEN. Third Araerican, from the Third London edition. In one neat octavo volume of about 550 pages, cloti, $3 75 ; leather, $4 75. S AVNE {JOSEPH GRIFFITHS), M.D., Physician-Aceoticlieur to the British General Hosj)ital, &C. OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- MENCING MIDWIFERY PRACTICE. Second American, from the Fifth and Revised London Edition, with Additions by E. R. HtrTCHiNS, M.D. With Illustrations. In one neat 12mo. volume. Cloth, $1 25. CHURCHILL ON THE PUERPERAL FEVER AND OTHER DISEASES PECULIAR TO WOiMEN. 1 vol. more dard authority — Cincinnati Med. NeiD9, Dec. ISSO. useful and reliable :han any work in the language This work needs no introduction to any of the on diseases of w. men. Thi* la-^t edition will add civilized nations of the world. The edition before °*'"' laurels 'o those already won. — Jfd. Med. us adds to the streng'h of former volumes. With ■^orirn., Nov. 1.5, ISSO. Hhe wisdom of a master teacher he here gives the I It ha* been enlarged and carefully revised. The results that, in his judgmen', are most trustworthy author has brought it fully ahrenst with the times, at the present time. In its own place it has no and a>- the wave of gynscological progression has rival, because the author is the best teacher on this i been widespread and rapid during the iwel ve years subject to the masses of the profession As hitherto ' that have elapsed since the issue of the first edition, this work will be the text-hook on difeases of wo- one can conceive of the great improvement this edi- men We only wish that in other branches of medi- tion must be upon the esrlier. It is a condensed en- cine a< capable teachers could be found to write our i cyclopedia of «yniec ilogical mediine. The style of te.^t-books. — Detroit Lancet, Jan ISSl. j arran«einent, the mauerly ra inner in which each Sluceitsfir>tappearance twelve years Hgo, until ' su^^ject is treated, and the honest convictions de- the pre-ent dav, it ha< held a position of high re- ^''^''^ ^^"^ pr.bably thfl Urt-est choical experience gard, and is generally concer'ed to be one of the , '° «ba* specialty of uny in this country, all serve to most practical and trustworthy volumes ye' pre- I commend it in the highest terms ^o the practitioner, sented to the physician and student in the depart- i — Nashville Journ. of Med. and Surf/., Jaa. 1881. meut ofgynsecology. The woik embodies not only F B DIS [ARTHUR TT:), M.D. Lond., F.R.C.P., M.R.CS. Assist. Obstetric Physician to Middlesex Hospital, late Physician to British Lying-in BospUaJ. THE DISEASES OF WOMEN. Including tlieir Pathoio^y, Causa- tion, Symptoms, Diagnosis, and Treatment. A manual for Students and Practitioners. In one handsome octavo volume with 149 illustrations. {Shortly.) ARNES [ROBERT], M.D.. F.R.C.F., Obstetric Physician to St. Thomas's Hoi-pital, i-e. A CLINICAL EXPOSITION OF THE MEDICAL AND SFRGI- CAL DISEASES OF WOMEN. Second American, from the Second Enlarged and Revised English Edition. In one handsome oct,avn volume, of 784 pages, with 181 illustrations. Cloth, $4 50; leather, $6 60; half Russia, $6. (Lately lis/ied.) Dr. Barnes stands at the head of his profession in plexity of the man of mature years. — Canadian the old country, and it requires but scant scrutiny Jnurn. of Med Science, Nov. 1S7S. of his hook to show that it has been sketched by a , d^ Barnes's work is one of a practical character, master. It is plain, practical common sense ; shows largely illustrated fmm cases in his own experienre, very deep research without being pedantic; is emi- ^at by no means coni ned to such, as will be learned nently calculated to inspire euthu.-iasm without in- f^om the fact that he quotes from no less than 628 cnlcaliMg rashness; points out the dangers to be medical authors in numerous countries. Coming avoided as well as the success to be achieved in the >om snch an author, it is not necessary to sav that various operations connected with this branch of j^g ^^^j, j^ ^ yaluable one, and should be largely medicine : and will do much to smooth the nigged con-ulted by the profession.-^m. S-'pp Obstetrical path of the young gynscologist and relieve the per- ; j„„^^ ^^ Britain and Ireland, Oct. 1S78. TJODGE {HUGH L.), M.D^, Emeritus Professor of Obstetrics, &c., in the University of Pennsylvania. ON DISEASES PECULIAR TO WOMEN ; including Displacementa of the Uterus. With original illustrations. Second edition, revised and eul.i.rged. In one beautifully printed octavo volume of 531 pages, cloth, $4 50. Henry C. Lea's Son & Co.'s Publications— ( Dis. of Women). 23 JPUMET [THOMAS ADDIS), M.D., -*-^ Surgeon to thf. Woman's Mo xp if al, New York,etn. THE PRIiNCIPLESAND PRACTICE OF GYNECOLOGY, for the use of Students and Practitioners of Medicine. Second Edition. Thorougly Revised. In one hirge and very handsome octavo volume of 875 pages, with 133 illustrations. Cloth, $6| leather, $6 ; half Russia, raised bands, $6 50. {Just Ready.) Preface to the Second Edition. The unusually rapid exhaustion of a large edition of this work, while flattering to the author as an evidence that his labors have proved acceptable, hns in a great measure heightened his sense of responsibility. He has therefore endeavored to take full advantage of the opportunity afforded to him for its revision. Every page has received his earnest scrutiny; the criticisms of his reviewers have been carefully weighed ; and while no marked increase has been made in the size of the volume, several portions have been rewritten, and much new matter has been added. In this minute and thorough revision, the labor involved has been much greater than is perhaps apparent in the results, but it has been cheerfully expended in the hope of rendering the work more worthy of the favor which has been accorded to it by the profession. In no country of the world has gynaicology re- ceived more attention than in America. It is, then, wiDh a feeling of pleasure that we welcome a work on diseases of women from so eminent a gynjecolo- gist as Dr. Emmet, und the work is essentially clini- cal, and leaves a strong impre.-s of the author's in- dividuality. To criticiza, with the care it merit?^, the book throughout, would demnnd far more space than is at our command. In parting, we can say that the work teems with original ideas, fresh and valuable methods of practice, and is written in a clear and elegant style, worthy of the literary repu- tation of the country of Longfellow and Oliver Wen- dell Holmes.— -Brif. Med. Journ. Feb. 21, 18S0. No gynaecological treatise has appeared which contains an equal amount of original and useful matter; nor does the medical and surgical history of America include a book mor« novel and useful. The tabular and statistical Information which it contains is marvellous, both in quantity and accu- racy, and cannot be otherwise than invaluable to future investigators. It is a work which demands not careless reading but profound study. Its value as a contribution to gynsecology is, perhaps, greater than that of all previous literature on the subject combined. — Chicago Med. Gaz., April 5, ISSO The wide reputation of the author makes its pub- lication an event in the gynecological world ; and a glance through its pages shows that it is a work to be studied with care. . . . It must always be a work to be carefully studied and frequently con- sulted by those who practise this branch of onr pro- fession. — Land. Med. Times and Gaz., Jan. 10, 18^0. The character of the work is too well known to require extended notice — suffice it to say that no recent work upon any subject has attained such great popularity so rapidly. As a work of general reference upon the subject of Diseases of Women it is invaluable. As a record of the largest clinical experience and observation it has no equal. So physician who pretends to keep up with the ad- vances of this department of medicine can afford to be without it. — Nashville Journ. of Medicine and Surgery, May, 1S80. nUNCAN [J. MATTHEWS), M.D., LL.D., F.R.S.E., etc. CLINICAL LECTURES ON THE DISEASES OF WOMEN, Delivered in S.nint Bartholomew's Hospital.. In one very neat octavo Tolume of 173 pages. Cloth, SI 50. (Just Ready.) The author ia a remarkably clear lecturer, and bin discussion of symptoms and treatment i>- full and suggestive. Ii will be a work which will not fail to be read with benefit by practitioner.^ as well by students. — P/iiia. Med. and Surg. Reporter, They are in every way worthy of their author ; indeed, we look upon them as among ttie most valu- ab e of his contribu'ions They are all np >n mat- ters of great interest to the general practitioner Some of thfm deal wi;h sulijects that are not, as a rule, adequately bundled in the text-books; others ] Feb. 7,1880. of them, while bearing upon topics that are usually treated of at length in such works, yet bear such a stamp of individuality that, if widely read, as they certainly deserve to be, they cannot fail to exert a wholesome restraint upon the undueeagerness with which many yo'ing physicidns «eem bent upon fol- We have read this book with a great deal of pleasure. It is full of good things. The hints on pathology and treai ment scattered through the book are sound, trustworthy, and of great value. A healthy scepticism, a large experience, and a clear judgment are everywhere manifest. Instead of lowing the wild teachings which so infe-t the gyn»- bri.^tiing with adfice oi doubtful value and nn oology of the present da.y.—N. T. Med. ■/'oMrJi., j sound character, the book is in every respect a safe March, 1880. | guide.— TAe Londofi Lancet, Jan. 21, 1880. r>AMSBOTHAM [FRANCIS H. THE PRINCIPLES AND PRACTICE M.D. OF OBSTETRIC MEDI- CINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the -author. With additions by W. V. Keating, M. D., Professor of Obstetrics, &e., in the Jefferson Medical College, Philadelphia. In one liree and handsome imperial octavo volume of 650 pages, strongly bound in leather, with rai.^ed bands ; with sixty-four beautiful plates, and numerous wood-outs in the text, containing in all nearly 200 large and beautiful figures. $7 00 ARRY [JOHN S.), M.D., Obstetrician to the Philadelphia Hospital, Vice-Pre.it of the 0>>stet. Sieiety of Philadelphia. EXTRA-UTERINE PREGNANCY: ITS CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS AND TREATMENT. In one handsome octavo volume. Cloth, $2 50. /TANNER [THOMAS H.), M.D. ON THE SIGNS AND DISEASES OF PREGNANCY. First American from the Second and Enlarged English Edition. With four colored plates and illustra- tions on wood. In one handsome octavo volume of about 500 pages, oloth, $4 25. P 24 Henry C. Lea's Son & Go.'s Publications — {Midwifery). TEISHMAN ( WILLIAM), M.D., Regius Professor of Mi/iwiftry in the University of Olasgow, &c. A SYSTEM OF MIDWIFERY, INCLUDIXG THE DISEASES OF PREGNANCY AND THE PUERPERAL STATE. Third American edition, revised by the Author, with additions by John S. Parry, M.D., Obstetrician to the Philadelphia Hospital, &c. In one large and very handsome octavo volume, of 733 pages, with over two hundred illustrations. Cloth, $4 50; leather, $5 50 ; half Russia, $6. {Just Ready.) Few works on this subject have met with as great seems to require, and we cannot bnt admire the a demand af this one appears to have. To judge : ability with which the task has been performed. by the frequency with which its author's views are : We consider it an admirable text-book for students quoted, and its statement.*; referred to iu obstetrical > during their attendance upon lectures, and have literature, one would judge thai there are fewphy- i great pleasure in recommending it. As an exponent sicians devoting much attention to obstetrics who i of the midwifery of the present day it has no supe- are without it. The author is evidently a man of ' rior in the Englishlanguage. — Canada Lancet, 3&n. ripe experience and conservative views, and in no branch of medicine are these more valuable than in this. — Ntiv Reraetiies, Jan. ISSO. We gladly welcome the new edition of this excel- lent textbookof midwifery. The former editions 1880. To the American student the work before us must prove admirably adapted, complete in all its parts, essentially modern in its teachings and with dem- on^traticius noted for clearness and precision, it will have been most favorably received by the profes- gain in favor and b« recognized as a work of stand- sion on both sides of the Atlantic In the prepara- ard merit The work caunot fail to be popular, and tion of the present edition the author has made such is cordially recommended. — N. 0. Med. and Surg. alterations as the progress of obstetricil science ' J'owrre., March, ISSO. PLAYFAIR ( W. S.), M.D., F.R.G.P., Professor <>f Obstetric Medicine in King's College, etc. etc. A TREATISE ON THE SCIENCE AND PRACTICE OF MIDWIFERY. Third American edition, revised by the author. Edited, with additions, by Robert P. Harris, M.D. In one handsome octavo volume of about 700 pages, with nearly 200 illustrations. Cloth, $4; leather, $5; half Russia, $5 50. {Just Ready.) The medical profession has now the opportunity | a very intelligent idea of them, yet all details not of adding to their stock of standard medical works neee'^sary for i full understanding of the subject are one of thebest volnmeson midwifery ever published, omitted. — Cincinnati Med. New-9, Jan. ISSO. The subject is taken up with a master hand. The | The rapiditv with which one edition of this work part devoted to laborin all its various pre.^^entations, ( follows another is proof alike of its excellence and the management and results, is admirably arranged, and the views entertained will be found essentially modern, and the opinions expressed trustworthy The work abounds with plates, illustrating various obstetrical positions; they are admirably wrought, and afford great assistance to the student. — N. 0. Med. and Surg. Journ., March, TS80. If inquired of by a medical student what work on obstetrics we should recommend for him, as par excellence, we would ncdoubtedly advise him to choose Playfair's. It is of convenient size, bnt what is of chief importance, i's treatment of the various subjects is concise and plain. While the discussions and descriptions are sufficiently elaborate to render of the estimate that the profession has formed of it. It is indeed so well known and so hii,'hly valued that nothing need be said of it as a whole. All things considered, we regard this treatise as the very best on Midwifery in the English language. — N. Y. MedicalJournnl^ Ma.y, ISSO It certainly is an admirable exposition of the Science and Practice of Midwifery. Of course the additions made by the American editor. Dr. R. P. Harris, who never utters an idle word, and whose studious re^earches in some special departments of obstetrics are so well known to the profession, are of great value. — The American Practitioner, April, 1880. jyARNES (FANCOURT), M.D., -*-' Physician to the General Lying-in Hospital. London. A MANUAL OF MIDWIFEPvY FOR MIDWIVES AND MEDICAL STUDENT >. With 50 illnstrations. In one neat royal 12mo. volume of 200 pages; cloth, $1 25. {Now Ready.) P ARVIN [THEOPHILUH], 31.1)., Prof, of Obstetrics and of the Med. and Surg. Diseases of Women t Ji the Med. Coll. of Indiana . A TREATISE ON MIDWIFERY. In one very handsome octavo volume of about 550 pages, with numerous illustrations. {Preparing.) TJODGE [HUGH L.), M.D. , Emeritus Professor of Midwifery, &c.,inthe University of Pennsylvania, &c. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- trated with large lithographic plates containing one hundred and fifty-nine figures from original photographs, and with numerous wood-cuts. In one large and beautifully printed quarto volume of 550 double-columned pages, strongly bound in cloth, $14. The work of Dr. Hodge is something more than a simple presentation of his particular views in the de )artment of Obstetrics; it is something more than an )rdinary treatise on midwifery; it is, in fact, a cyclopajdia of midwifery. He has aimed to em- body in a single volume the whole science and art of Obstetrics, in elaborate text is combined with ac- curate and varied pictorial illustrations, so that no fact or principle Is left unstated or unexplained. —Am. Med. Times, Sept. 3, 1864. ^*^ Specimens of the plates and letter-press wiU be forwarded to any address, free by mail, on receipt of six cents in postage stamps. o 'HAD WICK {JAMES R.), A.M., M.D. A MANUAL OF THE DISEASES PECULIAR TO WOMEN. neat volume, royal 12mo., with illustrations. {Prepari7ig.) In one Henry C. Lea's Son & Co.'s Pvbjacations— (Surgery). 25 // 'AMILTON {FRANK H.) M.D., LL.D., fiurgeon to the Bf.llevue Untipital. New York. A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- TIONS Sixth Edition, thoroughly revised, and mu.-h improved. In one very handsome octavo volume of over 900 pages, with 352 illustrations. Cloth, $6 50; leather, S6 50; half Russia, raised bands, $7 00. {Just Ready.) So many kind expression;-; ol' •welcome have been showered upon each successive edi ion of this val- uable treatise, that scarcely anyihing remains for to do but to expend the customary cordial greet ing. It is the only complete -work on the subject of Fractures in the English language- We con- gratulate the accomplished author on the deserved 8ucce!-s of his tvork, and hope tha; he may live to havemany .succeeding editions pass under his skill- ed supervision. — Phila. Coll. and Clin. Record, Nov. 15, ISSO. Universal verdict has pronounced it, humanly speaking, a perfect treat se upon this subject. As it is the only complet' and illustrated ivork in any language treating of fractures and dislocations, it i.s safe to affirm that every wide-awake surgeon and general practitioner will regard it as indispensable to the safe and pleasant conduct of tht-ir profes- sional work. — Detroit Lancet, Ifov. IS, 1>S0. Dr Hamilton has devoted great labor ;o the study of these S'lbjects. His large experience, extended research, :e of editorial dis- cretion, each subject has been entrusted, a^ far as possible, to a suigeon of the hospitals who is known to have given especial attention to it, and to possess facilities for summing up with authority the accepted opinions of the day, and adding original matter to the stock. — London Lancet. The work must be considered a very complete ac- count of everything connected with the science and practice of surgery, la conclusion we can cordially recommend this work as a valuable addition to the library of the surgeon. — Edinburgh Hi edieal Jour- nal . It is a cyclopedia of surgery of the most complete and extensive character; and we may justly state that its design and execution do great honor to those concerned, and that the large number and high standing of the authors selected for the various monographs render this "System" what it no doubt was intended to be, representative of the actual state of surgical science and art in the country. — London Lancet. In conclusion, we will add that we can most con- sciencionsly recommend the book to every medic, il practitioner. In recommending the "iSystonr^.S'U ■ gery" to our friends who have to deal in suigical cases, we by no means wish to conliae our recom- mendation to them alone. Every practitiouei of medicine may cull something worthy of note from a perusal of this volume.— The Britis'i M-id. Journal. The four volumes remain a monument to the sur- gical genius of our day. The great majority of me- tropolitan surgeons of eminence and proved ability are represented in them ; and for many years to coine, whoever wishes to know the most authori- tative words of English Surgical science on most subjects in the domain of surgery, must turn to these pages to read what there is tec forth, but taken as a whole it is the most important surgical work which has ever issued from the Euglish pie&s.— Loudon Lancet. 28 He\ry C. Lea's Son & Co.'s Publications — (Surgery). -DRYANT (THOMAS). F.R.C.S., J-^ S'crgeon to Guy's Hospital. THE PRACTICE OF SURGERY. Third American, from the Sec- ond and Revised English Edition. Thoroughly revised and much improved, by John B. Roberts, M.D. In one large and very handsome imperial octavo volame of over 1000 pages, with 672 illustrations. Cloth, $6 50 ; leather, $7 50 j very handsome half Russia, raised bands, $8 00. {Just Ready.) Jtr. Bryant's work ha« long been a favorite one ' the whole work has been carefully revised, ranch •with snrgeoas. As its n«me indicates, it is of a tho- of it has been rewritten, important additions have roughly practical character. It is distinctly indi- een made to almost every chapter. — Cincinnati vidaal in that it gives ihe results of the author's i Med. Setcn, Jan. l&Sl. large and varied experience as an operator and cli- The English edition, from which this is printed, nical teacher, aid IS on that account prized deserv- has been carefullv revised and rewritten; almost edly high as an original work. The .-tyle is neces- g^g^y chapter his received additions, atid nearly sarily condensed, the descriptions of surgical dis- ^^g hundred new cuts introduced. The labors of eases brief and to the point. The illustrations are the American editor, Dr. John B. Roberts, have well chosen, and the typical ca^es of the author s , .y.g,y ^^^^ increased the valne of the book. He experience are fall of Interest, and are of more than 1,^^ introduced manv new illustrations and much ordinary value to the working surgeon.— JS. Y. ^g^ material not found in the English e.iitioa. Medical Rteord, March 5, ISt-l. i Hg has written too with great conci^eness, which It is a work especially adapted to the wants of is a rare virtue in an American editor of an Eiig":i-h students and practitioners. While not prolix, it work. If one could procure or wished only one affjrds instruction in i-nfficient detail for a full un- surgery, ihis volume would certainly be selected, derstanding of surgical principles and the treat- . If he de>-ired two, Erich^en'6 Surgery would be ment of surgical diseases ltembrace>in its scope ' added, and if he wished a third, Gross's Surgery all the diseases that are recognized as belmgiug to ' would justly be the work selected A- the great surgery, and all traumatic injuries. In discus^inir i work of Gross is amply snflBci^nt for the waits of these it has seemed to be the aim of ihe author any surgeon, the priority given to Erieh«en, and rather to present the student with practical iiifor- \ above all others, to this work of Bryant, is no malion. ard that alone, than toburdec his memory labored eulogy of the last volume, but a simple and with the views of different writers, however dis ja>t statement of its demonstrable and pre-eminent tinguished they might have been. In this edition merits. — Am. Med. Bi- Weekly, Feb. 26, 1.S81. PRICHSEN {JOHN E.), -*-^ Profe,Heor of Surgery in tfnivergity College, London, etc. THE SCIENCE AXD ART OF SURGERY; being a Treatise on Sur- gical Injuries, Diseases and Operations. Carefully revised by the Author from the Seventh and enlarged English Edition. Illustrated by eight hundred and sixty-two en- gravings on wood. In two large and beautiful octavo volumes of nearly 2000 pages : cloth, $8 50 : leather, $10 50; half Russia, $11 50. {Now Ready.) Of the many treatises on :?urgery which it has been The seventh edition is before the world asthe last our ta.sk to .*tudy. or our pleasure to read, there is none I word of surgical science. There may be monographs which in all points has satisfied us so well as the classic which excel it upon certain points, but as a con- treatise of Erichsen. His polished, clear style, his free- spectns upon surgical principles and practice it is dom from prejudice and bobbies, his unsurpa.^ised grasf ; unrivalled. It will well reward practitioners to of his subject, and vast clinical experience, qualify him .read it, for it has been a peculiar province of Mr. admirably to write a model text-book. Whenwewish. ■ Erichsen to demonstrate the absolute interdepend- at the least cost of time, to learn the most of a topic it ence of medical and surgical science We need surgery, we turn, by preference, to his work. It is a scarcely add, in conclusion, that we heartily corn- pleasure, therefore, to see that the appreciation of it if mend the work to students that they may be general, and has led to the appearance of another edi I grounded in a sound faith, and to practitioners as tion. — Med.and Surg.Repiirur.feh.'i,\&'&. i an invaluable guide at the bed^ide. — Am Praeti- Xotwithstaniliog the increase in size, weobserve that i tioner, April, IS/S. much oM matter has been omitted. The entire work ; For the past twenty years Erichsen'a Surgery has has been thoroughly written up, and not merely amend- maintained its place as the leading text-book, not only ed by a few extra chapters. A great improvement ha^ I in this country, but in Great Britain. That'll is able been made in the illustrations. One hundred and fifty i to hold its ground, is abundantly proven by the tho- new ones have been added, and many of the old onet \ roughness with which the present editionhas been have been redrawn^ The author highly appreciates the revised, and by the large amount of valuable mate- favor with which his work has been received by Ameri- rial tha; has been added. Aside from this, c ne bun- can surgeons, and has endeavored to render his latest dred and fifty new illnstra-.ions have been inserted edition more than ever worthy of their approval. That including quite a number of microscopical appear- he has succeeded admirably, must, we think, be the inces of pathological processes, io marked is this general opinion. We heartily recommend the book tc change for the better, that the work almost appears both student and practitioner. — ^V. T.Med. Journal. I as an entirely new one. — Med. Record, Feb 23 1878 Feb. 1878. I • , . TIOLMES (TIMOTHY). M.D. , J--*- Surgeon to St. Oeorge's Hosjjital, London. SURGERY, ITS PRINCIPLES AXD PRACTICE. In one hand- some octavo volume of nearly lOUO pages, with 411 illustrations. Cloth, $6; leather =^7 • half Russia, $7 50. ' * ' This is a work which has been lookedfor on both f its force and distinctness.— A^. T. Jfed Record Anril sides ofthe Atlantic with much interest. Mr. Holmes 14, 1876. ' is a surgeon of large and varied experience, and one t.„:iiv,«c j „„ . i, ^ of the best known, and perhaps the most brilliant ^' ^^^^X , ' ^^.^eUent epitome of snr- writer upon surgical subjects in England It is a i f"'' .''^'^^ general practmoner who ha.s not the book for studentl-and an admirablf one-and or 'l'^X\''fl^^'T'"'V'' ^"J^^'^^)^ f^^ extended ipairea larworkin the profession, and especially as a text- I book, — Cincinnati Med. Ifetos, April, 1876, Henry C. Lea's Son & Co.'s Publications— (OpAfAaZwio^y). 29 JT/'ELLS (J. SOELBEEG), ~ ' r Professor of Ophthalmology in King's College Hospital &c A TREATISE ON DISEASES OF THE EYE. Third American from the Third London Edition. Thoroughly revised, with copious additions by Chas' S. Bull.M D., Surgeon and Pathologist to the New York Eye and Ear Infirmary. Illus- tratedwith about 260 engravings on wood, and six colored plates Together with sele'^- tions from the Test-types of Jaeger and Snellen. In one large and very handsome octavo volume of 900 pages. Cloth, §5 ; leather, $6 ; half Russia, raised bands, $6 50. {Just Ready. ) The long-continued illness of the author, with its fat.nl termination, has kept this work for some time out of print, and has deprived it of the advantage of the revi.-ion which he sought to give it during the last years of hi? life. This edition ha^s therefore been pla-ed under the editorial supervision of Dr. Bull, who has labored earnestly to introduce in it all the advances which observation and experience have acquired for the theory and practice of ophthalmology since the appearance of the last revision. To accomplish thi.s considerable additions have been required, and the work is now presented in the confidence that it will fully deserve a continu- ance of the very marked favor with which it has hitherto been greeted as a complete, but con- cise, exposition of the principles and facts of its important department of medical science. The additions made in the previous American editions by Dr. Hays have been retained, including the very full series of illustrations and the test-types of Jaeger and Snellen. This new edition of Dr. Wells's great wui-k on ihe guage. In tbe becond edi;ioii, the author showed eye will be welcomed by the profession at large a well as by the oculist. It contain s much new m'tter relating to treatment and pathology, and i.-s brought thoroughly up with the pre-ent ttatus of ophthal- mjlogy. Its chapter on refraction and accommo- datiou — a subject much discussed of late years, and of great importance — is exceedingly complete. — Louisville 3Ied. Ntws, Nov. 13, ISSO. The merits of Wells's treatise on diseases of the eye have been so universally acknowledged, and are so familiar to all who profess to have given any at- tention to ophthalmic surgery, that any discussion of them at this laie day will be a work of superero- gation. Very little that is practically useful in re- ceat ophthalmic literature has escaped the editor, and the third American edition is well up to the times. As a text-book on oph.halmic surgery for the English-speaking practitioner, it is without a rival. — Am. Journ. of Med. Sci., Jan. 18S1. The work has justly held a high place in English ophthalmic literature, and at the time of its first ap- pearance was the best treatise of its kind ia the lan- industriott.-i research in adding new material from every quarter, and his spirit was eminently candid. A work thus baill up by honest effort should not be suffered to die, and we are pleased to receive this third edition from the hands of Dr. Bull. His labor hxs been arduous, as the very great number of addi- tions bracketeu with his initial testify. Under the editorship which the third edition has enjoyed, the work is sure to sustain its good reputation, and to maintain its usefulness. — N. ¥. Mea. Journ., Jan. 18S1. There is really no work which approaches it in adaptation to the wants of the general practitioner, while the most advanced specialist cannot rise from a peni.^al of its ample pages without having added to his knowledge. The American editor, Dr. Bull, won his spurs in ophthalmology some time back. Hii? additions lo the woik of the lamented Wells are many, judicious, and timely, and in just so much have added to its value.— J.r/i. F ractitioner , Jan. IsSl. fJETTLESHIP {EDWARD), F.B.G.S., -^ ' ophthalmic Surg, and Led. on Ophth. Surg, at St. Thomas' Hospital, London. MANUAL OF OPHTHALMIC MEDICINE. In one royal 12mo. volume of over 350 pages, with 89 illustrations. Cloth, $2. (Just Ready.) The author is to be congratulated upou the very , information they contain. We do not hesitate to ful manner in which he has accomplished his : pronounce Mr. Nettleship's book the best manual on ophlhalraic turgery for ihe use of students and succe task; he has succeeded iu being concise without sacrificing clearnes.-j, and, including the whole ground covered by more voluminous text-books, has given an excellent risumi of all the practical " busy practitioners" with which we are acquain- ted. —Am. Jour. Med. Sciences, April, 1880. c- fARTER [R. BRUDENELL), F.R.G.S., ophthalmic Surgeon to St. George' s Hospital, etc. A PRACTICAL TREATISE ON DISEASES OF THE EYE. Edit- ed, with test-types and Additions, by John Green, M.D. (of St. Louis, Mo.). In one handsome octavo volume of about 500 pages, and 124 illustrations. Cloth, $.3 75. It is with great pleasure ihaiwecanendorse the work i chapter is devoted to a discus:?iou oi the uses andselec- as a most valuable contribution to practical ophthal- 1 tion ofspectacles, and is admirably compact, plain, and raology. Mr. Carter never deviates from the end he has ; useful, especially the paragraphs on the treatment of in view, and presents the subjectin a clear and concist ] pre.'ibyopia and myopia. In conclusion, our thanks are manner, easy of comprehension, and hence the more | due the author for many useful hintsin the great sub- valuable. We would especially commend, however, asject of ophthalmic surgery and therapeutics, afield worthy of high praise, the manner iu which the thera- j where of late years we glean but a few grains of sound peutics of disease of the eje is elaborated, for here the i wheat from a mass of chaff. — New York Medical Record, author is particularly clear and practical, where other Oct. 23, 1875. writ-ers are unfortunately too often deficient. The final I ROWNE {EDGAR A.), " Surgeonto the Liverpool Eye and 'Ear Infirmary , and tothe Dispensary for SMn Diseases. HOW TO USE THE OPHTHALMOSCOPE. Being Elementary In- structions in Ophthalmoscopy, arranged for the Use of Students. With thirty-five illustra- tions. In one small volume royal 12mo. of 120 pages : cloth, $1. B LAURENCE'S HANDST-BOOK OF OPHTHALMIC SORGERT, for the uoe of Practitioners. Second edition, revised and enlarged With numerous illustrations. In one very handsome octavo vol- »nie, cloth, $2 75. LAWSON'S INJURIES TO THE EYE, ORBIT AND EYELIDS: their Immediate and Remjte Effects. With about one hundred illustrations. In one very handsome octavo volume, cloth, *3 50. 30 Henry C. Lea's Son & Co.'s Publications — (Med. Jurisprudence). jyURNETT [CHARLES H.), M.A , M.D., J-^ Aurj.! Surg to the Presb. Hosp., Surgeoii'in-charge of the Infir. for Vis . of the Ear, Phila. THE EAR, ITS ANATOMY, PHYSIOLOGY AND DISEASES. A Practical Treatise for the Use of Medical Students and Practitioners. In one hand- some octavo volume of 6 1 5 pages, with eighty-seven illustrations : cloth, $4 50 j leather, $5 60; half Russia, $6 00. {Lately Issued.) ForemoPt among the numerons receut coutrihu- i ttie observations and discoveries of others, has pro- tioQs to aural literaturt will be ranked this work j duced a work which, as a text-book, stands /«cf/e of Dr. Burnett. It is impossible to do ju.-'tic" lo , priyicpti in our lanijuage. We had marked several this volume of over 600 pages in a nece.-'ariiy bii(?f notice. It must safflce to add ihat the book is pro- fusely and accurately illusirated, the references are conscientiously acknowledged, while the result liar, been to produce a treati^e which will hencefoiib rank with the classic writings of Wilde and Von Troltsch. — The Lond. Practiliiiner, May, 1879. On account of the great advances which have been made of late years in otology, and of the increased interest manifested in it, the medical profession will welcome this new work, which presents clearly and concisely its present aspect, whilst clearly indi- cating the direction in which further researches can be most profitably carried on. Dr. Barn-tt from his own matured experience, and availing himself of pa sages as well worthy of quotation and the atten- tion of the general practitioner, lint their number and the space at on r command forbid. Perhaps ii is bet- ter, as th« book ought to be in the hands of every medical studeut, and its study will well rejiay tl?e busy practitioner in the pleasure he will derive from the agreeable style in which many otherwise dry and luosily anknown sulijecis are treated. To the specialist tlie work is of the highest value, and his sense of graiilude to Dr. Burnett will we hope, be proportionate to the amount of benefit lie can obtain from the carelul study of the book, and a constant reference to its trustworthy pages. — Edinburgh Med. Jour., Aug. 1878. q^AYLOR [ALFRED S.),M.D., J. Lecturer on Med. Jurisp. and Ghemiatry in Ouy's Hospital. A MANUAL OF MEDICAL JURISPRUDENCE. Eighth Ameri- can edition. Thoroughly revised and rewritten. Edited by Johw J. Reese, M.D., Prcf. of Med. Jurisp. and Toxicology in the Univ. of Penn. In one large octavo volume of 933 pages, with 70 illostrations. Cloth, $5; leather, $6; half Russia, raised bands. $6 50. {Just Ready.) The American editions of this standard manual ( is to announce, not criticize the completed task. The have for a Ion,' time laid claim to the attention of ! value of the getn is too well known to require more the profession in this country ; and that the profes- [ than the telling 'ihat the mtster-hand has rebrigh^- Kion ha" recognized this claim with favor is proven \ ened its facets aod polished its angles before leaving by the call for frequent new editions of the work. | it as his legacy to h's brethren in the profession.— This one, the eighth, comes before us as embodying Phila M-:d. Tims, Dec. 4, 1880. the latest thoughts and emendations of Dr. Taylor, upon the subject to which he devo ed hirt life, with an assiduity aud success which made him facile prinreps among English writers on medical juris- prudence. Both the author and the book have mdde a mark too deep to be affected by criticism, whether it be censure or praise. In this case, how- ever, we should only have to seek for laudatory teims. — Am. Jnurn. of Med. Sci., Jan. ISSl. It is not very often that a m-idical book reaches its tenth edition, or that the last earthly labor is per- formed by the author in reioucluag the work that llrst came from his hand thirty-five years before. All this, however, has h.ippened ia the ca>e of Dr. Taylor and his classical treatise. The pen dropped from the grasp only when the shadows of old age were rapidly deepening into the darkness of death. Under the circamstances, all the journalist has to do It will suffice to remarit that this new edition shows the signs of judicious revision. A great uum- ber of illustrative medico- legal cases which have occurred since the last edition was puhlished are cited in heir proper connection, and add luach to the interest and value of the work; they comprise the buls of the additions to the text. As an iodica.- tionofthe reshuesiof the work, we notice n'jmer- ous references to medic i-legal experience that has transpired during the year just ended ; among tbes-e is a comment by the American editor upon that midsummer madness, the T.inner fasting exploit of last Augist. la these features and in others there is ample evidence that this admirable book will maintain its hi^h place as a standard authority con- cerning thf matters of which it ire-Ais. —Jiuston Mad. and Sarg. Journal, Jan. 13, 1881. f>Y THE SAME AUTHOR. THE PRINCIPLES AND PRACTICE OF MEDICAL JURISPRU- DENCE. Second Edition, Revised, with numerous Illustrations. In two large octavo volumes, cloth, $10 00 ; leather, $12 00 This great work is now recognized in England as the fullest and most authoritative treatise on everv departmentof its important subject. In laying it, in its improved form, beforethe Amer- ican profession, the publishers trust that it will assume the same position in this country. T>T THE SAME AUTHOR. POISONS IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Third American, from the Third and Revised English Edition. In one large octavo volume of 850 pages ; cloth, $5 50 ; leather, $6 60. The present is based upon the two previous edi- , being described which give rise to legal investiga- tions; ''bulthecompleterevision rendered necessary tions. — The Olinic, Wo v. 6, 187.'5. by time has converted it into a new work." This statement from the preface contains all that it is de- sired to know in reference to the new edition The works of this author are already in the library of every physician who is liable to be called upon for medico-legal testimony (and whatuneis not?), so that all that Is required to be known about the present book is that the author has kept it abreast with the Dr. Taylor hat brought to bear on the compilation of this volume, stores of learning, experience, and practicalacquaiutanee with his subject, probably tar beyond what any other living authority on toxicol- ogy could have amassed or utilized. He has fully sustained his reputation by the consummate skill and legal acumen he has displayed in thearrange- , . ,, , ment of tne subject-matter, and the result is a work times. What makes it now, as always, especially i qq Poisons which wiUbeindispensable to every siu- valuable to the practitioner is its conciseness and dentor practitioner in lawand medicine.— r/j«Z>ti6. practical character, only those poisonous substances | ;„^ Journ. of Med Sex., Oct. 1875. Henkt C. Lea's Son & Co.'s PrBLicATiONS — (Miscellaneous). 31 J^OBERTS [WILLIAM), M.D., -*■*' Lecturer on Medicine in the Manchester School of Medicine, etc. A PRACTICAL TREATISE ON URIXARY AND RENAL DIS- EASES, includingUrinary Deposits. Illustrated by numerons cases and engravings. Third American, from the Third Revised and Enlarged London Edition. In one largt and handsome octavo volume of over 600 pages. Cloth, $4. (Just Ready.) rr HO MP SON [SIR HENRY), •^ Surgeon and Professor of Clinical Surgery to University College Hospital . LECTURES ON DISEASES OF THE URINARY ORGANS. With illustrations on wood. Second American from the Third English Edition. In one neat octavo volume. Cloth, $2 25. J>T THE SAME AUTHOR. ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF THE URETHKA AND URINARY FISTULA. With plates and wood-cuts. From the third and revised English edition. In one very handsome octavo volume, cloth, %'6 5U. rrUKE [DANIEL HACK), M.D., J- Joint author of The Manual of Psychological Medicine, &o. ILLUSTRATIONS OF THE INFLUENCE OF THE MIND UPON THE BODY IN HEALTH AND DISEASE. Designed to illustrate the Action of the Imagination. In one handsome octavo volume of 416 pages, cloth, $3 25. -DLANDFORD [G. FIELDING), M.D., F.R.G.P., J-^ Lecturer on Psychological Medicine atthe School of St. George's Hospital, &e. INSANITY AND ITS TREATMENT: Lectures on the Treatment, Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very handsome octavo volume of 471 pages ; cloth, $3 25. It satisfies a want which mnsl have been sorely actually seen in practice and the appropriate treat- feltby the basygeneralpractitionersof thibconntry. ment for them, we find in Dr. Blandford's work a It takes the form ofa manual ofclinicaldescription considerable advanceover previous writings on the of the various forms of insanity, with a description ■ subject. His pictures of the various forms ofmental of the mode of examining persons suspected of in- i disease are so clear and goodthat no readercan fail si-aity. We call particular attention to this feature , to be struck with their superiority to those given in of the book, as giving it a unique valneto the gene- ndinary manuals in the English language or (so far f al practitioner. If we pass from theoretical conside-j as our own reading extends;! n any other. — London rations to descriptionsof the varieties of insanity as | Practitioner, Feb. 1871. f EA [HENRY C). SUPERSTITION AND FORCE : ESSAYS ON THE WAGER OF LAW, THE WAGER OF BATTLE, THE ORDEAL AND TORTURE. Third Revised and Enlarged Edition. In one handsome royal 12mo. volume of 552 pages. Cloth, $2 50. [Just Ready.) This valuable work is in reality a history of civi- . more accurate than either of the preceding, but, lization as interpreted by the progress of jurispru-' from the thorough elaboration, is more like a har- dence. ... In " Sapei'stition and Force" we have monious concert and less like a batch of studies.— a pnilosophic survey of the long period intervening The Nation, Aug. 1, 1S7S. between primitive barbarity and civilized enlight- jiany will be tempted to say that this, like the euuient. There is not a chapter in the work that ..X)eclineandFall."-isone of the uncriticizable books, should not be most carefully studied, and however , its facts are innumerable, its deductions simple and well versed the reader may be in the science of ^ inevitable, and its chevav^de-frise of references jui-isprud.-nce, he will find much in Mr. Lea's vol- bristlingand dense enough to make the keenest, ume of which he was previously ignorant. The stoutest, and best equipped assailant think twice b.jok is a valuable addition to the literature of before advancing. Xor is there anything contro- soc\d,\i<:\eaQe.— Westminster Review, 39,a. ma. versialinit to provoke assault. The author is no The appearance of a new edition of Mr. Henry C. ' polemic. Though he obviously feels and thinks Lea's "Saperstition and Force" is a sign that our strongly, he succeeds in attaining impartialify. highest scholarship is not without honor in its na Whetl er looked on as a picture or a mirror, a work ti/e country. Mr. Lea has met every fresh demand such as this has a lasting valae. — LippineotVs for hrs work with a careful revision of it, and the Magazine, Oct. 1S7S. present ecition is not only fuller and, if possible. JJY THE SAME AUTHOR. STUDIES IN CHURCH HISTORY. THE RISE OF THE TEM- PORAL POWER— BENEFIT OF CLERGY— EXCOMMUNICATION. In one large royal 12mo. volume of 516 pp.; cloth, $2 75. {Lately Published.) The story was never told more calmly or with las apecuIiarimportancefortheEnglishstudent.and greater learning or wiser thought. We doubt, indeed, is a chapter on Ancient Law likely to be regarded as If any other study of this field can be compared with flual. We can hardly pass from our mention of such this for clearness, accuracy, aad power. — Chicago works as these — with which that on "Sacerdotal Brraminer, Dec. 1S70. Celibjcv' " should be included— withoat notin? tt e Mr. Lea's latest work, -'Studiesin Church History," fully sustains the promise of the first. It deals with three subjects — the Temporal Power, Benefit of Clergy, and Excommunication, the record of which \ 32 Henry C. Lea's Son & Co.'s Publications. INDEX TO CATALOGUE. American Joarnalof the Medical Sciences Allen's Anatomy ..... Anatomical Atlas, by Smith and Horner A.shton on the Kectum and Anus Atttield's Chemistry .... Ashwell on Di.seases of Females *ishhurst'g Surgery .... Browne on Ophthalmoscope . . , Browne on the Throat . ♦Burnett on the Ear *Barne8 on Diseases of Women . Barnes' Midwifery .... Bellamy's Surgical Anatomy ♦Bryant's Practice of Surgery . Bloxam'sChemistry .... Blandford on Insanity . Basham on Renal Diseases . Bartholow on Electricity Barlows Practice ot Medicine . Bowman's (John E.) Practical Chemistry *Bristowe'& Practice .... *Bumsiead on Venerea] Biimslead and CuUerier's Atlasof Venereal ♦Carpenter's Human Physiology Carpenter on the Dae and Abuse of Alcoh ♦Corniland Kauvier Carter on the Eye . Clelaud's Dissector Classen's Chemistry Clowes' Chemistry Coleman's Dental Surgery . Century of American aleuicine Chadwick on Diseases of Women Chambers on Diet and Eegiuien Christisonand Griffith's Dispensatory Churchill on Puerperal Fever Condie on Diseases of Children . Cooper's (B. B.) Lectures on Surgery CuUerier's Atlas of Venereal Disease Duncan on Diseases of Women . ♦Dalton's Human Physiology Davis's Clinical Lectures Uewees on Diseases of Females . Druitt's ModernSurgery *Dunglison's Medical Dictionary Edis on Diseases of Women . Ellis's Demonstrations in Anatomy ♦Erichsen's System of Surgery ♦Emmet on Diseases of Wouea Farquharson's Therapeutics Foster's Physiology . . Fenwicb's Diagnosis . Finlayson's Clinical Diagnosis Plint on Respiratory Organs Flint on the Heart * •'lint's Practice of Medicine. Flint's Essays ♦Flint's Clinical Medicine . Flint on Phthisis . Flint on Percussion *Fothergiirs Handbook of Treatmeu Fdwnes's Elementary Chemistry Fox on Diseases of the Skin Fuller on the Lungs, &c. Green's Pathology and Morbid Anato Greene's Medical Chemistry Gibson's Surgery .... Gluge's Pathological Histology, by L ♦Gray's Anatomy,. Galloway's Analysis Griffith's (R. E.) Universal Formular; Gross ou Sterility .... Gross on Urinary Organs Gross on Foreign Bodies in Air-Passag ♦Cross's System of Surgery Habershon on the Abdomen . * Hamilton on Dislocations and Fractii Hartsliorne'a Essentials of Medicine Harts Home's Conspectus of the Medic Hartshorne's Anatomy and Physiology Hamilton on Nervous Diseases Hoffman's Chemical Analysis Henth's Practical Anatomy Hohlyn's Medical Dictionary Hodge on Women Hodge's Obstetrics idy 1 Sci PAOK . 1 7 7 . 26 Holland's Medical Notes and Reflections ♦Holmes' System of Surgery ♦Holmes's Surgery Holdon's Landmarks Horner's Anatomy and Histology Hudson on Fever .... Hill on Venereal Diseases . Hillier's Handbook of Skin Diseases Jones (C. Handfieid) on Nervous Disorders Knapp's Chemical Technology . Keating on lufauls Lea's Superstition and Force . . Lea's Studies in Church History Lee on Syphilis ♦Leishman's Midwifery .... La Roche on Yellow Fever. La Roche on Pneumonia, kc. Laurence and Moon's Ophthalmic Surgery Lawson on the Eye ... . . Lehmann's Physiological Chemistry, 2 vols. Lehmann's Chemical Physiology Ludlow's Manual of Examinations . Lyons on Fever ..... Maisch's Materia Medica Jliichell's Nervous Diseases of Women Medical News and Abstract Morris on Skin Diseases Meigs on Puerperal Fever . Miller's Practice of Surgery Miller's Principles of Surgery . Montgomery on Pregnancy Nettleship's Ophthalmic Medicine Neill and Smith's Compendium of Med Scienc Parvia's Midwifery .... Parry on Extra-Uterine Pregnancy Pavy on Digestion ♦Parrish's Practical Pharmacy . Pirrie's System of Surgery . . . ♦Playfair's Midwifery .... Quain and Sharpey's Anatomy, by Leidy ♦Reynolds' System of Medicine . Richardson's Preventive Medicine Robertson Urinary Disea.ses Ramsbotham on Parturition Remsen'a Principles of Chemistry Rigby's Midwifery .... Rodwell's Dictionary of Science . Stimson's Operative Surgery Swayne s Obstetric Aphorisms . Seller on the Throat Sargent's Minor Surgery Sbarpey and Quain's Anatomy, by Leidy Skey's Operative Surgery . Slade on Diphtheria .... SchSfer's Histology .... *Smith (J- L.) on Children . Smith {ri. H.) and Horner's Anatomical Atlas Smith (Edward) on Consumption Smith (East ) on Wasting Di-seases in Children ♦.•^'llll^'s Therapeutics .... ♦Stille & Maisch's Dispensatory . Starges on Clinical Medicine Stokes on Fever Tanner's Manual of Clinical Medicine Tanner on Pregnancy . ♦Taylor's Medical Jurisprudence Taylor's Principles and Practice of Med J 6 . 9 . 11 . 20 . 26 . 26 . 26 . 14 . 2.) . 16 ces 6 . 7 . 18 . 11 . 6 . 4 . 22 . 24 14 I Taylor on Poisons Tnke on the Infiueuce of the Mind ♦Thomas on Diseases of Females Thompson on Urinary Organs Thompson on Stricture .... Todd on Acute Diseases Woodbury's Practice .... Walshe on the Heart .... Watson's Practice of Physic ♦Wells on the Eye .... West on Diseases of Females Weston Diseases of Children West on Nervous Disorders of Children Williams on Consumption . Wilson's Human Anatomy . Wilson's Handbook of Cotaneons Medicin Wiihler's Organic Chemistry Winckel on Childbed .... nrisp A«B 14 27 28 6 7 20 20 19 19 10 21 31 31 20 24 14 20 29 29 6 20 '3 18 2 19 •^1 25 25 21 29 5 24 23 14 11 2-5 24 7 17 16 31 23 9 21 4 26 21 19 26 7 26 16 7 21 7 16 20 13 12 15 14 6 23 30 80 HO 31 31 14 16 16 16 29 21 21 21 16 7 20 Books marked * are also bound in half Russia. HENRY C. LEA'S SOW & CO.— Philadelphia. DATE DUE 'S^^^^^oJ^o. 38-293 ^lll«ffi'iftin^'^^''SITY LIBRARIES 0043061095 RC341 Hamilton Nervous diseases • H18 1881 MAY ?4 -set 1