Columbia SJntomitp mtfjeCttpofitagork College of ipfjpstciansi ano burgeons Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/syllabusofcourse02hunh A SV LL A BUS OF A COURSE OF LECTURES ON THE Diseases of the Nervous System DESIGNED AS A NOTE BOOK FOR THE USE OF STUDENTS BY HENRY HUN Professor of Diseases of the Nervous System in the Albany Medical College IN TWO VOLUMES Vol. II DISEASES OF THE BRAIN ILLUSTKATED AI.HANY. N V HP HIS SYLLABUS contains all the didactic lectures on the diseases of the nervous system delivered in the Albany Medical College on Monday mornings throughout a college year. In the appendix is included several lectures on the examination of the blood and excretions, delivered, or rather demonstrated, in the course on clinical medicine on Wednesday mornings, which lectures, with those published in volume i, complete the physical examination of patients. In the appendix is also a syllabus of the essentials of insanity, which was prepared by Dr. Mosher, and is based upon his course of clinical lectures on insanity. The sections on the examination of the gastric contents and of the faeces were revised by Dr. MacFarlane. It is intended that the blank spaces left in the book shall be filled by the student with notes taken at the lectures and in his subsequent reading. I am indebted to Dr. George L. Streeter for the illustrations in this book. COPYRIGHTED BY HKXRY HUN L9C2 LECTURE I. Diseases of the Brain EXAMINATION OF PATIENTS Introductory The method of l earning the history of a case and the physical examination necessary to discover disturbances of motion, sensation and reflex activity have been described in volume i of this note-book Method of testing disturbances of: (i) consciousness (coma, semi-coma, somnolence), (2) intelligence (amentia, dementia, hallucinations, delusions, delirium), (3) feelings (sad, joyous, confused, apathetic), (4) memory (amnesia) Method of testing disturbances of vision: (i) blindness, (2) field of vision for white and colors, (3) hemianopsia, (4) psychic blindness Method of testing disturbances of speech : (i) motor aphasia, (2) sensory aphasia, (3) transcortical aphasia Method of testing : (i) agraphia and (2) alexia Method of testing: 11) anosmia and (2) ageusia Other tests not given in volume one LECTURE II. Diseases of the Brain DISEASE OF THE CRANIUM AXD MEMBRANES Introductory Cranial abnormalities Developmental: (i) acrany, 12) anencephaly, (3) hemicrany, (4) enccphalocele. (5) microcephaly, (6) brachycephaly, (7) dolicocephaly 1 /' 1 Acquired from Disease: (i) hydrocephalus (general, anterior, posterior), (2) rickets, < j 1 asymetry MENINGITIS (a) Pachymeningitis (b) Leptomeningitis PACHYMENINGITIS EXTERNA, SIMPLE AND PURULENT Introductory Etiology: (i) age, (2) traumatism, (3) extension of inflammation (caries, otitis, erysipelas) Pathological anatomy: (1) congestion, (2) abscess, (3) thickening with adhesions 10 Symptomatology: (i) absent, (2) masked, (3) headache, (4) convulsions, (5) delirium. (6) coma, (7) fever Diagnosis Prognosis Treatment Pachymeningitis Interna Purulenta PACHYMENINGITIS INTERNA HAEMORRHAGICA (Haematoma of Dura Mater.) Introductory Etiology: (i) age, (2) sex, (3) infection (tuberculosis 23$, syphilis n#, puerperal sepsis 9$), (4) cerebral disease 19$, (5) cardiac disease i8#, (6) chronic alcoholism 5$, (7) blood diseases, (8) traumatism 12 L3 Pathological anatomy (a) Macroscopic: (i) appearance of membrane, (2) position, (3) haematoma (b) Microscopic: (1) structure, (2) inflammatory or hemorrhagic origin 14 Symptomatology (a) Previous to hemorrhage: (i) absent, {2) masked, (3) uncertain (b) At the time of and after hemorrhage: (1) headache, vertigo and vomiting, (2) coma, (3) hemiplegia (complete or partial), (4) convulsions and contractures, (5) reflexes (pupil, cutaneous and tendon), (6) mental symptoms, (7) relapses 15 Pathology: (i) origin, (2) symptoms caused by inflammation, (3) symptoms due to hem- orrhage, (4) transitory nature of symptoms 16 Diagonsis Prognosis Treatment LECTURE III. Diseases of the Brain DISEASES OF THE MEMBRANES (Continued) ACUTE LEPTOMENINGITIS Introductory Varieties: (i) cerebro-spinal (epidemic form), (2) tubercular, (3) purulent CEREBRO-SPINAL MENINGITIS Introductory ., 18 Etiology: (i) age, (2) sex, (3) epidemics, (4) season, (5) climate, (6) traumatism, (7) cold and dampness, (8) infection (Wechselbaum's diplococcus intracellulars meningitidis and Fraenkel's pneumococcusj 19 Pathological anatomy : An acute exudative inflammation of the pia mater of the brain and spinal cord and of the nerve sheaths: (i) hyperaemia, (2) hemorrhages, (3) exudation (serum, fibrin, pus), (4) dilated ventricles, (5) neuritis Symptomatology (a) Incubation (b) Prodromal 20 (c) Meningeal irritation: (i) sensory, (2) motor, (3) psychic 21 (d) Paralytic symptoms: (i) sensory, (2) motor, (3) psychic O) Cutaneous lesions: (1) herpes, (2) petechiae, (3) taches cerebrales, (4) corneal and conjunctival inflammations 22 (/) Reflexes: (i) pupil, (2) tendon, (3) cutaneous, (4) organic, (5) respiratory, (6) Kernig's (g) Constitutional symptoms: (1) temperature, (2) pulse, (3) emaciation, (4) constipation, (5) albuminuria, (6) glycosuria 23 (h) Lumbar puncture: (i) tension of cerebro-spinal fluid, (2) character of fluid, (3) bacte- rial content (t) Sequelae: (1) headache, (2) blindness, (3) deafness, (4) aphasia, (5) paralysis, (6) convulsions, (7) mental weakness 24 Pathology, (i) origin, (,) cause of irritative symptoms, (3) cause of parahtic svmptoms, (4) symptoms due to mvolvment of peripheral nerves, I 5 , cause of sequelae ' Diagnosis Differential diagnosis (a) From typhoid (b) From tetanus (c) From uraemia and diabetes (d) From sinus thrombosis (e) From alcoholic and other deliriums (f) From pachymeningitis (g) From cerebral abscess (h) From septicaemia 26 Prognosis and course: (i) great variations, (2) abortive form. (3) fulminating form, (4) average mortality Treatment: (1) prophylactic, (2) rest in dark, (3) cold to head and warmth to extremities, (3) blisters, (4*) drugs (morphine, mercury, etc.). (£) lumbar puncture 27 LECTURE IV. Diseases of the Brain DISEASES OF THE MEMBRANES (Continued) TUBERCULAR MENINGITIS Introductory Etiology: (i) age, (2) traumatism, (3) bacillus tuberculosis •is Pathological anatomy: (i) exudation, (2) thickening of pia mater, (3) miliary tubercles, (4) dilated ventricles, (5) hydrocephalus Symptomatology: (i) absent, (2) masked (a) Those of original disease (b) Prodomata: (1) peevishness, (2) anorexia, (3) emaciation, (4) mental dulness (c) Meningeal irritation: (1) sensory, (2) motor, (3) psychic, (4) hydrocephalic cry 30 (d) Hydrocephalus I e I < >phtalmoscopic changes: (i) choked disc, (2) tubercles in choroid I f ) Lumbar puncture ( g) Other symptoms are in the main quite similar to those of epidemic cerebro-spinal menin- gitis, but are usually less intense ::l Pathology Diagnosis Prognosis and course Treatment S2 PURULEXT MENINGITIS Introductory Etiology: (i) traumatism, (2) extension of inflammation (otitis, caries, sinus thrombosis, erysipelas, carbuncle, etc.), (3) infection (septicaemia, small-pox, etc.), (4) insolation Pathological anatomy: (i) congestion, (2) exudation (pus), (3) abscess, (4) extent, (5) bacteria Symptomatology: (1) absent, (2) masked (a) Those of original disease (b) Prodromal (c) Same as in epidemic form with minor exceptions 34 Pathology Diagnosis Differential diagnosis (a) Cerebro-spinal meningitis: (i) epidemic, (2) primary disease, (3) lumbar puncture (b) Tubercular meningitis: (1 ) primary disease, (2) lumbar puncture (c) Purulent meningitis: (1) primary disease, (2) lumbar puncture Prognosis and course Treatment SEROUS AND OTHER FORMS OF ACUTE MENINGITIS 36 LECTURE V. Diseases of the Brain DISEASES OF THE MEMBRANES (Concluded) CHRONIC LEPTOMENINGITIS Introductory Etiology, i Excluding syphilis and tuberculosis): (i) alcohol, (2) insanity, (3) age Pathological anatomy ; (i) color, (2) thickening, (3) structure, (4) vascular occlusion, (5) hydrocephalus Symptomatology: (1) absent, (2) headache, vertigo, vomiting, (3) tenderness, (4) delirium and mental dulness, (5) insanity, (6) localized spasms, (7) localized paralyses, (8) rigidity of extremities, (9) strabismus, nystagmus and optic neuritis :;,s Pathology: (i) congestion and irregular blood supply Diagnosis: (i) difficult and uncertain, (2) primary disease or injury Prognosis and course Treatment: (1) blisters, (2) drugs (mercury, iodides) 40 ACUTE HYDROCEPHALUS CHRONIC EXTERNAL HYDROCEPHALUS ii CHRONIC INTERNAL HYDROCEPHALUS Introductory Etiology (a) Congenital: (i) heredity, (2) syphilis in parents, (2) alcoholism in parents (b) Acquired: (1) rarer than congenital, (2) meningitis 42 Pathological anatomy (a) Congenital: (i) bones and sutures, (2) membranes of brain and choroid plexuses, (3) ventricles, (4) brain tissue, (5) miscroscopic appearance, (6) character of effusion (b) Acquired Symptomatology: (i) enlargement of head, (2) sutures and fontanelles, (3) small face, (4) idiocy, imbecility or feeble-minded, (5) headache and vomiting, (6) convulsions, (7) par- alyses, (8) rigidity, (9) reflexes, (10) optic neuritis, (11) lumbar puncture 44 Pathology Diagnosis: (i) enlarged head, (2) defective intelligence Differential diagnosis (a) From rickets (b) From cerebral tumor Prognosis and course Treatment 46 LECTURE VI. Diseases of the Brain INJURY Introductory CONCUSSION OF THE BRAIN Introductory Etiology: ( i) blow over large area of skull, (2) individuality, (3) drunkard Pathological anatomy (a) Many sources of error (b) In mild cases (c) In fatal cases: (i) microscopic changes in nerve elements, (2) vascular changes, (3) contusions, (4) hemorrhages (d) Secondary or remote changes: (1) meningitis, (2) tumor, (3) sclerosis 48 Symptomatology (a) Mental confusion, etc., occurs immediately and is very transitory (b) Mild cases: (i) bewildered, (2) nausea, (3) sweat, (4) tremor, (5) delirium (c) Severe cases: (1) coma or semi-coma, (2) vomiting, (3) vascular and respiratory ■changes, (4) temperature, (5) pupils, (6) delirium, (7) shock i" (d) Great variation in intensity and duration of symptoms (c) Remote symptoms of: (i) meningitis, (2) insanity, (3) tumor, (4) sclerosis n 50 Pathology: (i) shaking- of brain, (2) shock, (3) inhibition, (4) movement of cerebro-spinal fluid, (5) pressure 51 Diagnosis Prognosis and course: (i) guarded, (2) depends on severity and duration of symptoms Treatment: (1) cold to head, (2) warmth to extremities, (3) purgatives, (4) stimulants 52 COMPRESSION OF THE BRAIN Introductory Etiology: in injury, (2) depressed bone, (3) hemorrhage Pathological anatomy : (1) that of primary disease, (2) compression of brain, (3) cerebral veins empty, arteries congested Symptomatology (a) May not occur immediately (b) Those of concussion may precede and accompany those of compression (c) General not local (d) Symptoms of irritation: (i) congested face, (2) contracted pupil, (3) headache, (4) vomiting, (5) slow pulse (e) Symptoms of depression: (1) coma, (2) pupils dilated, (3) pulse and respiration, (4) paralyses 54 Pathology: (i) increased uniform pressure, (2) irritation and inhibition Diagnosis: (1) nature of injury, (2) escape of blood or fluid from ears. (3) delayed symp- toms, (4) severity and duration of symptoms Prognosis and course: (1) intensity and progressive nature of symptoms, (2) possibility of operation Treatment : (1) remove cause by trephining, 1 2 1 purgation LECTURE VII. INJURY (Concluded) CONTUSION OF THE BRAIN Introductory Etiology Pathological anatomy (a) Hemorrhage and laceration of cerebral cortex at point of injury or at point of brain directly opposite (contre coup), or at both (b) Clustered or widely disseminated minute extravasations of blood 56 Symptomatology (a) General: (i) shock or coma, (2) pulse. (3) temperature, (4) pupils (b) Local: (1) often absent, (2) spasm or contracture, (3) paralyses Pathology (a) General symptoms are a mixture of those of concussion and compression (b) Local symptoms depend on cortical centers injured Diagnosis Prognosis and course Treatment 58 PENETRATING WOUNDS OF THE BRAIN Introductory Etiology : (i) stabs, ( _> ) gun-shot wounds Pathological anatomy: (i) division of tissue. (2) hemorrhage, (3) laceration and infection, (4) sloughing, ( 5 ) suppuration Symptomatology (a) ( ieneral : I 1 ) shock or coma (/m Local: (1) irritative, (2) destructive (c) Great variations according to locality (d) Foreign bodies remaining in brain often after years lead to suppuration Pathology Diagnosis Prognosis and course 60 Treatment : (i) trephine, (2) disinfect, (3) close wound, (4; remove foreign body when pos- sible, (5) danger of probing MENINGEAL HEMORRHAGE Introductory Etiology: (1) injury, (2) aneurism, (3) pachymeningitis Pathological anatomy: (1) position, (2) extent, (3) appearance, (4) changes, (5) cyst, (6) brain compression and anaemia 61 Symptomatology (a) Absent or latent (b) General: (i) coma, (2) pulse and respiration, (3) pupils, (4) remission (c) Local: (1) varying with seat of lesion, (2) irritation, (3) paralytic, (4) temporary Pathology Diagnosis Prognosis and course Treatment 62 LECTURE VIII. Diseases of the Brain CIRCULATORY DISEASES OF THE BRAIN Introductory CEREBRAL ANAEMIA Etiology: (i) general anaemia, (2) cardiac inadequacy, (3) emotions and vaso-motor spasm, (4) atheromatous arteries Pathological anatomy (a) Conditions after death may differ from those during life and may vary with the manner of making the autopsy (b) Microscopic changes: (i) color, (2) punctae vasculosae, (3) atheromatous arteries, (4) softening (c) Microscopic changes Symptomatology (a) Functional anaemias : (1) fainting, (2) vertigo, (3) tinnitus aurium, (4) dimness oi vision, (5) nausea, (6) feebleness, (7) drowsiness, (8) convulsions 64 (b) Cerebral anaemia due to atheromatous arteries Pathology Diagnosis ( a ) All other conditions must be excluded ( b ) General anaemia, cardiac inadequacy, atheromatous arteries or emotional disturbances must be present Prognosis and course Treatment: (i) remove the cause, (2) posture, (3) blood tonics, (4) cardiac tonics, (5) vas- cular dilators, (6) nervines i;<) CEREBRAL HYPERAEMIA Etiology (a) Active: (i) worry and emotions. (2) vase-motor paralysis, (31 excessive cardiac action ( 7' I Passive: (1) venous obstruction Pathological anatomy (a) Condition of blood vessels may change after death and depend <»n manner of making autopsy (b) Macroscopic appearances : (1) color, (2) engorged vessels, (3) punctae vasculosae, ( 4 ) oedema Symptomatology (fanciful): (i) headache, (2) fulness, (3) mania and delirium, (4) apo- plectiform attacks Pathology: (1) pressure, (2) hyperactivity from excessive blood supply Diagnosis (a) All other conditions must be excluded (b) Possible etiological factors must be present Prognosis and course Treatment: (1) remove the cause, (2) posture, (3) purgatives, (4) diuretics, (5) diaphoret- ics, (6) drugs (ergot, belladonna, bromide, morphine) CEREBRAL OEDEMA Etiology: (always a secondary disease) (a) General: (i) nephritis, (2) general venous obstruction (b) Local: (1) local venous obstruction, (2) inflammation, (3) tumors Pathological anatomy: (1) color, (2) moisture, (3) punctae vasculosae Symptomatology: (1) coma, (2) convulsions (local or general), (3) paralyses (local or general ) 69 Pathology: (i) pressure, (2) loss of function from interference with blood supply Diagnosis Prognosis and course Treatment: (1) posture, (2) purgatives, (3) diuretics, (4) diaphoretics, (5) drugs (glonoin, digitalis) LECTURE IX. Diseases of the Brain CIRCULATORY CEREBRAL DISEASES (Continued) APOPLEXY Introductory CEREBRAL HEM( >RRHAGE Etiology km Predisposition: (i) heredity, (2) age, (3) sex 71 (&) Traumatism: (i) blows, (2) birth (c) Haemic diseases: (1) scurvy, (2) purpura, (3) pernicious anaemia, (4) leucocythaemia (d) Arterial degeneration: (1) miliary aneurism, (2) peculiar to brain, (3) peculiar character of cerebral arterioles, (4) relationship to atheroma, (5) dissecting aneurisms 72 (e) Causes of arterial degeneration : (i) syphilis, (2) nephritis, (3) alcoholism, (4) rheu- matism and gout, (5) lead, (6) chronic congestion (worry) (f) Increased blood tension : (i) doubtful cause, (2) posture 71 Pathological anatomy (a) Location in the order of relative frequency : (i) corpus striatum, optic thalamus and internal capsule, (2) centrum ovale, (3) cortex, (4) peduncle, (5) pons, (6) cerebellum (b) Arteries affected: (1) lenticulo-striate, (2) lenticulo-optic, (3) anterior corpus striate, (4) choroid (c) Appearance: (1) size and shape, (2) coagulum, (3) red softening, (4) compression of nerve tissue, (5) destruction of nerve tissue, (6) effusion into ventricles 75 (d) Alteration in appearance with time: (i) color, (2) degeneration, (3) liquefaction, (4) absorption, (5) cyst, (6) scar, (7) secondary degeneration 76 :: Symptomatology (a) Prodromal: (i) uncertain and uncommon, (2) headache, (3) vertigo, (4) tinnitus aurium, (5) irritability, (6) disordered mental action, (7) drowsiness, (8) local par- alyses, (9) paraesthesiae, (10) epistaxis (&) Cardinal symptoms: (1) sudden onset, (2) general shock, (3) local paralysis 78 (c) Onset: (i) from one second to 24 hours, (2) death, (3) coma, (4) headache, vertigo, confusion and vomiting, (5) paralysis, (6) convulsions (d) General shock or acute stage: (i) coma or semi-coma, (2) temperature, (3) pulse, (4) respiration, (5) pupils, (6) eye-balls and head, (7) motion, (8) sensation, (9) reflexes 80 (e) Local paralysis or chronic stage: (i) absent, (2) distribution (hemiplegia, hemianopsia, aphasia, etc.), (3) temporary and permanent, (4) order of recovery (face, leg, arm), (5) reflexes, (6) automatic movements, (7) mental weakness, (8) residual motor dis- turbances (contractures, tremor, chorea, athetosis, spasms, atrophy), (9) bed sores 82 LECTURE X. Diseases of the Brain CIRCULATORY CEREBRAL DISEASES (Continued) CEREBRAL HEMORRHAGE (Continued) Pathology (a) Prodromata due to atheromatous arteries (b) Coma due to the hemorrhage: (i) suddenly increased pressure, (2) local and general anaemia, (3) oedema of brain, (4) tearing of nerve tissue 84 (c) Temperature, pulse and respiration disturbed by irritation or paralysis of correspond- ing centers in brain (f the local paralysis and chronic stage Pathology Diagnosis Differential diagnosis (a) From embolism (b) From thrombosis (c) From hemorrhage Prognosis and course Treatment (a) Prophylactic (b) Of the attack and paralysis 98 SINUS THROMBOSIS Introductory Etiology: (i) infection (caries and otitis), (2) infectious diseases (especially of head and neck), (3) terminal infection (marantic), (4) sluggish circulation, (5) chlorosis, (6) age 100 Pathological anatomy: (i) thrombosis, (2) color, (3) oedema, (4) hemorrhage, (5) abscess Symptomatology (a) General: (1) very varied, (2) primary disease, (3) chill, (4) psychic, (5) spasm and convulsions, (6) pain, (7) fever KM (&) Special: (i) Superior longitudinal sinus (epistaxis, oedema of forehead), (2) trans- verse sinus (oedema behind ear, jugular veins), (3) cavernous sinus (oedema of con- junctiva, prominence of eyeball, oedema of temple) 102 Pathology: (i) local oedema, (2) abscess Diagnosis : (1) cause for thrombosis, (2) symptoms of meningitis of mild intensity and without retraction of head, (3) external oedema, (4) tenderness over jugular Prognosis and course Treatment [08 LECTURE XII. Diseases of the Brain CEREBRAL PALSY OF CHILDHOOD (PORENCEPHALY) Introductory Etiology: (i) age, (2) sex, (3) heredity, prenatal influences and injury at birth, (4) injury in infancy, (5) infection, (6) syphilis 104 Pathological anatomy : (i) porencephaly. (2) secondary degeneration, (3) developmental, (4) hemorrhage, (5) vascular occlusion, (6; inflammation. (7) sclerosis lu:> Symptomatology (a^ Hemiplegia: (i) paralysis, (2) convulsions, (3) coma, (4) fever, etc., (5) contracture, rigidity and increased reflexes, (6) atrophy, arrest of development and deformities, (7) posthemiplegic motor disorders, (8) epilepsy, (9) psychic 106 107 (b) Diplegia: (i) double hemiplegia, complete or partial, (2) same as in hemiplegic form but bilateral Pathology: ( 1 ) in general similar to that of meningeal hemorrhage, (2) paralytic symptoms, (3) irritative symptoms, (4) psychic symptoms, (5) atrophy and deformities 108 Diagnosis Differential diagnosis (a) From poliomyelitis anterior acuta: (i) reflexes, (2) electrical reaction of degeneration 1 /- 1 From multiple sclerosis: ( 1 1 chronic progressive course, (2) speech, (3) electrical reac- tion of degeneration iw (c) From Friedrich's Ataxia: (i) tendon reflexes, (2) spastic symptoms, (3) ataxia Prognosis and course Treatment: (1) electricity, (2) massage, (3) tenotomy, (4) orthopaedic apparatus, (5) drugs 110 LECTURE XIII. Diseases of the Brain INFLAMMATION ENCEPHALITIS Introductory Varieties: (i) polioencephalitis acuta hemorrhagica superior (Wernicke), (2) acute encepha- litis of children and adults (Struempell), (3) meningoencephalitis, (4) reactive inflam- mations, (5) abscess 111 CEREBRAL ABSCESS Introductory- Etiology : (i) age, (2) sex, (3) infection (injury 20-24$, caries 50$, infected thrombosis), (4) infectious diseases (meningitis, typhoid, scarletina, influenza, erysipelas, pyaemia, tuberculosis, actinomycosis) 112 Pathological anatomy: (i) location (cerebral hemispheres jii, cerebellum 25',. both cerebral hemispheres and cerebellum 2<£, brain stem \ r i), (2) number, (3) size. 141 capsule, (5) pus 118 Symptomatology (a) Of primary disease (b) General: (i) fever, (2) headache, vertigo and vomiting, (3) convulsions, (4) psychic, (5) optic neuritis, (6) pulse and respiration, (7) latent stage 114 (c) Local (d) Complications: (i) rupture, (2) meningitis 115 Pathology: (i) increased pressure, (2) irritation, (3) inhibition, (4) destruction Diagnosis : (1) etiology, (2) latent stage 116 Differential diagnosis (a) From meningitis: (i) intensity and acuteness of symptoms, (2) fever, (3) retraction of head, (4) optic neuritis. (5) pronounced psychic symptoms. (6) Kernig's symptom (b) From cerebral hemorrhage: (i) immediate result of injury, 121 no infection. (3) sud- denness of onset, (4) headache (c) Sinus thrombosis: (1) marantic condition. (2) moderate intensity of symptoms. 13) fever, (4) external oedema, (51 rarely local symptoms 1 (/ 1 1 lerebral tumor 117 Prognosis and course Treatment: (i) prophylactic, (2) evacuation and drainage, (3) same as meningitis 118 LECTURE XIV. Diseases of the Brain INTRACRANIAL TUMOR. Introductory Etiology: (i) age, (2) sex, (3) heredity, (4) congenital defect, (5) infection and parasites (syphilis, tubercle, etc.), (6) metastatic, (7) injury 119 Pathological anatomy: (i) location, (2) varieties (glioma, psamoma, sarcoma, carcinoma, tubercles, gumma, lipoma, myxoma, chloesteatoma, aneurism, cyst), (3) relative frequency, excluding gummata, which are most frequent, (tubercle 53^, glioma 15& sarcoma 15& others 17$), (4) differentiation from brain tissue, (5) changes in brain 120 121 Symptomatology (a) Absent (b) General: (i) headache, (2) vertigo and vomiting, (3) choked disc and optic neuritis, (4) psychic symptoms, (5) convulsions, (6) pulse and respiration 122 (c) Local Pathology: (i) increased pressure, (2) irritation, (3) inhibition, (4) destruction Diagnosis: (1) steady increase of severe psychic, motor and sensory symptoms, (2) headache, (3) choked disc, (4) local symptoms 121 Differential diagnosis (a) From meningitis: (i) fever, (2) retraction of head. (3) lumbar puncture (b) From abscess (1) etiology. (2) acute course, (3) latent si 125 (c) From general paresis: (i) speech and tremor, (2) exaltation. (3) choked disc (d) From epilepsy: (1) convulsion only symptom, (2) no choked disc (e) From hysteria: (1) hysterical stigmata (/) Atheromatous arteries with local softenings: (1) multiplicity of symptoms, (2) no choked disc (g) From internal hydrocephalus: (1) slow course, (2) multiplicity of symptoms, (3) deformity of skull 126 Prognosis and course Treatment : (i) palliative, (2) medicinal, (3) surgical LECTURE XV. Diseases of the Brain SYPHILIS OF THE NERVOUS SYSTEM Introductory: (i) in general, (2) post syphilitic nervous diseases, (3) tertiary nervous syph- ilis, (4) secondary nervous syphilis 128 Etiology: I'd age. (2) sex, (3) heredity, (4) syphilitic germ or toxine. congenital or acquired, (5) interval between infection and nervous symptoms, (6) predisposing can 129 Pathological anatomy (a) Of gumma: (i) appearance, (2) structure (b) Of meningitis gummosa 130 (c) Of arteritis syphilitica: (i) periarteritis gummosa, (2) endarteritis syphilitica, (3) local softening (d) Of perineuritis syphilitica (e) A combination of the above described lesions (f) Syphilitic inflammations are rare and 1111 rertain 131 Symptomatology (a) In general: (i) multiple, multiform and variable, (2) paretic rather than paralytic, (3) nocturnal headache (b) Of meningitis gummosa cerebralis : (1) headache (nocturnal), (2) vertigo and vomit- ing, (3) insomnia, (4) psychic, (5) convulsions, (6) polyuria, (7) implication of cra- nial nerves (meningitis basilaris), (8) cortical symptoms (meningitis corticalis) 132 LECTURE XVI. Diseases of the Brain SYPHILIS OF THE NERVOUS SYSTEM (Concluded) Symptomatology (concluded) (c) Of cerebro-spinal syphilis (cerebro-spinal syphilitic meningitis): (i) same symptoms as described under " b" but less intense, (2) sensory spinal symptoms, (3) motor spinal symptoms 134 (d) Of arteritis syphilitica: (i) cerebral or spinal anaemia, general or local, (2) cerebral or spinal thrombosis, (3) bulbar symptoms (e) Of perineuritis syphilitica: (i) usually associated with meningitis, (2) optic nerve, (3) oculo-motor nerve, (4) other cranial nerves, (5) spinal nerves, (6) multiple neuritis 136 (/) Of isolated gumma Pathology 187 Diagnosis: (i) history of infection or previous syphilitic symptoms, (2) nocturnal headache, (3) optic neuritis, ptosis, Argylle-Robertson pupil, (4) multiplicity, variability, incomplete- ness and transitory nature of symptoms 138 Differential diagnosis of the different forms Prognosis and course: (i) bad unless treated, (2) curability, (3) hereditary form, (4) arteritis, (5) meningitis, (6) neuritis, (7) effect of tuberculosis and alcoholism, (8) course Treatment: (i) prophylactic, (2) drugs, (3) duration of treatment 140 LECTURE XVII. Diseases of the Brain CEREBRAL LOCALISATION Introductory 141 (a) Localisation within the motor area: (i) extent of motor area, (2) leg, (3) arm, (4) face, (5) minute representation, (6) multiple representation, (7) centers of innervation feelings, (8) sensory disturbances, (9) involvment by lesion of projection and associa- tion fibres, (10) irritative symptoms, (11) inhibitory symptoms, (12) paralytic symp- toms, (13) diagnostic points, (14) restitution 142 143 144 146 (b) Localisation within the parietal lobe: (i) no local symptoms, (2) may involve motor centers, (3) muscle sense, (4) conjugate deviation of eyeballs, (5) hemianopsia, (6) alexia 146 1 1: (c) Localisation within the occipital lobe :( i ) no local symptoms, (2) hemianopsia, (3) hemiamblyopia and hemichromatopsia. (4) psychic blindness, (5) optic aphasia, (6) alexia, (7) visual hallucinations 14S 141) 150 CEREBRAL LOCALIZATION. Fig. i. The Lateral Surface of the Left Hemisphere showing the situation of the Cortical Centers. The principal motor area is dotted in black. The cutaneous and muscular sensory area is dotted in red, overlapping the motor area. TACIAL \ ARM HYPOGLOSSAL Fig. 2. Horizontal Section through Right Hemisphere showing, in red, the principal tracts situated in the Internal Capsule. Kn, Genu of Corpus Callosum; F, Fornix; NC, Caudate Nucleus: XL, Lenticular Nucleus; OT, Optic Thalamus: Sp, Splenium of Corpus Callosum, LECTURE XVIII. Diseases of the Brain CEREBRAL LOCALISATION (Concluded) (d) Localisation within the frontal lobe: (i) no local symptoms, (2) psychic, (3) cerebellar ataxia. (4) anosmia and amblyopia (5) trunk muscles, (6) agraphia, (7) motor aphasia 161 152 (e) Localisation within the temporal lobe: (i) no local symptoms, (2) sensory aphasia, (3) anosmia, (4) auditory and odoriferous hallucinations 154 (f) Localisation within the central white substance (g) Localisation within the internal capsule : (i) hemiplegia, (2) incomplete hemiplegia, (3) hemianaesthesia, (4) hemianopsia, (5) deafness, (6) hemichorea, hemiathetosis, tremor, (7) permanent and temporary symptoms 1 56 156 (h) Localisation within the nucleus caudatus and nucleus lenticularis : (i) no local symp- toms, (2) indirect hemiplegia, (3) elevation of temperature, (4) motor disturbances (i) Localisation within the optic thalamus : (1) no local symptoms, (2) indirect hemiplegia or hemianaesthesia, (3) hemianopsia, (4) motor disturbances, (5) mimic disturbances, (6) vaso-motor disturbances 157 158 (/) Localisation within the corpora quadrig-emina : (i) pupil reaction, (2) oculo-motor paralysis. (3) ataxia. (4) tremor, (5) deafness (k) Localisation within the cerebellum and its peduncles: (i) no local symptoms, (2) cerebellar ataxia, (3) vertigo, (4) vomiting, (5) tremor and nystagmus, (6) indirect hemiplegia, (7) retraction of neck 160 (/) Localisation within the brain stem considered in volume one ( m ) Localisation at the base of the brain ( tum< irs i : (a) Tumors of the pituitary body: (i) acromegaly, (2) amblyopia, (3) bitemporal hemianopsia, (4) opthalmoplegia and exophthalmos, (5) diabetes insipidus and mellitus 161 ( b ) Tumors of the sella turcica : ( I ) same as in " a" except no acromegaly (c) Tumors in anterior fossa of the skull: (i) anosmia, (2) amblyopia, (3) oph- thalmoplegia, (4) sensory disturbances in forehead, (5) motor aphasia 162 (d) Tumors in middle fossa of the skull: (i i trigeminal irritation and paralysis, (2) ophthalmoplegia Tumors in posterior fossa of the skull: (1 ) paralysis of the 5th to the 12th cranial nerves. (2) pressure on medulla (hemiplegia or paraplegia). >sure on cere- bellum (verti LECTURE XIX. Diseases of the Brain FUNCTIONAL DISEASES NEURASTHENIA Introductory Etiology: (i) race (Semetic), (2) sex, (3) age, (4) heredity, (5) occupation, (6) excesses (alcoholic, narcotics, venery, overwork), (7) emotions (fright, jealousy, misfortune), (8) mental strain (worry), (9) toxines, (10) chronic local disease (ocular, nasal, pelvic), (11) anaemia 164 16-5 Pathological anatomy: (i) negative 166 Symptomatology (a) General: (i) weakness and irritability, (2) lack of endurance, (3) insomnia, (4) sens- ory disturbances, (5) motor disturbances 167 168 (b) Psychic: (i) depression, (2) irritability. (31 anxiety. (4) mental inertia, (5) com- pulsory ideas. (6) pressure in head, hallucinations, delusions 170 (c) Alimentary: (I) anorexia, (2) constipation, (3) diarrhoea, (4) dyspepsia, flatulent and hyperacidity (d) Circulatory and secretory: (1) rapid and irregular pulse, (2) palpitation, (3) flushing, (4) sweating, (5) urine 171 (e) Sexual: (i) masturbation, (2) emissions, (3) obscene thoughts, (4) fear of impotency (/) Combined forms 172 Pathology: (i) lack of nerve force, (2) lack of endurance, (3) weakness, (4) irritability Prognosis and course 178 Treatment: (i) rest, (2) food, (3) change of conditions, (4) massage and electricity, (5) systematic exercise, (6) tonics Hi 175 176 LECTURE XX. Diseases of the Brain FUNCTIONAL DISEASES (Continued) HYSTERIA Introductory 17' Etiology: (i) race (Semetic and Latin), (2) climate, (3) civilization and cultivation, (4) age, (5) sex, (6) heredity, (7) education, (8) example, (9) psychic traumata, acute (emo- tions) or chronic (worry), or sexual (rape, jealousy, masturbation, etc.), (10) exhaustion and anaemia, (11) local disease, (12) menstruation, (13) excesses (alcoholic, narcotic, venery) 178 179 Pathological anatomy : ( i ) negative 180 Symptomatology (a) General: (i) variability, (2) simulation of other diseases, (3) fraud and feigning, (4) chronic general condition and acute or chronic local or general attack 161 (b) Psychic: (i) normal, (2) energetic and capable, (3) bright and attractive, (4) neur- asthenic, (5) self-centered, (6) emotional, theatrical and desirous of admiration, (7) childish liars, (8) suggestible, (9) irritable and lacking in self-control, but obstinate, (10) insanity, (11) double consciousness 182 184 (c) Sensory disturbances in hysteria: ( ii manifold and multiple. (2) acuteness of percep- tion. (3) paraesthesiae, (4) hyperaesmesia (ovarian, spinal, photophobia, etc.). neuralgia (ciavus, etc.), (6) anaesthesia (not limited to distribution of any nerve, hemi- anaesthesia), (7) transference. (8) concentric limitation of field of vision, (9) blindness, (ioj deafness, (11) anosmia and ageusia 186 187 (00 Pathological anatomy Symptomatology: (I) paroxysmal attacks, (2) premonitory symptoms, (3) aura, (4) head- ache (hemicrania), (5) hyperalgesia, (6) vaso-motor and secretory disturbances, (7) nausea and vomiting, (8) duration, (9) imperfect attacks, (10) the hemicranial equivalent SOI o02 Pathology : ( i ) vaso-motor spasm or paralysis Diagnosis Prognosis and course Treatment 304 LECTURE XXXI. Diseases of the Brain GEXERAL REVIEW AND SUMMARY Introductory Diseases to be considered General etiology (A) Primary Factors (a) Direct heredity and congenital defects: (] I mainly organic disi ' cranial abnormalities and encephalocele, (3) meningitis, tubercular and syphilitic, 14) cerebral palsy of childhood, (5) cerebral hemorrhage, (6) tumor, 171 convulsive disorders (epilepsy, chorea, infective and degenerative), (8) neurasthenia 1 ?) and hysteria 1 ? I (b) Indirect heredity (neuropathic predisposition): (i) all the functional diseases, (2) no organic diseases except degenerative chorea (c) Infections: (1) acute meningitis, (2) syphilis, (3) tetanus and hydrophobia, (4) infective chorea, (5) abscess 306 ( : (a) Loss of consciousness : (i) coma. (2) semi-coma or stupor, (3) sopor, 14) somno- lence, (5) confusion or giddiness, (6) drowsiness (traumatic compression, etc., apoplexy, epilepsy, sinus thrombosis, meningitis, tumor, general paresis, multiple sclerosis, alcoholism, narcotism, uraemia, diabetes, fever) (b) Loss of intelligence : (i) amentia (idiocy, imbecility, feeble minded), (2) dementia (result of insanity and of the diseases noted above under "a") (c) Loss of feeling (emotions) : (1) apathy (neurasthenia and insanity) (d) Loss of memory in general: (1) amnesia (diffuse atrophic or degenerative cor- tical changes usually of vascular origin ) 314 (B) Partial Diminution of Cerebral Activity (due to focal lesion) : (a) Loss of vision: d) limitation of field of vision for white and colors (hysteria), homonymous hemianopsia (apoplexy, tumor), (3) blindness (meningitis, apo- plexy, tumor, uraemia). (4) psychic blindness (meningitis, tumor, apoplexy) 315 (b) Loss of speech: (i) motor aphasia, (2) sensory aphasia, (3) transcortical aphasia (tumor, apoplexy, meningitis ) 316 (c) Loss of reading and writing: (i) alexia, (2) agraphia (tumor, apoplexy, menin- gitis) i d ) Loss of smell and taste: (i) anosmia. (2) ageusia (tumor, apoplexy, meningitis) ( (■ i Loss of cutaneous and muscular sensibilit) : (1) astereogn bemjanaesthesia, (3) hemianalgesia, (4) thermic hemianaesthesia, (5) loss of muscle sense (apo- plexy, tumor, meningitis, hysteria) 31' (/) Monoplegia (apoplexy, tumor, meningitis, hysteria) (g) Hemiplegia, total or partial (apoplexy, tumor, meningitis, hysteria, uraemia) 318 (h) Cerebral diplegia (cerebral palsy of childhood, double hemorrhage, tumor, hysteria) (t) Crossed hemiplegia, dysphasia, dysphagia, Cheyne-Stokes respiration, temporal and nasal hemianopsia, etc., have been discussed in volume one 319 (C) Exaggeration of Cerebral Activity: (a) Psychic: (i) insomnia (neurasthenia) (b) Sensory: (i) hyperesthesia, (2) hyperalgesia, (3) thermic hyperesthesia, (4) hyperosmia, (5) hypergeusia, (6) photophobia, (7) intolerance to sound (all may occur in hysteria) "20 (c) Motor: (i) contracture, active or passive (meningitis, apoplexy, cerebral pals; childhood, tetany, hysteria), (2) restlessness (neurasthenia and hysteria), (3) con- vulsion, general, unilateral or monospasm : tonic, clonic, tetanic, choreiform ( epil- epsy, tetanus, hydrophobia, hysteria, chorea, meningitis, apoplexy, cerebral palsy of childhood, tumor j (D) Perversion of Cerebral Activity: (a) Psychic: (i) depressed and apprehensive (insanity, traumatic neuroses, neuras- thenia, hysteria, chronic narcotism), (2) joyous and exalted (insanity, hysteria), (3) changeable (insanity, hysteria chronic narcotism), (4) hallucinations, (5) delusions, (6) delirium (last three may occur in fever, insanity, chronic nar- cotism, meningitis) 322 (b) Sensory: (i) headache, (2) peripheral pain, (3) paraesthesiae, (4) vertigo, (5) vomiting- (all may occur in meningitis, tumor, syphilis, neurasthenia, hysteria) Motor: (i) cortical ataxia (tumor, apoplexy, or meningitis of cerebral cortex, causing astereognosis), (2) cerebellar ataxia (lesions of cerebellum or its pe- duncles, (3) tremor (neurasthenia, hysteria, exophthalmic goitre, multiple sclerosis, post-hemiplegic), (4) athetosis (post-hemiplegic), (5) inertia (hysteria or cat- alepsy) 324 General pathology (a) Result of increased pressure: (i) general, (2) local (b) Result of anaemia: (1) general, (2) local 1 c 1 Result of irregular blood supply (d) Result of cortical irritation: (i) general, (2) local (e) Result of poisons (/) Result of lack of nerve force 326 Diagnosis : (ij psychic disturbances, (2) unilateral distribution of the paralyses, (3) convul- sions and other irritative symptoms, (4) absence of degenerative muscular atrophy, (5) local symptoms Prognosis and course Treatment (a) General prophylaxis: (i) direct inheritance, (2) neuropathic predisposition, (3) con- sanguinious marriages, (4) education, (5) manner of life, (6) food and stimulants 328 (b) The actual disease: (i) rest, (2) systematic exercise, (3) massage, (4) electricity, (5) hydrotherapeutics, (6) heat and cold, (7) drugs (hypnotics, sedatives, nerve tonics, circulatory) 330 332 APPENDIX INSANITY Introductory 334 336 Method of examination (a) A complete history and physical examination made according to the scheme given in volume one is necessary in every case (b) Points to be especially observed : (i) subjective symptoms (history) are much more important than the objective (physical examination), (2) obtain all the information possible before seeing the patient, (3) ascertain the degree of culture, peculiarities and temperament of the patient previous to the attack. (4) do not deceive the patient. note time of mental reaction General etiology (a) Predisposing causes: (i) age, (2) sex, (3) heredity (direct inheritance, neurasthenic predisposition, consanguineous marriages) 338 (b) Exciting causes: (i) acute psychical traumata (emotions), (2) chronic psychical trau- mata (worry and grief;, (3) alcoholism and narcotism, (4) infection (syphilis), (5) physical traumata, (6) organic and functional brain diseases, (7) visceral diseases, (pelvic, thyroid, etc.) 340 Pathological anatomy: (i) the brain, (2) the blood v 3) the lympathics, (4) the pia- arachnoid, (5) the dura mater, (6) the skull :.ii 342 General symptomatology (A) Prodromal or Neurasthenic Stage: (i) insomnia, (2) weakness, fatigue, morning tire, (3) irritability or languor, (4) weakened attention, (5) mental depression :;i I (B) Stage of Active Insanity: (a) Intellect (the patient's reasoning-) : (i) sense perception (hallucinations, illusions), (2) memory, recent and remote (arithmetical problems, dates, ages, names, etc.), (3) thought, flow of ideas (retarded, accelerated, incoherent), (4) judgment (de- lusions, imperative ideas) 341 345 (b) Feelings (the patient's mood): (i) depressed (fear, grief, remorse), (2) excited (irritability, turbulence, confusion), (3) enfeebled (indifference, apathy), (4) changeable 546 (c) Actions: (i) conduct (quiet, dull, agitated, violent, indecent), (2) habits and tend- encies (destructive, dirty, untidy, dangerous, homicidal, suicidal, criminal), (3) speech (mute, taciturn, voluble, disconnected, incoherent, thick, unintelligible, scan- ning), (4) handwriting 34* 348 (d) Consciousness: (i) of self, (2) of others and of surroundings, (3) delirium, coma, semi-coma, convulsions Special Symptomatology (A) Functional Insanity (a) Idiopathic: * Psychoses (i) melancholia {simple delusional fwith agitation (with stupor 350 ("simple (2) mania •{ delusional acute delirious .; ,1 (3) confusional insanity 352 (4 ) primary dementia f Psychic degenerations 354 (i) recurrent, periodic and circular insanity (2) chronic delusional insanity (paranoia) 356 (b) Symptomatic ( i ) epileptic insanity (2) hysterical insanity (3) neurasthenic insanity 358 (c) Terminal dementia (B) Organic Insanity ( i ) general paresis 360 senile insanity (2) insanity of arterio-sclerosis .. . lie insanity 362 (3) insanity with gross organic disease of the brain (cerebral syphilis, tumor, apoplexy, etc.) (C) Mental Disorders or Defects not Considered as Insanity: (i) idiocy, (2) imbecility, (3) crime, (4) alcoholism, (5) delirium 364 Diagnosis : (i) the determination of insanity, (2) feigned insanity 366 Differential diagnosis of the forms of insanity 307 Prognosis and course : (i) of the acute psychoses, (2) of psychic degenerations, (3) of organic insanity Treatment: (i) mental or moral, (2) physical, (3) hydrotherapeutics, (4) drugs, (5) at home, (G) general hospital, (j) in special hospital (asylum) 370 EXAMINATION OF THE BLOOD. Introductory Technic of obtaining the blood Technic of haemoglobin test : (i) Tallquist. (2) Cowers, (3) Fleischl, (4) Dare 371 372 Significance of haemoglobin percentage: (a) Increased i plethora;, (b) Diminished (chlorosis, leukaemia, pseudoleukemia, and all forms of anaemia) percentage of haemoglobin 1 ( l( ' Color Index = = _ = 100# percentage of red corpuscles 5,000,000 (a) Increased (pernicious anaemia, (b) diminished (chlorosis and most forms of anaemia) Technic of estimating the specific gravity of the blood : (i) Hammerschlag's Method, (2) Schmalz Significance of the specific gravity of the blood : (a) Varies with the haemoglobin SP. GR. HAEMOGL. SP. GR. HAEMOGL. SP. GR. HAEMOGL. SP. GR. HAEMOGL. 1030 20$ 1042.5 45$ 105 1 65$ 1057-5 90$ 1035 30$ 1045-5 5o$ J05 2 7o?< !059 100$ 1038 35$ 1048 55$ 1053.5 75$ 1 04 1 40$ 1049 60$ 1056 80$ (b) Increased relatively to the Haemoglobin (leukaemia), (c) relatively diminished (per- nicious anaemia) Technic of ascertaining the number of red corpuscles : (1) Thoma-Zeiss, (2) Haematokrit, (3) Haemocytometer 374 Significance of the number of red corpuscles I Increase or polycythaemia [(i) after recovery from anaemia, (2) after transfusion, (3) after profuse diarrhoea, sweating or vomiting, (4) high altitudes, (5) phosphorous poisoning] 376 (b) Decrease or anaemia, primary (pernicious) or secondary [(i) after hemorrha malaria, (3) acute septicaemia, 14; toxic intestinal parasites, chlorate of potash poisoning, etc.), (5) anaemias of early childhi rms of all anaemias] Technic of ascertaining the number of white corpuscles : (1 ) Zappert-Thoma-! Significance of the number of white cells (a) Diminution or leucopenia [always (i) starvation, sometimes (2) measles, (3) grippe, (4) tuberculosis, uncomplicated, (5) malaria, (6) typhoid, often (7) pernicious and severe secondary anaemias, (8) splenic anaemia] 378 (b) Increase or leucocytosis [physiological (i) new-born (24000), (2) digestion (12000). (31 pregnancy (13000 to 18000), (4) exercise and baths (12000). pathological (5) post-hemorrhagic (16000 to 18000), (6) moribund, inflammatory (j) cholera, (8) relapsing fever, (9) typhus, (10) scarletina, (11) diphtheria, (12) tonsilitis, (13) sec- ondary syphilis, (14) erysipelas, (15) bubonic plague, (16) yellow fever, (17) pneu- monia. (18) small-pox, (19) pyaemia and septicaemia, (20) actinomycosis, (21) trichi- nosis, (22) anthrax, (23; acute multiple neuritis, (24) acute articular rheumatism, (25) meningitis, non-tubercular, (26) cholecystitis. (2?) acute pancreatitis, (28) gonorrhoea, (29) abscess, (30) pyelo-nephritis, (31) appendicitis. (32; phlebitis, (33) osteomyelitis, (34) salpingitis. (35) peritonitis, (36) pericarditis, (37) pleuritis. (38) empyema, (39) gangrene, toxic (40) illuminating gas, (41) quinine, (42) rickets, (43) gout, (44) yellow atrophy of the liver, (45) advanced hepatic cirrhosis, (46) acute gastroenter- itis, (47 J uraemia, (48) after injections of tuberculin, thyroid and normal salt solutions, (49) malignant disease, (50) drugs (vegetable tonics, essential oils, pilocarpine potas- sium chlorate, chloroform and ether inhalations, salicylates, phenacetin and antipyrine] 380 Technic of examination of fresh specimen of blood Information derived from examination of fresh blood : (i) plasmodium malariae, (2) spi- rochaete of relapsing fever, (3) filaria sanguinis hominis, (4) anthrax and other bacteria, i 5 ) amount of fibrin, (6) approximate ratio of white and red corpuscles, (7) approximate ratio of different varieties of white corpuscles, (8) deformities of red corpuscles, (9) amount of blood plates Technic of making a smear of blood : (i) cover glass, (2) slides, (3) fixing, (4) staining (Ehrlick, Jenner, Goldham), (5) differential counting 382 . Information obtained from examination of blood smear (a) Red corpuscles : (i) normal, (2) endoglobular changes, (3) crenation and poikilocytosis, (4) oval, (5) staining reaction, (6) nucleated (normoblasts, megaloblasts, micro- blasts), (7) granular degeneration, (8) plasmodium malariae EXAMINATION OF THE BLOOD. .'"'•• :% X r.-o #5 r • %• tV Fig. i. VARIETIES OF LEUCOCYTES — Stained by Jenners Method, i, Small lymphocyte; 2, Intermediate between small and large lymphocyte: 3, Large lymphocyte; 4, Myelocyte: 5. Degenerat- ed polymorphonuclear; 6, Polymorphonuclear; 6', Polymorphonuclear containing a bacillus; :. Polymorphonuclear with Nei sser granules; S, Eosinophile myelocyte; o. Eosinophile: 10. M:ist cell. o % O Fig 2. VARIETIES OF RED CELLS— Stained with Eosin and Methylf.ni Blui i, Normal; 2, Deficient in Haemoglobin; 3, Microcyte; 4, Poikilocyte; 5. Vacuolated; 6, Megalocyte; 7. Polyehromatophilic ; 8, Microblast; 9, Megaloblast; u>. Normoblast: 11, Division form; 12, Punctate erythrocyte; 13, Blood plates. O Q ® OO© e a 10 The Tertian Form 01 Malarial Pa*a Figures 1 t.. 7 represent thi development »l a Haematotoon within the substanci ol a redbloodcell ■1 to 10 represent the d idult form into ni w parasites In figure 10 there is reprt II and the young parasites are fret to enter other blood cells (b) White corpuscles: (i) normal (small lymphocytes 20 — 30'/'. large lymphocytes, 4 polymorphonuclear neutrophile leucocytes 62 — 70^, eosinophle leucocytes [-2 — 4 .mast- cells [leucocytes] 1-40 — l-'2#), ( 2 ) leucocytosis, (3) lympho inophilia, ( 5 i myelocites 386 Technic of agglutination test, serum reaction (WidaPs test) as; 388 EXAMINATION OF SPUTUM Introductory Method of obtaining sputum in infants Macroscopic examination (a) Quantity: (i) swallowed in children and some adults (women), (2) scanty (bronchitis, incipient tuberculosis, whooping cough, laryngitis asthma), (3) abundant (empyema, perforating, advanced tuberculosis, chronic bronchitis and bronchiectasis, oedema) ( l> ) Reaction: (alkaline) 1 <■ i Odor: (1) gangrene, (2) abscess, (3) cavities (d) Sedimentation in layers: (i) cavities, (2) chronic bronchitis and bronchiectasis, (3) gangrene (e) Character of sputum: (1) watery or serous (oedema), (2) viscid or mucuous (pneu- monia, influenza, bronchitis, tuberculosis, whooping cough), (3) muco-purulent (chronic bronchitis, tuberculosis, pneumonia, resolving), (4) purulent (cavities, empy- ema), (5) nummular (tuberculosis, chronic bronchitis), (6) rusty (pneumonia), (7) prune juice and currant jelly (pneumonia, cancer), (8) frothy (oedema, broncho-pneu- monia, bronchitis), (9) hemorrhagic (tuberculosis, oedema, infarction, aneurism, purpura, hysteria), (10) black (inhaled dust), (11) yellow or green (hepatic abscess, perforat- ing), (12) bronchial casts (fibrinous or croupous bronchitis) 390 Microscopic examination (a) Selection of specimen : (i) inspection, (2) boiling with alkali, (3) centrifuging ( /' ) Technic of examination of fresh specimen (c) Results of examination of fresh specimen: (i) epithelium, (2) pus cells (empyema, tuberculosis, chronic bronchitis and bronchiectasis), (3) eosinophylic cells (asthma), (4) Charcot-Leyden's crystals (asthma), (5) Curschmann's spirals (asthma), (6) elastic fibres (gangrene, cavities), (7) hematoidin crystals (old hemorrhage, tuberculosis, cardiac disease), (8) Echinococcus hooklets, (9) actinomycoces 392 (d) Technic of examination of dried specimen: (i) smear, (2) fixing (heat). (3) staining (Koch, Ziehl-Xeelsen. Gabbett, Loemer, Gram), (4) microscope (e) Results of examination of dried specimen: (i) tubercle bacillus, (2) Fraenkel's pneu- mococcus, (3) Friedlaender's pneumococcus, (4) influenza bacillus, (5) streptococcus and staphylococcus, (6) aspergillus, (7) actinomycosis 394 EXAMINATION OF THE URIXE Introductory Physical characters (a) Quantity: (i) normal and physiological variations, (2) increased or polyuria (diabetes mellitus, diabetes insipidus, chronic interstitial nephritis, amyloid nephritis, elimination of large effusions, angina pectoris, hysteria, tumors of brain stem), (3) diminished or oliguria (parenchymatous nephritis, cardiac disease, fever, diarrhoea, hysteria) (b) Specific gravity : (i) normal and physiological variations, (2) varies in the quantity secreted, (3) a measure of the solids excreted by the kidneys, (4) large amount of urine with high specific gravity (diabetes mellitus), (5) small amount of urine with low spe- cific gravity (uraemia threatening) (c) Transparency and sediment: (1) normal, (2 ) urates, (3) phosphates, (4) mucus and pus, (5) bacteria, (6) shreds (d) Color: (1) normal and physiological variations, (2) pale (polyuria), (3) dark (oli- guria), (4) red, reddish-brown, smoky (haematuria), (5) greenish-brown or greenish- black (choluria), (6) black (alkapturia, carbolic acid, salicylic acid, santonin, naph- tholin, etc.), (7) milky ( chyluria ) , (8) blue (indigo, methylene blue) 896 (e) Odor: (i) normal. (2) ammoniacal, (31 eliminating odors. (/) Reaction: (1) normal and physiological variations, (2) increased acidity (fever, gout [?]), (3) ammonia alkalinity (decomposition, urethritis, cystitis), (4) fixed alkali alkalinity (vomiting and gastric disease, food, anaemia, neurasthenia) Normal chemical constituents Urea: 1 I 1 quantitative tests (Squibb, Doremus, from sp. gr. ). (2) normal amount and physiological variations, (3) renal adequacy. (4) increased (febrile diseases, diabetes, blood diseases, poisoning by phosphorus and arsenic), (5) diminished (nephritis, hepatic diseases, many chronic diseases) 897 (b) Uric acid: (i) quantitative tests (Haycraft Heintz), (2) normal amount and physio- logical variations, (3) increased (acute fevers, leukaemia, gout and rheumatism, food), (4) diminished (diabetes, anaemia, chronic interstital nephritis) (c) Salts: (1) chlorides, (2) phosphates, (3) sulphates Abnormal chemical constituents (a) Albumen: (1) qualitative tests (nitric acid, heat and nitric acid, Trichloracetic test), (2) quantitative test (Esbach), (3) albuminuria (all forms of nephritis, primary or second- ary, cystitis, urethritis, infectious fevers, haemic diseases, cardiac and pulmonary dis- eases, drugs, high arterial tension) 398 (b) Albumose: (i) tests (heat), (2) albumosuria (infectious fevers, suppuration, myelo- mata, osteomalacia) (c) Sugar: (1) qualitative test (Fehlings, Haines, Nylander fermentation), (2) quantitative test (Fehling, fermentation, Einhorn's saccharometer), (3) glycosuria (excessive sac- charine and starchy food with sedentary life and nerve strain, diabetes mellitus), infect- ious fevers during convalescence, injury to nervous system (d) Acetone: (i) tests (Gunning), (2) acetonuria (fever, hunger, meat diet, diabetes mell- itus digestive disturbances, carcinoma) (e) Di-acetic acid: (1) tests (Gerhardt), (2) diaceturia (diabetes mellitus, fever, dyspeptic disturbances, autointoxication in drinkers) (/) Blood: (1) tests (spectroscope, Schoenbein-Almen), (2) Haematuria and Haemoglobi- nuria (inflammations, tumors or injuries of any part of urinary tract, haemic diseases, purpura, infectious diseases) 400 (g) Haematin: (i) tests (barium chloride and - [aematoporphyrinuria i -ul tonal and trional poisoning i (In Indican: (i) tests (Jaffe), (2) indicanuria (deficiency of hydrochloric acid in stomach, intestinal disorders, especially obstruction or sluggish action, pu Bile pigments: (1) tests (Gmelin), (2) Icteric urine (when bile pigments are in the blood) (;') Diazoreaction (Ehrlich) (typhoid, acute miliary tuberculi re and rapid pulmo- nary tuberculosis, measles, etc.) 401 Microscopic examination of the urine (a) Method of collecting sediment: (i) sedimentation, (2) centrifuging, (3) both (b) Urates: (1) appearance, (2) significance (acid, concentrated urine, fevers) (c) Uric acid: (1) appearance, (2) significance (acid, concentrated urine, gout, rheuma- tism, fever) (d) Calcic oxalate: (1) appearance, (2) significance (food, dyspepsia) {e) Phosphates amorphous: (1) appearance, (2) significance (alkaline, decomposing urine) 402 (f) Fat: (i) appearance, (2) significance (phosphorous poisoning, obesity, fat embolism, chyluria) (g) Epithelial cells: (1) appearance, (2) significance (inflammations of urinary tract) (h) Pus cells: (1) appearance, (2) significance (inflammations of urinary tract) (») Red blood cells: (i) appearance, (2) significance (hemorrhage of urinary tract) 103 (/) Epithelial casts: (i) appearance, (2) significance (renal inflammation or degeneration) (k) Granular casts : (i) appearance, (2) significance (renal inflammation or degeneration) (/) Hyaline casts : (1) appearance, (2) significance (renal inflammation or degeneration) (m) Fatty casts: (1) appearance, (2) significance (renal inflammation or degeneration) («) Waxy casts: (1) appearance, (2) significance (renal inflammation or degeneration) 404 URINARY SEDIMENT. Epithelial Cells, a, felvic; b, Vaginal . c, Bladder. Fig. 2. a, Pus cells; b, Pus cells treated with acetic acid ; c, Gonorrheal thread ; d, Spermatozoa; e, Corpora Amylacea. Foreign Substances a. Linen fibre ; b, Cotton fibre; c. Air bubbles: d. Wool fibre ; e, Scale of moths wing. Fig. 4 Rarer Crystals a, Cyst in; b, Leucin; c, Tyrusin; d, Calcium Phos| Calcium Carbonate. Fig. 5. Acid 1'kine. a, Calcium Oxalate ; b, Uri nil of lira d, Colorless Uric Acid. Fig. ft. Alkalini Urine, a, Triple phosphate b, Ammonium urati Fig, 7 Casts ... Hyalim b, H fine granules; < . Mn. uus ihn d, Cylindi I d, Free blood cells (a) Blood, pus and bacterial casts: (i) appearance. (2) significance ( /> ) Cylindroids of unknown origin and significance (q) Parasites (1) filaria sanguinis hominis, (2) echinococcus Bacteria: (1) typhoid, (2) tubercle, (3) gonococcus, (4) coli communis, (5) staphyl- ococcus and streptococcus 106 EXAMINATION OF STOMACH CONTENTS Introductory- Vomited matter: (i) quantity, (2) odor, (3) reaction (A) Contains remnants of food (time and character of preceding meals) (1) Food completely digested (vomiting nervous, reflex, cerebral, spinal, beginning of gastric ulcer or catarrh) (2) Food partly digested (mucus present-gastritis) (3) Food not at all digested (atrophy — if there have been several hours between the taking of food and the vomiting) 40G (B) Abnormal substances: (i) Blood: Bright red to coffee-ground appearance (ulcer, carcinoma, hepatic cirrho- sis, gastric stases in circulatory disorders. Exclude non-gastric causes) (2) Pus: (Gastritis phlegmonosa, ulcerating carcinoma. It may come from bronchi, pharynx, posterior nares) (3) Mucus: In small quantities always present. In large quantities gastric catarrh, chronic pharyngeal catarrh, morning vomiting) ■107 (4) Bile : Often found in vomitus and seldom has a special significance (acute gas- tritis, peritonitis, gastro-intestinal disorders, reflexly in diseases of the liver, kidneys, ovaries, uterus and in tabes dorsalis) ( 5 ) Fasces (6) Parasites : (Ascarides, taeniae, oxyures, vermiculares, anchylostoma, trichinae) (7) Tissue particles (mucous membrane, tumors) 408 Gastric contents after test meals (i) Test breakfast of Ewald-Boas (2) Test meal of Riegel (A ) Appearance (1) Undigested, (2) partially digested, (3) completely digested (4) Presence of abnormal elements: (a) blood, (b) mucus, (c) bile, (d) relation of solids to liquids — 3 layers, mucus, liquid, chyme (/•') Quantity (20-50 c. 1.) (a) diminished (hypermotility, gastric neuroses, chronic tritis, incontinence of pylorus) (fc) increased (motor insufficienc (C) Odor (markedly sour, stale, sweetish) Chemical examination ( i ) Reaction (2) Presence of free acids (congo red, Tropaeolin tests) (3) Test for free hydrochloric acid (Phloroglucin, vanilla, Resorcin, dimethyl, amido azo- benzol ) 410 (4) Determination of total acidity (Phenolphathalein and i-io normal solution of caustic soda) (5) Test^for free lactic acid (Uffelman's) Determination of butyric and acetic acids 171 Examination for pepsin and Rennin fe ■in Microscopical examination (i) Chyme: (a) starches, (b) meat, ( c) fats (2) Abnormal elements: Epithelial cells, red and white, blood cells, sarcinae yeast cells, crystals, bacteria, tissue particles Determination of gastric motility (a) Test meals: (i) Leube test meal, (2) test breakfast ( b ) Salad test : ( 1 ) Huber modification 412 Gastric insufficiency due to ( i ) Weakness of contracting' muscles (2) Obstruction to the contracting muscles I 1 I Gastric myasthenia : (a) Congenital condition (rare) (b) Following constitutional diseases (anaemia, chlorosis, phthisis pulmonalis, chronic malaria, amyloid degeneration, syphilis, typhoid fever, nervous affections) (2) (a) Obstructions in the stomach itself (ulcer, carcinoma of pylorus, polypus) (b) Obstructions due to conditions outside of the stomach (tumors, adhesions, contract- ures, floating kidney, herniae ) ii:; Diagnostic significance of the gastric tests ( i ) Normal acidity : No severe textural disease of stomach, probably a neurosis. May also occur with gastric atony (2) Hyperacidity: Gastric neurosis, ulcer, a benign glandular hypertrophy, carcinoma upon the base of an ulcer (3) Anacidity: Chronic gastritis, gastric neurosis, carcinoma (4) Lactic acid : Occurs with stagnation and absence of hydrochloric acid, carcinoma (5) Acetic acid: Result of alcoholic fermentation where there is gastric stagnation advanced fermentation of carbohydrates (6) Diminution of pepsin and Rennin: Marked diminution indicates a permanent injury of the gastric glands (7) Presence of yeast cells and sarcinae: They occur in small numbers in different gastric- disease, but are observed in large numbers only in excessive stagnation 414 415 EXAMINATION OF FiECES Introductory (i) Quantity (depends on food. oz. iv.-vii.) (2) Color: Usually dark brown (light yellow, clay colored, green, black — food, drugs, bile, blood) (3) Consistency: Soft sausage-shaped (ribbon- shaped, scybala; abnormally mushy or liquid) (4) Odor : Increased by retention in bowel (sour, offensive, musty, putrid) (5) Reaction: Neutral or slightly alkaline (vegetable diet slightly acid, occlusion of bile strongly acid) 416 (6) Undigested food (normally small particles of vegetable substances. Meat indicates severe intestinal lesion. Milk curds) Abnormal contents (i) Blood: Red, dark or tarry (portion of intestine, state of peristalsis). Most frequent causes : hemorrhoids, typhoid fever, colitis, cancer of colon. Large hemorrhages (typhoid fever, portal engorgement, haemophilia, purpura, aneurism). Small hemor- rhages (hemorrhoids, injury to rectum, fissure, ulceration, intussusception in children) (2) Mucus: Glassy layer about faeces, membrane, yellowish in color and well mixed with faeces, small particles floating in watery dejecta. (Inflammation of large or small intestine, dysentery proctitis, impaction of faeces) 117 (3) Pus: Large quantity (abscess, pelvic periproctitic perinephritic). Small quantity (dys- entery, enteritis, proctitis, ulceration of rectum or colon) (4) Fatty stools (obstructive jaundice, disease of pancreas, indigestion or overfeeding in infants) (5) Calculi: (a) gall stones, (b) pancreatic calculi, (c) enteroliths, (d) coproliths (6) Foreign bodies : Coins, marbles, bones, needles (7) Parasites (ascaris lumbricoides, oxyuris vermicularis, taenia saginata, taenia solium) Microscopical examination (1) Remnants of food (fat, starches, muscle fibres) 418 (2) Crystals (Charcot-Leyden, lime crystals, fatty phosphates, cholesterin, haematoidin) (3) Blood: (Lower intestine, upper intestine, haematoidin or its crystals) (4) Pus: (ulcerations, abscess, dysentery) (5) Mucus: (Catarrh of intestines, membranous enteritis) (6) Parasites : (a) Animal: (1) worms, (2) protozoa (amoeba coli) 119 (b) Vegetable: (i) comma bacillus, bacillus typhosis, bacillus coli communis, bacillus tuberculosis (7) Ova of entozoa: (1) oxyuris vermicularis. (2) ascaris lumbricoides, (3) trichocephalus drspar, (4) taenia solium, (5) taenia medrocanellata, (6) Bothriocephalus latus, (7) Distoma hepaticum, (8) Distoma lanceolatum, (9) anchylostomum duodenale 420 INDEX Abscess of the brain, 112. Acetone and acetonuria, 400. Acid, free in gastric contents, tests for and signifi- cance of, 410. Acrany. 9. Acromegaly, 161, 270. Ageusia, 185, 317. Agglutination test, 387. Agraphia, 317; localization, 151; tests for, 7. Albumen in urine, tests for, 398. Albuminuria, significance of, 398. Albumose in urine, tests for and significance of, 399. Alcoholism, 88, 277, 278, 364. Alexia, 317; localization, 146, 148; tests for, 7. Amblyopia, 151, 161, 162. Amentia, 014 ; t sts for, 3. Amnesia, 314, 344; epileptic, 223, 225; tests for, 3, 344. Anaemia of the brain, 63. Anencephaly, 9. Aneurism in brain, 120; miliary. 72. Anosmia, 317; localization, 151, 153, 162; tests for, 7. Aphasia, motor, 5, 151, 102, 316; optic, 148; sensory, 5, 153, 316; tests for, 5; transcortical, 5, 316. Apoplexy, 71; differential diagnosis of, 87, 98. Arteritis syphilitica, 131, 135. la, abasia, 188. ■ ■gnosis. 112, 146, 317. Ataxia, cerebellar. 160, 324; cerebral, 151, 159, 324. Athetosis, 324; localization, 155. Auto-infection, cerebral diseases due to, 264. Belladonna poisoning Blood, color Index, 373; differential count, 382; exam- ination of, 371. 381; fixing, 382; haemoglobin in, 371, 373; in faeces, 417, 419; in urine, 400; In vomitus, 407; red corpuscles in, 374, 376, 377; smear, 382; specific gravity of, 373; staining, 382; white corpuscles in, 377, 378, 385. hycephaly, 9. Brain, abscess of, 112; anaemia of, 63; hemorrhage In, 71; hyperaemia of, 67; inflammation of. 111; injuries of, 47, 56; oedema of, 69; softening of, 93; tumor of, 119. in urine, (04. lepsy, 197, 200, Cephalalgia Cerebellum, localization In, 160. Cerebral absc maemia, 63; compression, 53; concussion, 47; contusion, 56; diplegia, 108; embolism, 93; hemorrhage, 09; hyperaemia, 67; Injuries, 47, 56; localization, Ml, I'.l ; oedema, 69; palsy of childhood, 111; inns thrombosis, 100; softening, 93; syphilis, thrombosis, 93; tumor, 119; cerebral diseases, diagnosis of, 327; rtlology of, 305; examination of, 3; pathological anatomy of. 310; pathology of, 325; prog- nosis of, 328; symptomatology of, 313; treatment of, 328. Cerebro-spinal syphilis, 134. Choked disc, 114, 122. -teatoma, 120. Chorea, degenerative, 240; habit, 206; Huntington's, 240; infective, 234; major, 207; minor, 234; rhythmic, 207; Sydenham's, 234. Color index of blood, 373. Coma, 313, 349; apoplectic, SO, 84; diabetic, 275; differ- ential diagnosis of, 87; epileptic, 223, 225; hysterical, 107; tests for, 3; uraemic, 272. Compression of the brain, 53. Concussion of the brain, 47. Confusional insanity, 352. Consciousness, 349; tests for, 3. Contracture, 18S, 321. Contusion of the brain, 56. Convulsions, 114, 122, 188, 321, 349; epileptic, 223; hys- terical, 188, 197. Convulsive disorders, 220, 234, 248. Convulsive tic, 205. Corpora quadrigemina, localization in, 159. Cranial abnormalities, 9. Cretinism, 264. Crime. 364. Cyst of brain, 12". Delirium, 322, 364. Delusions, 322. Dementia, 3, 227, 228, 314, 353, 359. Di-acetic acid in urine, 400. Diagnosis of brain disease, 327; of insanity, 366. Diabetic coma, 275. Diazoreaction, 401. Diplegia, cerebral, 10S, 319. Dolycocephaly, 9. Ecstasy, 197. Embolism of the brain, 93. Encephalitis, 111. Encephalocele, 9. Endarteritis syphilitica, 131. Eosinophils and eosinophilia, 385. :>sy, 89, 220; Jacksonlan, 142, Epileptic, aura, 223, 225; Insanity, 223, 226, 227, 357; Interval, 228; major attack, 223; minor attack, 225; . 228. Etiology of brain disease, 305; of Insanity, 338. (nation of cases of cerebral disease, S. Mialmlc goltn- Faeces, abnormal constituents, 417; blood in, 417. 418; calculi In, 418; examination of, 416; fat in, 418; micro- scopical examination of, 418; mucus in, 417, 419; ova In, 420; parasites In, 418, 419; physical characters of, 416; pus in, 118, 419. Fllaria sanguinis lmminis in blood, 381; in urine, 406. il lobe, localization in, 151. 421 INDEX Gastric contents after test meals, 409; bile in, 408; blood in, 407; examination of, 406; faeces in, 408; free acids in, 410; hydrochloric acid in, 410; lactic acid in, 411; microscopic examination of, 412; motility of. 409, 412; mucus in, 407; pus in, 407; total acidity, 411. General paresis, 359. Glioma, 120. Glycosuria, significance of, 399. Goitre, exophthalmic, 267. Gumma, 120; structure of, 130. Haematin and haematoporphyrinuria, 401. Haematoma of dura mater, 12, 14. Haemoglobin test, 371; percentage, 373. Hallucinations, 322, 344; auditory, 153; odoriferous, 153; optic, 148. Headache, 297, 323. Hemiamblyopia, 148. Hemianaesthesia, 155, 185, 317. Hemianopsia, 315; localization, 146, 148, 155, 157, •161; tests for, 5. Hemiathetosis, 155. Hemichorea, 155, 236. Hemichromatopsia, 148. Hemiplegia, 82, 106, 142, 155, 318. Hemorrhage, cerebral, 71; meningeal, 61. Hydrocephalus, 9, 29; acute, 41; chronic external, 41; chronic internal. 42. Hydrochloric acid in gastric contents, 410. Hydrophobia, 252. Hyperaesthesia, 320. Hyperaemia of the brain, 65. Hypnotism, 200. Hysteria, 89, 177. Hysterical insanity, 197, 358; major attacks, 197; minor attacks, 191. Idiocy, 314, 364. Imbecility, 314, 364. Indican and indicanuria, 401. Inertia, 324. Inflammation of the brain, 111. Injury of the brain, 47, 56. Insanity, 334; alcoholic, 277, 27S, 364; circular, 355; classi- fication of, 350; confusional 352; diagnosis of, 366; epileptic 223, 226, 227, 357; etiology of, 338; examination for, 337; functional, 350; hysterical, 197; in tetany, 246; neurasthenic, 358; organic, 363; pathology of, 341; prognosis of, 368; senile, 361; symptomatology of, 343, 350; treatment of, 369. Insomnia, 167, 280, 320, 343. Intelligence, tests for, 3. Internal capsule, localization in, 155. Intracranial tumor, 119. Jacksonian epilepsy, 142. Kernig's symptom, 23. Lactic acid in gastric contents, 411. Lead poisoning, 284. Leptomeningitis, 10; acute, la; chronic, 37. Leucocytes and leucocytosis, 377, 385. Leucopenia, 378. Localization, 141, 151; at base of brain, 161; central white substance, 155; cerebellar, 160; cerebral, 141; corpora quadrigemina, 159; frontal lobe, 151; internal capsule, 155; nucleus candatus, 157; nucleus lenticu- laris, 157; occipital lobe, 148; optic thalamus, 157; parietal lobe, 146; temporal lobe, 153. Lumbar puncture, 24, 27, 31, 35, 44. Lymphocytes and lymphocitosis, 385. Mania, 351. Melancholia, 350. Memory, tests for, 3. Meniere's disease, 291. Meningeal hemorrhage, 61; irritation, 22, 30, 290. Meningitis, 10; cerebro-spinal, 18; chronic, 37; gum- mosa, 130, 132; purulent, 33; serous, 36; syphilitic, 130, 132; tubercular, 28. Mental disorders, 3, 334. Microcephaly, 9. Migraine, 300. Miliary aneurism, 72. Monoplegia, 318. Morphine poisoning, 88, 2S0. Motor centers, localization of, 142. Myelocytes, 385. Myoclonus multiplex, 206. Myxoedema, 264. Narco-lethargy, 197, 200. Narcotism, 88, 280 Neurasthenia, 164. Neurasthenic insanity, 35S. Neuroses, occupation, 258; traumatic, 261. Nicotine poisoning, 282. Nucleated red blood corpuscles, 384'. Nucleus caudatus, localization in, 157. Nucleus lenticularis, localization in, 157. Nystagmus, 160. Occipital lobe, localization in, 148. Occupation neuroses, 258. Oedema, cerebral, 69. Oliguria, 395. Ophthalmoplegia, 161, 162, 163. Optic, aphasia, 148; neuritis, 114, 122, 136; thalamus, localization in, 157. Pachymeningitis, 10; externa, 10; interna haemor- rhagica, 12; interna purulenta, 12. Paramyoclonus multiplex, 206. Paranoia, 355. Paresis, 359. Parietal lobe, localization in, 146. Pathological anatomy of cerebral diseases, 310; of insanity, 341. Pathology of cerebral diseases, 327. Penetrating wounds of the brain, 59. Periarteritis syphilitica, 131, 135. Perineuritis syphilitica, 131, 136. Pituitary body, tumors of, 161. Plasmodium malariae in blood, 381, 384. Poikilocytosis, 381, 384. Poisoning, 277. Polyuria, 395. Porencephaly, 104. Post-syphilitic nervous diseases, 128. Prognosis of brain diseases, 328; of insanity, 36S. Psamoma, 120. Ptomaine poisoning, 276. Psychic blindness, 5, 148, 315; deafness, 153; degenera- tions, 354; depression, 322, 343, 346, 350; disorders, tests for, 3; equivalent, 227; exaltation, 322, 346; variability, 322, 346. Psychoses, 350. Red blood corpuscles, 374; counting of, 374; diminu- tion of, 377; increase of, 376. Review, 305. Senile insanity, 361. Sinus thrombosis, 100. Softening of the brain, 93. Somnambulism, 197, 200, 226. Spasms, local, 255. 422 INDEX Speech, disturbances of, 5, 347. Spirochaete of relapsing fever in blood, 381. Sputum, examination of, 389; macroscopic, 3S9; micro- scopic, 391. Stomach, motility of, 409, 412. Strychnine poisoning - , 283. Sugar in the urine, 399. Suggestion, 200. Summary, 305. Symptomatology of brain disease, 313; of insanity, 343, 350. Syphilis of the nervous system, 128, 134. Syphilitic, arteritis, 131, 135: endarteritis, 131; menin- gitis, 130, 132; neuritis, 131. Temporal lobe, localization in, 153. Telepathy, 200. Test breakfast in gastric diagnosis, 409, 412. Test meal in gastric diagnosis, 409, 412. Tetanus, 248. Tetany, 243. Thrombosis, cerebral, 93; sinus, 100. Tic, convulsive, 205. Toxic cerebral disease, 277. Trance, 197. Traumatic neuroses, 261. Treatment of brain diseases, 32S; of insanity, 369.' Tremor, 286, 324. Tumor, intracranial, 119. Uraemia, 87, 272. Urea in urine, 397. Uric acid in urine, 398, 402. Urine, abnormal constituents of, 398; bile pigments, in, 401; examination of, 395; microscopic examination of, 402; normal constituents of, 397; physical char- acters of, 395. Vertigo, 160, 288, 323; aural, 291; cerebellar, 160, 294; epileptic, 290; experimental, 2S8; hysterical. meningeal, 290; neurasthenic, 295; ocular, 295; toxic 296. "Vision, tests for disturbances of, 5. Vomiting, 160, 323, 406. Vomitus, 406; bile in, 408; blood in, 407; examination of, 406; faeces in, 408; microscopic examination of, 412; mucus in, 407; pus in, 407. AVhite blood corpuscles, 377; counting of, 377; decrease of, 378; increase of, 379. Widal's test, 387. Writer's cramp, 258. !■_•:; COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special arrange- ment with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE 'N(W n 4 ' C28(l14l)M100 KQ.Z5U